Cẩm nang điều trị nội khoa Washington PDF

Cm nang
IU TR NI KHOA
The Washington Manual of Medical Therapeutics 34th Edition
B mn Y hc
Trng i hc Y khoa Washington
St. Louis, Missouri
Bin tp vin
Hemant Godara, MD
Angela Hirbe, MD
Michael Nassif, MD
Hannah Otepka, MD
Aron Rosenstock, MD
Ch bin bn ting Vit
GS.TS. Ng Qu Chu
HH
NH XUT BN I HC HU
Hu
BIN MUC TRN XUT BAN PHM CUA TH VIN QUC GIA VIT NAM
Cm nang iu tr ni khoa / Hemant Godara, Angela Hirbe, Michael Nassif... ; Bin dch:
Ng Quy Chu (ch.b.)... - Hu: ai hoc Hu, 2015. - 1480tr. ; 24cm.
1. Bnh ni khoa 2. iu tr 3. Cm nang
616 - dc23
DUM0009p-CIP
Ma s sach: NC/114-2016
CM NANG IU TR NI KHOA, c xut ban theo thoa thun chuyn giao ban
quyn cua Lippincott Williams & Wilkins, USA vi Cng ty c phn Cao Trn.
Cng ty c phn Cao Trn gi ban quyn xut ban va phat hanh n ban ting Vit trn toan
th gii theo thoa thun chuyn giao ban quyn vi Lippincott Williams & Wilkins, USA.
y la ban dch cua THE WASHINGTON MANUAL OF MEDICAL THERAPEUTICS
34th Edition.
2014 by Department of Medicine, Washington University School of Medicine
n ban gc ting Anh c xut ban bi Lippincott Williams & Wilkins/Wolters Kluwer
Health.
Lippincott Williams & Wilkins/Wolters Kluwer Health khng tham gia vao vic dch tn
cun sach nay.
Vietnamese Edition 2016 by CAOTRAN.,JSC
All rights reserved.
Tt ca cac quyn c bao h. Cun sach nay c bao v bi lut ban quyn. Khng mt
phn nao cua cun sach nay c phep nhn ban, sao chep di moi hnh thc bi bt ky
muc ch va phng tin g, k ca la photocopy hoc s dung bi bt ky h thng lu tr
va truy cp thng tin ma khng co s cho phep bng vn ban cua chu s hu quyn tac gia.
ISBN 978-604-912-532-4
Cun sach nay cung cp ch nh chnh xac, phan ng bt li, liu lng va liu trnh s
dung thuc, nhng kha nng la co th co thay i. c gia buc phai xem xet d liu thng
tin nh kem hp thuc cua nha san xut cho nhng thuc dung n. Tac gia, ngi bin tp,
nha xut ban, hay nha phat hanh sach khng chu trach nhim v nhng li hay sai sot hoc
bt c hu qua nao t vic ap dung kin thc trong cun sach nay, va cung khng bao am
g i vi ni dung, cu th hay bao ham, cua cun sach. Tac gia, ngi bin tp, nha xut
ban, va nha phat hanh khng chu bt ky trach nhim nao cho bt c tn thng va/hoc tn
hai n ngi hoc tai san phat sinh t cun sach nay.
Cun sach nay c thc hin bi Cng ty c phn Cao Trn, Nha lin kt xut
ban sach Y hoc.
Lin h xut ban va moi yu cu thng tin xin gi v: Cng ty c phn
Cao Trn, 27/10 ph Vnh Tuy, qun Hai Ba Trng, thanh ph Ha Ni,
Vit Nam. in thoai: 0 43 987 0580, 0 90 452 8001,
Email: caotran_inc@yahoo.com. Website: http://caotranbooks.com
Chng ti dnh tng cm nang ny n i ng bc s ni tr ni khoa xut sc
ca i hc Washington v Bnh vin Barnes-JewishTr tu, tn ty cng hin,
v lng nhn i h lun l ngun c v chng ti hng ngy.
Mc lc
LI TNG iii
CC TC GI xxix
BAN BIN DCH V HIU NH xxxiii
LI CH BIN xxxv
LI TA xxxvii
LI CH BIN BN TING VIT xxxix
LI CM N xli
1 Chm sc bnh nhn ni khoa 1

Mark Thoelke, John Cras, Nathan Martin, Amy Sheldahl
PGS.TS. Phan Thu Phng, ThS. V Th Thu Trang
Tng quan chm sc bnh nhn ni tr 1
Bin php d phng 2

D phng huyt khi tnh mch 2
Lot do t th (Lot do t ) 3
D phng khc 5
Chm sc bnh nhn ni tr c triu chng cp tnh 6

au ngc 6
Kh th 7
Cn tng huyt p cp tnh 8
St 9
au 10
Ri lon thc 16
Mt ng v lo u 18
V
VI l MC LC
Ni khoa quanh phu thut (Perioperative) 17

nh gi tim mch trc phu thut 22
X tr chng ng v chng huyt khi quanh phu thut 31
X tr mt s bnh c th quanh phu thut 35

Tng huyt p 35
My to nhp tim v my kh rung cy trong c th 37
Bnh phi v nh gi phi trc phu thut 38
Thiu mu v truyn mu trong phu thut 43
Bnh gan 45
i tho ng 48
Suy thng thn v x tr corticosteroid 51
Suy thn mn tnh v bnh thn giai on cui 54
Suy thn cp 56
2 Dinh dng h tr 57
Dominic Reeds, Ben P. Bradenham, Jr.
PGS.TS. Nguyn Khoa Diu Vn, ThS. V Th Thu Trang
Nhu cu dinh dng 57

nh gi tnh trng dinh dng 75
Dinh dng qua ng tiu ha 77
Dinh dng tnh mch (Parentenal Nutrition) 84
Hi chng ti nui dng bnh nhn suy dinh dng nng 90
3 D phng bnh l tim mch 95

Angela L. Brown, Timothy J. Fendler, Anne C. Goldberg
PGS.TS. Phm Mnh Hng, TS. V Vn Gip
Tng huyt p 95
Ri lon chuyn ha lipid 120
4 Bnh tim thiu mu cc b 139

Mohammad Kizilbash, Jeffrey R. Parker, Muhammad A. Sarwar, Jason D. Meyers
Bnh mch vnh v au tht ngc n nh 139

Hi chng vnh cp, au tht ngc khng n nh, nhi mu c tim khng ST chnh 158
Nhi mu c tim ST chnh ln 178
MC LC l VII
5 Suy tim v bnh l c tim 215

Shane J. LaRue, Susan M. Joseph, Gregory A. Ewald
Suy tim 215

Suy tim cp v ph phi do tim 230
Bnh c tim 233

Bnh c tim gin 233
Suy tim vi phn sut tng mu c bo tn 235
Bnh c tim ph i 236
Bnh c tim hn ch 240
Bnh c tim chu sn 241
6 Bnh l mng ngoi tim v bnh van tim 245

Jay Shah, Brian R. Lindman
Bnh l mng ngoi tim 245

Vim mng ngoi tim co tht 245
Trn dch mng ngoi tim c p tim 248
Bnh van tim 251

Hp van hai l 251
Hp van ng mch ch 257
H van hai l 263
H van ng mch ch 270
Thay van tim nhn to 275
7 Lon nhp tim 279

Shivak Sharma, Daniel H. Cooper, Mitchell N. Faddis
Lon nhp nhanh 279

X l lon nhp nhanh 279
VIII l MC LC
Nhp nhanh trn tht 283

Rung nh 290
Nhp nhanh tht 309
Lon nhp chm 320
Ngt 333
iu tr ti ng b c tim 338
8 Chm sc cp cu 339
Anthony Boyer, Scott T. Micek, Marin H. Kollef
GS.TS. Ng Qu Chu, ThS. Nguyn Thanh Thy
Suy h hp 339
Liu php oxy khng xm nhp 342
Kim sot ng th v t ni kh qun 343
Th my 347
Sc 358
Theo di huyt ng 366
9 Bnh l phi tc nghn 369

Jeffrey J. Atkinson, Robert M. Senior, Ajay Sheshadri, Mario Castro
Bnh phi tc nghn mn tnh 369

Hen ph qun 384
10 Bnh l phi 405

Murali Chakinala, Colleen McEvoy, Tonya D. Russell, Rachel Bardowell, Alexander Chen, Daniel B. Rosenbluth
Tng p ng mch phi 405

Hi chng ngng th - gim th do tc nghn khi ng 419
Bnh phi k 427
Nt n c phi 437
Trn dch mng phi 445
MC LC l IX
Ho mu 454
X nang phi 462
11 D ng v min dch hc 473

Sarena Sawlani, Jennifer M. Welch, Andrew L. Kau
Phn ng c hi ca thuc 473

Sc phn v 478
Tng bch cu i toan 484
M ay (my ay) v ph mch 492
Suy gim min dch 497
12 Cn bng nc v in gii 503

Judy L. Jang, Steven Cheng
TS. Ngc Sn, ThS. L Hon
Cn bng dch v ri lon th tch 503

Bnh nhn ng th tch 504
Bnh nhn gim th tch 506
Bnh nhn tng th tch 507
Ri lon nng natri 509
H natri mu 509
Tng natri mu 516
Ri lon kali mu 520

H kali mu 521
Tng kali mu 524
Ri lon canxi mu 528

Tng canxi mu 528
H canxi mu 532
Ri lon phospho mu 535

Tng phosphate mu 536
H phosphate mu 537
X l MC LC
Ri lon magie mu 539

Tng magie mu 539
H magie mu 540
Ri lon thng bng kim toan 542

Toan chuyn ha 545
Kim chuyn ha 549
Toan h hp 551
Kim h hp 552
13 Bnh l thn 555

Seth Goldberg, Daniel Coyne
PGS.TS. Gia Tuyn, PGS.TS. Phan Thu Phng
nh gi bnh nhn mc bnh thn 555

Tn thng thn cp 558
Bnh cu thn 567
Bnh cu thn nguyn pht 569

Bnh cu thn tn thng ti thiu 569
Bnh x ha cu thn khu tr dng , on 569
Bnh cu thn mng 570
Vim cu thn mng tng sinh 571
Bnh thn IgA/Ban xut huyt HenochSchnleinin 572
Hi chng phi-thn 573
Bnh cu thn th pht 574

Bnh thn do i tho ng 574
Bnh thn do lupus 575
Bnh cu thn sau nhim khun 576
Ri lon lng ng/Ri lon protein mu 576
Bnh thn do HIV 578
Bnh thn a nang 578
Gim chc nng thn mn tnh 580

Bnh thn mn tnh 580
MC LC l XI
Liu php thay th thn 584

Phng cch lc mu 584
Thn nhn to 586
Lc mng bng 588
Ghp thn 590
Si thn 591
X l si thn 591
14 iu tr bnh truyn nhim 595

Stephen Y. Liang, Sara L. Cross, Nigar Kirmani
PGS.TS. Phan Thu Phng, TS. V Vn Gip, TS. Duy Cng, ThS. L Hon
Nguyn tc iu tr 595
Nhim trng gy ra bi c t 597

Nhim trng Clostridium difficile 597
Un vn 598
Hi chng sc c t 599
Hi chng sc c t t cu 599
Hi chng sc c t lin cu khun 600
Nhim trng da, m mm v xng 601

p-xe, mn nht v nht c 601
Vim m t bo 601
Chng vim qung 602
Nhim trng phc tp da v m mm 602
Lot t th nm v lot bn chn bnh nhn i tho ng 603
Vim m hoi t 603
Hoi t sinh hi (Gas Gangrene) 604
Vim ty xng 605
Nhim trng h thn kinh trung ng 606

Vim mng no 606
XII l MC LC
Nhim trng no tht v no tht shunt bng 609

Vim no 609
p-xe no 610
u trng sn dy ln no (neurocysticercosis) 611
Nhim trng tim mch 611

Vim ni tm mc nhim khun 611
Vim c tim 620
Vim mng ngoi tim 620
Nhim trng ng h hp trn 622

Vim hng 622
Vim thanh qun 623
Vim xoang 624
Nhim virus gy cm 625
Nhim trng ng h hp di 626

Vim ph qun cp 626
Vim phi nhim phi t cng ng 627
p-xe phi 629
Lao phi 630
Nhim trng ng tiu ha v d dy 634

Vim phc mc 634
Nhim trng gan mt 635
Nhim trng khc 637

Vim ti tha 637
Vim rut tha 639
Nhim trng ng sinh dc 639

Nhim trng ng tit niu di 639
Vim thnb thn 644
MC LC l XIII
Nhim trng qua ng tnh dc, lot sinh dc 645

Bnh herpes sinh dc 645
Bnh giang mai 646
Bnh h cam 650
Bnh ht xoi 650
Nhim trng qua ng tnh dc, 651

vim m o v nhim khun m o
Vim m o do Trichomoniasis 651
Vim m o do vi khun 651
Nhim trng men nm m o 652
Vim c t cung v niu o 652
Bnh vim vng chu hng 653
Nhim nm ton th v vi khun khng in hnh 654

Nhim nm candida 654
Nhim np cryptococcus 655
Nhim nm histoplasma 661
Nhim nm blastomyces 661
Nhim nm coccidioides 662
Nhim nm aspergillus 662
Nhim nm sporotrum 663
Nhim nm mucor 664
Nhim nm nocardia 665
Nhim nm actinomyces 665
Nhim Mycobacteria khng in hnh (Nontuberculous) 666
Bnh do tit tc truyn 666

Bnh Lyme 666
Bnh st m vng ni 667
Nhim ehrlichiosis v anaplasmosis 668
Bnh tularemia 669
Nhim baberia 670
XIV l MC LC
Nhim trng do mui truyn 670

Vim no, mng no do arbovirus 670
St rt 671
Bnh ly t th sang ngi 672

Bnh mo co (Bartonellosis) 673
Nhim xon khun leptospira 673
Nhim brucella 674
Bnh ly qua vt cn 675

Vt cn do th vt 675
Vt cn t ngi 676
Nhim trng lin quan ti chm sc y t 676

Nhim trng c ngun gc t catheter 677
Vim phi bnh vin v vim phi do thng kh xm nhp 679
Nhim t cu khng methicillin 680
Nhim cu khun ng rut khng vancomycin 680
Nhim vi khun gram m a khng 680
Bnh nhim trng mi ni v khng b sinh hc 544

Bnh than (nhim trc khun than) 681
Bnh u ma 682
Bnh dch hch 683
Ng c botulinum 684
Nhim virus st xut huyt 685
Hi chng suy h hp cp nng 686
i dch cm gia cm v cm ln 686
15 Thuc khng vi sinh vt 687

Bernard C. Camins, David J. Ritchie
GS.TS. Ng Qu Chu, TS. V Vn Gip
Thuc khng vi khun 687

Penicillin 687
MC LC l XV
Cephalosporin 690
Monobactam 692
Carbapenem 693
Aminoglycoside 694
Vancomycin 696
Fluoroquinolone 697
Macrolide v Lincosamide 699
Sulfonamide v Trimethoprim 701
Tetracycline 702
Thuc khng vi sinh vt, hn hp 703

Chloramphenicol 703
Colistin v Polymyxin B 704
Daptomycin 705
Fosfomycin 705
Linezolid 706
Methenamine 707
Metronidazole 707
Nitrofurantoin 708
Quinupristin/Dalfopristin 708
Telavancin 709
Tigecycline 710
Thuc chng vi khun ni bo 710

Isoniazid 711
Rifamycin 711
Pyrazinamide 712
Ethambutol 712
Streptomycin 713
Thuc khng virus 713

Thuc chng cm 713
Thuc tr herpes 714
Thuc khng cytomegalovirus 715
XVI l MC LC
Thuc chng nm 717

Amphotericin B 717
Azole 718
Echinocandin 719
Hn hp 721
16 Suy gim min dch ngi, HIV-AIDS 723

Sara L. Cross, E. Turner Overton
TS. Duy Cng, ThS. V Th Thu Trang
HIV type 1 723

Nhim trng c hi 739
Nhim cytomegalovirus 740
Bnh lao 741
Nhim phc hp mycobacterium avium 742
Vim phi do pneumocystis jiroveci 743
Nhim nm candida 744
Nhim nm cryptococcus neoformans 744
Nhim histoplasma capsulatum 745
Nhim n bo 746
Toxoplasma gondii 746
Cryptosporidium 747
Cyclospora 747
Isospora belli 747
Microsporidia 747
Bnh khi u lin quan 748

Kaposi Sarcoma 748
U lympho 748
Ung th c t cung v quanh hu mn 749
Bnh ly truyn qua ng tnh dc 749

Herpes sinh dc 749
Mn cc sinh dc hay si mo g 750
Giang mai 750
MC LC l XVII
17 Ghp tng 757

Christina L. Klein, Brent W. Miller
PGS.TS. H Phan Hi An, TS. V Vn Gip
Cn bn v ghp tng 757
Thi ghp 763

Thi ghp thn cp tnh 763
Thi ghp phi cp tnh 764
Thi ghp tim cp tnh 765
Thi ghp gan cp tnh 765
Thi ghp ty cp tnh 766
Ri lon chc nng tng ghp mn tnh 767
Bin chng 768
18 Bnh l ng tiu ha 773

C. Prakash Gyawali, Amit Patel
GS.TS. o Vn Long, PGS.TS. Phan Thu Phng
Xut huyt ng tiu ho 773

Kh nut v nut au 782
Bun nn v nn 784
Tiu chy 785
To bn 788
Ri lon ng tiu ha 791

Tro ngc d dy thc qun 791
Ri lon vn ng thc qun 797
Bnh lot d dy t trng 799
Bnh vim rut 804
Ri lon tiu ha chc nng 812
Gi tc rut cp tnh (lit rut) 814
Ri lon mt ty 816
Vim ty cp 816
Vim ty mn 819
Bnh si mt 821
XVIII l MC LC
Ri lon tiu ha khc 823

Ri lon hu mn trc trng 823
Bnh Celiac 823
Ti tha v vim ti tha 825
Chm lm trng d dy 826
Tn thng rut do thiu mu 828
19 Bnh l gan 831

M. Katherine Rude, Thomas Kerr, Mauricio Lisker-Melman
nh gi bnh l gan 831
Vim gan virus 835

Vim gan virus A 837
Vim gan virus B 840
Vim gan C 848
Vim gan D 853
Vim gan E 854
Vim gan do thuc 855
Bnh gan do ru 857
Bnh gan do trung gian min dch 861

Vim gan t min 861
X gan mt tin pht 863
Vim x ng mt nguyn pht 865
Bin chng ca mt 867

Thiu ht dinh dng 867
Long xng 868
Nga 869
Bnh gan chuyn ha 870

Bnh Wilson 870
MC LC l XIX
Nhim sc t st di truyn 873

Thiu ht 1-Antitrypsin 876
Bnh gan khc 877

Bnh gan nhim m khng do ru 877
Vim gan do thiu mu 880
Huyt khi tnh mch gan 881
Hi chng tc nghn xoang gan 882
Huyt khi tnh mch ca 883
p-xe gan do vi khun 884
p-xe gan do amip 885
Vim gan dng u ht 886
Suy gan cp 887
Bnh gan mn tnh 889

X gan 889
Tng p lc tnh mch ca 890
C trng 891
Vim phc mc do vi khun nguyn pht 893
Hi chng gan thn 894
Bnh no gan 896
Ung th biu m t bo gan 898
Ghp gan 900
20 Ri lon ng mu v huyt khi 901

Roger Yusen, Charles Eby, Kristen Sanfilippo, Brian F. Gage
GS.TS. Phm Quang Vinh, BSCKII. V Th Thanh Bnh
Ri lon ng mu 901
Bnh l tiu cu 905

Gim tiu cu 905
Gim tiu cu min dch 906
Ban xut huyt gim tiu cu huyt khi v hi chng ure mu tan huyt 908
Gim tiu cu do heparin 911
XX l MC LC
Ban xut huyt sau truyn mu 914

Gim tiu cu khi c thai 915
Tng tiu cu 916
Ri lon cht lng tiu cu 917
Ri lon chy mu di truyn 919

Hemophilia A 919
Hemophilia B 921
Bnh von Willebrand (vWD) 922
Ri lon ng mu mc phi 925

Thiu vitamin K 925
Bnh gan 927
ng mu ni mch ri rc 928
Cht c ch mc phi ca cc yu t ng mu 928
Ri lon huyt khi tnh mch 930

X l huyt khi tnh mch 930
21 Ri lon huyt hc v iu tr truyn mu 951

Ronald Jackups, Kristen Sanfilippo, Tzu-Fei Wang, Morey Blinder
GS.TS. Phm Quang Vinh, BSCKII. V Th Thanh Bnh
Thiu mu 951
Thiu mu lin quan n gim sn xut hng cu 954

Thiu mu hng cu nh 954
Thalassemia 958
Thiu mu nguyn hng cu st 960
Thiu mu hng cu to/Nguyn hng cu khng l 961
Thiu mu trong suy thn mn 964
Thiu mu trong cc bnh mn tnh 966
Thiu mu bnh nhn ung th 967
Thiu mu bnh nhn nhim HIV 967
Thiu mu bt sn 968
MC LC l XXI
Thiu mu do tng hy t bo mu 969

Thiu mu km theo tng to hng cu 969
Bnh hng cu hnh lim 971
Bnh thiu G6PD 975
Thiu mu tan mu t min 978
Thiu mu tan mu do thuc 980
Thiu mu tan mu vi mch 981
Ri lon dng bch cu 981

Tng v gim bch cu 981
Ri lon tiu cu 983
Ri lon ca ty xng 984

Hi chng ri lon sinh ty 984
Ri lon tng sinh ty 984
Bnh l gamma n dng 987

Bnh l gamma n dng khng c ngha bnh l 987
a u ty xng 988
Tng marcroglobulin mubnh Waldenstrm 988
Amyloidosis 989
Truyn mu cha tr 989
22 X tr ni khoa bnh l c tnh 997

Saiama N. Waqar, Janakiraman Subramanian, George Ansstas, Ramaswamy Govindan
GS.TS. Ng Qu Chu, ThS. L Hon
X tr ni khoa bnh c tnh 997

X l vi bnh nhn ung th 997
Ung th phi 1006
Ung th v 1009
Ung th vng u v c 1012
Sarcoma 1013
XXII l MC LC
Ung th ng tiu ha 1014

Ung th thc qun 1014
Ung th d dy 1015
Ung th i trc trng 1016
Ung th ty 1018
Ung th biu m t bo gan 1019
Ung th sinh dc tit niu 1020

Ung th thn 1020
Ung th bng quang 1022
Ung th tin lit tuyn 1023
Ung th tinh hon v khi u t bo mm 1025
Ung th ph khoa 1026

Ung th c t cung 1026
Ung th ni mc t cung 1028
Ung th bung trng 1029
Ung th khng r nguyn pht 1030
Ung th mu 1031
Hi chng ri lon sinh ty 1031
Bnh bch cu cp dng ty 1034
Bnh bch cu cp dng lympho 1036
Bnh bch cu mn dng ty 1038
Bnh bch cu mn dng lympho 1039
Bnh bch cu t bo tc 1041
U lympho Hodgkin 1042
U lympho khng Hodgkin 1043
a u ty xng 1046
Nguyn tc ca cy ghp t bo gc 1047
Cp cu ung th 1049
St gim bch cu 1049
Hi chng tiu u 1050
Tng canxi mu c tnh 1051
MC LC l XXIII
Chn p ty c tnh 1052

Di cn no vi tng p lc ni s 1053
Hi chng tnh mch ch trn 1054
X tr c tnh ca iu tr 1054
Bun nn 1054
Tiu chy 1055
Gim t bo mu 1055
Vim nim mc 1056
Vim phi 1056
Chm sc h tr: Bin chng ca ung th 1057

au do ung th 1057
Di cn xng 1058
Trn dch mng phi 1059
Huyt khi tc tnh mch 1060
Mt mi 1060
Chn n v suy kit 1061
23 Bnh i tho ng v ri lon lin quan 1063

Janet B. McGill
Bnh i tho ng 1063

i tho ng bnh nhn ni tr 1068
i tho ng type 1 v toan ceton 1072

do i tho ng
i tho ng type 1 1072
Toan ceton do i tho ng 1076
i tho ng type 2 v hi chng 1081

tng p lc thm thu khng ceton
i tho ng type 2 1081
Hi chng tng p lc thm thu khng ceton 1091
XXIV l MC LC
Bin chng mn tnh ca i tho ng 1094

Bnh vng mc i tho ng 1094
Bnh thn i tho ng 1095
Bnh l thn kinh do i tho ng 1097
Bin chng mch ln ca i tho ng 1099

Bnh tim mch vnh 1099
Bnh mch mu ngoi bin 1101
Bin chng khc 1102

Ri lon cng dng 1102
Lot bn chn i tho ng 1103
H ng huyt 1104
24 Bnh l ni tit 1109

William E. Clutter
Bnh l tuyn gip 1109

nh gi chc nng tuyn gip 1109
Suy chc nng tuyn gip 1112
Cng chc nng tuyn gip 1115
Bu gip bnh gip v nhn tuyn gip 1121
Ri lon chc nng tuyn thng thn 1123

Suy tuyn thng thn 1123
Hi chng Cushing 1126
U tuyn thng thn pht hin tnh c 1127
Ri lon chc nng thy trc tuyn yn 1128

Suy tuyn yn 1130
Tng prolactin mu 1132
To u chi 1134
MC LC l XXV
Bnh xng chuyn ha 1135

Bnh nhuyn xng 1135
Bnh Paget 1136
25 Vim khp v bnh l khp 1139

Hector Molina, Zarmeena Ali
PGS.TS. Nguyn Vnh Ngc, TS. V Vn Gip
X l c bn bnh xng khp 1139

Vim khp v mng hot dch khp nhim khun 1146
Vim bao hot dch nhim khun 1149
Bnh Lyme 1149
Vim mng hot dch do tinh th 1150
Vim khp dng thp 1155
Thoi ha khp 1164
Bnh l ct sng 1166
Vim ct sng dnh khp 1166
Vim khp bnh vim rut 1167
Vim khp phn ng 1168
Vim khp vy nn 1169
Lupus ban h thng 1170
X cng b ton th 1174
Hi chng Raynaud 1176
Vim mch hoi t 1177
au a c do thp 1181
Hi chng cryoglobulin 1181
Vim a c v vim da c 1182
26 Bnh l thn kinh 1185

Robert C. Bucelli, Beau Ances
TS. Trn Vit Lc, ThS. Trnh Tin Lc, ThS. V Th Thu Trang
Ri lon thc 1185

Bnh Alzheimer 1192
ng kinh 1195
Bnh mch no 1201
au u 1211
Chn thng u 1214
XXVI l MC LC
Ri lon chc nng ty sng cp tnh 1217

Bnh Parkinson 1221
Bnh thn kinh c 1223

Hi chng GuillainBarr 1223
Bnh nhc c 1227
Ri lon thn kinh c khc 1232
Ri lon thn kinh c c tng trng lc c 1233
27 Cp cu ni khoa 1237
Jason Wagner, Christopher Sampson, Rebecca Bavolek
Cp cu ngng th 1237
Tc nghn ng th trn cp tnh 1237
H tr ng th cp cu 1239
Trn kh mng phi 1240
ui nc 1244
Tn thng do nhit 1246

Kit sc do nng 1246
Ngt do nng 1246
t qu do nng 1247
Bnh l do lnh gy ra 1249

Cc 1249
Tn thng ngm nc (nt chn) 1250
T cng b mt 1250
T cng su 1250
H thn nhit 1251
MC LC l XXVII
28 Ng c hc 1257
S. Eliza Halcomb, Evan Schwarz, Michael E. Mullins
Qu liu 1257
Qu liu, Tng quan 1257
Acetaminophen 1263
Colchicin 1268
Thuc chng vim khng steroid 1271
Opioid 1272
Salicylat 1274
Phenytoin v fosphenytoin 1277
Carbamazepine/Oxcarbazepine 1280
Lamotrigine 1282
Levetiracetam 1283
Acid valproic 1283
Cht c ch monoamine oxidase 1285
Thuc chng trm cm ba vng 1288
Cht c ch ti hp thu serotonin chn lc 1291
Hi chng serotonin 1292
Lithium 1294
Bupropion 1296
Thuc chng lon thn, Tng quan 1297
Phenothiazine 1297
Clozapine 1299
Olanzapine 1300
Risperidone, ziprasidone v quetiapine 1300
Cht i khng -Adrenergic 1301
Thuc chn knh canxi 1304
Clonidine 1306
Thuc h huyt p khc 1308
Tc nhn i giao cm 1308
Thuc khng cholinergic 1308
Cht c ch cholinesterase 1311
Phospho hu c 1311
Carbamat 1315
Barbiturat 1316
XXVIII l MC LC
Benzodiazepin 1318
Thuc c tc dng giao cm, Tng quan 1319
Amphetamin 1320
Cocain 1322
Theophyllin 1325
Ru c, Tng quan 1327
Methanol 1328
Ethylen glycol 1332
Ethanol 1334
Cyanua 1336
Carbon monoxid 1338
Ph lc A Liu php min dch v d phng sau

phi nhim 1341
Carlos A. Q. Santos, Victoria J. Fraser
Ph lc B Kim sot vic ly nhim v khuyn

ngh cch ly 1361
Ph lc C Phc hi sc tim phi nng cao

1369
CH MC 1373
Cc Tc gi
Zarmeena Ali, MD Steven Cheng, MD
Instructor of Medicine Division of Assistant Professor of Medicine
Rheumatology Division of Renal Diseases
Beau Ances, MD, PhD, MS William E. Clutter, MD
Assistant Professor Division of Associate Professor of Medicine
Neurology Division of Medical Education
George Ansstas, MD Daniel H. Cooper, MD
Instructor of Medicine Hospitalist- Assistant Professor of Medicine
BMT Division of Cardiovascular Medicine
Jeffrey J. Atkinson, MD Daniel Coyne, MD
Assistant Professor of Medicine Professor of Medicine Division of
Division of Pulmonary Medicine Renal Diseases
Rachel Bardowell, MD John Cras, MD
Instructor in Medicine Hospitalist Assistant Professor of Medicine
Service Hospitalist Service
Rebecca Bavolek, MD Sara L. Cross, MD
Instructor in Emergency Medicine Clinical Fellow Division of Infectious
Division of Emergency Medicine Diseases
Morey Blinder, MD Charles Eby, MD
Associate Professor of Medicine Professor Department of Pathology &
Division of Hematology Immunology
Anthony Boyer, MD Gregory A. Ewald, MD
Clinical Fellow Division of Associate Professor of Medicine
Pulmonary Medicine Division of Cardiovascular Medicine
Ben P. Bradenham, Jr., MD Mitchell N. Faddis, MD, PhD
Resident Department of Medicine Associate Professor of Medicine
Angela L. Brown, MD Division of Cardiovascular Medicine
Assistant Professor of Medicine Timothy J. Fendler, MD
Division of Cardiology Resident Department of Medicine
Robert C. Bucelli, MD, PhD Victoria J. Fraser, MD
Assistant Professor Department of Adolphus Busch Professor of Medicine
Neurology and Chairman Department of
Bernard C. Camins, MD Medicine
Assistant Professor of Medicine
Division of Infectious Diseases
XXIX
XXX l CC TC GI
Mario Castro, MD Brian F. Gage, MD

Professor of Medicine Division of Professor of Medicine Division of
Pulmonary and Critical Care General Medical Sciences
Murali Chakinala, MD Anne C. Goldberg, MD
Associate Professor of Medicine Associate Professor of Medicine
Division of Pulmonary and Critical Division of Endocrinology and
Care Metabolism
Alexander Chen, MD Stephen Y. Liang, MD
Assistant Professor of Medicine Instructor in Medicine Division of
Division of Pulmonary and Critical Infectious Diseases
Care Brian R. Lindman, MD
Seth Goldberg, MD Assistant Professor of Medicine
Assistant Professor of Medicine Division of Cardiovascular Medicine
Division of Nephrology Mauricio Lisker-Melman, MD
Ramaswamy Govindan, MD Professor of Medicine Division of
Professor of Medicine Division of Gastroenterology
Medical Oncology Nathan Martin, MD
C. Prakash Gyawali, MD Instructor in Medicine Hospitalist
Professor of Medicine Division of Service
Gastroenterology Colleen McEvoy, MD
S. Eliza Halcomb, MD Clinical Fellow Division of Pulmonary
Assistant Professor Department of and Critical Care
Emergency Medicine Janet B. McGill, MD
Ronald Jackups, MD Professor of Medicine Division of
Assistant Professor of Pathology Endocrinology
and Immunology Laboratory and Jason D. Meyers, MD
Genomic Medicine Clinical Fellow Division of
Judy L. Jang, MD Cardiovascular Medicine
Assistant Professor of Medicine Scott T. Micek, PharmD, BCPS
Division of Renal Diseases Department of Pharmacy Barnes-
Susan M. Joseph, MD Jewish Hospital
Assistant Professor of Medicine Brent W. Miller, MD
Division of Cardiovascular Associate Professor of Medicine
Medicine Division of Nephrology
Andrew L. Kau, MD Hector Molina, MD
Clinical Fellow Division of Allergy Associate Professor of Medicine
and Immunology Division of Rheumatology
CC TC GI l XXXI
Thomas Kerr, MD Michael E. Mullins, MD

Assistant Professor of Medicine Associate Professor of Emergency
Division of Gastroenterology Medicine Department of Medicine
Nigar Kirmani, MD E. Turner Overton, MD
Professor of Medicine Division of Adjunct Assistant Professor of
Infectious Diseases Medicine Division of Infectious
Mohammad Kizilbash, MD Diseases
Assistant Professor of Medicine Jeffrey R. Parker, MD
Division of Cardiovascular Instructor in Medicine Division of
Medicine Hospitalist Medicine
Christina L. Klein, MD Amit Patel, MD
Assistant Professor of Medicine Resident Department of Medicine
Division of Renal Diseases Dominic Reeds, MD
Marin H. Kollef, MD Assistant Professor in Medicine
Professor of Medicine Division of Director, Clinical Nutrition Support
Pulmonary & Critical Care Service
Shane J. LaRue, MD Jay Shah, MD
Clinical Fellow Division of Instructor in Medicine Division of
Cardiovascular Medicine Cardiovascular Medicine
David J. Ritchie, PharmD Shivak Sharma, MD
Clinical Pharmacist Division of Clinical Fellow Division of
Infectious Diseases Cardiovascular Medicine
Daniel B. Rosenbluth, MD Amy Sheldahl, MD
Professor of Medicine and Pediatrics Instructor in Medicine Hospitalist
Division of Pulmonary and Critical Service
Care Ajay Sheshadri, MD
M. Katherine Rude, MD Clinical Fellow Division of Pulmonary
Clinical Fellow Division of and Critical Care
Gastroenterology Janakiraman Subramanian, MD
Tonya D. Russell, MD Instructor in Medicine Division of
Associate Professor of Medicine Medical Oncology
Division of Pulmonary and Critical Mark Thoelke, MD
Care Associate Professor Division of
Christopher Sampson, MD Hospital Medicine
Assistant Professor of Emergency
Medicine Division of Emergency
Medicine
XXXII l CC TC GI
Kristen Sanfilippo, MD Jason Wagner, MD

Clinical Fellow Division of Medical Assistant Professor of Emergency
Oncology Medicine Division of Emergency
Carlos A. Q. Santos, MD Medicine
Assistant Professor of Medicine Tzu-Fei Wang, MD
Division of Infectious Diseases Clinical Fellow Division of Medical
Muhammad A. Sarwar, MD Oncology
Research Fellow Division of Saiama N. Waqar, MD
Cardiovascular Medicine Instructor in Medicine Division of
Sarena Sawlani, MD Medical Oncology
Clinical Fellow Division of Allergy Jennifer M. Welch, MD
and Immunology Clinical Fellow Division of
Evan Schwarz, MD Immunology
Assistant Professor of Emergency Roger Yusen, MD, MPH
Medicine Division of Emergency Associate Professor of Medicine
Medicine Division of Pulmonary and Critical
Robert M. Senior, MDD Care
D & H Moog Professor of
Pulmonary Diseases Division of
Pulmonary and Critical Care
Ban Bin Dch V Hiu nh
GS.TS. Ng Quy Chu PGS.TS. Ha Phan Hai An
Trng b mn Ni tng hp - ai Trng phong Hp tac quc t ai
hoc Y Ha Ni, Giam c Trung hoc Y Ha Ni - B mn Ni tng hp
tm H hp - Pho Giam c Bnh - ai hoc Y Ha Ni, Trng khoa
vin Bach Mai, Chu tch Hi H Thn & Loc mau - Bnh vin Vit
hp Vit Nam - Pho chu tch Hi c
Ni khoa Vit Nam PGS.TS. Phan Thu Phng
GS.TS. Pham Quang Vinh Pho trng b mn Ni tng hp - ai
Trng b mn Huyt hoc - ai hoc hoc Y Ha Ni, Pho Giam c trung
Y Ha Ni, Trng khoa Huyt hoc tm H hp - Bnh vin Bach Mai
truyn mau - Bnh vin Bach Mai TS.BS. Vu Vn Giap
GS.TS. ao Vn Long Giao vu sau ai hoc B mn Ni tng
Pho trng b mn Ni tng hp - hp - ai hoc Y Ha Ni, Trung tm
ai hoc Y Ha Ni, Trng khoa H hp - Bnh vin Bach Mai, Tng
Tiu hoa - Bnh vin Bach Mai Th ky Hi H hp Vit Nam
PGS.TS. Nguyn Khoa Diu Vn TS.BS. Trn Vit Lc
Pho trng b mn Ni tng hp - B mn Thn kinh - ai hoc Y Ha Ni,
ai hoc Y Ha Ni, Trng khoa Trng khoa Kham bnh - Bnh vin
Ni tit - ai thao ng - Bnh Lao khoa trung ng
vin Bach Mai TS.BS. Ngoc Sn
PGS.TS. Pham Manh Hung Pho trng khoa Cp cu - Bnh vin
Pho trng b mn Tim mach - ai Bach Mai
hoc Y Ha Ni, Trng n v Tim TS.BS. Duy Cng
mach can thip - Pho Vin trng Pho trng khoa phu trach khoa
Vin Tim mach quc gia - Bnh Truyn nhim, Trng phong nhim
vin Bach Mai, Tng Th ky Hi khun tng hp - Bnh vin Bach
Tim mach Vit Nam Mai
PGS.TS. Gia Tuyn BSCKII. Vo Th Thanh Bnh
Pho trng b mn Ni tng hp - Trng khoa Ghep T bao gc - Vin
ai hoc Y Ha Ni, Trng khoa Huyt hoc Truyn mau Trung ng
Thn tit niu - Bnh vin Bach
ThS.BS. Trnh Tin Lc
Mai
Khoa Thn kinh - Bnh vin Bach Mai
PGS.TS. Nguyn Vnh Ngoc
Pho trng b mn Ni tng hp -
ai hoc Y Ha Ni, Pho Chu tch Hi
Thp khp hoc Ha Ni
XXXIII
XXXIV l BAN BIN DCH V HIU NH
ThS.BS. L Hoan
B mn Ni tng hp - ai hoc Y Ha
Ni, Trung tm H hp - Bnh vin
Bach Mai
ThS.BS. Nguyn Thanh Thuy
Bach Mai
ThS.BS. Vu Th Thu Trang
Bach Mai
Th k ban bin dch bn ting Vit

PGS.TS. Phan Thu Phng
TS.BS. Vu Vn Giap
Li Ch Bin
Kin thc y khoa ngay cang gia tng a t mt ganh nng khng l ln vai cac bac
s theo kp vi nhng tin b gn y, c bit v nhng cach tr liu mi cha
tr tt hn cho bnh nhn. Cun Cm nang Washington iu tr Ni khoa cung
cp mt ngun kin thc cp nht mi d tra tm, gm cha cac phng phap thc
hanh lm sang chn oan, thm do, iu tr cac ca bnh ph bin ma cac bac s
ni thng xuyn gp phai. Kch c gon gang cua cun Cm nang iu tr Ni khoa
am bao se tip tuc la sach cng cu h tr ln cho thc tp sinh, bac s ni tru, sinh
vin y khoa, va nhng ngi lam ngh Y ang tm kim mt ngun kin thc thc
hanh lm sang ap dung c ngay. Trong thi ai qua tai thng tin, no a ap ng
mt nhu cu quan trong ma trc y cha c ap ng.
Ti xin ghi nhn cng sc cua cac tac gia, nhng ngi bao gm cac thc
tp sinh va bac s ni tru, nghin cu sinh, va nhng bac s iu tr, tai ai hoc
Washington/Bnh vin Barnes-Jewish. Nhng n lc va ky nng ni bt cua ho
c minh chng cht lng cua cun sach c n hanh. c bit, ti rt t
hao v nhng bin tp vin cua chung ti-Hemant Godara, Angela Hirbe, Michael
Nassif, Hannah Otepka, va Aron Rosenstock va cac bin tp vin khac Tom De
Fer va Katherine. Ho la nhng ngi a lam vic khng mt moi cho ra mt n
ban k tip xut sc na cua cun Cm nang iu tr Ni khoa. Ti cung xin cam
n Melvin Blanchard, MD, Trng Ban Giao duc y hoc cua Khoa Y tai ai hoc
Washington, v nhng hng dn va li khuyn cua ng. Ti tin tng rng cun
Cm nang iu tr ni khoa se at c muc tiu mong mun cua no la cung cp
nhng kin thc thc hanh co th c ap dung trc tip chm soc bnh nhn
tt hn.
Victoria J. Fraser, MD
Giao s Adolphus Busch
Chu tch, B mn Y hoc
ai hoc Y khoa Washington
St. Louis, Missouri
XXXV
Li Ta
Chung ti hn hanh gii thiu n ban th 34 cua cun Cm nang Washington iu
tr Ni khoa. Cun Cm nang, khi a c gn nhan ai hoc Washington, t hao
vi truyn thng c bin tp chnh sa bi cac bac s ni tru trng Ni khoa. Ban
u cun cm nang c d nh ch danh cho sinh vin y khoa va bac s ni tru
nhng n nay, cun cm nang a tr thanh ban sach Y ban chay nht trn th gii.
Ngoai vic tng s lng, cun Cm nang iu tr ni khoa a tng thm nhiu v
kch thc va phc tap, phan anh vic thc hanh y khoa. Wayland MacFarlane
la ngi bin tp u tin vao nm 1943, trai qua rt nhiu sa i trong sut 70
nm tn tai, t mt cun sach giao khoa ngn bin chuyn thanh mt ngun tra cu
mang theo. Hm nay, chung ti hy vong se tip tuc cng cuc phat trin bng
vic cung cp cac trang sach nhiu minh hoa va bang biu ca di dang sach in va
sach in t oc c trn cac thit b in t cm tay (ch co n ban ting Anh).
Chung ti tip tuc phat huy nhng phm cht lam nn mt cun sach thanh
cng: dn giai ngn gon v sinh ly bnh, trnh bay phng phap iu tr da trn
chng c cp nht mi va b cuc trnh bay d nm bt. Ngoai ra, chung ti lun cp
nht cac ni dung phan anh ung nhng thay i tin b trong y hoc.
Cun Cm nang Washington iu tr Ni khoa a xy dng c mt truyn

thng thanh cng xut sc ma chung ti lun mong mun gn gi. Trong sut nm
nay, bac s ni tru, nghin cu sinh, sinh vin y khoa, va cac bac s iu tr a c vu
cho chung ti. Tai nng, tn tuy va long thng ngi cua ho tht ln lao. Chung
ti co vinh d c ho mang n cho cun Cm nang nhng ch dn. Chung ti
bit n su sc i vi nhng tr giup chnh yu va hng i ma Tom De Fer, bin
tp dong sach cm nang, a ong gop trong vic tao ra n ban k tip nay cua cun
Cm nang. Chung ti cung cam n Katie Sharp va cac bin tp vin nha xut ban
Lippincott Williams & Wilkins v s tr giup va kin nhn cua ho vi lch trnh bn
rn cua chung ti.
Chung ti vinh d va hanh phuc c lam vic vi nhng bac s ni tru trng
Shatz-Strauss, Karl-Flance, Kipnis-Daughaday, cac doanh nghip trong trng, va
Khoa chm soc y t ban u thuc Trung tm y t ngoai tru Barnes-Jewish. Ngi
ng u doanh nghip cua chung ti, Megan Wren, William Clutter, Geoffrey
Cislo, va E-P Barrette, a tham gia vao qua trnh lam sach trong sut nm, hoat
ng nh la c vn va nu gng. Giam c chng trnh cua chung ti, Melvin
Blanchard, cung a tr giup rt ln trong vic n hanh cun Cm nang. Chu tch
Y hoc cua chung ti, Vicky Fraser, a hng dn va h tr trong vic bin soan
XXXVII
XXXVIII l LI TA
cun sach nay. Chung ti cam n gia nh cua mnh a h tr va la ngun c vu

cho chung ti. Xin gi ti Ram Kumar, Malka, va Robbie; Patrick va Carla, TJ va
Gabriel; Edward, Cecelia, va Karla; Steve, Karen, va Arun; Julio, Katty, va Jessi...
long bit n v han.
Hemant Godara, MD
Angela Hirbe, MD, PhD
Michael Nassif, MD
Hannah Otepka, MD
Aron Rosenstock, MD
Li Ch Bin Bn Ting Vit
Trong xu th hi nhp va phat trin, trc nhng thach thc ln va tin b vt bc
trong lnh vc y khoa hin nay, oi hoi cac bac s phai lun cp nht, tip cn nhng
kin thc mi trong chn oan va iu tr bnh nhm em lai hiu qua tt nht n
vi bnh nhn. Kin thc Ni khoa la mt trong nhng lnh vc nn tang cua y hoc
c ban, khng ch quan trong vi cac bac s Ni khoa noi ring ma con v cung y
ngha vi cac bac s a khoa noi chung.
Cun sach The Washington Mannual of Medical Therapeutics n ban ln th

34, mt cun sach rt co gia tr, mang tnh hin ai vi tin cy cao, cp nht thc
tin cac chuyn nganh Ni khoa bao gm hu ht cac lnh vc: h hp, tim mach,
ni tit, huyt hoc, min dch - d ng, ung bu...
Vi tm huyt cua tp th Giao s, Pho giao s, Tin s, Thac s, Bac s chuyn

khoa B mn Ni tng hp trng ai hoc Y Ha Ni va Bnh vin Bach Mai cung
cac ban ng nghip mt s n v khac, cun sach a c bin dch, chuyn
ng sang ting Vit cac bac s Vit Nam co c hi nhanh chong tip cn cac kin
thc mi nht v bnh hoc, chn oan, x tr va la chon thuc theo nhng khuyn
cao mi nht. Cach trnh bay logic, ngn gon, d hiu hy vong se hp dn va b ch
cho quy cac ban ng nghip. Xin trn trong cam n s c gng n lc cua cac quy
thy c, cac ban ng nghip mc du cng vic rt bn rn, qua tai nhng vn danh
thi gian tm huyt cho cng tac bin dch cun sach nay.
Knh mi c gia on oc. Trong qua trnh bin dch chc con nhng thiu sot,
rt mong c gia gop y cho nhng ln tai ban, bin dch sau c tt hn. Xin
trn trong cam n Cng ty Cao Trn cung Nha xut ban ai hoc Hu a phi hp,
ng hanh cung Ban Bin dch va Hiu nh.
Thay mt Ban Bin dch va Hiu nh

GS.TS. Ng Quy Chu
Trng B mn Ni tng hp - ai hoc Y Ha Ni
Giam c Trung tm H hp - Bnh vin Bach Mai
Pho Giam c Bnh vin Bach Mai
XXXIX
Chn thnh v trn trng cm n qu cc Thy c, cc Gio s, Ph gio s,
cc Tin s, Thc s v Bc s chuyn khoa chuyn ng ting Vit cun sch ny.
Nhng tm huyt v nhit thnh, thi gian v cng sc, tr tu v am hiu
l nhng cng hin y ngha.
Bnh tim
4
thiu mu cc b
Mohammad kizilbash, JeffreyR. Parker,
Muhammad A. Sarwar, Jason D. Meyers
Bnh mch vnh v au tht ngc n nh
I CNG
nh ngha
Bnh ly ng mach vanh (coronary artery diseaseCAD) dung ch tnh trang
long ng mach vanh b hep lai, thng la do x va. CAD la yu t ong gop
hang u trong bnh mach vanh (coronary heart diseaseCHD). CHD bao gm
au tht ngc, nhi mau c tim (myocardial infarctionMI) va thiu mau c tim
thm lng.
Bnh tim mach (cardiovascular diseaseCVD) thng c nh ngha la bao
gm bnh mach vanh (CHD), suy tim, loan nhp tim, tng huyt ap, tai bin mach
nao (cerebrovascular accidentCVA), bnh ly ng mach chu, bnh ly mach mau
ngoai bin (peripheral vascular diseasePVD), bnh van tim va bnh tim bm
sinh.
Dch t hc
My, CHD la nguyn nhn cua 1 trong mi 6 ca t vong.
Nguy c mc CHD ca i sau 40 tui la 49% nam va 32% n.
Trung bnh s nm cuc sng b mt i do MI la 16,6 nm.
Trong s nhng bnh nhn b t t do CHD, khoang 64% phu n va 50% nam
gii khng co triu chng trc o (Circulation 2012;125:e2).
Nguyn nhn
CAD chu yu la hu qua cua tnh trang lng ong cac mang x va trong long mach.
Cac nguyn nhn khac cua CAD tc nghen bao gm cac bt thng ng mach
vanh bm sinh, cu c, vim ng mach va xa tr trc o.
Ngoai CAD tc nghen, cac nguyn nhn khac cua au tht ngc bao gm s dung
cocain, hep ng mach chu, bnh c tim ph ai, day tht trai, tng huyt ap ac
tnh, bnh c tim gian, boc tach mach vanh nguyn phat (thng xay ra phu n
co thai), au tht ngc bin i va hi chng X.
139
139 l Ch. 4 Bnh tim thiu mu cc b
Sinh l bnh
Cac biu hin thng gp cua CAD bao gm au tht ngc n nh, hi chng
vanh cp (acute coronary syndromesACS), t t do tim va suy tim.
ang chu y la cac tn thng khng ang k trn chup mach (hep <50% long
mach) lai chim a s trong cac trng hp MI cp, dn n khai nim v mang
x va d v (JACC 1988;12:56; Circulation 2003;108:1664)
S v hoc bong troc mang x va d v gy ra s tc nghen cp tnh cua dong
mau ng mach vanh.
ACS ai din cho s lin tip v mt lm sang t au tht ngc khng n nh
(unstable anginaUA), nhi mau c tim khng ST chnh ln (nonST-segment
MI [NSTEMI]) khi mc thiu mau c tim u nng gy ra s giai phong
cac marker sinh hoc cua tim, va nhi mau c tim co ST chnh ln (ST-segment
elevation MI [STEMI]).
au tht ngc n nh la do s tc nghen long mach cua cac ng mach vanh
thng tm mac nhn thy c trn chup mach nguyn nhn gy ra s khng
tng xng gia nhu cu va s cung cp oxy, dn n s ti mau cua h thng vi
mach ngoai bin khng y u. Ngc lai, hi chng X la bnh ly cua tun hoan
vi mach, khng quan sat thy khi chup mach.
Tn thng mach vanh trong au tht ngc n nh khac so vi mang x
va d v trong MI cp. Tn thng trong au tht ngc n nh la c nh,
t b bong v, do o gy ra cac triu chng d d oan hn (Circulation
2012;125:1147).
Cac tn thng ng mach vanh thng tm mac gy tc nghen t hn 50% long
mach khng gy anh hng ang k n dong chay ng mach vanh (ngoai tr
bnh ly thn chung ng mach vanh trai) va nhn chung thng khng gy ra
cn au tht ngc trong nhng hoan canh bnh thng nhng co th gy au
ngc khi c tim b giam ti mau qua mc (v.d., shock nhim khun).
au tht ngc khi gng sc thng xay ra khi hep >70% va hep trn 90%
thng i kem vi au tht ngc xay ra ngay ca khi ngh ngi.
Yu t nguy c
Trong cac bin c cua CHD, >90% la co vai tro cua s tng t nht mt yu t
nguy c chnh (JAMA 2003;290:891).
anh gia cac yu t nguy c truyn thng cua CVD:
Tui.
Huyt ap (BP blood pressure).
ng mau (CHU Y: ai thao ng c coi la yu t nguy c tng ng
cua CHD).
Lipid mau (lipoprotein ty trong thp [low-density lipoproteinLDL], lipoprotein
Bnh mch vnh v au tht ngc n nh l 141
ty trong cao [high-density lipoproteinHDL], triglycerides). iu chnh LDL

cho nhng mu ly khi khng oi hoc co nng triglycerides rt cao.
Hut thuc la (CHU Y: Ngng hut thuc phuc hi lai nguy c CHD xung bng
vi mt ngi khng hut thuc trong vong khoang 15 nm) (Arch Intern Med
1994;154(2):169).
Tin s gia nh co ngi mc CAD sm: c xac nh la ho hang bc 1 la nam
gii mc CHD trc 55 tui hoc la n gii trc tui 65.
anh gia tnh trang beo ph, c bit la beo ph th trung tm. Muc tiu ch s
khi c th (Body mass indexBMI) t 18,5 n 24,9 kg/m2. Muc tiu vong eo
la <101,6 cm i vi nam va <88,9 cm i vi n.
anh gia tnh trang t hoat ng th lc va ch n ngheo dinh dng.
anh gia nguy c CHD tng ng (bnh ly mach mau ngoai bin, tai bin
mach mau nao, phnh ng mach chu va ai thao ng)
anh gia v bnh thn man tnh hoc tin s mc cac bnh t min h thng
collagen mach mau.
n gii, anh gia tin s tin san git hoc ai thao ng thai ky.
Nn tnh toan im nguy c toan b (Global Risk ScoreGRS) xac nh nguy
c tuyt i mc CHD hoc CVD trong 10 nm ti da vao yu t nguy c ca
nhn tt ca nhng bnh nhn khng co CVD a bit hoc cac yu t nguy c
CHD tng ng.
Thang im c cng nhn nhiu nht la thang im nguy c Framingham
(xem trong phn tng lipid mau) giup anh gia cac bin c CHD chnh (MI hay
t vong do bnh mach vanh). (http://hp2010.nhlbihin.net/ATPiii/calculator.
asp?usertype=prof).
Lu y lun co sn thang s cp nht nguy c bnh tim mach Framingham
cho cac bin c CVD chnh. Do n gii co ganh nng t quy cao hn, c tnh
nguy c CVD cao hn nguy c cua ring CHD (JACC 2011; 57: 1404). (http://
www.framinghamheartstudy.org/risk/gencardio.html#)
Phng phap anh gia im GRS khac bao gm anh gia nguy c bnh mach
vanh h thng (Systemic Coronary Risk EvaluationSCORE) cho t vong do
bnh tim mach va im nguy c Reynolds cho cac bin c tim mach chnh.
Da trn cac GRS, bnh nhn co th c phn loai thanh nhom nguy c thp,
trung bnh hoc cao b CHD hay CVD trong 10 nm ti.
Bnh nhn nguy c thp (nguy c CHD <10%) khng phu hp cho cac iu
tr hoc xet nghim xa hn. Cac can thip v li sng c nhn manh.
Bnh nhn co nguy c trung bnh (1020%) nn c xet nghim nhiu hn
phn nh nguy c tt hn. Xet nghim co th h tr trong vic xac nh
bnh nhn co c li ch t iu tr aspirin hay statin hay khng, hoc c
s dung nh cht xuc tac cho bnh nhn thy cn thay i li sng. Cac xet
nghim su hn co th gm:
o mc canxi hoa mach vanh bng ct lp vi tnh (computed tomography

CT), im >400 co th c phn loai lai vao nhom nguy c cao.
Ty l ch s huyt ap c chn-canh tay (ty l huyt ap gia chn va canh tay)
<0,9 hay >1,3 gi y s co mt cua bnh mach ngoai bin va co th tai phn
loai vao nhom nguy c cao.
B day lp ao trong-ao gia ng mach canh (anh gia bng siu m) >75
phn trm cung co th tai phn loai thanh nhom nguy c cao.
Protein phan ng C nhay cao co th c xem xet bnh nhn nam trn
50 tui va n trn 60 tui vi lng LDL-Cholesterol (LDL-cholesterol
LDLC) <130 mg/dL co CRP-hs >2 mg/dL c s dung nh tiu chun
bt u tr liu vi statin.
Nhom bnh nhn nguy c cao (>20% nguy c CHD hoc >10 = % nguy c
bin c tim mach) khng thch hp anh gia nguy c thm va cn co cac
bin phap iu chnh cac yu t nguy c tch cc.
Nguy c sut i: Mt iu rt quan trong la phai chu y rng nhng ngi co nguy
c 10 nm thp/trung bnh co th vn nguy c mc cao trong thi gian dai hn
(v.d., 1 trong 25 ngi co nguy c trong 10 nm, nhng 1 trong 2 ngi co nguy
c trong thi gian dai hn) do hiu ng tch luy theo thi gian cua thm ch ch
1 yu t nguy c tng ln n c hay nhiu yu t nguy c khng ti u (JACC
2011;57:1404).
GRS 10 nm anh gia thp nguy c nhng ngi trng thanh tre tui.
Vic sm duy tr cac yu t ly tng nguy c tim mach ngi trng thanh,
trc khi cn bt c s iu tr thuc hoc can thip nao khac la cha khoa cua
d phong tin phat bnh tim mach (Bang 41).
D phng
Aspirin (acetylsalicylic acidASA) (75162 mg/ngay) nn c cn nhc s
dung cho bnh nhn nam co nguy c bin c tim mach trong 10 nm >10%.
Aspirin (75162 mg/ngay) nn c cn nhc s dung cho bnh nhn n co nguy
c cao (nguy c bin c tim mach >20%). Nguy c chay mau lin quan n
aspirin khng c vt qua li ch tim nng cua no.
Kim soat tt cholesterol va huyt ap (xem Chng 3, D phong bnh ly tim
mach).
Khuyn khch ngi bnh hoat ng th lc >150 phut/tun vi cng trung
bnh hoc vi cng manh >75 phut/tun.
Ch n khoe manh nh DASH co th em lai li ch. Xem tai www.nhlbi.nih.
gov/health/public/heart/hbp/dash/new_dash.pdf.
Nn tranh cac san phm thuc la
anh gia s sn sang cai thuc la cua bnh nhn
Phat trin k hoach cai thuc la.
Bng 41 Tnh trng tim mch l tng bao gm tt c nhng iu sau
Yu t nguy c Tiu chun
Cholesterol ton <200 mg/dL khng iu tr

phn
Huyt p <120/80 mm Hg khng iu tr
Glucose mu lc <100 mg/dL
i
Ch s khi c <25 kg/m2
th (Body mass
indexBMI)
Ht thuc l Cha bao gi ht
Hot ng th lc >150 pht/tun vi cng trung bnh hoc
>75 pht vi cng mnh
Ch n Duy tr ch n khe mnh (v.d., ch DASH)
DASH (Dietary Approaches to Stop Hypertension), Ch n ngn chn tng huyt p

Phng theo Mosca L, Benjamin EJ, Berra K, v cng s. Hng dn da trn tnh hiu qu cho vic
phng nga bnh tim mch Ph n Cp nht 2011: Hng dn ca Hi Tim mch Hoa K. J Am
Coll Cardiol 2011;57:1404.
Xem xet cac liu phap dung thuc hin co:

Ming dan nicotin, nicotin dang nhai, nicotin dang xt, nicotin dang ht.
Bupropion n c hoc kt hp vi liu phap thay th nicotin.
Liu dung bupropion: ung 150 mg hang ngay trong vong 3 ngay, sau o
ung 150 mg 2 ln mi ngay trong 8 n 12 tun. Bnh nhn c hng dn
tranh hoan toan thuc la trong cac ngay th 5 n th 7. Thuc chng ch
nh cho bnh nhn co nguy c ng kinh.
Vareniclin c s dung trong 12 n 24 tun. Bnh nhn cn c theo doi
v triu chng trm cam va y tng t t. Vic s dung vareniclin lam tng
nhe nguy c bin c tim mach.
Liu phap hormon thay th, cac thuc chng oxy hoa va axit folic khng c ch
nh cho vic phong CVD tin phat hay th phat (JAC 2011;57:1404)
Biu hin lm sng
Bnh s
au tht ngc: Cn au tht ngc in hnh co 3 c im: (1) au ngc sau
xng c vi tnh cht va s keo dai c trng la (2) xay ra do stress hoc gng
sc va (3) au ngc giam i khi ngh ngi hoc dung (nitroglycerinNTG).
au tht ngc khng in hnh co 2 trong 3 c im nu trn.

au ngc khng phai do nguyn nhn tim mach ch co 1 hoc khng co c
im nao trong s cac c im k trn.
au tht ngc n nh man tnh xay ra lp lai theo cach co th d oan c khi
gng sc hoc stress v cam xuc va giam i sau 510 phut dung nitroglycerin
di li hoc ngh ngi.
Mc nng cua cn au tht ngc co th nh lng bng h thng phn loai
cua Hi tim mach Canada (Canadian Cardiovascular SocietyCCS) (Bang 42).
Cac triu chng kem theo co th bao gm kho th, va m hi, nn, bun nn va
hoa mt chong mt.
Bnh nhn n va nhng ngi b ai thao ng hoc bnh thn man tnh co
th co t triu chng hoc triu chng khng in hnh tng ng vi au tht
ngc. Nhng triu chng nay bao gm kho th (thng gp nht), au thng v
va bun nn.
anh gia kha nng mc CAD trc test la rt quan trong i vi bnh nhn co au
tht ngc. Kha nng mc bnh trc test se hng dn vic la chon phng phap
thm do chn oan cung nh vic phn tch kt qua cac xet nghim nhng bnh
nhn co au ngc nghi ng (Bang 43). V du, bnh nhn tre tui co triu chng
cua cn au tht ngc in hnh t khi co CAD ang k khi xet nghim, trong khi
o cn au tht ngc khng in hnh ngi ln tui nn tin hanh thm do cn
lm sang khng xm nhp. Tuy nhin, bnh nhn nam hoc n ln tui co cn
au ngc in hnh, c bit la nhng ngi co cac yu t nguy c bnh tim mach
H thng phn loi ca Hi tim mch Canada (Canadian

Bng 42
Cardiovascular SocietyCCS)
Phn loi nh ngha
CCS 1 au tht ngc khi gng sc nng hoc hot ng ko di

CCS 2 au tht ngc khi hot ng mc trung bnh (i b di hn 2 dy
nh hoc leo nhiu hn 1 tng cu thang)
CCS 3 au tht ngc khi hot ng nh (i b ngn hn 2 dy nh hoc
leo t hn 1 tng cu thang)
CCS 4 au tht ngc khi lm bt k hot ng no hoc xy ra ngay c khi
ngh ngi
Cc triu chng ca au tht ngc c th bao gm kh chu ngc in hnh hoc au tht ngc tng
ng. CCS, Hi tim mch Canada
T Sangareddi V, Anand C, Gnanavelu G, v cng s. Phn loi au ngc khi gng sc ca Hi Tim mch
Canada: lin quan v chp mch. Coronary Artery Dis 2004;15:111-114.
Bng 43 Kh nng b CAD trc test theo tui, gii v triu chng
au ngc
khng phi Cn au tht Cn au tht
Khng triu cn au tht ngc khng ngc in
Nhm tui chng ngc in hnh hnh/r rng
N Nam N Nam N Nam N N

30-39 <5 <5 2 4 12 34 26 76
40-49 <5 <10 3 13 22 51 55 87
50-59 <5 <10 7 20 31 65 73 93
60-69 <5 <5 14 27 51 72 86 94
Rt thp <5% Thp <10% Trung bnh Cao >80%
10-80%
S liu t Gibbons RJ, Balady GJ, Bricker JT v cng s. Hng dn cp nht 2002 ca ACC/AHA v test
gng sc: Bi bo tm tt. Bo co ca Nhm chc nng v cc hng dn thc hnh ca ACC/AHA (Hi
ng cp nht hng dn v test gng sc 1997). Circulation 2002;106:1883.
kem theo, tt hn nn c chup mach vanh chn oan v test gng sc khng
xm nhp co nguy c cao cho kt qua m tnh gia.
Khm thc th
Kham lm sang nn bao gm o huyt ap, nhp tim va bt mach.
Ting thi do h van 2 la (mitral regurgitationMR) mi xut hin hoc nng ln
la du hiu lm sang nguy c cao. Cac ting thi bt thng khac gi y tn thng
cua hep ng mach chu hay bnh c tim ph ai trong o ting thi trong bnh c
tim ph ai la ting thi duy nht tng ln khi lam nghim phap Valsava.
Chu y cac du hiu cua tng lipid mau nh vong cung giac mac va cuc m vang
trn da.
Du hiu suy tim nh ting nga phi S3, ran m phi th ht vao, tnh mach c ni
hay phu ngoai bin cung la cac yu t lm sang nguy c cao.
Chn on phn bit

Co rt nhiu bnh co biu hin au ngc, bao gm ca nguyn nhn tim mach va
khng do nguyn nhn tim mach (Bang 44).
Khai thac tin s, bnh s cn thn, chu y tp trung vao cac yu t nguy c tim
mach, kham thc th va lam mt s xet nghim c ban ban u giup thu hep lai
cac chn oan phn bit.
146 l Ch 4 Bnh tim thiu mu cc b
Bng 44 Chn on phn bit ca au ngc
Chn on c im
Cn nguyn tim mch

Hp ng mch ch au tht ngc c th xut hin khi hp ng mch ch nng
Bnh c tim ph i Thiu mu c tim di ni tm mc c th xut hin khi luyn
(HCM) tp v/hoc gng sc
Cn au tht ngc Co tht mch vnh c th xy ra khi gng sc hoc sang chn
kiu Prinzmetal tinh thn
Hi chng X au ngc do thiu mu c tim, chp mch vnh bnh thng,
c cho c lin quan n bnh l vi mch
Vim mng ngoi tim au ngc kiu mng phi km theo vim mng ngoi tim do
nhim trng hoc bnh t min
Bc tch ng mch au ngc c th ging nh cn au tht ngc v/hoc c lin
ch quan n ng mch vnh
S dng cocain Gy co tht mch vnh v/hoc to thnh huyt khi
au ngc do nguyn nhn khc
Thiu mu Thiu mu r rt c th gy ra mt cn bng cung-cu oxy c
tim.
Nhim c gip Tng nhu cu oxy ca c tim gy ra mt cn bng cung-cu
oxy cho c tim.
Bnh l thc qun GERD v co tht thc qun c th gy ra triu chng ging
au ngc (p ng vi NTG)
Si ng mt Si ti mt thng c th quan st c qua siu m bng
Bnh h hp Vim phi km theo au ngc kiu mng phi, tc ng mch
phi, tng p ng mch phi.
Bnh c xng khp Vim sn sn, bnh l r thn kinh ct sng c.
GERD (gastroesophageal reflux disease), Tro ngc d dy thc qun;

HCM (hypertrophic cardiomyopathy), Bnh c tim ph ai; NTG, nitroglycerin
Test chn on
Test gng sc va ch nh
Bnh nhn khng co CAD a bit trc:
Khng c ch nh nhng bnh nhn khng co triu chng nh mt test
sang loc.
Bnh nhn co triu chng au tht ngc.
Bnh nhn khng co triu chng, nguy c trung bnh nhng chun b bt u
chng trnh luyn tp gng sc hay nhng ngi lam ngh nguy c cao (v.d.,
phi cng).
Bnh nhn khng co triu chng, nguy c cao vi cac yu t nguy c nh ai
thao ng hay bnh mach mau ngoai vi.
Bnh nhn co CAD a bit:
Phn tng nguy c sau MI (xem phn v STEMI).
anh gia nguy c trc phu thut.
Triu chng au tht ngc tai phat mc du a iu tr thuc va tai thng ng
mach.
Vic sang loc thng quy cho nhng bnh nhn khng triu chng sau tai
thng ng mach con nhiu tranh cai.
Test gng sc bng luyn tp
La test c la chon anh gia hu ht nhng bnh nhn nguy c CAD mc
trung bnh (Bang 43).
Bruce protocol: Gm cac giai oan keo dai 3 phut tng tc va dc cua
tham chay. Cac thng s huyt ap, nhp tim va in tm (electrocardiogram
ECG) c ghi trong sut qua trnh khao sat va giai oan hi phuc cua bnh
nhn.
c hiu va nhay tng ng at 70% n 80% nu bnh nhn co in tm
luc ngh bnh thng va at c nhp tim muc tiu (nhp tim muc tiu at
85% cua nhp tim d oan ln nht theo tui).
Kt qua c coi la dng tnh khi:
Xut hin oan ST chnh xung mi >1 mm trn nhiu chuyn ao.
ap ng tut huyt ap do vn ng
Ri loan nhp tht bn b khi phat do gng sc
Ch s Duke cung cp thng tin v tin lng cho bnh nhn co cn au tht
ngc man tnh (Bang 45).
Test gng sc vi chn oan hnh anh
c khuyn cao cho bnh nhn co nhng bt thng trn in tim ban u
di y:
Hi chng tin kch thch (WolfParkinsonWhite)
Ph ai tht trai
Block nhanh trai (left bundle branch blockLBBB) hay nhp cua may tao nhp
Dn truyn chm trong tht (intraventricular conduction delayIVCD)
Tac dung cua Digoxin
Thay i song T hay oan ST trn in tm khi ngh ngi
Tao hnh ti mau c tim. Thng s dung cht anh du la Thalium201
hoc Technitium99 m kt hp vi test gng sc bng th lc hoc bng thuc.
Bng 45 Test gng sc th lc: Ch s Duke
Ch s Duke = S pht luyn tp (5 x lch on ST ln nht) (4 x im au tht

ngc). im au ngc: 0 = khng c, 1 = khng b hn ch bi test, 2 = b hn ch
bi test
Ch s Duke
5 T l t vong hng nm 0,25% Nguy c thp
10 n 4 T l t vong hng nm 1,25% Nguy c trung bnh
<10 T l t vong hng nm 5% Nguy c cao
Ni chung, thuc chn , thuc c ch dn truyn v nitrat nn c ngng trc khi lm test gng sc.
S liu t N Engl J Med 1991;325:849.
Hnh anh ti mau c tim cho phep chn oan xac nh, nh khu vung thiu
mau va cho phep xac nh phn sut tng mau (ejection fractionEF). Kha nng
sng sot cua c tim cung co th c anh gia da vao ky thut nay. Tao hnh
ti mau c tim gng sc hat nhn co nhay 8590% va c hiu 70%.
Siu m tim gng sc. Test gng sc bng vn ng hoc dobutamine co th
c tin hanh cung vi siu m tim h tr vic chn oan CAD. Cung nh
tao hnh hat nhn, siu m tim gop phn lam tng thm nhay va c hiu
cua test gng sc v giup bc l ro cac ri loan vn ng vung cua thanh tim.
Cht lng k thut cua phng phap nay co th b han ch bi cht lng hnh
anh (v.d., ngi qua beo). Siu m tim gng sc co nhay 75% va c hiu
8590%.
Chup cng hng t anh gia ti mau c tim s dung adenosin va thuc i
quang t cung la mt trong nhng phng phap giup anh gia thiu mau c tim
va kha nng sng con cua c tim.
Test gng sc bng thuc
bnh nhn khng th vn ng c, test gng sc bng thuc co th c
a chung hn.
Dipyridamole, adenosin, regadenoson la cac thuc gian mach thng c s
dung kt hp vi phng phap xa hnh ti mau c tim. Cac thuc nay la nhng
thuc c la chon cho cho nhng bnh nhn co block nhanh trai nhp cua
may tao nhp trn in tm v ty l dng tnh gia tng ln khi test gng sc
bng vn ng hoc truyn dobutamin.
Dobutamin la loai thuc gy tng co bop c tim thng c s dung trong siu
m tim gng sc.
Chng ch nh lam test gng sc
MI cp trong vong 2 ngay

au tht ngc khng n nh ma trc o cha n nh c bng thuc
Loan nhp tim co triu chng hoc co anh hng n huyt ng
Hep mach chu nng co triu chng
Suy tim co triu chng
Tc mach phi cp, vim c tim, vim mang ngoai tim hoc tach ng mach chu
K nng chn on
Chup mach vanh (Angiography)
Chup ng mach vanh c xem la tiu chun vang giup anh gia cu truc giai
phu ng mach vanh thng tm mac do no xac nh c s hin din va mc
hep cua cac tn thng x va.
Chup mach vanh la thu thut xm ln va co i kem vi nguy c nho b: t vong,
MI, tai bin mach nao, chay mau, loan nhp cac bin chng mach mau. Do o,
chup mach vanh c ch nh cho nhng bnh nhn ma ty s li ch nguy c
nghing v pha cac thu thut xm ln nh:
Nhng bnh nhn b nhi mau c tim co ST chnh ln
Phn ln bnh nhn UA/NSTEMI
Bnh nhn co triu chng va test gng sc co nguy c cao c hi vong la se
co li ch t vic tai thng mach mau
au tht ngc nhom III, IV mc du a c iu tr ni khoa
Bnh nhn sau cp cu ngng tim t ngt hoc bnh nhn b ri loan nhp
tht nguy him
Du hiu hoc triu chng cua suy tim hoc giam phn sut tng mau tht trai
au tht ngc, ma t quan im cua bnh nhn, khng c kim soat mt
cach y u vi iu tr ni khoa n c vi li sng ring cua ho.
Bnh nhn co tin s m bc cu ni ng mach vanh (coronary artery bypass
graftingCABG) hoc can thip ng mach vanh qua da (percutaneous
coronary interventionPCI)
Nghi ng hoc a chn oan xac nh hep >50% thn chung ng mach vanh
trai hoc bnh 3 thn ng mach vanh nng
Giup xac nh chn oan CAD nhng bnh nhn au tht ngc khng thc
hin test gng sc v thuc nhom co kha nng rt cao mc CAD (xem Bang
43)
Co th va chup mach vanh chn oan va iu tr nu cn lam PCI.
Co th c s dung anh gia nhng bnh nhn nghi ng thiu mau c tim
khng do nguyn nhn x va mach (v.d., nh d dang ng mach vanh, loc
tach ng mach vanh hay bnh mach vanh do xa tr).
Co th tin hanh siu m ni mach (Intravascular ultrasoundIVUS) anh
gia su hn cac mang x va, cung cp s anh gia chnh xac v h thng mach
vanh tai thi im chup mach.
Mc y ngha v mt chc nng cua tn thng hep ng mach vanh co th
c anh gia su hn da vao phn s d tr lu lng mach vanh (fractional
flow reserveFFR) tai thi im chup mach. iu nay co th hu ch trong vic
anh gia cac tn thng mach vanh khi mc nng trn lm sang cha xac
nh hay cac tn thng c phat hin mt cach tnh c vi ch s FFR <0,8
c xem nh han ch lu lng.
t catheter vao bung tht trai cung cho phep o ap lc y tht trai (chc
nng tm trng), chnh ap gia van 2 la va van ng mach chu, anh gia vn ng
vung thanh tim, chc nng tht trai va mt s bnh ly ng mach chu kem theo.
Bnh thn do thuc can quang (contrast-induced nephropathyCIN) xay ra
khoang 5% bnh nhn va thng gp hn nhng bnh nhn a co suy thn va
ai thao ng. phn ln bnh nhn, nng creatinin se tr v mc nn trong
vong 7 ngay sau khi chup. Nhng im cn xem xet phong nga CIN:
S dung lng thuc can quang t nht co th va xem xet can thip thanh tng
giai oan nhng ngi co thanh thai creatinin <60 mL/phut.
Cung cp u nc trc khi chup mach.
Thuc can quang khng ion ap lc thm thu thp nn c s dung. N-acetyl-
L-cystein va bicarbonate tim tnh mach (intravenousIV) khng co li cho vic
ngn nga bnh thn do thuc can quang, bt k co nguy c sn co hay khng.
Chup ct lp vi tnh mach vanh
y la mt ky thut khng xm ln dc s dung khng nh chn oan
CAD. Tng t nh thng tim, bnh nhn b phi nhim vi ca phong xa va
thuc can quang. Hin nay vai tro cua chup CT mach vanh ang c tip tuc
nghin cu.
Chup CT mach vanh co gia tr d oan m tnh cao va do o phu hp hn cho
cac bnh nhn co triu chng vi kha nng mc CAD c xac nh trc khi
lam test la trung bnh va thp loai tr bnh. V du nh cac bnh nhn nhp
vao khoa cp cu nhiu ln v au ngc hay bnh nhn co kt qua test gng sc
khng ro rang.
Co th h tr vic xac nh cac bt thng bm sinh cua ng mach vanh.
Ky thut nay khng hu ch i vi nhng bnh nhn co canxi hoa mach vanh
lan toa, co stent mach vanh hay nhng ng mach khu knh nho do cht lng
cua ky thut b giam xung.
IU TR
Muc tiu chnh cua iu tr la ngn nga nhi mau c tim, t vong do cn nguyn
tim mach va giam cac triu chng.
iu tr CAD co th phi hp vic iu chnh li sng, iu tr ni khoa va tai

thng ng mach vanh. Chin lc c khuyn cao cho vic anh gia va x tr
bnh nhn au tht ngc n nh c trnh bay trong Hnh 41.
iu tr thuc nhm vao vic cai thin s cung cp oxy cho c tim, giam nhu cu
s dung oxy cua c tim, kim soat cac yu t gy t cp (thiu mau, bnh van
tim) va han ch s phat trin thm na cua bnh x va. Thng iu tr thuc la
u kim soat triu chng au tht ngc trong au ngc n nh man tnh, va khi
so sanh vi tai thng mach vanh, cung mang lai kt qua lu dai tng t.
Thuc
ASA (75 n 162 mg/ngay) giam cac bin c tim mach bao gm lp lai tai
thng mach vanh, nhi mau c tim va t vong do tim mach khoang 33% (BMJ
1994;308:81; Lancet 1992;114:1421).
ASA 81 mg co ve la u cho hu ht bnh nhn (phong nga tin phat hoc th
phat cho ca CHD va tai bin mach nao).
Co th tin hanh giai mn cam ASA cho nhng bnh nhn d ng vi ASA.
Co th dung clopidogrel (75 mg/ngay) cho nhng bnh nhn d ng/khng chu
c ASA.
Thuc chen giao cam (Bang 46) kim soat triu chng au tht ngc bng
cach giam nhp tim, giam vn ng c tim do vy giam nhu cu oxy c tim.
Tranh dung cac thuc chen co hoat tnh ging giao cam ni tai.
iu chnh liu thuc gi nhp tim bnh nhn khi ngh ngi t 5060 ln/
phut.
S dung thuc chen c s dung thn trong hoc tranh dung bnh nhn
block nh tht (atrioventricularAV), ang co co tht ph quan, nhp chm khi
ngh ngi, hay suy tim (heart failureHF) mt bu.
Chen giao cam co th lam nng thm tnh trang co tht mach vanh va nn
tranh dung i vi nhng bnh nhn b au ngc do co tht mach vanh hoc
cn au ngc kiu Prinzmetal.
Thuc chen knh canxi cung co th c s dung kt hp vi hoc thay th
thuc chen beta giao cam nhng bnh nhn co chng ch nh hay co cac tac
dung phu nh la chon th 2 (Bang 47).
Thuc chen knh canxi thng c s dung kt hp vi chen giao cam nu
thuc chen giao cam khng em lai hiu qua y u trong vic giam cac triu
chng au ngc. Ca hai nhom thuc dihydropyridines va nondihydropyridine
tac dung keo dai u co th s dung.
Thuc chen knh canxi la thuc co hiu qua trong iu tr co tht mach
vanh.
Tranh dung nhom thuc nondihydropyridine (verapamil/diltiazem) bnh nhn
au ngc n nh
NYHA nhom IIIIV NYHA nhom III

CCS nhom IIIIV CCS nhom III
Ri loan chc nng LV Chc nng LV c bao tn
Test gng sc
Nguy c cao hoc Nguy c

Nguy c thp
ri loan chc nng LV trung bnh
WMA ngh ngi Khng co WMA

Thiu mau trung bnh ngh ngi, thiu mau nhe
Chup mach vanh iu tr ni khoa

Triu chng keo dai
dai dng
Thn chung Tc 3 mach Tc 3 mach Tc 1-2 mach Khng co

vanh trai nng trung bnh tn thng
CABG CABG iu tr ni khoa iu tr ni khoa NICM
PCI1 PCI1 PCI2 PCI2 Hi chng X
Bnh vi mach
Co tht mach vanh
Hnh 41. Phng cach anh gia va x tr bnh nhn au tht ngc n nh. Nhng bnh nhn
vi suy tim trn lm sang, au tht ngc gy han ch nng va nhng ngi co ri loan chc
nng tht trai nn c chup ng mach vanh xac nh nguyn nhn bnh ly cua ng mach
vanh. Nhng bnh nhn khng co nhng c im trn co th c phn tng nguy c su hn
na vi test gng sc. Sau test gng sc, bnh nhn co th c chup ng mach vanh hoc
c iu tr ni khoa theo kinh nghim da trn h s v nguy c cua ho. Nhng bnh nhn
ban u c iu tr ni khoa co cac triu chng keo dai dai dng nn c chup ng mach
vanh. 1CABG thng c a dung hn do no co li ch a bit ro v mt sng con so vi vic
iu tr ni khoa n c; tuy nhin, nu cac tn thng mach vanh khng phc tap, PCI co
th em lai kt qua tng t nh CABG nhng vi nhu cu cao hn v tai thng ng mach
trong tng lai. 2PCI nn danh cho nhng bnh nhn co tn thng mc cao, thiu mau nng
va khang vi iu tr ni khoa. CABG, bc cu ng mach vanh; CCS, phn loai (au ngc)
cua Hi tim mach Canada; LV (left ventricle), tm tht trai; NICM (nonischemic cardiomy-
opathy), bnh c tim khng thiu mau; NYHA, Hi tim mach New York; PCI, can thip ng
mach vanh qua da; WMA (wall motion abnormality), bt thng vn ng thanh tim.
Bng 46 Thuc chn thng dng trong bnh thiu mu c tim
Thuc S chn lc trn recepter Liu
Propranolol 1 v 2 2080 mg 2 ln/ngy

Metoprolol 1 50200 mg 2 ln/ngy
Atenolol 1 50200 mg hng ngy
Nebivolol 1 540 mg hng ngy
Nadolol 1 v 2 4080 mg hng ngy
Timolol 1 v 2 1030 mg 3 ln/ngy
Acebutolol* 1 200600 mg 2 ln/ngy
Bisoprolol 1 1020 mg hng ngy
Esmolol 1 50300 mcg/kg/pht

Labetalol C v 1, 2 200600 mg 2 ln/ngy
Pindolol* 1 v 2 2,57,5 mg 3 ln/ngy
Carvedilol C v 1, 2 3,12525 mg 2 ln/ngy
*Loi thuc chn c hot tnh ging giao cm ni ti
co ri loan chc nng tm thu do cac thuc nay co c tnh lam giam co bop
c tim.
Tranh s dung dihydropyridines tac dung ngn (nifedipine) do kha nng tng
nguy c b cac bin c tim mach chnh.
Nitrate, co dang tac dung keo dai cho bnh nhn s dung lu dai hay dang
tai ch/di li x tr cn au ngc cp. Thng c s dung lam thuc
chng au ngc b sung (Bang 48)
Dang di li nn c s dung lam ch nh u tin cho au tht ngc hay
dung d phong trc khi tin hanh cac hoat ng a c bit la khi phat
au tht ngc. Bnh nhn cn tm kim s tr giup cua y t ngay nu cn au
tht ngc xut hin khi ngh ngi hoc a dung 3 liu nitrates di li ma
khng co hiu qua.
Hin tng dung nap nitrate dn n giam ap ng iu tr co th xay ra vi
tt ca cac dang bao ch cua nitrate. Vic s dung mt khoang thi gian khng
co nitrate keo dai 10 n 12 gi (thng vao bui ti) co th giup tng hiu
qua iu tr.
Nitrate khng giup giam t vong bnh nhn b bnh mach vanh.
Nitrate chng ch nh (thm ch ca vi bnh nhn b ACS) cho bnh nhn
Bng 47 Thuc chn knh canxi thng dng trong bnh thiu mu c tim
Thuc Thi gian hot ng Liu thng dng
Dihydropyridine
Nifedipine
Phng thch chm Di 30180 mg/ngy
Amlodipine Di 510 mg/ngy
Felodipine Di 510 mg/ngy
Isradipine Trung bnh 2,510 mg/ngy
Nicardipine Ngn 2040 mg
Nondihydropyridin
Diltiazem
Phng thch trung bnh Ngn 3080 mg
Verapamil
Phng thch trung bnh Ngn 80160 mg
ang s dung thuc c ch 5phosphodiesterase v co nguy c gy ha huyt

ap nng. Trc khi dung nitrate, bnh nhn phai dng thuc nhom c ch 5
phosphodiesterase t nht 24 gi i vi sildenafil, vardenafil hoc 48 gi i
vi tadalafil.
Thuc c ch men chuyn co th mang lai thm li ch trong iu tr au tht
ngc n nh.
iu tr vi thuc c ch men chuyn (ACE inhibitorsACEIs) hay chen thu
th angiotensin (angiotensin receptor blockersARBs) bnh nhn khng
dung nap thuc c ch men chuyn, nn c s dung vi tt ca cac bnh
nhn co EF tht trai <40% va nhng bnh nhn tng huyt ap, ai thao ng
hay bnh thn man tnh.
S dung thuc c ch men chuyn tt ca cac bnh nhn au tht ngc n
nh la hp ly.
S dung thuc c ch men chuyn co th gy phu mach nng e doa n tnh
mang, ho va co th gy suy giam chc nng thn (c bit nhng ngi mt
nc, han ch mui nghim ngt, co dung ng thi thuc chng vim khng
steroid (nonsteroidal anti-inflammatory drugNSAIDs) va khoang 5 n 10%
bnh nhn co hep ng mach thn 2 bn).
Bng 48 Dng nitrates thng c s dng trong bnh thiu mu c tim
Thi gian bt
u tc dng
Dng Liu (pht) Thi gian tc dng
Nitroglycerin di li 0,30,6 mg 25 1030 pht

Nitroglycerin phun git nh 0,4 mg 25 1030 pht
Dinitrat isosorbide ung 540 3060 46 gi
Mononitrat isosobide ung 1020 mg 3060 68 gi
Mononitrat isosobide phng 30120 3060 1218 gi
thch chm ng ung
Du nitroglycerin 2% 0,52 2060 38 gi
Ming dn nitroglycerin 515 mg >60 12 gi
qua da
Nitroglycerin tnh mch 10200 mcg/pht <2 Trong sut qu
trnh truyn
Ho va phu mach do thuc c ch men chuyn him gp hn khi dung thuc

chen thu th Angiotensin.
Ranolazine la mt thuc chng au tht ngc khng phu thuc vao giam nhp
tim va huyt ap. Nhn chung thuc khng c s dung lam thuc u tay hoc
thuc hang th 2 trong iu tr au tht ngc.
Thuc giam cholesterol mau gm statins, fibrat, li mt va niacin (xem thm
Chng 3. D phong bnh ly tim mach). Lu y, trong phong bnh th phat
CHD th ngoai statin, khng co thuc ha cholesterol nao khac c chng minh
la em lai li ch v t vong.
X tr phu thut
Tai thng mach vanh
Nhn chung, nn c gng iu tr ni khoa ti u vi t nht 2 hay tt hn la 3
nhom thuc chng au ngc trc khi iu tr ni khoa c coi la tht bai va
xem xet vic tai thng ng mach vanh.
bnh nhn au tht ngc n nh va khng co nguy c cao (v.d., test gng
sc kt qua nguy c cao hay chc nng tht trai thp), iu tr ni khoa cho kt
qua v tim mach tng t vi PCI, ngoai tr vic PCI giam cac triu chng au
tht ngc ngn han va dai han tt hn. Bnh nhn cn c nhn thc c
mt phn cua ban ng y rng nguy c nhi mau c tim hay t vong cua ho
la khng thay i (N Engl J Med 2007;256:1503; Lancet 1997;350:461). Tuy

nhin, nhng bnh nhn co mt s tn thng mach vanh nht nh th vic tai
thng mach vanh co u th v mt sng con khi so sanh vi iu tr ni khoa
n thun (xem phn tip theo).
La chon gia PCI va CABG phu thuc vao giai phu ng mach vanh, cac
thuc dung ng thi, va la chon cua bnh nhn.
Noi chung, bnh nhn vi bnh hn hp va phc tap th CABG tt hn, trong
khi PCI bnh nhn c la chon co giai phu mach vanh thch hp co th
cho kt qua co th so sanh c vi CABG. Do CABG co pham vi rng hn,
cac bnh nhn co bnh kem theo thng cn PCI tai thng mach vanh.
Quyt nh gia vic iu tr ni khoa, PCI hay CABG nn c xem xet da
trn vic cn giam ca ty l t vong va triu chng hay ch giam triu chng
la u. PCI va CABG u hiu qua trong vic lam giam triu chng au ngc.
Chung ti khuyn cao rng vic quyt nh la chon gia PCI va CABG, khi
ca 2 u co th, cn xem xet n nguy c do phu thut s dung im nguy c
cua Hi phu thut lng ngc (Society of Thoracic SurgeonsSTS) cung nh
im Syntax xac nh giai phu cua mach vanh phu hp nh th nao cho PCI.
(http://riskcalc.sts.org/STSWebRiskCalc273/, http://www.syntaxscore.com/).
Tai thng mach vanh c chng minh cai thin sng con so vi iu tr ni
khoa trong cac trng hp sau:
CABG cho bnh thn chung ng mach vanh trai >50%. PCI la la chon thay
th hp ly cho bnh nhn b CAD trai nu bnh nhn khng am bao iu
kin phu thut va hnh thai hoc phu hp vi PCI hn. PCI, trong tnh hung
lm sang ung th co ty l nhi mau c tim, tai bin mach nao hay t vong
tng t nh CABG (N Engl J Med 2009;360:961).
CABG i vi bnh 3 thn ng mach vanh hoc bnh oan gn cua ng
mach lin tht trc (left anterior descendingLAD) va mt ng mach khac
bnh nhn co EF >35% va trn test gng sc khng xm ln ghi nhn hoc
la co thiu mau c tim co hi phuc hoc la vung c tim co kha nng sng sot.
Li ch v sng con cua CABG bnh nhn co EF tht trai <35% (co hay
khng co kha nng sng sot) co th tt hn so vi iu tr ni khoa (N Engl
J Med 2011;364:1607). PCI cha c anh gia so vi CABG nhng bnh
nhn co giam chc nng tht trai va vic la chon gia CABG va PCI nn da
vao giai phu ng mach, co hay khng mc ai thao ng hay bnh thn
man tnh, cac yu t ng mc co anh hng n phu thut.
CABG cho bnh 2 thn ng mach trong bnh canh co thiu mau nng quan
sat thy qua thm do chn oan hnh anh gng sc (v.d., >20% thiu mau c
tim hay vung c tim con co kha nng sng sot ang k trn chn oan hnh
anh tim).
Bnh nhn co bnh oan gn LAD n c co th co li ch v sng con vi

PCI hoc CABG (JACC 2008;1:483; Am Thorac Surg 2006;82:1420).
CABG, cung nh vi PCI hay iu tr ni khoa, bnh nhn tn thng nhiu
ng mach va ai thao ng, nu co th t c oan ni t ng mach
vu trong trai (left internal mammary arteryLIMA) n LAD (N Engl J Med
1996;335:217). PCI co th mang n hiu qua sng sot bnh nhn ai thao
ng b bnh nhiu mach va im Syntax thp (<22) nhng vi nhu cu cao
hn phai lp lai vic tai thng ng mach vanh (JACC 2010;55:1067).
PCI hay CABG bnh nhn sng sot sau ngng tim t ngt do nhp nhanh
tht do thiu mau.
PCI hay CABG bnh nhn b ACS.
Do vic lp lai CABG co ty l mc bnh cao nn PCI thng c s dung
cai thin triu chng bnh nhn au ngc tai phat sau CABG.
CABG co ty l t vong la 1% n 3%, ty l mi mc MI xung quanh phu thut
la 5% n 10%, va mt nguy c nho b t quy quanh phu thut. S dung cu
ni bng ng mach vu trong i kem vi ty l cu ni con thng la 90% sau 10
nm, so vi 40 n 50% khi s dung cu ni tnh mach hin. Ty l cu ni con
thng dai han khi s dung cu ni ng mach quay la 80% sau 5 nm. Sau 10
nm theo doi, 50% bnh nhn xut hin au tht ngc tai phat hoc cac bin c
tim mach khac lin quan n suy ng thng tnh mach mun hay tin trin t
nhin cua CAD (N Engl J Med 1996;334:216).
Nguy c cua PCI chon loc bao gm <1% t vong, 25% MI khng t vong,
<1% cn tin hanh CABG cp cu v thu thut khng thanh cng. Bnh nhn
c tin hanh PCI co thi gian nm vin ngn hn. PCI co ty l tai hep tn
thng ch cao hn oi hoi phai lp lai thu thut va khi so sanh vi CABG th
no co ty l bin c tim mach thp hn. S dung stent phu thuc a cho thy s
giam nguy c tai hep, nhng nhu cu phai lp lai thu thut vn cao hn ty l
quan sat c trn bnh nhn sau CABG (N Engl J Med 2009;260:961; N Engl
J Med 2005;352:2174). CHU Y: mt s bnh nhn au tht ngc n nh va
bnh nhiu mach co im Syntax thp (thang im da vao s phc tap, dai
va v tr tn thng) nho hn 22, PCI co th tng ng CABG v mt sng
con va co nguy c t quy lin quan n thu thut t hn.
Sau PCI, bnh nhn cn phai dung ASA va thuc c ch P2Y12 trong 12 thang;
tuy nhin, bnh nhn dung stent kim loai thng co th ngng dung thuc c
ch P2Y12 sau t nht 1 thang. iu nay co th cn thit va la la chon c ln
k hoach vi bnh nhn co th cn phai phu thut trong vong 1 nm hoc co
nguy c cao b chay mau. CHU Y: Nhng bnh nhn c d oan khng tun
thu co hoc khng th dung nap liu phap khang tiu cu kep vi ASA va thuc
c ch P2Y12 trong thi gian ti thiu cho loai stent ma ho nhn th khng nn
lam PCI vi t stent mach vanh.
HNG DN BNH NHN

Cn nhn manh vic tun thu iu tr thuc, ch n va luyn tp c vi bnh
nhn. Tt ca bnh nhn nn c khuyn khch tham gia vao vic phuc hi chc
nng tim cung nh kham t vn dinh dng.
Bnh nhn b CAD a c xac nh nn c anh gia lai nu co bt ky thay i
nao trong dang, tn sut, cng cua au ngc.
Bnh nhn nn c anh gia lai nu ho bao cao bt ky triu chng nao cua suy tim.
GIM ST/THEO DI
Theo doi bnh nhn cht che la mt yu t quan trong trong iu tr CAD v vic
iu chnh li sng va giam cac yu t nguy c th phat oi hoi vic anh gia lai
va cac can thip hang loat.
Nhng thay i tng i nho v cac triu chng au ngc co th c iu tr
mt cach an toan bng cach chnh liu va/hoc thm thuc chng au ngc.
Nhng thay i ang k v au ngc (tn sut, nng, hay thi gian khi phat
au ngc sau khi hoat ng) nn c anh gia hoc bng test gng sc (thng
kt hp vi 1 phng phap chn oan hnh anh) hoc bng chup ng mach vanh
da theo khuyn cao.
Phuc hi chc nng tim hay chng trnh luyn tp nn c lp k hoach hoc
tin hanh.
Tt ca nhng n lc phong bnh tin phat (c thao lun trc o) u co gia tr
phong bnh th phat
Hi chng vnh cp, au tht ngc khng n nh,

nhi mu c tim khng ST chnh
I CNG
NSTEMI va UA co lin quan mt thit vi nhau, co sinh bnh hoc va biu hin
lm sang tng t nhau nhng khac nhau mc nng.
Nu lu thng mach vanh khng u nng hay s tc khng tn tai u lu gy
hoai t c tim (c ch im bi du n sinh hoc cua tim dng tnh), hi chng
c goi la au ngc khng n nh.
NSTEMI c nh ngha bi s tng men tim (creatine kinase MB [CK-MB]
hay Troponin) va khng co ST chnh ln. Trong cac bnh nhn NSTEMI, co 25%
bnh nhn tin trin thanh song MI co song Q.
iu tr ACS nn tp trung vao phn tng nguy c da trn bnh s, c im cua
cn au ngc, kham lm sang, in tm va men tim.
Hi chng vnh cp, au ngc khng n nh, nhi mu... khng ST chnh l 159
Dch t hc
Ty l mi mc MI hang nm la 785.000 ca mi, va 470.000 ca tai phat (Circulation
2011;123:e18).
Trong s cac bnh nhn b ACS, khoang 60% b au tht ngc khng n nh va
khoang 40% b nhi mau c tim (1/3 trong s MI biu hin la STEMI cp).
Trong 1 nm, bnh nhn UA/NSTEMI co nguy c t vong khoang ang k
(~6%), MI tai phat (11%) va nhu cu tai thng ng mach vanh (~50 n 60%).
Mt iu quan trong phai chu y la mc du ty l t vong ngn han cua STEMI ln
hn NSTEMI, nhng ty l t vong dai han cua 2 bnh la tng t nhau (JACC
2007;50:e1; JAMA 1996;275:1104).
Ty l mi mc CHD n gii chm hn nam gii khoang 10 nm va khoang 20
nm cho cac bin c lm sang nguy him nh nhi mau c tim hay t t.
Sinh l bnh
Thiu mau c tim xay ra do giam cung cp oxy cho c tim va/hoc tng nhu cu.
Trong phn ln cac trng hp, NSTEMI la do giam t ngt cung cp mau do
tc nghen mt phn cua mach mau b anh hng. Trong vai trng hp, nhu cu
oxy c tim tng ang k co th dn n NSTEMI (thiu mau do tng nhu cu),
nh trong thiu mau nng hoc cn tng huyt ap.
UA/NSTEMI thng la biu hin cua hep ng mach vanh nng hay bong/v
mang x va cp va s tao thanh huyt khi chng ln. Thm vao o, no cung co
th do tc nghen c hoc tin trin do bnh x va mach tin trin, tai hep trong
stent (in-stent restenosisISR), hay bnh cu ni.
Bong mang x va co th b gy ra bi vim tai ch va/hoc h thng cung nh
ap lc ct. S bong mang x va dn n vic b l phc hp di ni m giau
lipid cho cac tiu cu trong dong mau va cac t bao vim, tao nn phn nn cho
s hnh thanh huyt khi.
Cac nguyn nhn t gp hn bao gm tc nghen ng hoc ng mach vanh do co
tht mach (au ngc do prinzmetal, cocain), loc tach ng mach vanh (xem xet
phu n thi ky chu san), vim mach vanh, va huyt khi.
Biu hin lm sng
Bnh s
Cac triu chng cua ACS gm tt ca cac c im cua au tht ngc in hnh
ngoai tr cac cn au nng hn, thi gian dai hn va co th xut hin ngay ca luc
ngh ngi.
Co 3 biu hin chnh cua au tht ngc khng n nh la au ngc khi ngh ngi
(au ngc xut hin khi ngh ngi va keo dai, thng >20 phut), au tht ngc
mi xut hin, va au tht ngc tin trin (au ngc a c chn oan trc
o tr nn thng xuyn hn, keo dai hn, hay xut hin khi gng sc t hn). au
ngc tin trin va mi xut hin nn xay vi hoat ng t nht la nhe n trung
bnh, mc CCS nhom III.
Gii n, ai thao ng, suy tim va bnh thn giai oan cui va tui gia la cac
yu t lin quan n kha nng cao co triu chng cua ACS khng in hnh.
Kho th la triu chng thng gp nht cua MI thm lng.
au ham, c, canh tay, lng va thng v cung co th la triu chng cua au
tht ngc.
Khm thc th
Kham lm sang nn hng ti vic xac nh tnh trang huyt ng khng n nh,
sung huyt phi va cac nguyn nhn khac gy ra au ngc cp tnh.
Bng chng khach quan cua suy tim, bao gm giam ti mau ngoai vi, ting thi
tim (c bit la ting thi cua HoHL), tnh mach canh tng p, phu phi, ha
huyt ap, phu ngoai bin lam tin lng ti i va anh hng n iu tr.
Kham lm sang cung co th thy du hiu cua nguyn nhn gy thiu mau khac
nh ng c giap hay loc tach ng mach chu (xem Bang 44).
Test chn on
in tm
Nn lam in tm c ban cho tt ca cac bnh nhn nghi ng b ACS, trc khi
hoc ngay khi n khoa cp cu. Kt qua bnh thng cung khng loai tr c
bnh.
S xut hin cua song Q, thay i oan ST hay s ao ngc song T la cac du
hiu gi y cua CAD.
Song Q n c chuyn ao DIII la bnh thng.
Nn tin hanh lam in tm hang loat anh gia cac thay i ng hoc v
thiu mau.
So sanh in tm vi in tm u tin la ht sc quan trong khi anh gia
cac thay i ng hoc.
Khoang 50% bnh nhn UA/NSTEMI co nhng bt thng in tm ang
k, gm ST chnh ln thoang qua, ST chnh xung, song T ao ngc (JACC
2007;50:e1).
oan ST chnh xung 2 chuyn ao lin tip la mt ch im nhay cho thiu
mau c tim, c bit nu bin i va co cac triu chng kem theo.
Gia tr ngng cua im J chnh xung bt thng nn la -0,05 mm chuyn
ao V2 va V3 va -1 mm cac chuyn ao khac.
oan ST chnh xung nhiu chuyn ao va ST chnh ln aVR va/hoc
V1 gi y thiu mau do tc thn chung ng mach vanh trai hay nhiu mach.
T m su (>5 mm) vi QT keo dai chuyn ao V2V4 (song Wellens) gi
y manh me n tn thng c bit ang lo ngai ng mach LAD hay xut

huyt nao gn y.
Thay i ST khng c hiu hay song T ao ngc (khng ap ng u cac tiu
chun v bin ) khng co gia tr chn oan va khng co li ch g trong vic
iu tr thiu mau cp nhng co i kem vi nguy c b cac bin c tim mach
trong tng lai cao hn.
Xt nghim
T bao mau toan phn, chuyn hoa c ban, glucose mau luc oi, lipid mau nn
c ch nh nhng bnh nhn nghi ng b CAD. Cac tnh trang khac co th
gop phn thm vao thiu mau c tim (v.d., thiu mau), ging thiu mau c tim
(v.d., cac thay i trn in tm lin quan ti tng kali mau), hay co th thay
i iu tr (v.d., thiu tiu cu nng).
Cac du n sinh hoc cua tim la rt cn thit trong chn oan au ngc khng
n nh/NSTEMI va nn c ch nh tt ca cac bnh nhn co au ngc co
tnh cht gi y ACS. nhng bnh nhn co men tim m tnh trong vong 6 gi
k t khi khi phat au ngc, mu th 2 nn lam vao luc 8 n 12 gi k t khi
khi phat triu chng. Cac du n thng lam nht la Troponin, CKMB va
Myoglobin (Bang 49).
Troponin c hiu tim la du n hay dung nht va nn c o tt ca cac bnh
nhn.
Troponin T hay I la du n c bit nhay va c hiu cho hoai t c tim. Nng
troponin huyt thanh thng khng phat hin c ngi bnh thng va
bt ky s tng nao cung c cho la bt thng.
Kch thc cua vung c tim b nhi mau va tin lng ty l mt cach trc tip vi
s tng troponin (N Engl J Med 1996;335:1333; Circulation 1998;98:1853).
CKMB cung la du n c chp nhn do hoai t c tim, nhng thiu tnh c
hiu, bi no cung co trong ca t bao c tim va c xng.
c hiu co th c cai thin bng cach s dung ty s CKMB/CK toan
phn. Ty s CKMB ln hn 2,5% gi y tn thng c tim.
CKMB la mt xet nghim hu ch phat hin thiu mau sau nhi mau, bi
v s giam ri sau o lai tng ln cua nng enzym gi y tai nhi mau, c
bit nu i cung triu chng thiu mau c tim tai phat hoc cac thay i trn
in tm .
Tng t, nng CKMB thng c theo doi sau tai thng ng mach vanh
qua da. CKMB tng nhe thng la biu hin cua vi huyt khi oan xa, trong
khi s tng ln nhiu gi y cac bin chng nng hn, chng han nh huyt khi
trong stent cp tnh.
Vi bnh nhn co nng troponin ban u bnh thng, sau o tng ln gp
3 ln sau PCI gi y nhi mau c tim sau PCI; nu nng luc u tng nhng
Bng 49 Du n sinh hc ca tim
Tr li gi tr
Pht hin c t nh ban u
Troponin I, T 36 gi 2436 gi 514 ngy

CKMB 26 gi 1218 gi 2448 gi
Myoglobin 12 gi 68 gi 1224 gi
CKMB, tng men tim.
n nh/ang giam, mc tng 20% c s dung lam ngng. Tuy nhin,

CKMB hay c dung hn Troponin trong chn oan MI sau PCI (JACC
2011;57:653).
Myoglobin c giai phong nhanh hn sau tn thng c tim hn la CKMB,
Troponin T, hoc Troponin I, nhng lai thiu tnh c hiu. o Myoblobin co
th hu ch nhng bnh nhn n vin trong vai gi u k t khi khi phat
triu chng.
IU TR
Cac phng cach thm do cn lm sang, iu tr bng thuc, va tnh khoang thi
gian cho cac iu tr xm ln b ch ao bi kha nng tin trin thanh MI cp, nguy
c tai nhi mau va nguy c t vong sau nay.
Nguy c t vong hay tin trin thanh MI tng ln vi cac c tnh cua ACS nguy
c cao nh sau:
au ngc tng ln/tai phat du a iu tr thuc y u
Du hiu hay triu chng cua suy tim mi, phu phi hay shock
HoHL mi xut hin hoc nng ln

Block nhanh trai mi xut hin
Nhp nhanh tht c ghi lai trn may theo doi
Cac c im trn (tai thi im bnh nhn n vin hay bt ky thi gian nao
trong thi gian vin) la ch im cho vic tin hanh thng tim khn cp vi
muc ch tai thng mach vanh.
Mt vai cng cu lm sang co th c tnh nguy c MI hay t vong do tim, nh
im nguy c Huyt khi trong nhi mau c tim (Thrombolysis in Myocardial
InfarctionTIMI) hay S ng ky toan cu v cac bin c mach vanh cp tnh
(Global Registry of Acute Coronary EventsGRACE). im nguy c TIMI
co th c s dung xac nh nguy c cht hay MI khng t vong trong 14
ngay cua bnh nhn (JAMA 2000;284:835). Bnh nhn co th c phn loai
thanh nguy c cao, trung bnh va thp da vao cac biu hin lm sang cua ho.
(Hnh 42).
Bnh nhn nguy c thp (TIMI 0 hoc 1) co th c quan sat bng monitor
n v au ngc hay n v quan sat.
Bnh nhn co nguy c cao hay trung bnh nn c nhp vin theo doi va
iu tr.
nhng bnh nhn n nh, co 2 chin lc c chp nhn la: x ly bao tn
t u hay x ly xm ln t u. Chin lc x ly c la chon lun lun nn
c ca th hoa theo tng bnh nhn cu th (Hnh 43).
Trong chin lc bao tn t u, s dung iu tr ni khoa ti a va nu hiu
qua, bnh nhn se c tin hanh mt test gng sc khng xm ln trc khi
ra vin.
Co th c xem xet bnh nhn nguy c TIMI/GRACE thp va nhng bnh
nhn nguy c trung bnh chon loc vi kt qua ky vong tng t nh chin lc
iu tr xm ln trc tip.
Nu bnh nhn khng tin trin thanh co cac yu t cua ACS nguy c cao,
nng men tim sau o tr v bnh thng, khng co thay i ng hoc trn
in tm , nn tin hanh mt test gng sc khng xm ln phn tng
nguy c su hn na.
Bnh nhn khng co au tht ngc trong vong t nht 12 gi trc khi tin
hanh test gng sc.
Nu bnh nhn co men tim dng tnh c chon lam test khng xm
ln, co th tin hanh test gng sc di mc ti a hoc gng sc bng thuc
72 gi sau khi men tim at gia tr nh.
Chup mach vanh c danh cho nhng bnh nhn tin trin thanh co cac c
im cua ACS nguy c cao, co mt test gng sc nguy c cao, co au tht
ngc mc du mc gng sc t, hay co EF tht trai <40%.
50
T vong, MI, hoc tai thng mach (%)
40
30
20
10
0
01 2 3 4 5 67
im TIMI
im nguy c TIMI (mi yu t 1 im)
1. Tui >65
2. CAD a bit (hep >50%)
3. 2+ t au ngc trong 24 gi
4. Cac thay i oan ST hoc song T
5. Tng marker sinh hoc cua tim
6. ASA trong 7 ngay trc
7. 3+ Yu t nguy c cua CAD
Chin lc bao tn Chin lc xm ln sm
-Blocker, nitrates, oxygen

UFH, LMWH
ASA
Liu phap khang tiu cu kep
Liu phap khang tiu cu 3
im TIMI
Hnh 42. Ty l t vong, MI, hay phai tai thng mach vanh khn cp trong vong 14 ngay t
th nghim TIMI 11B va ESSENCE da trn s tng im TIMI. Cac yu t nguy c CAD
gm tin s gia nh b CAD, ai thao ng, tng huyt ap, tng lipid mau va hut thuc. ASA,
aspirin; MI, nhi mau c tim; TIMI, Thrombolysis in Myocardial Infarction, Huyt khi trong
nhi mau c tim; UFH, heparin khng phn oan (Phong theo JAMA 2000;284:835-842).
Trong chin lc xm ln t u, bnh nhn c ln k hoach chup mach

vanh vi muc ch tai thng mach vanh (trong vong 12 n 48 gi) ma khng
cn lam test gng sc trc hoc am bao rng vic iu tr ni khoa tht
bai trong vic kim soat triu chng (Lancet 1999;354:708; N Engl J Med
2001;344:1879; JAMA 2003;290:1593; Lancet 2002;360:743; N Engl J Med
2009; 360:2165; JAMA 2005;293:2908)
Cac c im, ngoai cac c im cua ACS nguy c cao a c cp
ti trc o, khin cho chin lc iu tr xm ln c a chung hn bao
gm:
Tng men tim.
ST chnh xung mi xut hin.
Tin s CABG hay mi tin hanh PCI (6 thang).
EF tht trai <40%.
Co ai thao ng.
Co giam chc nng thn nhe n trung bnh.
Bnh nhn co thanh thai creatinine di 30 hoc nhng ngi ang chay
thn co th khng at c li ch t chin lc iu tr xm ln (Circulation
2009;120:851).
im GRACE hay TIMI cao.
Nn xem xet chin lc can thip sm (chup mach trong vong 12 n 24
gi) bnh nhn n nh vi im GRACE >140.
Chin lc can thip sm cung c khuyn cao bnh nhn nguy c thp
hay trung bnh ma co ACS tai phat mc du a c dung thuc y u.
Thuc
Bnh nhn UA/NSTEMI nn c iu tr thuc lam giam thiu mau c tim thng
qua vic lam giam nhu cu oxy c tim, cai thin ti mau mach vanh va ngn nga
s hnh thanh huyt khi.
Cac thuc gm chng tiu cu, chng ng, va chng au ngc.
Cung cp oxy khi bnh nhn co ha oxy mau (<90%) hay co kho th. S dung oxy
thng quy la khng cn thit va co th gy hai (HEART 2009;95:198).
Liu phap khang tiu cu
Aspirin ngn chn s kt tp tiu cu trong vong vai phut (Bang 410).
ASA nhai c liu 162325 mg nn c dung ngay khi co triu chng hay
ngay khi tip cn vi h thng y t u tin, tr khi co chng ch nh. Sau o
dung ASA 81 mg mi ngay mt cach v han nh.
Nu co d ng vi ASA (v.d., co tht ph quan bnh nhn hen co polyp mui),
co th dung clopidogrel (vi liu bolus) thay th. Nn tin hanh hi chn v d
ng v kha nng giai mn cam, tt nht la trc khi cn phai t stent.
Triu chng ACS

ASA 325 mg, ECG,
men tim
Loai tr ACS Chc chn ACS STEMI
Tc ngc PCI/
UA/NSTEMI
ECG, men tim Tiu huyt khi
Quan sat 12-24 gi +Tc ngc

ECG hang loat, men tim +ECG, +men tim
Nguy c trung bnh

n cao Nguy c thp
Test gng sc
Chin lc Chin lc
Gng sc +Gng sc xm ln sm bao tn sm
Khng ging au UFH hoc LMWH* UFH hoc LMWH*

ngc do tim anh gia chc nng Clopidogrel+ Clopidogrel+
tht trai GPIIb/IIIa++
Thiu mau
tai phat
+Thiu mau
tai phat#
Chup mach EF <40% anh gia chc nng
chn oan tht trai
+WMA
EF >40%
WMA
Test gng sc
+Gng sc
Gng sc
CABG PCI iu tr ni khoa (CAD) Khng co CAD iu tr ni khoa

ASA ASA ASA Tm nguyn ASA
UFH hoc LMWH* Clopidogrel Clopidogrel nhn khac + Clopidogrel3
1 2
GPIIb/IIIa GPIIb/IIIa UFH hoc LMWH
Dng clopidogrel
5 ngay trc o vi nhng
trng hp chon loc
Cac hng dn gi y nn dung liu ASA duy tr t 162325 mg trong 1

thang cho bnh nhn ACS c t stent kim loai va n 6 thang cho bnh
nhn c t stent phu thuc, sau o dung 75162 mg hang ngay mt cach
v han nh.
- Tuy nhin dung 81 mg ASA hang ngay cho tt ca cac bnh nhn sau PCI
cung hp ly. Liu ASA cao hn 100 mg bnh nhn co dung thuc khang
tiu cu th 2 lam tng nguy c chay mau ma khng mang lai thm li ch
(N Engl J Med 2010;363:930).
Thuc khang tiu cu ng ung, clopidogrel, ticlopidine, prasugrel la cac
thuc khang thu th P2Y12 thienopyridine va ticagrelor la thuc khang thu th
P2Y12 co hi phuc khng phai thienopyridine duy nht con s dung. Chung
c ch s hoat hoa va ngng tp tiu cu bng cach khoa thu th ADP trn b
mt tiu cu.
Clopidogrel la tin cht ma cht chuyn hoa cua no chen thu th P2Y12; do
o, se khng thy hoat ng tiu cu ti a trong vai gi.
Khi so sanh vi cac thuc khac trong cung nhom, no co t nguy c chay mau
hn. Nhng bnh nhn cung cn dung wafarin va ASA, clopidogrel co th
an toan hn ticagrelor va prasugrel. Muc tiu INR nn t 2,0 n 2,5.
No la mt phn cua chin lc thn trong sm va iu tr can thip sm (ch
nh ngay khi bnh nhn n vin hay trong sut qua trnh tin hanh PCI).
Hnh 43. Phng cach chn oan va iu tr bnh nhn ACS tp trung vao iu tr chng
huyt khi va chng tiu cu. *Bivalirudin la mt thay th thch hp cho UFH va LMWH, hay
tai thi im tin hanh PCI bnh nhn ang dung UFH co th chuyn sang dung bivalirudin.
+
Chon hoc clopidogrel, ticargrelor hoc prasugrel nh thuc chng tiu cu th 2. Co th s
dung thuc c ch thu th GP IIb/IIIa nh la thuc thay th nu cn trong trng hp co kha
nng cao phai tin hanh CABG. ++Thuc c ch GPIIb/IIIa cung co th c tai thi im
tin hanh PCI b sung cho ASA va thuc c ch P2Y12 nhng bnh nhn nguy c cao hoc
c s dung nh liu phap b sung cho nhng bnh nhn co triu chng tai phat hoc nng
ln. #Cac ch im cua tai thiu mau bao gm au ngc nng ln, tng men tim, du hiu/triu
chng cua suy tim, loan nhp (Nhanh tht/rung tht) va thay i ng hoc trn in tm .
1
Thuc c ch GPIIb/IIIa nn c s dung mt cach chon loc, hay bivalirudin co th c s
dung cho du bnh nhn co c dung UFH trc o hay khng. 2UFH s dung trong vong 48
gi hay LMWH hay fondaparinux cho n 8 ngay va clopidogrel hoc ticagrelor n 1 nm.
Thuc c ch P2Y12 gm cac thuc khang tiu cu clopidogrel, ticargrelor hoc prasugrel.
ASA, aspirin; CABG, bc cu ni ng mach vanh; CAD, CAD; ECG, in tm ; EF, phn
sut tng mau; GPIIb/IIIa (glycoprotein IIb/IIIa inhibitor), thuc c ch thu th glycoprotein
IIb/IIIa; LMWH, heparin trong lng phn t thp; NSTEMI, nhi mau c tim khng ST
chnh ln; PCI, can thip ng mach vanh qua da; Rx (treatment), iu tr; STEMI, nhi mau
c tim ST chnh ln; UA, au ngc khng n nh; VT/VF, nhanh tht, rung tht; WMA (wall
motion abnormality), vn ng thanh tim bt thng. (Phong theo Hng dn 2007 cua ACC/
AHA v X tr bnh nhn b au ngc khng n nh/Nhi mau c tim khng ST chnh ln).
Thuc khng tiu cu dng trong au tht ngc khng n nh/

Bng 410
NSTEMI
Thuc Liu Nhn xt
Aspirin (ASA) 162325 khi bnh nhn dng ticagrelor, liu duy tr ASA
u, sau khng nn vt qu 100 mg.
75100 mg
Clopidogrel 300600 mg liu Dng kt hp vi ASA, clopidogrel (liu np
np, sau 75 300 mg600 mg sau 75 mg/ngy) lm
mg/ngy gim tiu ch chnh kt hp 1830% v t
vong do tim mch, MI hay t qu bnh
nhn au tht ngc khng n nh/NSTEMI
(N Engl J Med 2001;345:494; Lancet
2001;358:527; JAMA 2002;288:2411).
Ticagrelor 180 mg liu np, Ticagrelor lm gim t l mi mc ca t vong
sau 90 mg do mch mu, MI hoc t qu no (9,8%
2 ln/ngy so vi 11%) nhng nguy c chy mu ln
cao hn khng lin quan n CABG (4,5%
so vi 3,8%) khi so vi clopidogrel (N Engl J
Med 2009;361:1045).
Prasugrel 60 mg liu np, Prasugrel c kh nng khng tiu cu cao
sau 10 mg hn so vi clopidogrel. Prasugrel lm gim
hng ngy t l mi mc ca t vong do tim mch, MI
v t qy no (9,9% so vi 12,1%) nhng
nguy c chy mu ln (2,4% so vi 1,1%) v
chy mu gy t vong (0,4% so vi 0,1%)
cao hn so vi clopidogrel (N Engl J Med
2007;357:2001).
Eptifibatide 180 mcg/kg Epfitibatid lm gim nguy c t vong hay MI
bolus ng bnh nhn ACS d c iu tr xm ln
tnh mch, hay khng xm ln khi kt hp vi ASA v
2 mcg/kg/phta Heparin (N Engl J Med 1998;339:436;
Circulation 2000;101:751). So snh vi
abciximab v tirofiban, epfitibatid c hiu
qu n nh nht trong c ch tiu cu vi
thi hn v thi gian bn thi ngn nht
(Circulation 2002;106:1470-1476).
(cn tip)
Thuc khng tiu cu dng trong au tht ngc khng n nh/

Bng 410
NSTEMI (Tip theo)
Thuc Liu Nhn xt
Tirofiban 0,4 mcg/kg Tirofiban gim nguy c t vong v MI

bolus ng bnh nhn ACS d iu tr xm ln hay
tnh mch, khng xm ln kt hp vi ASA hay
0,1 mcg/kg/ heparin (Circulation 1997;96:1445; N
phta Engl J Med 1998;338:1498; N Engl J Med
1998;339:1488).
Abciximab 0,25 mg/kg Abciximab gim nguy c t vong hay MI
bolus ng bnh nhn ACS c can thip mch
tnh mch, vnh (N Engl J Med 1994;330:956;
10 mcg/phtb Lancet 1997;349:1429; N Engl J Med
1997;36:1689). Khng nn s dng bnh
nhn khng c k hoch can thip ng
mch vnh qua da (Lancet 2001;357:1915).
S c ch tiu cu c th o ngc bng
cch truyn tiu cu.
a Liu truyn nn c gim 50% nhng bnh nhn c GFR di 30 mL/pht v nn trnh dng nhng
bnh nhn ang c lc mu.

bAbciximab c th dng c nhng bnh nhn ESRD v n khng c lc bi thn.
ACS, hi chng vnh cp; CABG, bc cu ni ng mch vnh; ESRD (endstage renal disease), bnh
thn giai on cui; GFR (glomerular filtration rate), mc lc cu thn; MI, nhi mu c tim; NSTEMI, nhi
mu c tim khng ST chnh ln; UA, au tht ngc khng n nh.
Hiu qua cua thuc cung c chng minh trong iu tr bnh nhn
STEMI (Lancet 2005;366:1607; N Engl J Med 2005;352:1179; JAMA
2005;294:1224).
TTP la mt tac dung phu him gp, va nn theo doi s lng tiu cu.
No a thay th ticlopidine mt cach rng rai (nguy c TTP giam bach cu
t hn). CHU Y: Mc du khang tiu cu kep la cn thit cho ACS va la bt
buc cho nhng bnh nhn c tin hanh PCI, vic kt hp cua ASA va
clopidogrel b chng ch nh nhng bnh nhn co TIA/CVA trc o
trong cac hng dn v t quy (Lancet 2004;364:331).
Prasugrel cung la mt tin cht, s chuyn hoa cua no thanh dang hoat ng
xay ra nhanh hn va mc rng hn clopidogrel.
Dn n tac dung c ch tiu cu nhanh hn, ln hn va ng nht hn khi
so sanh vi clopidogrel nhng lai co nguy c chay mau cao hn.
No lam giam nguy c t vong do CVD, MI, tai bin mach nao va huyt khi
trong stent cp so sanh vi clopidogrel nhng bnh nhn b ACS, bao gm

ca nhng bnh nhn STEMI.
No nn c s dung mt cach cn thn hay nn tranh s dung bnh nhn
gia hn 75 tui va nhng ngi nhe hn 60 kg. Thuc b chng ch nh
bnh nhn b t quy hoc TIA trc o.
Ch s dung trong chin lc iu tr xm ln ACS, va tt hn ch dung sau
khi bit ro giai phu mach vanh va bnh nhn c ln k hoach tin hanh
lam PCI.
Ticagrelor khng phai la tin cht, va v vy khng cn qua trnh chuyn hoa.
Giam nguy c t vong, MI, tai bin mach nao va huyt khi trong stent khi
so sanh vi clopidgrel bnh nhn ACS, gm ca bnh nhn STEMI (N Engl
J Med 2009;361:1045).
Ticagrelor so sanh vi clopidogrel co nguy c chay mau ln cao hn (khng
lin quan ti CABG).
Sau liu nap ASA, liu duy tr ASA phai di 100 mg (Circulation
2011;124:544).
Co th c dung trong ca 2 phac iu tr ca thn trong sm va xm ln sm
(ngay khi n vin hoc trong sut qua trnh PCI) (BMJ 2011;342:d3527).
S dung thuc c ch bm proton (proton pump inhibitorsPPIs) vi thuc
khang thu th P2Y12.
PPI nn c s dung bnh nhn cn dung ca ASA va khang thu th P2Y12
co tin s xut huyt tiu hoa va co th c xem xet nhng bnh nhn co tng
nguy c chay mau (v.d., nh ngi gia, loet da day hay nhim Helicobacter
pylori), va bnh nhn ang s dung wafarin, steroid hay NSAIDs (Circulation
2010;122:2619).
Cac nghin cu v dc ly a lam dy ln mi lo ngai v kha nng PPI
lam giam hiu qua cua clopidogrel. Tuy nhin, trong cac th nghim ngu
nhin, tin cu, khng co cac tng tac tim mach ang chu y gia PPIs va
clopidogrel (N Engl J Med 2010;363:1909).
Thuc c ch Glycoprotein IIb/IIIa (GPIIb/IIIa) (abciximab, eptifibatide,
hoc tirofiban) ngn chn s tng tac gia tiu cu va fibrinogen, do o tac ng
n cua con ng thng gp cui cung cua qua trnh ngng tp tiu cu (JAMA
2006;295:1531; Circulation 2001;104:2767; N Engl J Med 2009;360:2176).
Nhiu s liu v vic s dung thuc GPIIb/IIIa co t thi ky trc khi co
thuc c ch thu th P2Y12 va bivalirudin. Cac d liu hin tai noi chung ung
h nht cho vic s dung thuc bnh nhn co troponin dng tnh.
Thuc GPIIb/IIIa (da trn cac th ngim gn y) co li ch nht khi s dung
chon loc nhng bnh nhn nht nh:
Nhng bnh nhn cn iu tr b sung do thiu mau tim nng ln bt ky
thi im nao trc khi chup mach hay nh mt phn cua iu tr bao tn
thm ch khi bnh nhn a c iu tr vi clopidogrel va/hoc bivalirudin.
nhng bnh nhn Troponin dng tnh, dung thuc trong sut qua trnh
PCI (k ca khi bnh nhn a c dung clopidogrel trc o). S dung
thng qui thuc c ch GPIIb/IIIa bnh nhn iu tr xm ln ngay t
u a c iu tr vi clopidogrel (t nht 6 gi trc PCI) va bivalirudin
la khng cn thit k ca khi troponin dng tnh.
S dung mt cach thn trong trong sut qua trnh PCI khi co tn thng
mach vanh phc tap hay huyt khi mach vanh.
Nn tranh s dung thng quy thuc c ch thu th GPIIb/IIIa ngay t u,
trc khi chup mach, nhng bnh nhn c tip cn theo hng iu tr
xm ln do lam tng nguy c chay mau ln vi
S dung thng quy nhng bnh nhn a c iu tr bi thuc khang
tiu cu kep tr khi co ST chnh xung ang k, troponin dng tnh, im
TIMI >3 hoc ai thao ng.
S dung thng quy vi bivalirudin va clopidogrel.
Bnh nhn ang co tng nguy c chay mau.
Abciximab ch c dung trong sut qua trnh PCI, bt u khng sm hn 4
gi trc thu thut theo d nh.
Giam tiu cu, co th nguy him, la mt bin chng khng thng gp cua
cac thuc nay va nn dng thuc ngay.
Khang tiu cu va tnh thi gian tin hanh CABG
Do co s tng nguy c chay mau, hin nay khuyn cao dng s dung
clopidogrel t nht 5 ngay trc CABG va t nht 7 ngay i vi prasugrel.
Nn dng ticagrelor 3 n 5 ngay trc khi tin hanh CABGl; tuy nhin, do
chay mau lin quan n CABG co th khng tng ln, vic tnh thi gian/s
cn thit phai ngng thuc la khng ro rang.
Thuc c ch GPIIb/IIIa co thi gian ban thai trong huyt tng ngn, va do
o CABG ch b tr hoan 4 gi. Nhng thuc nay co th dung thay th cho
clopidogrel, ticagrelor, va prasugrel trong iu tr trc can thip (trc chup
mach) nhng bnh nhn thch hp b UA/NSTEMI ma cui cung se cn
phai tai ti mau bng phu thut.
Bin i ca th trong ap ng vi clopidogrel
S a hnh thai cua gen CYP2C19 i kem vi s giam c ch tiu cu va tng
nguy c cac bin c tim mach chnh nhng bnh nhn dung clopidogrel (N
Engl J Med 2009;360:354; N Engl J Med 2009;360:363).
Hoat ng cua CYP2C19 giam dn n suy giam qua trnh chuyn hoa
cua clopidogrel thanh dang hoat ng cua no. Mt khac, bnh nhn co alen
CYP2C17 manh, lam tng qua mc dang hoat ng.
Co th sang loc s khang clopidogrel bng cach s dung th nghim im c

ch tiu cu hay phn tch kiu gen.
Chin lc c xut trong trng hp khang clopidogrel gm dung liu
clopidogrel cao hn, hoc s dung thuc c ch thu th GPIIb/IIIa, hay s
dung prasugrel/ticagrelor. Prasugrel va ticagrelor hoat ng tiu cu co th
khng b anh hng ging nhau bi cac alen nay.
iu tr chng ng
Thuc iu tr hin co gm c ch thrombin gian tip (heparin khng phn
oan [unfractionated heparinUFH] va heparin trong lng phn t thp
[lowmolecular-weight heparinLMWH] enoxaparin), c ch thrombin trc
tip (bivalirudin), va c ch yu t Xa chon loc (fondaparinux) (Bang 411).
Chng ng cung vi liu phap tiu cu kep la bt buc vi tt ca nhng bnh
nhn UA/NSTEMI, du iu tr bao tn hay xm nhp.
UFH c truyn tnh mach lin tuc va thi gian Thromboplastin tng phn
(partial thromboplastin timesPTTs) phai c kim soat xac nh c
mc chng ng. So vi cac thuc khac, UFH co nguy c cao nht gy ra
giam tiu cu lin quan n heparin qua trung gian min dch (heparin-induced
thrombocytopeniaHIT). Do nguy c b HIT, nn tranh s dung keo dai UFH
(>48 gi).
LMWH rt d s dung (da vao cn nng, tim di da 2 ln/ngay), va v mc
PTT noi chung khng b anh hng nn khng cn phai theo doi. Nguy c HIT
la thp hn nhng khng phai khng co.
Khi so sanh vi UFH no co hiu qua chng ng d d oan hn.
No co hiu qua tng t nh UFH nhng no co nguy c chay mau cao
hn bnh nhn cung c iu tr vi thuc khang tiu cu kep (JAMA
2004;292:45).
Vi bnh nhn iu tr bao tn, enoxaparin c a dung hn UFH.
Fondaparinux c dung theo ng tim di da 1 ln/ngay va noi chung
khng anh hng n mc PTT, nn vic theo doi PTT la khng cn thit.
No khng gy ra HIT.
Khi so sanh vi enoxaparin, nghin cu a ch ra rng thuc i kem vi t
vong, MI hay thiu mau c tim dai dng t hn vi t nguy c chay mau ln
(N Engl J Med 2006;354:1464)
No co th c s dung nh mt phn cua chin lc bao tn hay xm ln.
Vi nhng bnh nhn c iu tr bao tn, fondaparinux c a dung hn
UFH.
Thuc i kem vi huyt khi lin quan n catheter, vy nn bnh nhn c
tin hanh PCI phai dung UFH ng thi.
Bivalirudin cung c dung ng truyn tnh mach lin tuc va co keo dai PTT.
Bng 411 Thuc chng ng
Thuc Liu Ch gii
Heparin (UFH) 60 U/kg bolus ng iu tr Heparin, khi s dng kt hp

tnh mch, vi ASA, c chng minh gim t l
(liu ti a 4000 U), t vong hoc MI sm n 60% (JAMA
1214 U/kg/gi 1996;276:811).
aPTT nn c iu chnh duy tr gi
tr gp 1,52,0 thi gian chng.
Enoxaparin 1 mg/kg tim di da 2 LMWH t nht cng c hiu qu ngang
(LMWH) ln/ngya bng UFH v c th gim hn na t
l t vong, MI hay au ngc ti pht
(N Engl J Med 1997;337:447).
LMWH c th tng t l chy mu
(JAMA 2004;292:45) v khng th
o ngc c trong bnh cnh
chy mu dai dng.
LMWH khng i hi phi theo di hiu
qu lm sng. Nu vic thng tim
c ln k hoch, nn dng liu
s dng vo bui sng tin hnh th
thut.
Fondaparinux 2,5 mg tim di da Hiu qu ca Fondaparinux tng
hng ngy t nh LMWH vi kh nng t l
chy mu thp hn (N Engl J Med
2006;354:1464).
Bivalirudinb 0,75 mg/kg bolus ng Khi s dng phi hp vi ASA v
tnh mch, 1,75 mg/ clopidogrel, bivalirudin t nht cng
kg/gi c hiu qu nh khi kt hp ASA,
UFH, clopidogrel v thuc c ch
th th GPIIb/IIIa vi t l chy
mu gim xung (N Engl J Med
2006;355:2203).
Cn kim sot aPTT mc tiu gp
1,52 ln thi gian chng
aLMWH nn c gim liu (50%) bnh nhn c creatinin huyt thanh >2 mg/dL hoc GFR <30 mL/pht.
bBivalirudin i hi phi chnh liu bnh nhn GFR <30 mL/pht hoc nhng bnh nhn lc mu
nhn to.
aPTT, thi gian hot ha thromboplastin tng phn; ASA, aspirin; GFR, mc lc cu thn; GP, glycoprotein;
LMWH, heparin trng lng phn t thp; MI, nhi mu c tim; UFH, heparin khng phn on.
No khng gy ra HIT va c s dung trong iu tr nhng bnh nhn tin

trin HIT hoc nhng bnh nhn b ACS co tin s b HIT.
Bivalirudin co th c dung kt hp vi ASA va clopidogrel bnh nhn co
UA/NSTEMI, nhng ngi se sm c thc hin can thip. No cha c
nghin cu cho vic s dung trong iu tr bao tn.
Bivalirudin vi khang tiu cu kep co hiu qua tng t nh kt hp UFH/
LMWH vi thuc c ch GPIIb/IIIa nhng co t nguy c chay mau hn (N
Engl J Med 2006;355:2203).
iu tr tan huyt khi khng c ch nh trong au tht ngc khng n
nh/NSTEMI.
iu tr chng thiu mau cuc b (xin tham khao thm muc iu tr phn au
tht ngc n nh)
Nitroglycerin
iu tr co th khi u ngay khi bnh nhn n vin vi nitroglycerin di
li. Chu y rng, 40% bnh nhn au ngc khng phai do CAD cung se
giam triu chng khi dung nitroglycerin (Bang 412) (Ann J Intern Med
2013;139:979).
Triu chng thiu mau tip din bnh nhn hay nhng ngi oi hoi phai
dung thm thuc kim soat tng huyt ap ang k co th c iu tr vi
nitroglycerin tnh mach cho n khi giam au, kim soat c huyt ap hay
at c ca 2.
Phai loai tr MI tht phai trc khi cho nitrat v no co th gy ra ha ap huyt
nng.
Thuc chen giao cam (-Adrenergic blockersBBL) (xin tham khao thm
muc iu tr phn au tht ngc n nh)
Nn c s dung sm nu khng co chng ch nh.
iu tr ng tnh mach nn danh cho iu tr loan nhp, au ngc tip din
va tng huyt ap nng hn la s dung thng quy.
Muc tiu iu tr la giam nhp tim n 60 va duy tr huyt ap tm thu (systolic
blood pressureSBP) hn 90100 mm Hg.
Chng ch nh dung chen gm block nh tht nng, co tht ph quan hoat
ng, suy tim mt bu, shock tim, ha ap va nhp chm.
Thuc chen knh Canxi (xin tham khao thm muc iu tr phn au tht ngc
n nh) co th c s dung nh la chon th 3 bnh nhn vn tip tuc au
ngc sau khi a s dung u thuc chen va nitrate.
Nifedipin, amlodipin, diltiazem, va verapamil co ve co li ch gian mach vanh
tng t nhau. Khng co thuc nao trong s cac thuc nay co hiu qua v t
vong hay MI tai phat.
Diltiazem va verapamil co th lam cung lng tim tr nn ti hn.
Bng 412 Thuc chng au tht ngc
Thuc Liu Nhn xt
Nitroglycerin Di li: 0,4 mg mi Hiu qu chng au ngc ng k khng

(NTG) 5 pht thy liu trn 200 mcg/pht, nhng
Ti ch: 0,52 liu n 400 mcg/pht c th c s
Tnh mch: 10200 dng kim sot huyt p.
mcg/pht NTG b chng ch nh bnh nhn c s
dng c ch PDE5 (v.d., dng sidenafil
trong vng 24 gi hoc tadalafil trong
vng 48 gi) v c nguy c gy tng
huyt p nng. Thi hn thch hp
dng vardenafil vi nitrat cha c bit
r v nn trnh.
Nitrat b chng ch nh tng i bnh
nhn b ph thuc tin gnh, gm nhng
ngi b hp ch nng hay bnh nhn
bnh c tim ph i tc nghn.
Morphin 24 mg tnh mch Narcotics ng tnh mch l thuc hiu
qu trong gim triu chng au ngc v
nn c s dng nu NTG khng lm
gim hon ton triu chng hoc khng
th c chnh liu thm na do h p
hoc au u.
Chn giao 25 mg ng ung Chn giao cm lm gim nguy c thiu
cm Bisoprolol: 1020 mg mu ti pht, MI v t vong bnh
ung hng ngy nhn au tht ngc khng n nh/
Carvedilol: 3,12525 MI khng ST chnh (J Interv Cardiol
mg ung 2 ln/ 2003;16:299). Hiu qu ca chn beta
ngy b hn ch bi s tin trin ca sc
Atenolol: 50200 mg tim. Nhng bnh nhn c nguy c bao
ung 2 ln/ngy gm nhng ngi >70 tui, SBP<120
Propranolol: 20 mm Hg v nhp tim >110 hay <60.
80mg 2 ln/ngy Trong nhng trng hp ny, c th s
Esmolol: 50300 dng mt cch thn trng cc thuc
mcg/kg/pht ng ung vi liu gim i (Lancet
Nebivolol: 540mg 2005;366:1622).
ung hng ngy
(cn tip)
Bng 412 Thuc chng au ngc (Tip theo)
Thuc Liu Nhn xt
Chn knh canxi Nifedipin: 30180 mg Nn trnh dng nifedipin tc dng ngn
hng ngy bnh nhn khng c iu tr ng thi
Amlodipin: 510 mg vi chn giao cm do tng nguy c MI
hng ngy v t vong.
Diltiazem: 3080 mg Nn trnh s dng Verapamil v Diltiazem
4 ln/ngy nhng bnh nhn c bng chng ri
Verapamil: 80160 lon chc nng tht tri nng, sung
3 ln/ngy huyt phi hay block nh tht
MI, nhi mu c tim; NSTEMI, nhi mu c tim khng ST chnh ln; SBP, huyt p tm thu.
Cac thuc khac

c ch men chuyn (xin tham khao muc iu tr phn au tht ngc n nh)
la thuc ha huyt ap hiu qua va cho thy giam t vong bnh nhn b CAD
va ri loan chc nng tm thu tht trai. Thuc c ch men chuyn nn c s
dung bnh nhn ri loan chc nng tm thu tht trai (EF <40%), tng huyt
ap hoc ai thao ng co ACS. Thuc chen thu th angiotensin (ARBs
angiotensin receptor blockers) phu hp vi nhng bnh nhn khng dung nap
c ACEI (N Engl J Med 2003;349:1893).
Khang aldosteron nn c thm vao nu khng co chng ch nh (kali>5
mEq/L hay thanh thai Creatinin <30 mL/phut) sau khi bt u bng ACEI
cho bnh nhn ai thao ng hoc EF tht trai <40%.
Thuc c ch enzym HMGCoA reductase (statin) la thuc giam lipid mau
lam giam ty l mi mc thiu mau c tim, MI va t vong nhng bnh nhn b
CAD. Statin liu cao nn c dung mt cach thng quy trong vong 24 gi t
khi n vin cho nhng bnh nhn b ACS. Nn xet nghim lipid mau tt ca
cac bnh nhn.
iu tr statin lam giam tac dung phu thng qua vic giam lipid mau va co th
la thng qua tac ng nhiu hng (tac dung chng vim/n nh mang x va)
iu tr statin tch cc giam nguy c thiu mau c tim tai phat, MI va t vong
nhng bnh nhn b ACS (JAMA 2001;285:1711).
Quan sat thy s giam hu qua cua AVD do bt u liu cao statin sm vi
vic at c nng LDL t hn 70 mg/dL trong 30 ngay k t khi co triu
chng ACS (N Engl J Med 2004;350:1495). Ha LDL tch cc cung lam giam
ty l mi mc MI quanh thu thut PCI (JACC 2007;49:1272).
NSAIDs cung i kem vi tng nguy c t vong, MI, thung thanh tim, tng
huyt ap, va suy tim cac nghin cu phn tch tng hp ln (Circulation
2006;113:1906). Quan sat thy co tac dung phu ca nhom dung thuc chon loc
COX 2 ln thuc khng chon loc.
Nn ngng NSAIDs nhng bnh nhn UA/NSTEMI.
Acetaminophen la thuc thay th chp nhn c trong iu tr bnh loang
xng hay cac au c xng khp khac.
Cac iu tr khng dung thuc khac
Truyn mau cai thin kha nng mang oxy va s cung cp oxy cho c tim. Li
ch tim tang cua vic truyn mau thng quy cho bnh nhn NSTEMI da trn
cac s liu lm sang han ch (N Engl J Med 2001;345:1230).
Muc tiu hemoglobin va hematocrit c khuyn cao tng ng la 10 mg/
dL va 30%.
Bnh nhn co UA/NSTEMI ang chay mau va/hoc thiu mau nng nn c
truyn mau mt cach thng quy.
Liu php khc ngoi ni khoa
Tai thng mach
Ch nh lam PCI va CABG nhng bnh nhn UA/NSTEMI ging vi nhng
bnh nhn au tht ngc n nh man tnh (xin xem phn tai thng mach vanh
trong au tht ngc n nh man tnh).
Nhng bnh nhn c iu tr vi CABG mt cach ti u bao gm nhng
bnh nhn co
CAD thn chung ng mach vanh trai nng
Bnh 3 ng mach vanh co ri loan chc nng tht trai
Bnh 2 ng mach vanh vi hep ang k oan gn ng mach LAD nng
va bnh phc tap
ai thao ng hay bnh nhiu mach
Bnh nhn b bnh nhiu nhanh mach vanh cn tai thng mach co th c
iu tr bng CABG hoc PCI. Bnh nhn c iu tr bng CABG co xu
hng t cn tai thng sau nay nhng lai tng nguy c t quy. Li ch v
mt sng con cua CABG so sanh vi PCI cung phu thuc vao im Syntax.
Trong khi iu tr c a dung hn trong bnh thn chung ng mach vanh
trai khng c bao v vn la CABG, vn co vai tro cua PCI (Circulation
2008;118:1146; N Engl J Med 2009;360:961).
Quyt nh gia dung PCI hay CABG nn da trn mc rng va phc
tap cua bnh mach vanh, cac bnh i kem va la chon cua bnh nhn.
Nu nh khng chc chn v anh hng huyt ng cua tn thng mach vanh,
co th tin hanh o FFR nh lng mc nng v mt chc nng cua s
han ch lu thng mau. Phng phap nay c cho thy la lam giam t vong,
MI tai phat hay tai thng mach so vi PCI thng thng thi im sau 1
nm nhng bnh nhn tn thng nhiu nhanh mach vanh (N Engl J Med
2009;360:213).
Stent boc thuc (Drug eluting stentsDES) lam giam ang k ty l ISR va vai
hu qua ln tim so vi stent kim loai thng (bare metal stentsBMS) (N Engl J
Med 2003;349:1315; Circulation 2003;108:788). Tuy nhin DES co tng nguy
c huyt khi trong stent mun, chu yu la do ngng sm clopidogrel trong 1
nm sau khi t stent (JAMA 2007;297:159).
GIM ST/THEO DI
Ty l cao nht cua tin trin thanh MI hay tai phat MI la trong 2 thang u sau biu
hin cua t bnh. Sau thi gian nay, phn ln bnh nhn co triu chng lm sang
ging nh nhng bnh nhn b au ngc n nh man tnh.
Bnh nhn nn c xut vin trong khi dung cac thuc khang tiu cu, chen
giao cam va statin c khuyn cao trn.
Phn ln bnh nhn nn c dung ACEI khi ra vin.
anh gia nhu cu s dung thuc li tiu khang aldosteron.
Tm soat cac yu t stress va nguy c trm cam cua bnh nhn. Gi chuyn khoa
iu tr trm cam nu cn.
Cn nhn manh tm quan trong cua bo thuc la va iu chnh cac yu t nguy c.
Gi kham chuyn khoa phuc hi chc nng tim mach.
Nhi mu c tim ST chnh ln
I CNG
Nhi mau c tim co ST chnh ln la mt cp cu ni khoa do tc nghen hoan toan
ng mach vanh thng tm mac cp tnh, hu ht la do nt v/loet mang x va
va sau o tao thanh huyt khi.
So sanh vi UA/NSTEMI, STEMI co ty l mc bnh va t vong trong thi gian
nm vin va trong 30 ngay cao hn. Nu khng iu tr, ty l t vong cua STEMI
co th vt qua 30% va s co mt cua cac bin chng c hoc (t c nhu, thng
lin tht [ventricular septal defectVSD], v thanh t do c tim) lam tng ty l t
vong ln ti 90%. Trong vai thp ky va qua, s tin b vt bc trong vic cai
thin ty l t vong ngn han xung ty l hin tai la 610%.
Rung tht la nguyn nhn gy t vong khoang 50% trng hp va thng xut
hin trong vong vai gi k t khi khi phat triu chng.
im mu cht trong vic iu tr STEMI gm nhn bit va chn oan nhanh
chong, s hp tac vn chuyn gia cac ngun lc chm soc sc khoe va tin hanh
tai ti mau kp thi.
Nhi mu c tim ST chnh ln l 179
T vong lin quan mt cach trc tip n tng thi gian thiu mau.
D phng
Phong nga th phat. Cac chin lc c vach ra cho vic phong nga tin phat
va iu tr au tht ngc n nh a cho thy lam giam ty l tai nhi mau, tin trin
n suy tim va ty l mi mc t vong do tim mach bnh nhn co CAD a c
chn oan (xem cac phn pha trc).
CHN ON
Biu hin lm sng
Nhiu cng cu anh gia nguy c a c phat trin phn tng bnh nhn vao
vin v STEMI cp thanh nhom nguy c thp, trung bnh va cao da trn bnh s,
kham lm sang va theo doi huyt ng (Hnh 44).
H thng phn loai Killip s dung bnh s va kham lm sang (co ting nga
phi S3, sung huyt phi va shock tim) d oan ty l t vong trong 30 ngay
khi khng iu tr tai ti mau (Am J Cardiol 1967;20:457). Ngc lai, im
nguy c TIMI cho STEMI phi hp gia bnh s va kham lm sang d oan
ty l t vong trong 30 ngay cua nhom bnh nhn co iu tr tiu huyt khi
(Circulation 2000;102:2031). H thng phn loai Forrester s dung thng s
huyt ng xm nhp gm ch s tim, ap lc mao mach phi bt (N Engl J Med
1976;295:1356).
Bnh s
au ngc trong STEMI ging nh au tht ngc, nhng keo dai hn, nng hn
va khng giam khi ngh ngi hay dung nitroglycerin ng di li. Ngoai cam
giac kho chu ngc, bnh nhn con co th co kho th, va m hi, trng ngc,
nn, bun nn, mt moi va/hoc ngt i kem.
Bt buc phai xac nh thi im khi phat triu chng, v iu nay rt quan trong
trong vic quyt nh phng phap tai ti mau (Bang 413).
STEMI co th co biu hin khng in hnh, c bit phu n, ngi gia va
nhng bnh nhn sau phu thut, cung nh nhng ngi b ai thao ng hay
bnh thn man hoc bnh thn giai oan cui. Nhng bnh nhn nay co th co
triu chng khng in hnh hay khng au ngc va thay vao o, co th co biu
hin l m, kho th, ha huyt ap khng giai thch c, hay suy tim.
Nu bnh nhn co tin s thng tim hoc tai thng mach mau trc o, vic thu
thp cac giy t v cac thu thut nay la ht sc quan trong, v chung co th cung
cp nhng thng tin co gia tr trong vic ln k hoach tin hanh PCI, c bit la
trong trng hp bnh nhn a lam CABG trc o. Tuy nhin vic nay khng
nn lam tr hoan bin phap iu tr trit .
50
T vong tai thi im 30 ngay (%)
40
30
20
10
0
01 2 3 4 5 6 7 8 >8
im TIMI
im nguy c TIMI im
1. Tui 65-74 2
2. Tui >75 3
3. ai thao ng, HTN va au tht ngc 1
4. BP tm thu <100 3
5. Nhp tim >100 2
6. Killip II-IV 2
7. STEMI trc vach hay LBBB 1
8. Thi gian tai ti mau >4 gi 1
9. Cn nng <67 kg 1
Phn Killip nh ngha Ty l cht (%)
I Khng co du hiu cua suy tim tin trin 6
II Co S3 hay ran phi 17
III Phu phi 3040
IV Shock tim 6080
Hnh 44. Cac ch s nguy c cho nhi mau c tim ST chnh ln. Phn loai Killip trong MI cp.
Pha trn. Thang im nguy c TIMI cho STEMI (Circulation 2000;102:2031). Pha di.
H thng phn loai Killip (Am J Cardiol 1967;20:457). Thang im nguy c TIMI kt hp tin
lng sau tai ti mau mach vanh vi bin phap iu tr huyt khi. H thng phn loai Killip
c phat minh trc khi liu phap tai ti mau c s dung mt cach thng quy. BP, huyt
ap; HTN (hypertension), tng huyt ap; LBBB, block nhanh trai.
Bng 413 Thng tin mu cht ca nhng bnh nhn b STEMI
Cc gi tr
Bnh s v thm khm cn lm sng Bn ghi
Hi thi gian khi pht au tht ngc Tng phn tch in tm

chnh xc t bo mu trc
Xem xt cc nguyn nhn khc gy au Ha sinh c bn t catheter tim
ngc c ST chnh ln (v.d., lc tch ln cui cng
ng mch ch, s dng cocain)
Xc nh cc chng ch nh tuyt i v PTT, PT v INR Bo co chun b
tng i ca PCI v tiu huyt khi m CABG
nh gi du hiu suy tim, bin chng Men tim Siu m trc o
c hc ca MI, lc tch ng mch
ch, v bnh thn kinh.
CABG: bc cu ni ng mch vnh; INR (international normalized ratio), t s chun ha quc t; MI,
nhi mu c tim; PCI, can thip ng mch vnh qua da; PT (prothrombin time), thi gian prothrombin;
PTT (partial prothrombin time), thi gian prothrombin tng phn; STEMI, nhi mu c tim ST chnh ln.
anh gia cac chng ch nh tuyt i va tng i cua iu tr tiu huyt khi
(xem phn tip theo) va cac vn tim tang co th gy ra bin chng khi tin
hanh PCI th u (d ng thuc can quang ng tnh mach, tai thng mach ngoai
bin/bnh ng mach ngoai bin, ri loan chc nng thn, bnh thn kinh trung
ng [central nervous systemCNS], co thai, chay mau tang hoc cac bnh nng
kem theo).
Hoi v tin s s dung cocain gn y. Trong trng hp nay, nn xem xet iu
tr ni khoa tch cc bng nitroglycerin, thuc gian mach vanh, va benzodiazepin
trc khi tin hanh cac bin phap tai ti mau.
Khm thc th
Kham lm sang nn hng ti vic xac nh s bt n v huyt ng, sung huyt
phi, cac bin chng c hoc cua MI va cac nguyn nhn khac co th gy au ngc.
Ting thi tm thu mi xut hin co th gi y MR thiu mau hoc VSD.
Thm kham thn kinh mt cach gii han anh gia nhn thc c ban cua bnh
nhn va nhng thiu hut v vn ng va kham mach (mach chi di va ting thi)
se h tr s vic xac nh nhng i tng thch hp va vic ln k hoach iu
tr tai ti mau.
Co th nghi ng b shock tim do MI tht phai (right ventricular myocardial
infarctionRVMI) trn lm sang khi co ha huyt ap, tng ap lc tm mach c ma
khng co sung huyt phi. Co th thy MI tht phai n c, shock tim thng la
bin chng cua MI thanh sau/thanh di hn.
Nn o BP 2 tay anh gia xem co loc tach ng mach chu hay khng.
Tiu chun chn on
Chn oan STEMI va s bt u iu tr c tin hanh nhng bnh nhn co kho
chu ngc keo dai hoc au tht ngc tng ng vi bin i in tm u tiu
chun. C gng ch kt qua cac marker sinh hoc cua tim la s tr hoan khng cn
thit. Bin i in tm bao gm ST chnh ln 2 chuyn ao k nhau, LBBB
mi xut hin, hay bng chng cua MI thanh sau (xem phn in tm ).
Test chn on
Xt nghim
Xet nghim mau nn lam cac men tim (Troponin, CKMB), tng phn tch t bao
mau, xet nghim ng mau (PTT, thi gian prothrombin, INR), creatinin, in giai
gm ca magie, nh loai va sang loc. M mau khi oi nn c lam tt ca cac
bnh nhn STEMI phong bnh th phat (tuy nhin cn chu y rng nng lipid
co th se ha thp mt cach gia tao trong pha cp cua MI).
Xet nghim men tim luc u (gm ca Troponin) co th bnh thng, phu thuc
vao thi gian t khi bt u co triu chng. Myoglobin se la enzyme tng u tin.
CK-MB co th c s dung khng nh tn thng c tim xut hin trong
vong 48 gi, v nng Troponin co th vn tng trong vong vai ngay sau MI.
Nguy c t vong do tim sau o ty l trc tip vi mc tng troponin c hiu tim,
thm ch khi nng CKMB khng tng. o men tim n khi at c mc
nh c lng kch thc vung nhi mau.
Vic s dung thng quy cac phng phap chn oan hnh anh tim khng xm
nhp khng c khuyn cao cho vic chn oan ban u STEMI. Khi chn
oan con nghi ng, co th thc hin siu m tim qua thanh ngc (transthoracic
echocardiogramTTE) phat hin bt thng vn ng vung thanh tim. Nu
TTE khng anh gia c mt cach y u, co th tin hanh siu m tim qua thc
quan (transesophageal echocardiogramTEE) anh gia cac bin chng cp
tnh cua MI va s co mt cua loc tach ng mach chu.
Phim chup ngc tai ging la hu ch trong vic anh gia phu phi cp hay anh
gia cac nguyn nhn gy au ngc khac bao gm loc tach ng mach chu. Mt
iu quan trong la rng trung tht bnh thng cung khng loai tr c loc
tach ng mach chu, c bit khi lm sang nghi ng.
in tm
in tm ong vai tro quan trong nht trong chn oan STEMI va nn c lam
trong vong 10 phut k t khi bnh nhn n vin. Nu chn oan STEMI con nghi
ng, in tm hang loat co th giup lam sang to chn oan. Cac biu hin kinh
in gm (Bang 414):
nh song T cao nhon la du hiu u tin in tm cua tn thng tim.
oan ST chnh ln tng xng vi vung c tim tn thng (Hnh 45).
Tiu chun chn oan STEMI trn in tm (JACC 2009;53:1003)
Khi ST chnh ln cham ngng gia tr 2 hay nhiu chuyn ao lin tip v giai
phu th co th a ra chn oan STEMI.
bnh nhn nam >40 tui, gia tr ngng cua ST chnh ln bt thng tai im
J la 2 mm chuyn ao V2 va V3 mm, va >1 mm tt ca cac chuyn ao
khac. bnh nhn nam <40 tui, gia tr ngng cua ST chnh ln chuyn ao
V2 va V3 la >2,5 mm.
bnh nhn n, gia tr ngng bt thng cua s chnh ln cua ST tai im J
la 1,5 mm V2 hay V3 va >1 mm tt ca cac chuyn ao khac.
cac chuyn ao tim phai (V3R va V4R), ngng bt thng cua s chnh ln
cua ST tai im J la 0,5 mm, ngoai tr nam gii <30 tui la 1 mm. Nn lam cac
chuyn ao tim phai tt ca nhng bnh nhn co bng chng thiu mau c tim
thanh di loai tr thiu mau c tim tht phai. Nhi mau c tim tht phai
co th xay ra vi tn thng oan gn ng mach vanh phai (right coronary
arteryRCA).
cac chuyn ao pha sau (V7, V8 va V9), ngng bt thng cua s chnh ln
cua ST tai im J la 0,5 mm.
Bng 414 Phn b gii phu da trn in tm
ST chnh Vng c tim ng mch vnh
VV hay LBBB Thnh trc hay vch on gn LAD hay thn chung
ng mch vnh tri
VV Vch lin tht on gn LAD hay nhnh vch
lin tht
VV Thnh trc LAD
VV Thnh bn LCX
II, III, aVF Thnh di RCA hoc LCX
I. aVL Thnh bn cao on gn hay on chch ca
LCX
LAD, ng mch lin tht trc; LBBB, block nhnh tri; LCX (left circumflex artery), ng mch m tri;
RCA, ng mch vnh phi.
ST chnh ln mi
Sc tim xut hin hoc
(STEMI) tai phat
PCI cu
Khi phat sm Khi phat mun
van
tai thi im n vin sau khi tai ti mau
Siu m tim
IABP
Thuc
Chup mach ng vn Chc nng Tran dch mang Bin chng
tht trai kem ngoai tim gy c hoc
chn oan
WMA mi ep tim
TEE, CT, Thuc n nh, IABP,

hay MRI thuc ng vn
V thanh tim
gia phnh
Choc dch Phu thut

mang ngoai tim cp cu
Thn chung Tc 3 nhanh Tc 3 nhanh Tc 1-2 nhanh Khng co

vanh trai nng trung bnh tn thng mi
CABG CABG PCI PCI IABP hay ep tim
PCI1 PCI1 h tr, theo doi
huyt ng
Nu khng cai
thin th t thit
b h tr tht trai
hay ghep tim2
Hnh 45. Chin lc chn oan va phac iu tr bnh nhn STEMI va shock tim c
khuyn cao. 1PCI co th thch hp hn nu CABG khng co sn hoc nu phu thut phai i
mt vi nguy c khng th chp nhn c. 2Co th cn phai co cac phng phap iu tr tim
nng cao gm thit b h tr tht trai qua da (TandemHeart, Impella), thit b h tr tht t
bn ngoai, va tim phi nhn tao (ECMOextracorporeal membrane oxygenation) trc khi t
thit b h tr tht trai vnh vin hay ghep tim. CABG, bc cu ni ng mach vanh; CT, chup
ct lp vi tnh; IABP (Intraaortic ballon pump), bm bong trong long ng mach chu; LVAD
(lefft ventricular assist device), thit b h tr tht trai; PCI, can thip ng mach vanh qua
da; STEMI, nhi mau c tim co ST chnh ln; TEE, siu m tim qua thanh ngc; WMA, bt
thng vn ng thanh tim.
Tt ca bnh nhn co ST chnh xung V1 n V3, ST chnh ln thanh

di hay song R cao V1 n V3 nn lam cac chuyn ao pha sau chn
oan MI thanh sau. STEMI thanh sau thng do tc nghen ng mach mu va
thng b chn oan nhm thanh UA/NSTEMI. Song R V1 hay V2 ai din
cho song Q thanh sau.
Thiu mau ng mach mu co th khng co thay i g trn in tm .
S co mt cua ST chnh xung tng ng vung i din vi vung nhi mau
lam tng c hiu cua MI cp.
Block nhanh trai mi. Gi y nhi mau c tim thanh trc rng vi tin
lng ti.
Tiu chun in tim cua STEMI bnh nhn co LBBB t trc hay a iu
tr may tao nhp c trnh bay trong Bang 415. Cac tiu chun pha trn
khng c ap dung trong trng hp nay.
Song Q. S tin trin cua song Q bnh ly mi c xem nh tiu chun chn
oan MI xuyn thanh hoc tun hoan bang h ngheo nan. Ch s co mt cua
song Q khng phai la ch nh cua tai ti mau cp, tuy nhin, vic co mt
in tm cu so sanh la rt hu ch trong vic xac nh tnh man tnh. Tiu
chun chn oan gm:
chuyn ao V2 va V3, song Q bnh ly la song 0,02 giy hoc phc b
QS V2 hay V3. Song Q n c chuyn ao V1 hay V3 la bnh thng.
cac chuyn ao khac ngoai V1 n V3, co song Q 0,03 giy va su 0,1
mV hay co phc b QS bt ky 2 chuyn ao lin tip nao gi y MI co t
trc.
Song R 0,04 giy V1 va V2 va ty l R/S 1 vi song T dng gi y MI
thanh sau co t trc (khi khng co RVH hay block nhanh phai [right bundle
branch blockRBBB]).
Tiu chun ST chnh ln bnh nhn c LBBB trc hay bnh

Bng 415
nhn t my to nhp
Thay i in tm
ST chnh ln hn 1 mm bnh nhn c phc b QRS dng (ng hng vi QRS)

ST chnh ln hn 5 mm bnh nhn c phc b QRS m (khng ng hng vi QRS)
ST chnh xung hn 1 mm V1V3
LBBB, block nhnh tri.

Tiu chun Sgarbossa (GUSTO): Am J Cardiol 1996;77:423; N Engl J Med 1996;334:481; PACE
2001;24:1289.
Bng 416 Chn on phn bit ca ST chnh ln
Cc nguyn nhn tim mch Cc nguyn nhn khc

MI t trc vi s hnh thnh phnh mch Huyt tc ng mch phi
Lc tch ng mch ch lan n ng mch vnh Tng kali mu
Vim mng ngoi tim
Vim c tim
Ph i tht tht tri hay hp ng mch ch (co tht)a
Bnh c tim ph i
Co tht mch vnh (au tht ngc do cocain, prinzmetal)
Ti cc sm (bin i bnh thng)
Hi chng Brugada
aCo tht c th xut hin trong nhiu trng hp gm tng huyt p h thng, h huyt p, nhp nhanh,
luyn tp v nhim trng huyt.

MI, nhi mu c tim.
Thay i in tim ging nhi mau c tim. ST chnh ln va song Q co th do

nhiu nguyn nhn khac ngoai nhi mau c tim cp, bao gm nhi mau c tim t
trc o vi s hnh thanh phnh mach, loc tach ng mach chu, ph ai tht trai,
vim mang ngoai tim, vim c tim, huyt tc ng mach phi, hoc co th la mt
du hiu bnh thng (xem Bang 416). Vic co c in tm trc o la rt
quan trong lam ro chn oan.
IU TR
Trc khi n bnh vin. Ca cng ng nn c thng bao v cac du hiu va
triu chng cua nhi mau c tim hng dn ho tm n s chm soc v y t
khn cp. S sn co cua s in thoai cp cu va cac dch vu y t cp cu a tao
thun li cho vic vn chuyn bnh nhn n cac c s cp cu d dang.
X tr cp. Nn bt u iu tr nhanh chong ngay khi nghi ng chn oan
STEMI, v t vong va nguy c suy tim sau o lin quan trc tip n thi gian
thiu mau (Hnh 46).
Tt ca trung tm y t nn co va s dung phac iu tr STEMI da trn cac
khuyn cao cua Hi tim mach Hoa Ky/Trng Tim mach Hoa Ky (American
Heart Association/American College of CardiologyAHA/ACC). Nhng trung
tm khng co PCI th u nn co cac phac phu hp trong khoang thi gian
c chp nhn cho vic s dung cac liu phap iu tr trong hng dn, hoc la
nhanh chong chuyn bnh nhn n ni co th lam PCI hay lam tiu huyt khi
ri sau o chuyn n trung tm PCI.
khoa cp cu, nn kch hoat phac iu tr MI cp bao gm vic hoan thanh
100
80
Giam ty l t vong (%)
60
40
20
0
0 4 8 12 16 20 24
Thi gian n khi c tai ti mau (gi)
Khi phat triu chng

5 phut
n EMS
10 phut
n phong cp cu
10 phut
in tm : STEMI
90 phut 30 phut
PCI Tiu huyt khi
Hnh 46. Li ch cua tai ti mau ng mach vanh lin quan ngc vi thi gian thiu mau.
Pha trn. Biu biu hin li ch v t vong cua tai ti mau mach vanh theo thi gian thiu
mau. Pha di. Khung thi gian c khuyn cao v cac hanh ng sau khi phat au ngc
theo hng dn cua AHA/ACC (Circulation 2008;117:296). ACC/AHA, Trng Tim mach
Hoa Ky/Hi tim mach Hoa Ky; EMS (emergency medical service), dch vu cp cu y t; PCI,
can thip ng mach vanh qua da; STEMI, nhi mau c tim ST chnh ln.
thm kham lm sang co muc tiu va in tm 12 chuyn ao trong vong 10

phut k t khi bnh nhn n vin.
iu tr ngay lp tc. Muc ch cua iu tr ngay lp tc nhng bnh nhn
STEMI la xac nh nhng ngi phu hp cho iu tr tai ti mau va ngay lp
tc bt u qua trnh nay. Cac u tin khac gm giam au do thiu mau, cung nh
nhn bit va iu tr ha huyt ap, phu phi va ri loan nhp.
Nhng bin phap chung

Nn b sung oxy nu nh bao hoa <90%. Nu cn thit, s dung thng kh
nhn tao giam cng h hp va giam nhu cu oxy c tim.
Nn t 2 ng truyn tnh mach ngoai bin trn ng chuyn ti.
Nn lam in tm hang loat nhng bnh nhn khng co ST chnh ln trong
cac in tm u tin nhng co au ngc lin tuc bi ho co th co MI. Kim
soat t xa cac ri loan nhp.
Thuc
iu tr thuc ban u nn gm ASA va thuc chng ng, cung nh cac thuc lam
giam thiu mau c tim (Bang 417).
Nn dung ASA nhai 162325 mg ngay lp tc tt ca cac bnh nhn nghi ng MI
cp, 325 mg c dung cac bnh nhn mi dung ASA. Sau PCI, liu tip theo
cua ASA la 81 mg/ngay la chp nhn c va nn c dung mt cach v han
nh (Eur Heart J 2009;30:900).
Nn dung liu nap cua thuc c ch P2Y12 cho tt ca cac bnh nhn STEMI,
nh mt phn cua iu tr khang tiu cu kep, ngay khi co th sau khi bnh nhn
n vin. Co th xem xet n gia thanh va nguy c chay mau khi la chon thuc.
Xin tham khao phn khang tiu cu bnh nhn UA/NSTEMI v thng tin c ban
v cac thuc nay c lit k di y.
Nu bnh nhn phai iu tr tiu si huyt, cung vi ASA va thuc chng ng,
bnh nhn nn dung thm
Clopidogrel liu nap 300 mg nu c dung trong 24 gi u iu tr, con nu
c dung sau 24 gi sau khi tiu si huyt, liu nap 600 mg c a dung
hn. Liu duy tr la 75 mg/ngay.
Khng nn dung liu nap cho bnh nhn trn 75 tui.
Nu bnh nhn chun b c lam PCI, mt trong cac thuc sau nn c thm
vao cung ASA va chng ng:
Clopidogrel liu nap 600 mg, sau o 75 mg mi ngay trong 12 thang. Co th
cho trc khi chup mach chn oan
Prasugrel liu nap 60 mg, sau o 10 mg mi ngay trong t nht 12 thang
(chng ch nh bnh nhn co tai bin mach nao trc o va tranh dung
nhng ngi >75 tui va cn nng <60 kg). Nhn chung nn dung prasugrel
sau chup mach chn oan (hoc trong vong 1 gi cua PCI) khi chc chn rng
bnh nhn khng cn lam phu thut CABG v thuc co ty l mi mc chay
mau lin quan n phu thut cao hn clopidogrel (Lancet 2009;373:723).
Ticagrelor liu nap 180 mg, sau o 90 mg 2 ln/ngay (CHU Y: liu duy tr
ASA ch la 81 hay 100 mg mi ngay) trong ti thiu 12 thang. Co th dung khi
nhp vin. No khng i kem nguy c cao hn chay mau lin quan n CABG;
Bng 417 Thuc ban u cho nhi mu c tim ST chnh ln
Thuc Liu Ch gii
ASA 162325 mg Dng bao vin (nhai hay dng tn) khng tan
trong rut dng ng ung hay t trc trng
to thun li cho s hp thu thuc v c ch
tiu cu.
Clopidogrel 600 mg liu 600 mg liu np, sau dng liu 150 mg trong
np, 75150 7 ngy c th lm gim t l mi mc huyt
mg hng khi trong stent v MI khi so snh vi iu tr
ngy tiu chun vi liu np tiu chun 300 mg v
liu duy tr 75 mg.
Thn trng khi s dng ngi gi v cc th
nghim lm sng nh gi vic s dng
clopidogrel cho bnh nhn STEMI hoc khng
bao gm ngi cao tui hoc khng s dng
liu np.
Prasugrel 60 mg liu np, So vi clopidogrel, prasugrel tc ng nhanh hn
10 mg hng v kh nng khng tiu cu ln hn vi hiu
ngy qu c ci thin nhng li lm tng ng k
t l chy mu trong CABG.
Khng nn dng prasugreo cho bnh nhn trn
75 tui, t hn 60 kg, hay vi tin s t qu/
TIA.
Ticagrelor 180 mg liu Liu ASA khng nn qu 100 mg. Ticagrelor
np, sau cho thy li ch ci thin t l t vong hn
90 mg 2 ln/ clopidogrel nhng li c t l chy mu cao
ngy hn.
Heparin khng 60 U/kg ng UFH nn c ch nh cho tt c cc bnh
phn on tnh mch nhn c lm PCI v nhng bnh nhn c
(unfractionated bolus, sau tiu huyt khi ngoi tr streptokinase. Bolus
heparinUFH) 12 U/kg/gi. ng tnh mch ti a l 4.000 n v.
Enoxaparin (low 30 mg bolus Bnh nhn trn 75 tui khng nn dng liu np
molecular ng tnh v nhn 0,75 mg TDD 2 ln/ngy.
weight mch, 1 mg/ Nn dng liu np b sung 0,3 mg/kg nu liu
heparin kg TDD 2 LMWH cui cng l hn 8 gi trc khi tin
LMWH) ln/ngy hnh PCI. S dng LMWH mi ch c nh
gi vi iu tr tiu huyt khi hay PCI cu vn.
(cn tip)
Bng 417 Thuc ban u cho nhi mu c tim ST chnh ln (Tip theo)
Thuc Liu Ch gii
Bivalirudin 0,75 mg/kg Bivalirudin c nh gi bnh nhn c

bolus ng lm PCI v cha c nghin cu khi kt hp
tnh mch, vi tiu huyt khi.
1,75mg/kg/ Nhng bnh nhn dng heparin bolus trc
gi khi dng bivalirudin c t l mi mc huyt
khi trong stent thp hn so vi nhm ch dng
bivalirudin.
Fondaparinux 2,5 mg bolus c ch ra rng tt hn UFH khi c dng
tnh mch, trong sut qu trnh tiu huyt khi vi t l
2,5 mg TDD chy mu gim.
hng ngy Fondaparinux lm tng nguy c huyt khi
trong catheter khi c dng trong PCI (JAMA
2006;295:1519).
Nitroglycerin 0,4 mg ng C th dng nitroglycerin gii dng phun hay
di li hay ng di li mi 5 pht trong tng s 3
dng phun liu nu khng c h huyt p. C th dng
Truyn 10200 nitroglycerin ng tnh mch cho bnh nhn
mcg/pht au ngc kh kim sot.
Metoprolol 25 mg ng Nn trnh s dng thuc chn bnh nhn c
ung 4 ln/ bng chng ca suy tim, huyt ng khng n
ngy, tng nh, block nh tht cp 1 r rng, block tim
liu nu cn cao v co tht ph qun
CABG, bc cu ni ng mch vnh; LMWH, heparin trng lng phn t thp; MI, nhi mu c tim; PCI,
can thip ng mch vnh qua da; STEMI, NSTEMI; TIA (transient ischemic attack), tai bin mch no
thong qua.
mc du bin chng chay mau nng khng do thu thut vn cao hn so vi

clopidogrel.
Thuc c ch GPIIb/IIIa. Phn ln cac th nghim cua cac thuc nay u c
thc hin trc khi thuc c ch P2Y12 c s dung mt cach thng quy.
Chung khng co vai tro trong biu hin ban u cua nhng bnh nhn STEMI
hoc la mt phn cua liu phap b sung cho tiu huyt khi.
Thuc c ch GPIIb/IIIa hu ch nht khi c cho vao thi gian tin hanh PCI
bnh nhn c iu tr UFH va bnh nhn c cho la khng co nguy c
chay mau cao hn.
Thuc c ch GPIIb/IIIa nn c s dung mt cach chon loc trong thi gian
tin hanh PCI, bnh nhn a c iu tr y u vi clopidogrel va UFH hoc
clopidogrel va bivalirudin (v.d., co huyt khi ln, MI trc rng, lu thng

mach vanh kem sau PCI).
Vic s dung thuc c ch GPIIb/IIIa co th hp ly thay th cho thuc c ch
P2Y12 nhng bnh nhn co bin chng cp cua MI oi hoi phai phu thut
(MR thiu mau, t c nhu, hoc VSD).
Bolus kep epfitibatid va bolus liu cao tirofiban co th cho hiu qua tng
t vi abciximab (Am J Cardiol 2004;94:35; JAMA 2008;299:1788; JACC
2008;51:529).
Thuc chng ng nn cho ngay t u khi bnh nhn n vin, tt ca cac bnh
nhn STEMI du chon PCI hay tiu huyt khi. Xin tham khao phn khang tiu
cu bnh nhn UA/NSTEMI co thng tin c ban v cac thuc c trnh bay
cu th di y.
Bnh nhn se iu tr tiu si huyt nn c bt u bng mt trong cac
thuc:
UFH trong 48 gi. Thuc c a dung hn tip tuc chng ng trong
qua trnh nm vin (nhng khng qua 8 ngay), vic s dung UFH kem hp
dn hn do no co nguy c gy HIT. Cac nghin cu gi y enoxaparin hay
fondaparinux u th hn so vi UFH (Lancet 2001;358:605; Circulation
2002;105:1642; N Engl J Med 2006;354:1477; JAMA 2006;295:1519).
Nu d oan trc vic chup mach vi muc ch thc hin PCI se c tin
hanh sm sau tiu si huyt, th UFH co th c a dung hn.
Liu UFH: liu bolus 60 U/kg (ti a 4.000 U), sau o 12 U/kg/gi (khng
qua 1.000 U/gi) gi PTT mc 50 n 70 giy.
Enoxaparin, nu creatinin huyt tng nho hn 2,5 mg/dL nam hoc nho
hn 2,0 mg/dL n, dung liu bolus tnh mach khi u 30 mg, 15 phut sau
dung liu 1 mg/kg tim di da 2 ln/ngay. Dung thuc trong toan b thi
gian nm vin nhng khng qua 8 ngay.
Bnh nhn 75 tui hoc gia hn, khng dung liu bolus va liu tim di da
la 0,75 mg/kg 2 ln/ngay.
Nu thanh thai creatinin <30 mL/phut, liu tim di da la 1 mg/kg hang
ngay.
Fondaparinux, nu creatinin huyt tng nho hn 3 mg/dL, liu tnh mach
u tin la 2,5 mg, sau o la 2,5 mg tim di da hang ngay. Dung thuc trong
toan b thi gian nm vin nhng khng qua 8 ngay.
La chon chng ng cho bnh nhn se c lam PCI th u:
Nhiu phu thut vin thng a dung UFH trong PCI do tnh sn co cua vic
theo doi iu tr thi gian thc vi thi gian ng mau hoat hoa (activating
clotting timesACTs) phong t catheter (Hnh 47). Liu UFH bolus b
sung c dung tai thi im lam PCI, vi liu va ACT phu thuc vao vic co
s dung thuc c ch GPIIb/IIIa hay khng.
Vic s dung Enoxaparin cho bnh nhn STEMI chng ng cho PCI la
khng ro rang.
Co th cn liu tnh mach b sung trong PCI phu thuc vao thi gian dung
liu cui cung va tng liu a dung.
Khng nn dung dung UFH cho bnh nhn ang iu tr Enoxaparin.
Co th dung bivalirudin cho bnh nhn va mi c iu tr vi ASA va
clopidogrel khi va n vin (xem Hnh 47).
Bivalirudin la thuc thay th chp nhn c cho s dung kt hp Heparin va
thuc c ch GPIIb/IIIa trong sut qua trnh PCI vi ty l chay mau thp hn
nhng ty l huyt khi stent cao hn (N Engl J Med 2008;358:2218; JAMA
2003;19:853).
Thuc la la chon iu tr cho bnh nhn co HIT a c chn oan.
Thuc co th c dung khi co hoc khng co iu tr vi UFH trc o. Nu
bnh nhn ang c iu tr UFH, dng UFH trong 30 phut trc khi bt
u dung bivalirudin.
No la thuc c a dung hn bnh nhn co nguy c chay mau cao hn.
Nguy c huyt khi stent co th thp hn nu bnh nhn a c iu tr trc
bng clopidogrel liu nap 600 mg hay UFH.
Liu bolus 0,75 mg/kg, sau o 1,75 mg/kg/gi truyn tnh mach.
Fondaparinux khng c ch nh bnh nhn STEMI nh mt chng ng
n c va phai dung cung vi UFH do nguy c huyt khi lin quan n
catheter.
iu tr chng thiu mau cuc b. (Xem thm phn Thuc trong iu tr UA/
NSTEMI v thng tin c ban cua cac thuc c lit k y).
Nitroglycerin nn c ch nh bnh nhn au ngc do thiu mau c tim, h
tr thm cho kim soat tng huyt ap, hay nh mt phn cua iu tr suy tim.
Nitroglycerin nn hoc tranh hoc s dung rt thn trong bnh nhn co
Ha huyt ap (SBP <90 mm Hg)
MI tht phai
Nhp tim >100 nhp/phut hay <50 nhp/phut
S dung thuc c ch phosphodiesterase trong 48 gi trc o
Morphin (2 n 4 mg tnh mach) co th c dung cho bnh nhn au ngc
keo dai khng ap ng vi nitroglycerin. Giam au y u lam giam mc
cathecolamin tun hoan va lam giam tiu thu oxy cua c tim.
BBLs cai thin thiu mau c tim, han ch kch thc nhi mau, va giam cac
bin c tim mach chnh gm t vong, thiu mau c tim tai phat, va loan nhp
ac tnh.
BBLs nn c bt u tt ca nhng bnh nhn STEMI ngay trong vong 24
gi u nu khng co du hiu cua suy tim mi xut hin, bng chng cua shock
iu tr ban u iu tr ban u iu tr ban u

ASA, clopidogrel1 ASA, clopidogrel1 ASA, clopidogrel1
UFH (bolus) UFH (bolus) LMWH (bolus)
PCI PCI PCI

UFH bivalirudin LMWH UFH
Abciximab Bivalirudin Abciximab
u im Hiu qua a c Ty l chay mau D s dung

chng minh thp hn
Cai thin v t vong2
Nhc im Ty l chay mau Tng ty l huyt khi Ch c anh gia

cao hn trong stent nu khng trong PCI cu van3
bolus UFH chng ng khng
n nh
Hnh 47. Chin lc c khuyn cao trong iu tr ban u trc PCI. 1Prasugrel hay
Ticagrelor co th c s dung thay cho Clopidogrel cho bnh nhn c lam PCI. Thuc c
ch GPIIb/IIIa co th c s dung thay cho clopidogrel, prasugrel hoc ticagrelor bnh nhn
co bin chng c hoc cua MI hay oi hoi phai c phu thut tim khn cp. 2Trong so sanh
gia UFH + thuc c ch GPIIb/IIIa, bivalirudin cai thin t vong va giam chay mau bnh
nhn b STEMI. Nn dung Bolus Heparin va/hoc liu nap 600 mg clopidogrel trc khi dung
bivalirudin giam ty l huyt khi stent (N Engl J Med 2008;358:2218). 3LMWH mi ch
c nghin cu trong PCI cu van va cha c anh gia trong PCI th u (N Engl J Med
2006;354:1477). ASA, aspirin; GP, glycoprotein; LMWH, heparin trong lng phn t thp;
PCI, can thip ng mach vanh qua da; STEMI, nhi mau c tim ST chnh ln; UFH, heparin
khng phn oan.
tim (Killip II hay ln hn), tui trn 70, SBP <120 mm Hg, nhp tim >110 nhp/
phut hay <60 nhp/phut hay co block tim cao (Lancet 2005;366:1622).
BBLs tnh mach co th gy tng t vong bnh nhn STEMI va nn c
danh cho vic iu tr loan nhp tim hay iu tr cp cac tng huyt ap tin
trin nhanh bnh nhn khng co cac c im c nhc n trn. Nhp
nhanh xoang trong bnh canh STEMI co th la mt ap ng bu tr duy tr
cung lng tim.
Khng nn dung NSAIDs (chon loc va khng chon loc) trong thi gian nm
vin do thuc co i kem vi s tng nguy c MI, suy tim, tng huyt ap, v tim
va t vong.
Ti ti mu mch vnh cp
Phn ln bnh nhn b STEMI cp co tc nghen ng mach vanh do huyt khi.
Hi phuc ti mau mach vanh sm han ch kch thc nhi mau, bao tn c
chc nng tht trai va giam t vong.
Tt ca cac bin phap iu tr khac la th phat va khng nn tr hoan muc tiu kp
thi tai ti mau mach vanh.
Tr khi co s phuc hi t nhin cua s thiu mau (c xac nh bi ht au ngc
va s tr lai bnh thng cua ST chnh ln), s la chon cac chin lc tai ti
mau bao gm tiu huyt khi, PCI th u hoc CABG cp cu (Hnh 48).
S tr lai bnh thng cua in tm va cac triu chng khng loai tr kha
nng bnh nhn c ch nh chup mach chn oan cp cu. Morphin co th
che du triu chng cua thiu mau ang tin trin.
CHU Y: Triu chng tip din khng phai la tiu chun iu tr STEMI
trong 12 gi u k t khi khi phat triu chng. Bnh nhn n vin trong
vong 12 gi t khi bt u triu chng, du triu chng a ht, nhng vn co
thay i in tm cua STEMI th vn la ng c vin cho tai ti mau ngay
lp tc (hoc PCI th u hoc tiu si huyt). Mc du vy, chung ti khuyn
cao chup mach vanh vi muc ch tin hanh PCI/CABG trong nhng trng
hp nay.
Vic la chon phng phap tai ti mau nn c coi la yu t quan trong th hai
sau muc tiu chung la at c s tai ti mau mt cach kp thi.
PCI th u
PCI th u la chin lc tai ti mau c a dung hn khi co th tin hanh
trong vong 90 phut k t khi bnh nhn tip xuc vi c s y t. So vi iu
tr tiu si huyt, PCI em lai s m thng mach va ti mau u vit hn hn
(dong chay TIMI 3) vi tai nhi mau t hn, t nguy c xut huyt ni so hn,
va cai thin sng con bt k v tr tn thng hay tui bnh nhn (N Engl J
Med 1997;336:1621; Lancet 2003;361:13).
Bnh nhn STEMI vi khi phat triu chng t hn 12 gi co tin lng va kt
qua sau PCI tt hn. Tuy nhin, PCI vn nn c ch nh cho nhng bnh
nhn STEMI co triu chng ang tip din, nhng ngi bt u triu chng
t 12 n 24 gi trc bi v nhng bnh nhn nay vn co nhiu kha nng se
c li ch t vic tai thng mach mau. PCI cung co th c xem xet, mc
du bng chng v li ch con han ch, bnh nhn hin tai khng co triu
chng nhng co triu chng giai oan 12 n 24 gi trc o. Bnh nhn
khng triu chng, co n nh v mt huyt ng va in hoc, khng co bng
chng thiu mau, nhng ngi ma triu chng bt u t trc o hn 24 gi,
khng nn c lam PCI cho ng mach gy nhi mau b tc nghen mt cach
hoan toan (Circulation 2011;22:2320).
STEMI
iu tr ban u
ASA, clopidogrel1
UFH/LMWH/bivalirudin2
NTG, Chen
Thi gian ca bong <90 phut, Thi gian ca bong >90 phut,
nguy c cao hoc sc tim, tr hoan trong vic vn
tiu huyt khi b chuyn n c s thc hin PCL
chng ch nh, chn oan PCL b chng ch nh
cha ro rang
au ngc khng giam i/tai phat
ST chnh ln3
Chup mach Tiu huyt PCL cu

vanh khi van
Tai ti mau thanh cng4

CABG PCI
Phn tng nguy c
Chup mach Test gng

vanh sc
Hnh 48. Cac chin lc tai ti mau ng mach vanh va anh gia nguy c. 1Nu ch nh
tiu si huyt, ch s dung duy nht Clopidogrel. Nu ln k hoach lam PCI th u, cho hoc
ticagrelor, prasugrel, hoc clopidogrel. 2UFH co th c s dung cho bnh nhn hoc c
lam PCI hoc c tiu huyt khi, trong khi bivalirudin mi ch c nghin cu vi PCI va
LMWH mi ch c anh gia trong iu tr tiu si huyt va PCI cu van. Vi bnh nhn
c tiu si huyt, LMWH hay Fondaparinux c a dung hn UFH. 3Bnh nhn au ngc
khng giam, hay au ngc tai phat, loan nhp khng n nh, tin trin suy tim hay ST khng
tr lai bnh thng sau 60 n 90 phut sau khi tiu si huyt nn c lam PCI cu van. 4Du
hiu cua tai ti mau thanh cng la giam au ngc, giam 50% chnh ln cua ST, va nhp t
tht. Cac thuc c ch P2Y12 bao gm cac thuc khang tiu cu: clopidogrel, prasugrel, va
ticagrelor, ASA, aspirin; CABG, bc cu ni ng mach vanh; LMWH, heparin trong lng
phn t thp; NTG, nitroglycerin; PCI, can thip ng mach vanh qua da; STEMI, nhi mau
c tim khng ST chnh ln; UFH, heparin khng phn oan.
PCI c a dung hn tiu si huyt trong cac tnh hung sau:

Bnh nhn vao vin trong tnh trang suy tim nng hay shock tim nn c
lam PCI th u (k ca khi vic chuyn bnh nhn n trung tm PCI co th
gy tr hoan muc tiu v thi gian tai ti mau).
- Killip III/IV hay im TIMI 5, la biu hin cua nhom nguy c cao,
nhom ma PCI c a dung hn mc du co kha nng b tr hoan v thi
gian (Eur Heart J 2010;31:676; Circulation 2005;112:2017).
- Bnh nhn shock tim, nhng ngi khng n nh mt cach nhanh chong,
nn c s dung cac thit b h tr huyt ng.
Co chng ch nh vi tiu si huyt.
Mi c lam PCI gn y hay CABG trc o.
PCI noi chung c a dung hn tiu si huyt bnh nhn khi phat triu
chng qua 12 gi trc (N Engl J Med 1997;336:1621; Lancet 2003;361:13).
Ti u, phu thut vin nn thc hin hn 75 ca PCI mi nm nhng trung
tm co kinh nghim vi lng PCI hn 200 ca mi nm (36 ca PCI trn bnh
nhn STEMI).
Nu bnh nhn co bnh nhiu nhanh mach vanh, ch ng mach gy ra nhi
mau (infarct-related arteryIRA) nn c tai thng, tr khi vic tai thng
ng mach khng gy ra nhi mau c ky vong em lai li ch bnh nhn
b shock. Trong cac trng hp khac, vic tr hoan tai thng mach hoan toan
la thch hp hn, nhn chung la sau khi ng mach gy ra nhi mau c tai
thng va bnh nhn n nh trong 24 gi. Tai thng hoan toan thng c
thc hin theo giai oan han ch c tnh trn thn cua thuc can quang.
t stent mach vanh u vit hn nong mach vanh bng bong n thun
va lam giam ty l tai thng mach ch (N Engl J Med 1999;341:1949; N
Engl J Med 2002;346:957). DES lam giam hn na nhu cu tai thng mach
ch ma khng lam tng ty l mi mc huyt khi trong stent (Circulation
2009;120:964; JACC 2008;51:618; JAMA 2008;299:1788).
PCI c tao thun, mt chin lc s dung liu thuc c ch GPIIb/IIIa va
thuc tiu si huyt giam i ngay trc PCI, khng nn c lam thng
quy v no khng cai thin hiu qua ma con lam tng ty l chay mau mt
cach ang k (Lancet 2006;367:569; N Engl J Med 2008;358:2205; Lancet
2006;367:579).
iu tr tiu si huyt
iu tr tiu si huyt co u th chnh la s co mt rng rai va d s dung.
Nhc im chnh cua tiu si huyt la nguy c xut huyt ni so, s khng
chc chn co tai lp c lu thng mach vanh hay khng, nguy c tai tc
nghen cua IRA. No c s dung khi PCI khng co sn trong thi gian ly
tng.
Ch nh dung tiu si huyt nu thuc c dung trong vong 12 gi k t

khi khi phat triu chng vi nhng thay i in tm u tiu chun cua
ST chnh ln, LBBB mi, hay MI thanh sau thc s. Khi c ch nh, no
nn c thc hin trong vong 30 phut k t ln tip xuc bnh nhn u
tin.
iu tr tiu si huyt thanh cng nht khi c dung trong vong 3 gi k
t khi co triu chng, sau o li ch giam dn.
Bnh nhn n mt bnh vin khng co PCI nn c chuyn i lam
PCI th u, hn la iu tr tiu si huyt nu thi gian t khi tip xuc y
t ln u n khi lam PCI se khng qua 120 phut (tuy nhin, muc tiu
h thng nn tip tuc at c muc tiu <90 phut). iu nay co ve c
bit lin quan n nhng bnh nhn n vin trong vong 3 n 12 gi
k t khi co triu chng (J Am Coll Cardiol 2011;57:272; Circulation
2007;116:721; Circulation 2008;117:1145). Trong cac bnh nhn c
chuyn n lam PCI, PCI th u lam giam ang k ty l mi mc t
vong, nhi mau c tim hay t quy khi so vi nhom c iu tr tiu si
huyt tai ch (N Engl J Med 2003;249:733; JACC 2002;39:1713; Eur
Heart J 2000;21:823).
Cac thuc tiu si huyt hin co bao gm cac thuc chon loc fibrin nh
alteplase (yu t hoat hoa plasminogen tai t hp, recombinant tissue
plasminogen activatorrt-PA), reteplase (reteplaser-PA), tenecplase
(TNK-tPA). Streptokinase la thuc khng chon loc duy nht c s dung.
Chi tit hn va thng tin v liu co th xem Bang 418.
TNK-tPA la thuc hin tai c la chon do hiu qua tng t, nguy c
chay mau thp hn va ch co mt liu bolus, thun tin cho s dung hn so
vi rt-PA. Streptokinase la thuc re nht va vn c s dung rng rai trn
toan th gii.
Thuc chon loc fibrin nn c s dung kt hp vi liu phap iu tr
chng ng, ASA, va clopidogrel (xem phn trc). Thuc c ch GPIIb/
IIIa khng nn c s dung kt hp. Prasugrel va ticagrelor cha c
nghin cu s dung cung vi thuc tiu si huyt.
iu tr tiu si huyt b chng ch nh nhng bnh nhn:
ST chnh xung (tr khi nghi ng MI thanh sau).
Bnh nhn hin tai khng triu chng, vi triu chng ban u t hn 24 gi
trc (iu nay ngc vi bnh nhn khng co triu chng nhng khi phat
triu chng trong vong t hn 12 gi trc, xem phn trc).
Cac chng ch nh khac cua dung thuc tiu si huyt c lit k Bang
419.
Co 5 hoc hn cac yu t nguy c cua chay mau ni so.
Bng 418 Thuc tiu si huyt
Thuc Liu Ch gii
Streptokinase 1,5 triu n v tnh To ra tnh trng tiu si huyt ni chung

(SK) mch trong 60 (khng c hiu im)
pht SK lm gim t l t vong sau STEMI, gim
18% nguy c tng i v gim 2% nguy
c tuyt i (Lancet 1987;2:871).
Phn ng d ng bao gm ni ban da, st v
phn v c th thy 12% bnh nhn. H
huyt p n c xy ra 10% bnh nhn
v thng p ng vi gin th tch.
V s to thnh khng th, bnh nhn iu
tr SK trc nn c iu tr bng mt
thuc tiu si huyt khc.
Yu t hot ha Bolus 15 mg tnh Thuc chn lc fibrin vi s ci thin c
plasminogen mch hiu im so vi SK.
ti t hp 0,75 mg/kg trong Khng gy phn ng d ng hay h p.
(rtPA) 30 pht (ti a Gim t vong so vi SK nhng tng nguy
50mg) c xut huyt ni s (N Engl J Med
0,50 mg/kg trong 1993;329:673).
60 pht (ti a
35 mg)
Reteplase (rPA) 2 liu bolus tnh Thuc chn lc fibrin vi thi gian bn thi
mch 10 n v di hn nhng li gim tnh c hiu im
trong 30 pht so vi rtPA.
ring r Li ch v t vong tng ng vi rtPA (N
Engl J Med 1997;337:1118).
Tenecplase Bolus tnh mch 0,5 Bin th v sp t gen ca rtPA vi
(TNKtPA) mg/kg (tng liu thanh thi trong huyt tng chm hn,
3050 mg) c hiu fibrin c ci thin v khng
PAI1 cao hn.
Li ch v t vong tng ng vi rtPA
vi t l chy mu gim xung (Lancet
1999;354:716).
Cn phi theo di t c aPTT mc tiu
l 1,5 n 2,5 ln chng.
aPTT (activated partial thromboplastin time), thi gian hot ha thromboplastin tng phn; PAI1
(plasminogen activator inhibitor1), thuc c ch hot ha plasminogen1; STEMI, nhi mu c tim ST
chnh ln.
Bng 419 Chng ch nh dng thuc tiu si huyt
Chng ch nh tuyt i Chng ch nh tng i
Tin s xut huyt ni s hay t qy do xut t qu do thiu mu trc hn 3

huyt thng
t qu do thiu mu trong vng 3 thng D ng hoc tng s dng SK trc
Tn thng cu trc mch no c bit (hn 5 ngy trc)a
(AVMs, phnh mch no, khi u) Chy mu tng gn y (24 tun)
Chn thng u kn trong vng 3 thng CPR gy tn thng/ko di hn 10
Lc tch ng mch ch pht
Tng huyt p nng khng kim sot c Phu thut ln trong vng 3 tun
(SBP >180, DBP >130 mm Hg) Lot d dy ang hot ng
Chy mu ang hot ng hay chy mu Thng mch khng p c
tng Tin s chy mu trong nhn cu
Vim mng ngoi tim cp C thai
Tng huyt p khng kim sot c
S dng thuc chng ng ng ung
a C th s dng cc thuc tiu si huyt khc ngoi streptokinase.
AVM (arteriovenous malformation), bt thng ng tnh mch; CPR (cardiopulmonary resuscitation), hi

sc tim phi; SBP, huyt p tm thu; DBP (diastolic blood pressure), huyt p tm trng.
Bin chng thng gp nht cua iu tr tiu si huyt la chay mau. Xut
huyt ni so xay ra >4% bnh nhn co 5 hoc hn cac yu t nguy c cua
xut huyt ni so sau y (Stroke 2000;31:1802).
Tui 75
Cn nng 65 kg n va 80 kg nam.
Gii n
Da en
Tin s t quy
SBP 160 mm Hg
INR >4 hay PT >24
S dung Alteplase
Bt ky bnh nhn nao co thay i t ngt tnh trang thn kinh nn c chup
CT so khn cp va dng tt ca cac thuc tiu si huyt va chng ng. Nn
dung huyt tng ti ng lanh nn cho bnh nhn co xut huyt ni so.
Tua lanh co th cung c s dung cung cp thm fibrin va nng yu
t VIII. Truyn tiu cu va Protamin co th hu ch vi bnh nhn co thi
gian mau chay keo dai ro. Nn hi chn ngoai thn kinh va thn kinh ngay
lp tc. Bin chng chay mau ln oi hoi phai truyn mau xay ra khoang
10% bnh nhn.
Chm soc sau iu tr tiu si huyt

Sau tiu si huyt, bnh nhn nn c chuyn n ni co th lam PCI vi
d nh se thc hin PCI trong 3 n 24 gi sau khi bt u iu tr tiu si
huyt k ca khi tiu si huyt thanh cng va huyt ng cua bnh nhn n
nh.
Chup mach vanh thng quy trong vong 24 gi tiu huyt khi lam giam
cac bin c tim mach so vi PCI cu van (Lancet 2004;264:1045). Ngay lp
tc chuyn bnh nhn i chup mach (3 n 24 gi sau tiu si huyt) ni
co th lam PCI a c chng minh la co li ch (Lancet 2008;371:559).
Chin lc nay, c bit nh la chin lc xm nhp va dung thuc, nn
c phn bit vi PCI c tao thun khi thuc tiu huyt khi c ch
nh ngay trc khi lam PCI th u.
Tuy nhin PCI c tao thun i kem vi n ty l t vong, t quy va
thung thanh t do cua tim cao hn.
PCI cu van sau khi tiu si huyt tht bai
iu tr tiu huyt khi khng at c s tai thng mach vanh khoang
30% bnh nhn. Ngc lai, PCI th u hi phuc c lu thng mach vanh
(TIMI 3) trn 95% trng hp.
Bnh nhn tht bai vi iu tr tiu si huyt nn c ch nh lam PCI
cu van.
PCI cu van lam giam gn 50% ty l mi mc t vong, tai nhi mau va suy
tim (Circulation 1994;90:2280; N Engl J Med 2005;353:2758).
Bng chng cua tiu si huyt tht bai bao gm:
- Triu chng thiu mau c tim tai phat hoc keo dai dai dng
- ST phuc hi <50%, 90 phut sau iu tr tiu huyt khi
- in hoc hay huyt ng khng n nh
- Tin trin cac triu chng cua suy tim
CABG cp cu la mt thu thut nguy c cao ch nn c xem xet khi bnh nhn
b tc nhanh thn chung ng mach vanh trai nng hoc thiu mau c tim dai dng
vi PCI tht bai hoc giai phu khng thch hp cho PCI. Phu thut cp cu cung
nn c xem xet bnh nhn co bin chng c hoc cp cua MI gm t c nhu,
MR thiu mau nng, VSD, s tao thanh phnh tht trong bnh canh loan nhp tht
kho cha, hoc thung thanh t do cua tht.
X tr quanh nhi mu
n v chm soc mach vanh (coronary care unitCCU) la tin b ln u tin
trong ky nguyn hin ai cua iu tr MI cp. Phn ln bnh nhn c hng
li t s ao tao chuyn bit cua cac y ta va i ngu h tr CCU. Hu ht bnh
nhn MI cp nn c theo doi trong 24 n 48 gi CCU.
Ngh ngi tai ging la iu tr ngay lp tc thch hp trong 24 gi u sau biu

hin MI cp. Sau 24 gi, bnh nhn n nh v lm sang co th tng dn hoat
ng cua ban thn mc co th chu ng c.
Bnh nhn nn tip tuc c theo doi t xa phat hin thiu mau tai phat va loan
nhp. anh gia hang ngay nn bao gm anh gia triu chng au ngc tai phat,
triu chng cua suy tim mi xut hin, va cac in tm thng quy. Kham lm
sang nn tp trung vao phat hin ting thi mi tim hoc bt k bng chng nao
cua suy tim.
Nn lam siu m tim luc u anh gia EF, bt thng vn ng thanh tim, tn
thng van tim va s co mt cua huyt khi trong bung tht.
Theo doi huyt ng co th hu ch trong vic ti u hoa iu tr ni khoa
nhng bnh nhn khng n nh (xem phn tip theo).
Co th cn t may tao nhp tim bnh nhn MI cp. Ri loan nhp co th ch
thoang qua, trong trng hp nay t may tao nhp tam thi la u cho n khi nhp
n nh tr lai (xem phn tip theo). Khi so sanh MI thanh di, khi block nh tht
thoang qua va n nh, block nh tht trong MI thanh trc co th khng n nh
vi QRS rng nhp thoat vi ty l t vong 80% va thng oi hoi may tao nhp
tam thi va sau o la vnh vin.
iu tr sau MI
Xem phn thuc iu tr UA/NSTEMI.
Nn tip tuc dung ASA v thi han. Liu 81 mg/ngay cho thy co hiu qua sau
PCI, tuy nhin mc t 75 n 162 mg/ngay cung c ng thun.
Clopidogrel (75 mg/ngay), prasugrel (10 mg/ngay), hay ticagrelor (90 mg 2
ln/ngay) nn cho ti thiu 12 thang du dung BMS hay DES. (iu nay trai ngc
vi bnh nhn khng co ACS dung BMS va thi gian iu tr ti thiu la 1 thang).
BBLs cho li ch giam t vong sau MI cp. iu tr nn bt u cang sm cang
tt (tt hn ht la trong vong 24 gi u) va tip tuc dung v thi han tr khi co
chng ch nh.
Thuc c ch men chuyn lam giam t vong ngn han, ty l mi mc suy tim va
MI tai lai khi c dung ngay trong 24 gi u cua MI cp (Lancet 1994;343:1115;
Lancet 1995;345:669).
Bnh nhn co EF<40%, MI trc rng, tin s MI trc o la nhng bnh nhn
c li ln nht t vic iu tr vi thuc c ch men chuyn.
Chng ch nh gm ha huyt ap, tin s phu mach khi s dung, co thai, suy
thn cp, va tng kali mau. Cn chu y tranh ha huyt ap va khi s dung
bnh nhn hep ng mach thn 2 bn.
Co th dung thuc chen thu th Angiotensin II bnh nhn khng dung nap
thuc c ch men chuyn.
c ch HMG-CoA reductase nn c bt u tt ca cac bnh nhn khi khng

co chng ch nh. Mt s th nghim cho thy li ch cua vic s dung statin liu
cao sm va tch cc sau MI cp. Muc tiu la giam t nht 50% LDL hoc LDL<70
mg/dL.
Thuc khang thu th Aldosteron (aldacton va eplerenon) cho thy li ch
nhom bnh nhn sau MI co EF <40% va co ai thao ng (N Engl J Med
2003;348:1309). Thn trong khi s dung trn bnh nhn co tng kali mau va thiu
hut chc nng thn.
Tt ca bnh nhn nn c ch nh phuc hi chc nng tim.
LU C BIT
nh gi nguy c
Bnh nhn khng triu chng n vin qua 24 gi k t khi khi phat triu chng,
nhng bnh nhn ch iu tr bng thuc, nhng bnh nhn c tai thng mach
khng hoan toan nn c anh gia nguy c su hn na. Bnh nhn co th c
anh gia bng cach s dung cac test gng sc khng xm ln hay cac chin lc
xm ln (chup mach vanh).
Test gng sc co th c s dung xac nh tin lng, thiu mau tn d va
tr lng chc nng. Nhng bnh nhn tai thng thanh cng khng nn lam thm
test gng sc trc khi xut vin tr khi cn phai ch nh hi phuc chc nng tim.
Test gng sc vn ng gn ti a co th c thc hin sm vao thi im 2
n 3 ngay sau MI cp bnh nhn n nh - nhng ngi khng co thm du
hiu/triu chng thiu mau hay du hiu cua suy tim.
Mt khac, test gng sc co th c thc hin sau khi ra vin (2 n 6 tun) cho
nhng bnh nhn nguy c thp va cho bnh nhn ang bt u phuc hi chc
nng tim.
Nn chup ng mach vanh cho nhng bnh nhn au ngc han ch, thiu mau
c tim ang k, va nhng ngi co dung tch chc nng kem.
Nhng bnh nhn c iu tr ni khoa hay iu tr tiu si huyt va co bin
chng cua MI, bao gm au tht ngc/thiu mau tai lai, suy tim, loan nhp tht
ang k, hoc cac bin chng c hoc cua MI nn c chup mach vanh xac
nh giai phu mach vanh va a ra chin lc tai thng phu hp.
Cac tnh hung lm sang c bit
MI tht phai gp gn 50% bnh nhn MI thanh di cp. Gn mt na bnh
nhn co ri loan huyt ng do tn thng tht phai.
Du hiu lm sang co th gm ha huyt ap, shock tim, tnh mach c tng ng,
du hiu Kussmal (s tng ap lc tnh mach canh khi ht vao), va ting T3 va T4
phai. Trng phi thng ro (tr khi co HF hay MR tin trin).
Ap lc y tht trai thng bnh thng hoc giam, ap lc nh phai tng

(>10 mm Hg), va ch s tim giam. mt vai bnh nhn, ap lc nh phai tng
co th khng ro rang cho n khi c dung dch ng tnh mach.
Liu phap iu tr khi u la bu dch ng tnh mach. Nu ha huyt ap keo
dai, h tr co bop c tim bng dobutamin va/hoc bm bong trong ng mach
chu (intra-aortic balloon pumpIABP) co th cn thit. Theo doi huyt ng
xm ln la quan trong bnh nhn ha huyt ap v no hng dn tnh trang th
tch va s cn thit h tr c hoc va co bop tim.
bnh nhn co block tim va khng ng b nh tht, tao nhp nh tht theo
chui co li ch ang k.
ISR va huyt khi stent la bnh ch gp nhng bnh nhn trc o a c
sa mach vanh bng cach t stent. Cac yu t nguy c cho ISR va huyt khi
stent c trnh bay Bang 420.
ISR la hu qua cua tng san ni mac va xay ra trong vong 6 n 9 thang sau
khi nong mach bng bong va t stent. au ngc khi gng sc tin trin la
triu chng in hnh. Trc khi co BMS, ty l mi mc cua tai hep tn thng
ch 1 nm sau khi nong mach bng bong la 35% n 40%. Vic t BMS
lam giam ty l tai hep mach trn chup mach xung con 20% n 30%, va
DES lam giam hn na ty l tai hep trong 1 nm xung con 3% n 5%.
t DES la iu tr c la chon cho bnh nhn ISR (N Engl J Med
2002;346:1773; N Engl J Med 2003;349:1315; JAMA 2005;294:1215).
Cac iu tr khac c xem xet cho ISR bao gm khoan ct mang x va va
iu tr nhp chm cho kt qua kem hn so vi vic t DES, va trong cac
Bng 420 Yu t nguy c gy ti hp stent hay huyt khi stent
ISR Huyt khi trong stent

i tho ng Ngng dng clopidogrel
Bnh thn mn tnh Khng clopidogrel
Ti hp t trc i tho ng
t stent t trc trong bnh cnh ACS Bnh thn mn tnh
ng knh lng mch nh (<2,5 mm) Bnh c tnh
Chiu di tn thng di iu tr nhp chm t trc
Tn thng on gn LAD ng knh lng mch nh (<3 mm)
Tn thng cu ni tnh mch hin Chiu di on tn thng di
Hp tn d t ln can thip trc Tn thng on chia i
Lc tch vin
p thnh khng hon ton
Cc stent gi ln nhau
ACS, hi chng vnh cp; ISR, ti hp trong stent; LAD, ng mch lin tht trc.
trng hp iu tr nhp chm, tng nguy c huyt khi trong stent (JAMA
2006;295:1264; JAMA 2006:295:1253).
Huyt khi trong stent xay ra vi BMS hoc DES va la do sa cha ni
mach kem hay bnh nhn khng c dung thuc c ch P2Y12. Huyt
khi trong stent thng biu hin hoc nh mt ACS hoc t t do nguyn
nhn tim mach va co ty l t vong cao. Nguyn nhn cua huyt khi trong
stent c xac nh da vao thi gian t ln can thip mach trc o (JAMA
2005;293:2126; JACC 2009;53:1399).
Huyt khi trong stent cp tnh xay ra trong vong 24 gi va co th do bin
chng c hoc cua thu thut cung nh do iu tr chng ng va khang tiu
cu khng y u.
Huyt khi stent ban cp (24 gi n 30 ngay) la hu qua cua c ch tiu
cu khng y u va bin chng c hoc cua stent. Ngng thuc c ch
P2Y12 (clopidogrel, prasugrel, ticagrelor) trong thi gian nay gy ra nguy
c huyt khi trong stent cao gp 30 n 100 ln.
Huyt khi trong stent mun (30 ngay n 1 nm) chu yu xay ra vi DES
va lin quan n vic ngng thuc c ch P2Y12 (nguy c tng ln gp 4
n 6 ln nu ngng sm) va/hoc khang thuc.
- Noi chung, PCI cung vi hut huyt khi va lp lai vic t stent c
khuyn cao. Sang loc khang clopidogrel va co th xem xet vic bt u
s dung cac thuc co kha nng khang tiu cu tt hn nh prasugrel,
ticagrelor, hoc dung kt hp clopidogrel 150 mg vi cilostazol (JACC
2005;46:1833; Circulation 2009;119:3207).
MR thiu mau gi y tin lng nng sau MI va co th biu hin vi suy tim hay
phu phi cp ma khng co ri loan chc nng tht trai. No i kem vi MI thanh
sau va do t/s lin quan cua c nhu sau. C nhu trc co s cp mau kep, nn
t b tn thng hn. S co mt cua MR sau MI lam tng ang k ty l t vong
(Ann J Intern Med 1992;117:10; Am J Med 2006;119:103).
C ch cua MR cp bao gm ri loan chc nng c nhu hay ket la van do giam
vn ng thanh sau.
MR tin trin sau MI co th la hu qua cua gian bung tht trai, tai t chc
nh hay giam vn ng thanh sau. Cac thay i nay dn n ket la van hay
gian vong van 2 la.
Siu m tim la phng tin chn oan c la chon. MR thiu mau cp, khi
so sanh vi MR tin trin chm, khng phai luc nao cung xac nh c bng
kham lm sang, va co th ch co ting thi nho hoc khng co trong trng
hp MR cp. Tng t nh vy, TTEs co th bo sot MR cp nng va nu trn
lm sang rt nghi ng th nn tin hanh TTEs kp thi anh gia nng
va c ch cua MR. Bnh nhn b MR cp nng se biu hin phu phi cp ma
khng co nguyn nhn ro rang. Nn ngh n MR nhng bnh nhn nh vy

va ch nh lam TTEs nu nh khng co nguyn nhn tc nghen phi ro rang
hoc nu chc nng tht trai co ve tng ng.
iu tr ban u cua MR lin quan n giam hu ganh tch cc va tai thng
mach vanh. Bnh nhn n nh nn c th iu tr bng thuc va ch phu
thut khi bnh nhn khng cai thin. Can thip phu thut sm c khuyn
cao bnh nhn co MR thiu mau nng do t c nhu.
STEMI co s dung cocain gn y la mt tnh trang iu tr c nht va y
thach thc (Circulation 2008;117:18971907). ST chnh co th la do thiu mau
c tim do co tht mach vanh, s hnh thanh huyt khi tai ch, va/hoc tng nhu
cu oxy c tim. Sinh ly bnh thng thng la s kch thch qua mc cac thu th
- va -adrenergic. au ngc do s dung cocain thng xay ra trong vong 3 gi
nhng cung co th xay ra vai ngay sau khi s dung.
Nn s dung Oxy, ASA, va Heparin (UFH hoc LMWH) cho tt ca cac bnh
nhn STEMI lin quan n s dung cocain.
Nn u tin s dung nitrate iu tr tnh trang co tht mach. Thm vao o,
benzodiazepin co th co thm tac dung giam au do giam trng lc giao
cam.
BBLs b chng ch nh, nn tranh s dung ca thuc BBL chon loc va khng
chon loc.
Phentolamin (khang alpha adrenergic) va thuc chen knh canxi co th ao
ngc tnh trang co tht mach vanh va c khuyn cao s dung nh thuc
th hai.
Vic s dung cac bin phap tai ti mau vn con nhiu tranh cai va nn c
danh cho cac bnh nhn ma triu chng vn con tn tai du a iu tr ni khoa
ban u.
PCI th u la phng phap x ly c a dung cho nhng bnh nhn ma
triu chng va bin i in tm vn tn tai dai dng mc du a iu
tr ni khoa tch cc. Mt iu ht sc quan trong la phai chu y rng chup
mach va can thip mach co nguy c ang k lam ti t thm tnh trang co
tht mach.
iu tr tiu si huyt nn danh cho nhng bnh nhn ro rang b STEMI ma
khng th thc hin PCI.
BIN CHNG
Tn thng c tim dn n mt vai hu qua va bin chng tim tang cn phai ngh
n nu bnh nhn co cac du hiu/triu chng lm sang mi. Cac triu chng nay
gm co au ngc tai phat, loan nhp tim, shock tim va cac bin chng c hoc cua
MI.
au ngc tai phat co th do thiu mau vung nhi mau c tim nguyn thuy,
vim mang ngoai tim, v tim, hoc huyt tc mach phi.
au tht ngc tai lai gp 20 n 30% bnh nhn sau MI c iu tr thuc
tiu si huyt va n 10% bnh nhn trong giai oan sm sau tai thng mach
qua da. Cac triu chng nay co th la biu hin cua thiu mau tai phat hay s
m rng cua vung nhi mau.
Vic anh gia bnh nhn co th bao gm phat hin ting thi hoc ting co
mi xut hin, in tm anh gia cac bin i thiu mau mi, men tim
(troponin va CKMB), siu m tim va lp lai chup mach nu co ch nh.
Bnh nhn au ngc tai lai nn tip tuc dung ASA, thuc c ch P2Y12,
heparin, nitroglycerin, va BBL.
Nu au tht ngc tai phat khang vi iu tr ni khoa, nn xem xet lp lai
chup mach vanh va can thip lai cung vi kha nng t IABP.
Vim mang ngoai tim cp xay ra 24 n 96 gi sau MI khoang 10% n
15% bnh nhn. au ngc i kem vim mang ngoai tim thng co tnh cht
mang phi va co th giam t th ng thng. Kham lm sang co th thy ting
co, va in tm co th cho thy ST chnh ln khuch tan va PR chnh xung.
Chuyn ao aVR co th co PR chnh ln. iu tr hng ti vic x tr au.
ASA liu cao (n ti a 650 mg 4 ln/ngay) nhn chung c xem la thuc
iu tr u tay. Co th dung NSAIDs nh ibuprofen nu ASA khng hiu qua
nhng nn tranh bnh nhn sau MI cp giai oan sm.
Colchicin cung vi ASA cung co th co li ch vi cac triu chng tai phat va
cung co th u vit hn tng thuc n c.
Glucocorticoid (prednisone 1 mg/kg hang ngay) co th hu ch nu triu
chng nng va khang vi iu tr ban u. Steroid nn c s dung mt cach
han ch v chung co th lam tng nguy c vim mang ngoai tim tai phat. Vic
s dung cung nn c tr hoan cho n t nht cho n 4 tun sau MI cp do
thuc co tac dung co hai i vi s lin cua vung nhi mau va co nguy c gy
phnh thanh tht (Am Heart J 1981;101:750).
Nn tranh s dung heparin trong vim mang ngoai tim co hay khng co tran
dch v co th gy chay mau mang ngoai tim.
Hi chng Dressler c cho la mt qua trnh t min c trng bi s kho
chu, st, au kiu mang tim, tng bach cu, tc mau lng tng, va thng
co tran dch mang ngoai tim. Trai ngc vi tran dch mang ngoai tim cp, hi
chng Dressler thng xut hin sau MI 1 n 8 tun. iu tr ging vi iu
tr vim mang ngoai tim cp.
Loan nhp. Cac bt thng v nhp tim la thng gp sau MI va co th gm block
dn truyn, loan nhp nh va loan nhp tht. Loan nhp gy ri loan huyt ng oi
hoi phai c can thip tch cc, kp thi. Nu loan nhp dn n au tht ngc dai
dng hay suy tim, iu tr cp cu c khuyn cao. Trong tt ca nhng trng

hp ri loan nhp, cn xac nh c yu t lam nng thm, gm co mt cn bng
in giai, giam oxy, toan mau, va cac tac dung phu cua thuc (Chi tit v tng
loan nhp cu th c trnh bay Bang 421)
t may tao nhp qua da hoc qua ng tnh mach. Bnh ly cua h thng
dn truyn tin trin thanh block tim hoan toan hoc gy ra nhp chm co triu
chng co th c iu tr hiu qua vi tao nhp tim. Thit b tao nhp qua da co
th c s dung trong trng hp cp cu, tuy nhin nn s dung h thng tao
nhp tam thi ng tnh mach cho giai oan iu tr dai hn.
Cac ch nh tuyt i cho vic tao nhp qua tnh mach tam thi gm v tm
thu, nhp chm co triu chng, ngng xoang tai phat, block tim hoan toan, va
nhp nhanh tht lin tuc.
Tao nhp tam thi ng tnh mach co th c ch nh khi co block 3 nhanh
mi xut hin, block Mobitz II mi xut hin va cho nhng bnh nhn LBBB
cn phai t catheter ng mach phi do co nguy c phat trin block tim hoan
toan.
Khng nn t may kh rung cy di da (Implantable cardioverter-
defibrillatorsICDs) mt cach thng quy nhng bnh nhn co chc nng
tht trai giam sau nhi mau c tim hay rung tht/nhp nhanh tht (ventricular
tachycardia/fibrillationVF/VT) trong bnh canh thiu mau hoc ngay sau khi
tai ti mau.
t ICDs thng quy cho bnh nhn co giam chc nng tht trai ngay sau MI
khng cai thin kt qua (N Engl J Med 2004;351:2481).
Ngc lai, bnh nhn nhng ngi tip tuc co chc nng tht trai giam
(EF<35% va NYHA 2 hay 3 hoc EF<30% bt k nhom NYHA) hn 40
ngay sau MI se co li khi iu tr ICD (N Engl J Med 2005;352:255; N Engl
J Med 2002;346:877).
iu tr ICD cung c ch nh cho bnh nhn co nhng t nhp nhanh tht
hay rung tht bn b tai phat du a tai ti mau ng mach vanh.
Shock tim la mt bin chng khng thng gp nhng nguy him cua MI va
c xac nh bi ha ap bnh nhn chc nng tht khng y u ap ng nhu
cu chuyn hoa cua m ngoai vi. Cac yu t nguy c gm MI trc o, tui cao,
ai thao ng, va nhi mau c tim thanh trc. Giam ti mau tang co th biu
hin nh suy thn tin trin, kho th, toat m hi, hoc thay i y thc. Theo doi
huyt ng cho thy ap lc y tng (ap lc ging mao mach >20 mm Hg),
ch s tim giam (<2,5 L/kg/phut), va ha huyt ap (xem Hnh 45).
Bnh nhn b shock tim do MI co ty l t vong n hn 50%. Nhng bnh nhn
nh vy co th oi hoi kim soat huyt ng xm nhp va phng thc iu tr
nng cao gm h tr c hoc va ep tim.
Bng 421 Lon nhp bin chng ca nhi mu c tim
Lon nhp iu tr Ch gii
Chm dn truyn Khng Phn nhnh tri trc thng b tc ng nht v

trong tht n ch c cung cp mu t mt mch vnh
n c.
Block 2 hay 3 nhnh c th tin trin thnh
block tim hon ton v cc ri lon nhp khc.
Nhp chm Khng Nhp chm xoang thng thy bnh nhn MI
xoang Atropin 0,5 mg nhnh RCA.
To nhp Nu khng c h p hay ngoi tm thu tht trm
tm thia trng th ch theo di.
Block nh tht To nhp Block nh tht cp 1 thng khng cn iu tr
tm thia g c bit.
Block nh tht cp 2 Mobitz 1 thng xy ra vi
MI thnh di. Block thng xy ra trong b
His v khng cn iu tr tr phi nhp chm c
triu chng.
Block nh tht cp 2 Mobitz 2 bt ngun t
di b His v thng lin quan n MI thnh
trc. Do nguy c cao s tin trin thnh
block tim hon ton, bnh nhn nn c
theo di ti CCU v t my to nhp tm thi
nu c triu chng.
Block nh tht cp 3 do MI tht phi v trc
rng. bnh nhn c MI thnh trc, block
cp 3 thng xy ra trong 12 n 24 gi k
t khi c triu chng v c th xut hin t
ngt. t my to nhp to nhp tm thi c
khuyn co v nguy c tin trin thnh v tm
thu tht.
Nhp nhanh Khngb Nhp nhanh xoang l thng gp bnh nhn MI
xoang cp v thng do cng giao cm do au, lo
lng, gim th tch, suy tim hoc st.
Cung nh v Chn Cung nh v rung nh gp 20% bnh nhn MI
rung nh Chng ng cp.
Chuyn nhp Bi rung nh v cung nh thng thong qua
trong giai on cp ca MI, chng ng lu
di l khng cn thit sau khi thnh lp c
nhp xoang n nh.
(cn tip)
Bng 421 Lon nhp bin chng ca nhi mu c tim (Tip theo)
Lon nhp iu tr Ch gii
Nhp b ni gia Khng Nhp b ni gia tc xy ra kt hp vi MI thnh

tc di. Nhp thng lnh tnh v ch iu tr khi
c h huyt p. Nn xem xt ng c digitalis
bnh nhn c nhp b ni gia tc.
Kh cc tht Chn nu c VPDs thng gp trong giai on MI cp.
sm (VPD) triu chngc iu tr phng nga vi lidocain hay cc thuc
chng lon nhp khc gy tng t l t vong
v v vy khng c khuyn co (N Engl J
Med 1989:321:406).
Nhp t tht gia Khng Thng thy trong vng 48 gi ti ti mu
tc thnh cng v khng lin quan n tng t l
mi mc cc hu qu c hi.
Nu huyt ng khng n nh, c th phc hi
nhp xoang bng atropin hoc to nhp nh tm
thi.
Nhp nhanh tht Chuyn nhp vi Nhp nhanh tht khng bn b (<30 giy) thng
nhp nhanh gp trong vng 24 gi u sau MI v ch i
tht bn b km vi tng t l t vong khi xut hin mun
Lidocain hay sau giai on nhi mu.
amiodaron Nhp nhanh tht bn b (>30 giy) trong 48 gi
trong 24 n u sau MI c tim cp c n tng t vong ti
48 gid vin tng ln.
Rung tht (VF) Chuyn nhp Rung tht xy ra ti 5% bnh nhn trong giai
khng ng on sm sau MI v e da tnh mng.
b
Lidocain hay
amiodaron
trong 24 n
48 gi
aCh nn s dng Atropin v t my to nhp tm thi cho nhng bnh nhn c triu chng hoc huyt
ng khng n nh.
bS dng chn cho bnh nhn nhp nhanh xoang v chc nng tht tri km c th gy ra suy tim mt
b.
cChn giao cm nn c s dng thn trng bnh nhn nhp chm v VPD thng xuyn v n c
th lm tng nguy c nhp nhanh tht a hnh thi.
dLidocain nn c s dng liu bolus 1 mg/kg, sau l 12 mg/kg/gi truyn tnh mch.
Amiodaron nn c dng vi liu 150300 mg bolus, sau truyn 1 mg/kg/gi trong 6 gi v sau
0,5 mg/kg/gi trong 18 gi.
AV, nh tht; CCU (coronary care unit), n v chm sc tim mch; MI, nhi mu c tim; RCA, ng mch
vnh phi.
Dobutamin la thuc tng co bop c tim c la chon cho bnh nhn co SBP
vn c bao tn tng i (>90 mm Hg) v no va tng co bop c tim va giam
hu ganh tht.
Dopamin la thuc a dung bnh nhn co SBP <80 mm Hg. Co th cn dung
thm norepinephrin hay phenylephrin nhng bnh nhn ha huyt ap nng
(SBP<70 mm Hg).
Milrinone nn c cho bnh nhn hoc khng ap ng vi dobutamin hoc
nhng ngi nhp nhanh qua mc trong ap ng vi dobutamin. Thuc khng
nn c s dung thng quy bnh nhn co thiu hut chc nng thn.
nhng bnh nhn nu khng co chng ch nh nn c xem xet t bm
bong trong ng mach chu v cac thuc ng vn lam tng tiu thu oxy cua c
tim va co th lam thiu mau nng thm va tht bai trong lam tng cung lng
tim (Bang 422).
mt s bnh nhn, cac thit b h tr tun hoan khac co th c xem xet.
Phn ln phai phu thut t (xem Chng 5, Suy tim va bnh ly c tim),
tr LVAD (LV assist device) qua van qua da co th c t phong thng
tim, va h tr cung lng tim n 3,5 L/phut.
Tt ca bnh nhn co shock tim nn c siu m tim anh gia cac bin chng
c hoc cua MI (xem cac oan sau).
Mt s bnh nhn chon loc co suy tim dai dng tht bai trong ap ng vi thuc
tng co bop va oi hoi h tr c hoc keo dai co th c xem xet hoc ghep tim
hoc phu thut t thit b h tr tht trai hay trao i oxy qua mang ngoai c
th (extracorporeal membrane oxygenationECMO).
Bng 422 Bm bng i xung ng mch ch
Ch nh Chng ch nh Theo di
Shock tim, suy bm Thiu ht ng mch ch Chp X-quang, xt nghim s

t c nh Bnh mch ngoi bin lng tiu cu v creatinine
H hai l thiu mu nng nng hng ngy
VSD Nhim trng h thng, nh gi thng xuyn mch
To thun cho vic sa nhim trng huyt chi di
mch LAD hoc ng Heparin truyn tnh mch
mch vnh tri khng (PTT)
bo v hay CABG
PCI phc tp vi CAD
nng
CABG, bc cu ni ng mch vnh; LAD, ng mch lin tht trc; PCI, can thip ng mch vnh qua
da; PTT, thi gian thromboplastin tng phn; VSD, thng lin tht.
Bnh nhn co huyt khi tht trai, phnh tht trai, hay rung nh man tnh nn tip
tuc s dung thuc chng ng. Co th dung heparin (UFH hoc LMWH) cho n
khi at c INR co y ngha iu tr. Bnh nhn ang iu tr ASA va thuc c
ch P2Y12 nn gi INR mc 2,0 n 2,5.
Bnh nhn co huyt khi tht trai c ghi nhn trn siu m tim nn c dung
warfarin trong 3 n 6 thang tr khi cac ch nh khac am bao s dung tip tuc.
Bnh nhn nhp xoang va EF<35% va khng co bng chng huyt khi khi s
dung warfarin se lam giam nguy c t quy do thiu mau; tuy nhin, li ch nay
b bu lai bi tng nguy c chay mau. Quyt nh thm warfarin cung ASA phu
thuc vao tng bnh nhn (N Engl J Med 2012;366).
Bin chng c hoc
Phnh thanh tim. Sau MI, vung c tim b anh hng co th tip tuc b tn
thng rng hn lam cho thanh tim b mong i, hnh thanh khi phnh thanh
tim. Vn ng thanh tim b ri loan dn n d hnh thanh huyt khi bam thanh
ni tm mac.
Phnh tht trai c gi y bi ST chnh ln c nh trn in tm va co th
c chn oan da vao cac phng phap chn oan hnh anh bao gm chup
bung tht, siu m tim va chup MRI.
Khuyn khch dung thuc chng ng lam giam cac bin c huyt tc, c
bit la khi co huyt khi bam thanh.
Can thip phu thut co th thch hp nu phnh thanh tim gy suy tim hoc
loan nhp tht ma khng x tr c mt cach thch hp bng iu tr ni khoa.
Gia phnh tht. Tn thng khng hoan toan thanh t do cua c tim co th gy
hnh thanh gia phnh tht. Trong trng hp nay, mau thoat ra t thanh tim va
c gi lai bi la tang mang ngoai tim. nhng bnh nhn sau CABG, xut
huyt thng t ch v tm tht co th c gi lai trong bao x mang ngoai tim
sinh ra gia phnh.
Siu m tim (TTE vi cht tng cng can m hoc TEE) la phng tin chn
oan c a dung anh gia gia phnh va cho phep phn bit vi phnh
thc s.
Cn can thip phu thut kp thi v bin chng nay co ty l mi mc cua v
thanh tim cao.
V thanh t do la bin chng nng n cua MI cp, chim khoang 10% s ca
t vong sm. V tim thng xay ra trong tun u tin sau MI vi triu chng
ri loan huyt ng tin trin t ngt. Bin chng nay co th xay ra trong
MI thanh trc hoc thanh di va thng gp hn nhng bnh nhn la n
gii co tng huyt ap vi MI xuyn thanh ln ln u tin, nhng bnh nhn
iu tr thuc tiu si huyt mun hoc nhng bnh nhn dung NSAIDs hay
glucocorticoids.
Siu m tim co th giup xac nh nhng bnh nhn co thanh tht c bit
mong co nguy c b v.
Cn phai phu thut cp cu.
Du c can thip ti u, ty l t vong cua v thanh t do cua tim vn con
cao, trn 90%.
t c nhu (xin tham khao thm phn MR pha trc) la bin chng him gp
sau MI vi tnh trang lm sang xu i rt t ngt. Thng gp t c nhu gia
sau v no ch co mt ngun cp mau n c, nhng cung co nhng bnh nhn
b t c nhu trc bn. Cn lu y, t c nhu co xay ra ngay ca khi MI cp din
tng i nho hoc thm ch NSTEMI.
Phng tin chn oan c la chon la siu m tim vi hnh anh Doppler va/
hoc siu m tim qua thc quan v kham lm sang ch phat hin ting thi
khoang 50% trng hp.
iu tr ni khoa ban u nn bao gm cac thuc giam hu ganh tch cc.
Bnh nhn biu hin suy tim dai dng va huyt ng khng n nh co th
cn h tr tng co bop tim bng dobutamin va/hoc bm bong i xung trong
ng mach chu. Phn ln bnh nhn c ch nh phu thut sa cha
tn thng.
Thung vach lin tht thng gp nht trong MI thanh trc, xut hin 35
ngay sau MI. L thung co th thng thng trc tip gia 2 tht hoc lach theo
ng hm trong thanh vach lin tht trc khi thng sang tht kia.
Co th chn oan da vao siu m tim vi hnh anh Doppler va thng cn
TEE.
Cn ngh n bin chng thung vach lin tht nhng bnh nhn sau nhi
mau c tim tin trin cac triu chng cua suy tim va xut hin ting thi tm
thu toan tm thu mi.
n nh bnh nhn bng giam hu ganh, h tr co bop c tim, va/hoc IABP
co th cn thit cho nhng bnh nhn huyt ng khng n nh cho n khi
co th tin hanh bin phap iu tr trit bng phu thut.
nhng bnh nhn huyt ng n nh, tt nht nn tr hoan phu thut t
nht la 1 tun cai thin kt qua cua bnh nhn. Nu khng iu tr, ty l t
vong la khoang 90%.
Co th tin hanh ong l thng qua da bng dung cu trong phong thng tim
cho nhng bnh nhn choc loc nu nguy c phu thut la khng chp nhn
c.
GIM ST/THEO DI
Bnh nhn MI cp c khuyn khch kham lai thng quy 1 thang sau ra vin va
sau o mi 3 n 12 thang.
Bnh nhn nn c hng dn tm n s anh gia theo doi thng xuyn hn

hoc khn cp nu tnh trang lm sang cua ho co s thay i ang k.
Cac k hoach c bit cho vic theo doi chm soc dai han nn c ca th hoa
da trn tnh trang lm sang, giai phu, cac can thip trc o va nhng thay i
v triu chng.
7
Lon nhp tim
Shivak Sharma, Daniel H. Cooper, Mitchell N. Faddis
LON NHP NHANH
X l lon nhp nhanh
I CNG
Loan nhp nhanh thng gp nhng bnh nhn ang iu tr ni tru.
Vic tip cn mt cach nhanh chong va theo tng bc mt se tao thun li cho
vic nhn bit sm cac ri loan nhp c ban va bt u cac bin phap iu tr thch
hp mt cach kp thi.
Vic a ra cac quyt nh lm sang da vao cac triu chng cua bnh nhn va
cac du hiu cua ri loan huyt ng.
nh ngha
Nhp tim vi tn s tht vt qua 100 nhp/phut (beats per minutebpm).
Phn loi
Loan nhp nhanh c phn loai da vao rng cua phc b QRS trn in tm
(electrocardiogramECG):
Loan nhp nhanh QRS thanh manh (QRS <120 ms): nhp nhanh trn tht: bt
ngun ngay tai nut nh tht (atrioventricularAV) hoc trn nut nh tht, va kch
hoat nhanh chong tm tht thng qua h thng His- Purkinje bnh thng.
Loan nhp nhanh QRS rng (QRS 120 ms): loan nhp bt ngun t ngoai h
thng dn truyn bnh thng (nhp nhanh tht [ventricular tachycardiaVT])
hoc dn truyn qua h thng His-Purkinje bt thng (nhp nhanh trn tht dn
truyn lch hng) kch hoat tht theo mt cach chm bt thng.
Nguyn nhn
C ch gy loan nhp nhanh chia thanh 2 loai: Ri loan dn truyn xung va ri
loan hnh thanh xung:
Ri loan dn truyn xung: Vong vao lai la c ch chnh cua cac loan nhp
nhanh. Vong vao lai dung ch s dn truyn cua cac song kch hoat in hoc
279
280 l Ch. 7 Lon nhp tim
ngc chiu vao vung c tim luc u tr vi s dn truyn xui dong cua song
khi phat. Giai oan tr khac nhau cua m c tim la yu t cn thit vong vao
lai xay ra. Kt qua vong vao lai la s lan truyn cua song hoat ng vung c tim
lam duy tr loan nhp (v.d., nhp nhanh tht).
Ri loan hnh thanh xung: Gia tng tnh t ng (v.d., nhp b ni va nhp t
tht gia tc), va c ch hoat ng khi phat (v.d., hi chng QT keo dai va ng
c digoxin) la nhng c ch gy loan nhp nhanh t ph bin hn.
CHN ON
Biu hin lm sng
Loan nhp nhanh co th la nguyn nhn cua ln thm kham u tin tai phong
kham ngoai tru hoc tai phong kham cp cu.
Loan nhp nhanh cung co th xay ra bnh nhn mc cac bnh h thng ang
c anh gia n v cp cu hoc ang c iu tr ni tru.
Bnh s
Cac triu chng ong vai tro quan trong giup cac bac s lm sang a ra quyt
nh phu hp.
Kho th, au tht ngc, choang hoc ngt, giam y thc la nhng triu chng
canh bao hng cac bac s n nhng la chon iu tr khn cp hn.
Cac triu chng lin quan n giam chc nng tht trai (left ventricularLV)
nh kho th khi gng sc, kho th khi nm, kho th kch phat v m va phu chi
di cn c lam ro.
anh trng ngc: Thng i kem vi loan nhp nhanh nhng iu quan trong la
cn tm hiu v ban cht cua s khi phat va kt thuc cua no.
Khi phat va kt thuc t ngt rt co tnh gi y n loan nhp nhanh.
Triu chng giam i khi nn th hoc dung nghim phap Valsalva thng ngh
n nhp nhanh trn tht. Nut nh tht (atriventricularAV) gi vai tro quan
trong trong vic duy tr ri loan nhp kiu nay.
Cn hoi v tin s mc cac bnh tim thc tn (o la, bnh c tim do thiu mau,
khng do thiu mau, do van tim) hoc cac bnh ly ni tit (o la, bnh tuyn
giap, u thng thn).
Tin s mc cac nguyn nhn gy loan nhp bm sinh hoc co tnh gia nh
nh bnh c tim ph ai (hypertrophic cardiomyopathyHCM), hi chng QT
keo dai bm sinh; hoc cac bnh tim bm sinh khac cung nn c lam ro.
Bnh c tim ph ai tc nghen (Hypertrophic obstructive cardiomyopathy
HOCM) lin quan n ri loan nhp nh (2025% rung nh [atrial fibrillation]),
cung nh cac ri loan nhp tht nguy him.
Sa van hai la (Mitral valve prolapseMVP) co cac ri loan nhp tht va trn
tht i kem.
Lon nhp nhanh X l lon nhp nhanh l 281
Lin quan n dung thuc: Lit k y u danh sach cac thuc hin ang dung,
bao gm cac thuc khng cn k n va cac loai thao dc.
Khm thc th
Cac du hiu cho thy bnh nhn n nh hay khng n nh v lm sang da vao
cac du hiu sinh tn, tri giac, ti mau ngoai vi, v.v... la rt quan trong trong vic
hng dn vic a ra quyt nh u tin.
Nu lm sang bnh nhn n nh, vic thm kham nn tp trung vao vic xac nh
cac bt thng tim mach khin cho cac loai ri loan nhp nht nh co nhiu hoc
t kha nng xay ra hn.
Du hiu cua suy tim sung huyt (congestive heart failureCHF) bao gm ap
lc tnh mach c (jugular venous pressureJVP) tng, rales phi, phu ngoai vi
va ting nga phi S3 khin cho chn oan loan nhp tht nguy him tr nn co
nhiu kha nng hn.
Nu ri loan nhp keo dai, di y la mt s cn nhc c bit khi thm kham
lm sang:
Bt mach, anh gia v tn s va u.
Nu tn s la khoang 150 nhp/phut, nghi ng cung nh (atrial flutterAFl)
b block 2:1.
Nu tn s >150 nhp/phut, nghi ng nhp nhanh vao lai tai nut nh tht
(atrioventricular nodal reentrant tachycardiaAVNRT) hoc nhp nhanh vao
lai nh tht (atrioventricular reentrant tachycardiaAVRT).
Trong ri loan nhp tht tn s thng bin i hn.
Nu mach khng u va khng theo mt kiu nao, nghi ng rung nh (AF)
Mach khng u nhng theo mt kiu co th nhn bit c (v.d., nhp p
theo nhom) gi y co block dn truyn cp 2.
Cac song ai bac A: c phat hin khi thm kham JVP va phan anh s co
bop cua nh trong khi van ba la ang ong.
Nu cac song khng u, gi y s phn ly nh tht va la mt du hiu cua nhp
nhanh tht.
Nu cac song u theo ty l 1:1 vi mach ngoai vi, gi y AVNRT, AVRT,
hoc nhp b ni nhanh, tt ca cac ri loan nhp nay u dn n s hoat hoa
nh ngc chiu xay ra ng thi vi s co cua tht.
Test chn on
Xt nghim
Nn cn nhc xet nghim cac cht in giai, tng phn tch t bao mau, xet nghim
chc nng tuyn giap, nng digoxin trong huyt thanh (khi co th) va sang loc
c cht trong nc tiu tt ca bnh nhn.
in tm
in tm 12 chuyn ao la quan trong trong anh gia ban u, va co th phai
lp i lp lai nhiu ln tuy thuc vao nhng thay i trn lm sang cua bnh nhn.
Nu lm sang bnh nhn n nh, cn co 1 in tm 12 chuyn ao va ghi
1 oan dai lin tuc trn cac chuyn ao th hin hoat ng nh tt nht (v.d.,
V1,VII, VIII, aVF).
oc in tm tm bng chng cua cac ri loan dn truyn nh ngoai tm thu
hoc block nhanh, hoc cac du hiu cua bnh cu truc tim nh nhi mau c tim
(myocardial infarctionMI) trc o.
So sanh in tm ghi c luc co loan nhp vi in tm luc u co th ch
ra nhng thay i rt nho v lch cua phc b QRS la du hiu ch im cua
s kh cc chng lp cua tm nh va tm tht.
Vic ghi mt chuyn ao keo dai rt hu ch trong vic ghi lai ap ng vi cac
can thip (v.d., nghim phap cng ph v, cac thuc chng loan nhp, sc in
chuyn nhp).
Chn on hnh nh
Chup X-quang tim phi va siu m tim qua thanh ngc co th giup cung cp
cac bng chng cua bnh tim cu truc ma co th khin chn oan nhiu kha nng
la loan nhp tht.
K nng chn on
Theo doi ghi in tm lin tuc ngoai tru
Trong mt hoc nhiu ngay; hu ch trong vic ghi lai cac loan nhp thoang qua
gy triu chng xay ra vi tn sut ang k.
y la phng phap ghi in tim hu ch cho vic anh gia ap ng v nhp tim
cua bnh nhn vi cac hoat ng hang ngay hoc cac thuc chng loan nhp.
Mi lin quan gia cac triu chng c bnh nhn ghi lai theo thi gian vi
ban ghi nhp tim la cha khoa xac nh liu co phai cac triu chng nay la do
ri loan nhp gy ra khng.
Theo doi qua man hnh monitoring trong bnh vin
La phng phap theo doi chu yu trong thi gian nm vin cho nhng bnh nhn
co ri loan nhp tim bnh rt nng hoc co nhng ri loan nhp e doa tnh mang.
May ghi s kin
Trong nhiu tun hoc nhiu thang, hu ch ghi lai cac ri loan nhp thoang
qua co triu chng xay ra khng thng xuyn.
Bnh nhn c eo mt thit b ghi va thit b nay se lin tuc ghi lai in
tm . Khi c kch hoat bi bnh nhn hoc bng cac c tnh t ng phat
hin, ban ghi in tm se c lu lai cung vi cac d liu v nhp tim trong
vong vai phut trc o.
Lon nhp nhanh Nhp nhanh trn tht l 283
May theo doi s kin c kt ni ch khi bnh nhn co triu chng.

May ghi in tm cy di da hoc may ghi in tm dnh vao c th
(insertable loop recorderILR) la mt thit b theo doi di da, co th t kch
hoat hoc do bnh nhn t kch hoat ghi lai cac ri loan nhp ang k xut
hin rt khng thng xuyn trong vong vai thang hoc cho nhng bnh nhn
khng th kch hoat cac may ghi bn ngoai.
in tm gng sc
Hu ch trong vic nghin cu cac ri loan nhp do gng sc hoc anh gia ap
ng cua nut xoang vi gng sc.
Thm do in sinh ly (Electrophysiology studyEPS)
La thu thut xm ln, da trn catheter c s dung nghin cu tnh mn
cam cua bnh nhn vi loan nhp hoc nghin cu c ch cua loan nhp a bit
t trc.
EPS cung c kt hp vi t bng catheter trong vic iu tr nhiu c ch
ri loan nhp.
Hiu qua cua EPS trong vic tao ra va nghin cu ri loan nhp la cao nht i
vi cac ri loan nhp co c ch vong vao lai.
IU TR
Xin tham khao phn iu tr cho tng ri loan nhp cu th nhng bnh nhn co
huyt ng n nh va phac hi sc tim phi nng cao ngi ln (advanced
cardiac life supportACLS) cho nhng loan nhp nhanh Phu luc C.
Nhp nhanh trn tht
I CNG
Nhp nhanh trn tht (Supraventricular tachyarrhythmiasSVTs) thng tai
phat, thnh thoang keo dai va la nguyn nhn thng gp khin bnh nhn n
khoa cp cu hoc vn phong cua cac bac s chm soc sc khoe ban u.
Vic anh gia nhng bnh nhn co SVT nn lun lun bt u bng vic anh gia
kp thi s n nh v huyt ng va nn tang v lm sang. Nhng ngi trng
thanh tre tui va khoe manh chu ng nhp nhanh tt hn nhng bnh nhn co
bnh tim phi ang k kem theo.
Vic thao lun v chn oan va iu tr sau khi anh gia bnh nhn la danh cho
nhng bnh nhn huyt ng n nh. Nhng bnh nhn co ve bt n v lm sang
da trn cac du hiu, triu chng lm sang hoc cac thng s huyt ng nn
c tin hanh sc in chuyn nhp da theo hng dn ACLS.
nh ngha
Ri loan nhp nhanh oi hoi co nh hoc nut nh tht, hoc ca hai cho s bt u
va duy tr cua loan nhp c goi la SVT.
Phc b QRS trong hu ht cac trng hp SVTs hep (QRS <120 ms). Tuy nhin
no co th biu hin la ri loan nhp nhanh vi phc b QRS gian rng (wide-
complex tachycardiaWCT) (QRS 120 ms) trong SVT vi dn truyn lch
hng hoc ngoai tm thu nhanh.
Phn loi
SVT co th c phn loai theo vai cachbiu hin trn ECG, c ch, s phu
thuc vao nut nh tht, vv..
Tip cn chn oan nhp nhanh trn tht c tng kt Bang 7-1 la phn loai
lm sang hu ch tip cn nhng bnh nhn nay.
Dch t hc
Ty l mi mc c cng b co th co s khac bit ln gia cac nghin cu va kho
co th co con s chnh xac v co mt ty l ln bnh nhn co cn nhp nhanh khng
co triu chng.
CHN ON
Cac kho khn la g?Khi bt tay vao bt c mt chn oan kho khn nao, mt iu
ht sc hu ch la vic suy ngh xem chn oan o ph bin hoc him gp nh th
nao trong qun th bnh nhn cua ban.
Rung nh (AF) la nhp nhanh QRS hep thng gp nht nhng bnh nhn iu
tr ni tru. Cung nh (AFl) co th thng phi hp vi rung nh, va c chn
oan bng 1/10 so vi rung nh, nhng lai hay gp hn 2 ln so vi SVTs kch
phat. Nhng ri loan nhp nhanh cua nh khac t gp hn rt nhiu.
Trong mt nghin cu bao cao trng hp, nhp nhanh vao lai nut nh tht
(AVNRT) c bao cao la chn oan thng gp nht cua SVTs kch phat (60%),
tip theo la nhp nhanh vao lai nh tht (AVRT) (30%). (Crit Care Med 2000;
28(10 suppl):N129).
Tuy nhin, nu bnh nhn tre, di 40 tui, nhp nhanh vao lai nh tht, thng la
trong bnh canh hi chng Wolff-Parkinson-White, hay gp hn.
Tham khao Hnh 71 v phng cach chn oan nhp nhanh.
Biu hin lm sng

Biu hin lm sang cua SVT tng t cac nhp nhanh noi chung va a c m ta
trc o trong chng nay.
Nhp tim >100 nhp/phut
QRS <120 QRS 120
u Khng u u Khng u
Khng Co
Song P
VT hoc SVT vi dn AF vi dn AF + VT a dang
Ngim phap cng ph v Rung nh nhp khng truyn lac truyn lac WPW
hoc IV Adenosine AFI vi ap ng ly giai c hng hng
tht a dang
MAT
Lon nhp nhanh

Song dang ST kem PACs
Ht cn EAT co block
tim nhanh cung nh Khoang RP
thay i
AVNRT, AVRT, AFI RP ngn (RP < 50% RP dai (RP > 50%
va tim nhanh nh cua oan RP) cua oan RP)

Nhp nhanh trn tht
AVNRT in hnh ST khng phu hp
O-AVRT SANRT
ST hoc EAT lch hng AVNRT khng in hnh
co block AV O-AVRT vi dn truyn
Nhp nhanh b ni chm qua ng phu
EAT
Hnh 71. Phng cach chn oan loan nhp nhanh: AF (atrial fibrillation): rung nh; AFl: cung nh; AV: nh tht; AVNRT: nhp nhanh vao lai nut
nh tht; AVRT: nhp nhanh vao lai nh tht; EAT: nhp nhanh nh lch hng: MAT: nhp nhanh nh a ; O-AVRT: nhp nhanh nh tht xui chiu;
l
PAC: ngoai tm thu nh; SANRT: nhp nhanh co vong vao lai tai nut xoang nh; ST: nhp nhanh xoang; SVT: nhp nhanh trn tht; VT: nhp nhanh
285
tht; WPW (Wolff-Parkinson-White): hi chng Wolff-Parkinson-White.
Chn on phn bit

AF
La ri loan nhp nhanh keo dai ph bin nht va c thao lun nh la mt chu
ring trong chng nay.
AFl
La ri loan nhp nh ph bin th hai, c tnh khoang 200.000 trng hp mi
mc hang nm tai My, lin quan n tui cao, bnh tim tim n, va gii nam (J
Am Coll Cardiol 2000;36:2242).
Cung nh thng biu hin vi nhp u nhng co th loan nhp hoan toan
khi no kt hp vi block nh tht bin i (2:1 n 4-1 n 3-1;..).
C ch: Vong vao lai xung quanh hang rao dn truyn chc nng hoc cu
truc trong nh. Nhp nh la 250350 nhp/phut, vi s dn truyn xung tht
thng khng phai la 1:1, ma thng la 2:1. (SVT vi nhp tht u khoang
150 nhp/phut th ngh nhiu n cung nh).
Ging nh rung nh, cung nh i kem vi giai oan sau phu thut tim, cac
bnh phi, nhim c giap, va gian bung nh.
ECG: Trong cung nh in hnh, thy cac song hnh rng nhn ro nht cac
chuyn ao DII, DII, va aVF, va m V1.
Nhp nhanh nh a (Multifocal atrial tachycardiMAT)
SVT khng u mt cach khng u thng gp nhng bnh nhn ln tui
ang nm vin co nhiu bnh kem theo.
MAT thng i kem vi bnh phi tc nghen man tnh (chronic obstructive
pulmonary diseaseCOPD), va suy tim nhng con i kem vi giam dung nap
glucose, ha kali mau, ha magie mau, thuc (v.d., theophyline), va suy thn man.
ECG: SVT vi t nht 3 song P co hnh thai khac nhau, thng nhn ro nht
cac chuyn ao DII, DIII va V1.
Nhp nhanh xoang (Sinus tachycardiaST)
Nhp nhanh xoang vi ngoai tm thu nh (premature atrial complexesPACs)
thng xuyn co th dn n nhp khng u mt cach khng u.
o cung la c ch ph bin nht gy nhp nhanh co RP keo dai.
Thng thng, nhp nhanh xoang la ap ng sinh ly bnh thng vi tnh trang
cng giao cam (nh st, au, giam th tch, thiu mau, thiu oxy...) nhng cung
co th do cac thuc gy nghin (cocaine, amphetamine, methamphetamine) va
cac thuc c k n (theophylline, atropine, thuc cng giao cam).
Nhp nhanh xoang khng thch hp dung ch nhp xoang tng ln mt cach
dai dng ma khng xac nh c cac yu t sinh ly, bnh ly hoc do dc ly
nao gy anh hng.
Nhp nhanh nh do ngoai vi (Ectopic atrial tachycardiaEAT)
EAT vi block tim bin i co th biu hin nhp tim khng u mt cach
khng u, va co th phn bit c vi cung nh bi nhp nh trong EAT

khoang 150200 nhp/phut.
EAT vi block tim bin i thng do ng c digoxin.
EAT c c trng bi kiu hoat hoa nh u vi hnh thai song P xut phat t
bn ngoai phc hp nut xoang dn n nhp nhanh xoang co RP keo dai.
C ch: tnh t ng gia tng, c ch hoat ng khi phat va co th co vong
vao lai nho.
Nhp nhanh vao lai nut nh tht (atrioventricular nodal reentrant tachycardia
AVNRT)
Ri loan nhp co vong vao lai nay xay ra nhng bnh nhn co s phn ly chc
nng nut nh tht thanh ng chm va ng nhanh. AVNRT co th xay
ra moi la tui vi ty l cao hn gii n va la tui trung nin. Bnh nhn
khng bt buc phai co bnh cu truc tim.
AVNRT in hnh
Hay gp hn, dn truyn xung xui chiu theo con ng chm va dn
truyn ngc ln theo con ng nhanh, dn n nhp nhanh co RP ngn.
ECG: Song P n trong phc hp QRS hoc hoa nhp vao oan cui cua phc
b QRS tao ra song r gia (V1) hoc song s gia (DII). So sanh QRS va oan ST
khi nhp nhanh vi luc nhp xoang tm song P ngc.
AVNRT khng in hnh
t gp hn, xung dn truyn xung theo con ng nhanh trn nut AV, va dn
truyn ngc ln theo con ng chm trn nut AV, dn n nhp nhanh co
RP keo dai.
ECG: Song P ngc xut hin sau QRS na cui cua oan RR.
Nhp nhanh vao lai nh tht (atrioventricular reentrant tachycardiaAVRT)
Nhp nhanh vao lai nh tht xui chiu (Orthodromic AVRTO-AVRT) la
loai AVRT hay gp nht, chim khoang 95% trong tt ca cac loai nhp nhanh
vao lai nh tht.
Vong vao lai nh tht thng qua ng dn truyn phu: dn truyn cac xung
xung tm tht qua nut nh tht va s dn truyn ngc thng qua ng phu
hoc ng tt, dn n nhp nhanh co PR ngn.
ECG: Song P ngc thng xut hin sau phc b QRS va thng tach bit
vi phc hp QRS (cach >70 ms).
O-AVRT xui chiu la c ch chu yu hnh thanh SVTs bnh nhn co hi
chng tin kch thch nh hi chng WPW (c nh ngha bi oan PR
ngn, song delta oan ln cua phc b QRS).
O-AVRT xui chiu co th xay ra ma khng co tin kch thch dn truyn qua
ng tt theo chiu ngc ch xay ra khi co loan nhp nhanh (ng phu n).
t ph bin hn, vic dn truyn ngc qua con ng phu n tm nh din
ra u chm hoat ng co bop cua tm nh xay ra na sau cua oan RR,

dn n nhp nhanh co PR keo dai. Nhp nhanh khng ngng kem theo co th
gy ra bnh c tim do nhp nhanh.
Nhp nhanh vao lai nh tht ngc chiu (Antidromic AVRTA-AVRT):
Vong vao lai tao ra SVT xay ra khi dn truyn xung tm tht theo con ng
phu va dn truyn ngc lai qua nut AV hoc qua con ng phu th 2.
ECG: Phc b QRS ging nhp nhanh tht, tuy nhin co s hin din cua tin
kch thch trn phc b QRS ban u nn c chn oan la hi chng WPW.
A-AVRT gp <5% bnh nhn co hi chng WPW.
Nhp nhanh b ni (Junctional tachycardia)
Do tng cng tnh t ng chi ni nh tht, xung in dn truyn xung tht
va ln nh mt cach ng thi, ging vi AVNRT in hnh, song P ngc cung
b ln vao phc b QRS.
Thng hay gp tre nho, c bit la sau phu thut tim.
Nhp nhanh vao lai nut xoang nh (Sinoatrial nodal reentrant tachycardia
SANRT)
Vong vao lai khu tru t nht mt phn trong nut xoang (sinoatrialSA).
Khi u va kt thuc t ngt, gy ra bi mt PAC.
ECG: Hnh thai song P va truc in tim hoan toan ging vi song P xoang khi
bnh nhn co nhp xoang bnh thng.
IU TR
Xin tham khao Bang 71 tng hp phng cach iu tr cac loai loan nhp nhanh
trn tht ph bin.
iu tr cp cu SVTs co triu chng nn da trn phac ACLS c m ta
Phu luc C.
iu tr lu dai nn hng ti vic d phong tai phat hoc phong cac bin chng
i kem vi cac SVT c bit.
Nhiu SVTs co th chm dt bng cac thuc hoc ky thut block nut nh tht
(Bang 72), trong khi AF, cung nh va mt vai ri loan nhp nh nhanh se keo dai
vi tn s thp chm dn xung do block nut nh tht mt phn.
Vic iu chnh cac ri loan in giai nh ha kali mau hoc ha magie mau co th
co gia tr iu tr va phong nga trong vic iu tr mt vai SVTs.
Trit t bng song cao tn (Radiofrequency ablationRFA): Phng phap iu
tr trit vi ty l thanh cng cao t 85% n 95% vi nhiu loai SVTs, bao gm
AVNRT, nhp nhanh thng qua ng phu, nhp nhanh nh mt va cung nh.
Ty l bin chng phu thuc tng thu thut cu th va thng <1%, gm chay mau,
tu mau vung sinh duc, thung tim hoc chen ep tim, t quy, tc mach phi va
block tim hoan toan oi hoi phai cy may tao nhp vnh vin.
Bng 71 iu tr cc ri lon nhp nhanh trn tht thng gp
Cc chin lc iu tr
Cung nh (AFl) Chng ng tng t vi AF; nguy c b huyt khi tc mch l

nh nhau.
Nu bnh nhn c nhiu triu chng hoc kh kim sot c tn
s, vic chuyn nhp bng sc in hoc thuc l thch hp.
Nu c my to nhp, vic overdrive nhp nh c th chuyn c
nhp.
iu tr AFl bn phi in hnh bng t in vi catheter c t l
thnh cng di hn l 90% v rt t xy ra bin chng.
Nhp nhanh nh a iu tr qu trnh sinh l bnh c bn.
(MAT) Duy tr s cn bng in gii kali v magie.
Dng thuc chng lon nhp nu bnh nhn c tn s p ng tht
nhanh c triu chng.
C th ha vic iu tr bng thuc chn v thuc chn knh canxi.
Sc in chuyn nhp khng hiu qu.
Nhp nhanh xoang iu tr qu trnh sinh l bnh c bn.
(ST) iu tr cp: Xc nh v iu tr cc yu t kch thch ngoi tm
Ngoi tm thu nh thu nh ng c digoxin; nu huyt ng n nh th dng thuc
nhanh (EAT) chn v thuc chn knh canxi. Trong mt s t trng hp, s
dng amiodarone, flecainide hoc sotalol.
iu tr lu di: Kim sot tn s bng thuc chn v thuc chn
knh canxi. Nu khng thnh cng, cc la chn iu tr khc
bao gm t in qua catheter (t l thnh cng 86%), flecinide,
propafenone, stalol hoc amiodarone.
Nhp nhanh vng Trit t qua catheter c t l thnh cng cao (96%) nhng phi
vo li nt nh c c th ha vi tng bnh nhn.
tht (AVNRT) Nu mun iu tr ni khoa hn th c th s dng thuc chn ,
thuc chn knh canxi, v digoxin; sau xem xt propafenone,
flecinide, v. v...
Nhp nhanh vng iu tr cp: Nghim php cng ph v, adenosine, thuc chn
vo li nh knh canxi. Nu khng hiu qu th dng procainamide hoc
tht xui chiu thuc chn .
(O-AVRT) iu tr c ch lu di: Trit t qua catheter c t l thnh cng
cao (95%) nhng cng phi c th ha tng bnh nhn. Nu
mun iu tr ni khoa d phng hn th dng flecainide v
procainamide c ch nh.
(cn tip)
Bng 71 iu tr cc ri lon nhp nhanh trn tht thng gp (Tip theo)
Cc chin lc iu tr
Nhp nhanh vng iu tr cp: Trnh s dng adenosine hoc cc thuc block c
vo li nh tht hiu nt nh tht khc. Xem xt ibutilide, procainamide hoc
ngc chiu flecainide.
(A-AVRT) iu tr c ch lu di: Trit t ng ph qua catheter l
phng php a dng v thnh cng (95%). Nu mun iu tr
ni khoa, xem xt flecainide v propafenone.
AF, rung nh;

T Blomstrom-Lundqvist C, Scheinman MM, Aliot EM, v cng s. Hng dn ca ACC/AHA/ESC v x
tr bnh nhn b ri lon nhp trn tht bn tm tt: bo co ca nhm chc nng v hng dn thc
hnh ca Trng mn Tim mch Hoa K/ Hi tim mch Hoa K v hi ng v hng dn thc hnh ca
Hip hi Tim mch Chu u. J Am Coll Cardiol, 2003;42:1493.
Ngay cang co nhiu bng chng nhng con thiu cac th nghim ngu nhin ln
vi thi gian theo doi dai cho thy trit t bng catheter so vi iu tr chng
loan nhp giup cai thin cht lng sng va co tnh chi phhiu qua tt hn trong
thi gian dai (Am J Cardiol 1998;82:589).
Rung nh
I CNG
Vic kim soat rung nh cn phai xem xet cn thn trn 3 vn : kim soat tn
s, d phong huyt khi va kim soat nhp.
nh ngha
Rung nh la ri loan nhp nh c trng bi tnh trang mt ng b cac nhom c nh
gy hu qua suy giam chc nng c hoc cua nh. Rung nh th hin trn in tm
12 chuyn ao la mt hnh anh song P, thay bng nhng song nho ln tn hoc
rung khng u v bin , thi gian, hnh dang so vi ng c s cua ECG. ap
ng cua tht vi rung nh thng khng u va thng nhanh nu dn truyn nh
tht con nguyn ven. Rung nh la ri loan nhp ph bin nht.
Phn loi
Rung nh c phn lam 4 dang da trn biu hin lm sang: rung nh xut hin
ln u (first occurrence), rung nh kch phat (paroxysmal AF), rung nh dai dng
(persistent AF), rung nh man tnh (permanent AF).
Bng 72 iu tr cng ph v v Adenosine
Liu lng/ Cht Tc dng

Chun b thi gian/ kch thch/ ph
bnh nhna C ch chi tit c tnh Chng ch nh c ch thng gp
Valsava M t th thut. Kch thch Th ra gng sc khi Bnh nhn Bnh nhn
dy thn ng th ng chu ng khng lm
kinh ph kn trong vi giy c. theo hng
v trong sau th gin. dn c.
giai
on
th
gin.
Xoa xoang Kim tra xem Kch thch u tin, n vi p Bnh nhn TIA hoc t
cnh c ting thn lc va cm chu ng qu gn
Lon nhp nhanh

thi ng kinh ph nhn c mch c. y, hoc
mch cnh v. cnh bng ngn Nguy c hp ng k
hoc tin s tr v ngn gia. mng x ng mch
t qu hay Nu khng hiu va ng cnh cng
khng, sau qu, lm ng tc mch bn hoc c
t bnh quay trong 35 cnh gy ting thi

nhn t th giy. huyt tc. ng mch
Rung nh
nm nghing Khng bao cnh.
vi c t gi xoa c 2 Co tht ph
th dui. xng cnh qun ng
l
k.
(cn tip)
291
292
Bng 72 iu tr cng ph v v Adenosine (Tip theo)
l
Liu lng/ Cht Tc dng
Ch. 7
Chun b thi gian/ kch thch/ ph
bnh nhna C ch chi tit c tnh Chng ch nh c ch thng gp

Lon nhp tim
Adenosine Gii thch tc Thuc c Liu khi u: 6 mg Gy ra Co tht ph Cht kch thch: mt,
dng ph c block IV bolus nhanh vo ngng qun ng Dipyridamole, hi hp
kh nng xy nt nh tnh mch khuu xoang k. carbamaze- nh
ra vi bnh tht. tay, sau 1030 ko di pine trng
nhn. Tc ml nc mui sinh nhng Hiu qu r ngc,
dng l ui thuc. bnh nhn rng nhng au
ngn Nu mun, khi vn c hi bnh nhn ngc, h
(thi cha t c tc chng suy ghp tim. huyt p,
gian dng, c th lp li nt xoang Cht c ch: lm nng
bn thi vi liu 12 mg vi hoc Caffeine v thm co
trong khong cch 12 block nh theophylline. tht ph
huyt pht. tht cp 2 qun.
thanh ng tnh mch hoc cp
l 48 trung tm: liu khi 3.
pht). u 3 mg IV.
Nhp nhanh vng vo li nt nh tht, nhp nhanh vng vo li nh tht, v nhiu nhp nhanh nh khc s kt thc khi dng cc nghim php cng ph v hoc
adenosine v trong rung nh, s c mt ca cc sng dng rung s gip a ra chn on.
Ngm nc, n nhn cu, ho, gagging, ht th sau, v. v... l cc nghim php cng ph v thay th khc.
aBnh nhn nn c theo di in tm lin tc trong bt c th thut no nhc n trn. tng gi tr chn on ca vic ghi chuyn o ko di, s
dng chuyn on V1, DII (th hin hot ng nhp nh).

TIA (transient ischemic attack), thiu mu no thong qua. IV (intravenous), tim tnh mch.
Lon nhp nhanh Rung nh l 293
Rung nh xut hin ln u co th co triu chng hoc khng biu hin triu
chng. Ty l chuyn nhp t phat thng cao, ti >60% trong s nhng bnh nhn
phai nhp vin.
Rung nh kch phat rung nh tai phat trong o mi cn ring le <7 ngay va
thng keo dai <48 gi.
Rung nh dai dng rung nh tai phat trong o mi cn ring le keo dai >7 ngay
hoc oi hoi phai sc in chuyn nhp ct cn.
Rung nh man tnh la dang rung nh tn tai keo dai ma chuyn nhp bng sc
in hoc thuc tht bai hoc chp nhn rung nh tn tai do co chng ch nh
vi sc in hoc khng co triu chng.
Dch t hc
Rung nh la loan nhp nhanh keo dai ph bin nht khin bnh nhn phai iu tr
va la nguyn nhn hay gp nht gy ri loan nhp khng u mt cach khng u
phat hin c trn ECG cua cac bnh nhn ang iu tr ni tru. AF la bnh in
hnh ngi gia, gp >10% nhng ngi >75 tui.
Cac yu t nguy c c lp cua rung nh ngoai tui cao gm gii nam, ai thao
ng, bnh tim mach nh suy tim, bnh van tim, tng huyt ap, nhi mau c
tim trc o (JAMA 1994;271:840). Di 65 tui, beo ph va ngng th khi ngu
la nhng yu t nguy c quan trong cua AF mi khi phat (J Am Coll Cardiol
2007;49(5):565). Mc du cng giap trn lm sang co AF mi khi phat i
kem, nhng lai chim ty l nho trong nhng bnh nhn b rung nh (J Epidemiol
2008:18(5):209).
Sau phu thut tim-lng ngc, rung nh xay ra 2050% bnh nhn (J Am Coll
Cardiol 2006;48(4):8540).
Sinh l bnh
C ch chnh xac dn n rung nh vn cha c hiu bit mt cach y u. S
khi phat cua AF thng la do s kch hoat nhanh va lp lai cua mt ngoai vi
trong tnh mach phi vi s dn truyn dang dung trong toan b tm nh. S duy tr
cua AF dai dng thng oi hoi co nhiu vong vao lai khac nhau v v tr va thi
gian giai thch c im t keo dai cua AF. S tai t chc lai cu truc va in hoc
cua nh i kem vi cac bnh ly tim mach thuc y cac hoat ng ngoai vi va s dn
truyn ng nht cung cp nn tang cho AF. AF, mt khi xut hin, cung se thuc
y s tai t chc v cu truc va in hoc nh va do o lam bn vng nhp. Vim
va x hoa co th ong vai tro quan trong trong s khi phat va duy tr AF. Cac cht
ch im vim, v du nh interleukin-6 va protein phan ng C u tng ln trong AF
va co lin quan vi thi gian keo dai cua AF, s thanh cng cua sc in chuyn
nhp va tiu huyt khi.
D phng
Hin nay vn con thiu cac th nghim lm sang tin cu anh gia vai tro cua d
phong tin phat rung nh khng lin quan n hu phu thng qua vic iu tr
bnh phi hp va iu chnh yu t nguy c. Mt s nghin cu cho thy statin co
th rung nh tai phat ti 61%, c lp vi tac dung ha lipid mau cua thuc (J Am
Coll Cardiol 2008;51:828). Thuc c ch men chuyn (Angiotensin-converting
enzyme inhibitorACE-I) va chen thu th angiotensine (angiotensin receptor
blockersARBs) c chng minh d phong tai cu truc tm nh trn ng vt
thng qua vic c ch h thng renin-angiotensine. Mt phn tch tng hp cua
nhng bnh nhn suy tim sung huyt va tng huyt ap c iu tr hoc bng
thuc ACE hoc thuc chen thu th cho thy s giam ty l AF mi khi phat 20%
n 30% (J Am Coll Cardiol 2005;45:1832).
Mt s chin lc dung thuc va khng dung thuc a c nghin cu d
phong rung nh sau phu thut. Vic tip tuc duy tr thuc chen giao cam sau
phu thut a cho thy giam ty l AF sau phu thut. S dung Amiodarone,
sotalol, magnesium, hoc acid beo cha omega-3 trong giai oan trc m giup
giam ty l rung nh sau phu thut (Ann Pharmacother 2007;41:587).
CHN ON
Rung nh c chn oan bng ghi in tm 12 chuyn ao ma in hnh la
ng c ban dao ng mt cach khng u vi ap ng tht khng u va thng
la nhanh (>100 nhp/phut). Rung nh nn c phn bit vi nhng nhp nhanh khac
ma co ap ng nhp tht khng u nh MAT va cung nh vi dn truyn bin i.
Biu hin lm sng
Cac triu chng i kem vi AF co th thay i t rt nng (phu phi cp, hi hp
anh trng ngc, au tht ngc, ngt) ti khng c hiu (mt moi) hoc hoan toan
khng co triu chng. Cac triu chng thng la th phat do ap ng tht nhanh vi
AF hn la do mt chc nng tm thu cua nh. Tuy nhin, nhng bnh nhn co ri
loan chc nng tm thu hoc tm trng cua tht ang k co th co cac triu chng
gy ra trc tip bi mt chc nng tm thu cua nh. Cn nhp nhanh keo dai do rung
nh co th dn n bnh c tim do nhp tim nhanh.
IU TR
iu tr rung nh hng ti 3 muc tiu: kim soat tn s tht, d phong huyt
khi va kim soat nhp thng qua vic duy tr nhp xoang. Cac nghin cu gn
y a ch ra rng chin lc iu tr hng ti vic duy tr nhp xoang khng em
lai li ch v ty l t vong (N Engl J Med 2002;347:1825). V vy tip cn iu tr
rung nh nhng bnh nhn t triu chng chu yu la d phong huyt khi va kim
soat tn s ap ng tht bng thuc. Duy tr nhp xoang bng thuc la bin phap
danh cho nhng bnh nhn con triu chng du a ti u hoa vic kim soat tn s
ap ng tht vi rung nh.
Thuc
iu tr AF nn bt u vi vic cn nhc dung thuc chng ng thch hp.
Wafarin a c chng minh la u vit hn so vi aspirin hoc aspirin phi hp
vi clopidogrel trong d phong huyt khi. Ca dabigatran va rivaroxaban a c
so sanh mt cach trc tip vi wafarin trong cac th nghim ngu nhin tin cu
va c ghi nhn la co ty l huyt tc mach h thng hoc mach nao thp hn vi
ty l bin chng chay mau tng t nh warfarin. Co th at c s kim soat tn
s cua ap ng tht vi AF bng cac thuc han ch dn truyn qua nut nh tht nh
verapamil, diltiazem, chen giao cam va digoxin. Co th kim soat tn s bng
cach duy tr nhp xoang bng mt s thuc nht nh. Thuc chng loan nhp co
hiu qua nht trong vic phong nga s tai phat cua AF, nhng t hiu qua hn khi
chuyn nhp (Bang 73).
La chn hng u
D phong bin chng huyt khi tc mach la mt nguyn ly trung tm trong
iu tr rung nh, va nn bt u bng vic anh gia nguy c cho tng bnh nhn.
Chng ng keo dai vi warfarin, dabigatran, hoc rivaxovaban la phng phap
iu tr hiu qua nht trong vic giam nguy c t quy i kem vi AF; tuy nhin
vic s dung bt c thuc nao trong cac thuc trn oi hoi phai co phn tch li
ch-nguy c cn thn xac nh nhng bnh nhn co nguy c ang k b tai bin
mach nao (CVA cerebrovascular accident) vt trn s tng nguy c b cac bin
chng xut huyt.
Bang im CHADS2 la mt cng cu phn tng nguy c a c kim nh co th
phn chia nhng bnh nhn co AF khng do bnh van tim thanh nhom nguy c
thp, trung bnh hoc cao b t quy da trn s co mt cua cac yu t nguy c:
CHF, tng huyt ap (hypertensionHTN), tui (Age) >75 tui, ai thao ng (Di-
abetes), hoc tai bin mach nao thoang qua/t quy (Stroke) trc o (Bang 74).
Trong 1 nghin cu, nhng bnh nhn rung nh nguy c cao b t quy t 6-7%
mi nm, co th giam con 3,6% mi nm nu dung Aspirin 325 mg/ngay, va
giam nhiu hn con 2,3% mi nm dung warfarin liu iu tr (Circulation
1991;84:527). Co mt s ng thun chung rng nhng bnh nhn di 65
tui ma khng co bnh tim thc tn hoc tng huyt ap (hay AF n c) co
nguy c thp (khoang 1% mi nm) va co th iu tr ch bng asparin ung
hang ngay. Cac khuyn cao v dung thuc chng ng lu dai trong AF cua
AHA (American Heart Association)/American College of Cardiology (ACC)/
European Society of Cardiology c tom tt Bang 75.
296
Bng 73 Thuc dng kim sot tn s tim trong rung nh
l
Ch. 7
Khi pht
Thuc Liu np tc dng Liu duy tr Tc dng ph chnh Khuyn co

Lon nhp tim
Khng c bng chng ca ng dn truyn ph
Esmolola Tim tnh mch: 0,5 5 phtb 0,060,2 mg/kg/pht huyt p, nhp tim, I
mg/kg trong 1 pht block tim, suy tim,
co tht ph qun
Metoprolola Tim tnh mch: 2,5 5 pht Khng c huyt p, nhp tim, I
5,0 mg bolus trong block tim, suy tim,
2 pht (n 3 liu) co tht ph qun
Ung: Ging liu duy
tr 46 gi 25100 mg 2 ln/ngy
Propranolola Tim tnh mch: 0,15 5 pht Khng dng huyt p, nhp tim, I
mg/kg block tim, suy tim,
Ung: Ging liu duy 6090 80240 mg/ngy chia nhiu co tht ph qun
tr pht ln
Diltiazem Tim tnh mch: 0,25 27 pht 515 mg/gi huyt p, block tim, suy I
mg/kg trong 2 pht tim
Ung: Ging liu duy 24 gi 120360 mg/ngy chia lm
tr nhiu ln, c dng phng
thch chm
Verapamil Tim tnh mch: 35 pht Khng dng huyt p, block tim, suy I
0,0750,15 mg/kg tim
trong 2 pht
Ung: Ging liu duy 12 gi 120360 mg/ngy, chia nhiu
tr ln, c dng phng thch
chm
C bng chng ca ng dn truyn phc
Amiodarone Tim tnh mch: 150 Nhiu 1 mg/pht trong 6 gi, sau Xem di IIa
mg trong 10 pht ngy 0,5 mg/pht
Lon nhp nhanh

nhng bnh nhn suy tim v khng c ng dn truyn ph
Digoxin Tim tnh mch: 0,25 60 pht 0,125-0,375 mg/ngy tim Ng c digoxin, block tim, I
mg mi 2 gi, tng hoc tnh mch hoc ung nhp tim
liu n 1,5 mg lu hn
Ung: 0,5 mg/ngy 2 ngy

(cn tip)
Rung nh
l
297
298
l
Ch. 7
Bng 73 Thuc dng kim sot tn s tim trong rung nh (Tip theo)

Khi pht
Lon nhp tim

Thuc Liu np tc dng Liu duy tr Tc dng ph chnh Khuyn co
Amiodaroned Tim tnh mch: 150 Nhiu 1 mg/pht trong 6 gi, sau huyt p, block tim, iu tr
mg trong 10 pht ngy 0,5 mg/pht nhp tim, tng tc vi cp: IIa
100400 mg ung 1 ln/ngy warfarin; xem phn vn (tim tnh
Ung: 800 mg/ ngy 13 tun bn m t cc tc dng mch)
trong 1 tun ph trn da, tuyn gip, iu tr
600 mg/ngy cho 1 phi, gic mc v gan. khng
tun, cp/lu
400 mg/ngy cho 1 di: IIb
tun, (ung)
a Ch c cc i din ca cc nhm thuc chn c th hin trong bng nhng cc thuc tng t c th c s dng cho ch nh ny vi liu thch hp.
bS khi pht tc dng bin i v mt vi tc dng xy ra sm hn.
cChuyn nhp xoang v trit t ng dn truyn ph qua catheter thng c khuyn co; iu tr bng thuc kim sot tn s tim c th l bin php
iu tr thch hp mt bi bnh nhn nht nh. Xem phn vn bn di tho lun v rung nh trong bnh cnh hi chng tin kch thch/W.P.W.
dAmiodarone c th hu ch trong vic kim sot tn s p ng tht b rung nh khi cc phng php khc khng thnh cng hoc b chng ch nh.
Phng theo Fuster V. Ryden LE, Cannom DS, v cng s. Hng dn ca ACC/AHA/ESC 2006 cho vic x tr bnh nhn vo vin v rung nh: bo co ca nhm
chc nng v hng dn thc hnh ca Trng Tim mch Hoa K/ Hi tim mch Hoa K v hi ng v hng dn thc hnh ca Hip hi Tim mch Chu u
(Hi ng vit bi xem li hng dn nm 2011 v x tr bnh nhn b rung nh). Circulation 2006;114:e354.
Nguy c t qu bnh nhn rung nh khng c bnh van tim khng

Bng 74
c iu tr bng thuc chng ng theo ch s CHADS2
Tiu chun nguy c CHADS2 im
t qy hoc TIA trc 2
Tui >75 1
Tng huyt p 1
i tho ng 1
Suy tim 1
T l t qu hiu Phn
chnha (%/nm) nhm
Bnh nhn (Khong tin cy im nguy Liu php chng huyt khi
(N = 1.733) 95%) CHADS2 c c khuyn co
Aspirin 81325 mg
120 1,9 (1,23,0) 0 Thp
ung hng ngy
Trung Aspirin hoc Warfarin
463 2,8 (2,03,8) 1
bnh
Trung Tin s CVA/TIA/huyt
523 4,0 (3,15,1) 2
bnh tc
C = Warfarin
337 5,9 (4,67,3) 3 Cao Khng = Aspirin hay
Warfarin
220 8,5 (6,311,1) 4 Cao
Warfarin (INR 2,03,0)
65 12,5 (8,217,5) 5 Cao
5 18,2 (10,527,4) 6 Cao
Aspirin, 81325 mg ung hng ngy. Warfarin, ch s chun ha quc t (INR), 2,03,0.
aT l t qu hiu chnh xut pht t phn tch a bin vi gi thit khng dng aspirin. AF, rung nh;
CHADS2 (cardiac failure, hypertension, age, diabetes, and stroke [doubled]), suy tim, tng huyt p,
tui, i tho ng, t qu (nhn i); CVA, tai bin mch no; TIA, tai bin mch no thong qua.
Phng theo Fuster V. Ryden LE, Cannom DS, v cng s. Hng dn 2006 ca ACC/AHA/ESC v x tr
bnh nhn rung nh: bo co ca Nhm chc nng v hng dn thc hnh ca Trng Tim mch Hoa
K/Hi tim mch Hoa K v Hi ng v hng dn thc hnh ca Hip hi tim mch chu u cho vic x
tr bnh nhn rung nh. Circulation. 2006;114:e257-e354. S liu t Gage BF, Waterman AD, Shannon
W. v cng s. nh gi cc chin lc phn loi lm sng d on t qu: kt qu t s ng k
quc gia v rung nh. JAMA. 2001;385:2864-2870.
Liu php chng ng thch hp trong cc qun th rung nh

Bng 75
khc nhau
Mc
c im bnh nhn Liu php chng ng khuyn co
Tui <60, khng c bnh tim (AF Aspirin (81325 mg/ngy) I

n c) hoc khng iu tr
Tui <60, c bnh tim nhng Aspirin (81325 mg/ngy) I
khng c yu t nguy ca
Tui 6074, khng c yu t Aspirin (81325 mg/ngy) I
nguy ca
Tui 6574 tui b i tho ng Chng ng ng ung (INR I
hoc CAD 2,03,0)
Tui 75 hoc hn, ph n Chng ng ng ung (INR I
2,03,0)
Tui 75 hoc hn, nam, khng c Chng ng ng ung I
yu t nguy c khc (INR 2,03,0) hoc aspirin
(81325 mg/ngy
Tui 65 hoc hn, suy tim Chng ng ng ung (INR I
2,03,0)
Phn sut tng mu tht tri Chng ng ng ung (INR I
<35% hoc phn sut co ngn 2,03,0)
<25%, v tng huyt p
Bnh tim do thp (hp hai l) Chng ng ng ung (INR I
2,03,0)
Van tim nhn to; huyt khi tc Chng ng ng ung (INR I
mch trc 2,03,0 hoc cao hn)
Huyt khi nh tri ko di trn Chng ng ng ung (INR IIa
TEE 2,03,0 hoc cao hn)
aYu t nguy c ca huyt khi gy tc mch bao gm suy tim, phn sut tng mu tht tri <35%, v
tin s tng huyt p.

AF, rung nh; CAD (coronary artery disease), bnh ng mch vnh; INR, ch s chun ha quc t; TEE
(transesophageal echcardiography), siu m tim qua thc qun.
Phng theo Fuster V. Ryden LE, Cannom DS, v cng s. Hng dn 2006 ca ACC/AHA/ESC v x tr
bnh nhn rung nh: bo co ca Nhm chc nng v hng dn thc hnh ca Trng Tim mch Hoa
K/ Hi tim mch Hoa K v Hi ng v hng dn thc hnh ca Hip hi tim mch chu u cho vic
x tr bnh nhn rung nh (Hi ng vit bi xem li Hng dn nm 2001 v x tr bnh nhn rung nh).
Circulation. 2006;114:e257-e354.
Vai tro cua iu tr chng ng dn n va sau khi chuyn nhp xoang c

cp phn sau trong bi canh co chuyn nhp.
Kim soat tn s cua AF co th at c bng vic s dung cac thuc keo
dai thi gian dn truyn qua nut nh tht. Cac thuc nay bao gm thuc chen
knh canxi loai nondihydropyridine (diltiazem, verapamil), chen giao cam va
digoxin. Tham khao Bang 73 v khuyn cao s dung liu nap va liu duy tr cac
thuc nay.
Digoxin hu ch trong vic kim soat tn s tht khi ngh trong rung nh bnh
nhn co ri loan chc nng tht trai va suy tim sung huyt, va co th hu ch nu
dung kt hp vi thuc chen knh canxi hoc chen giao cam kim soat tn
s ti u nhng trng hp rung nh man tnh. Digoxin t hiu qua hn i vi
kim soat tn s tht khi gng sc.
Ng c digoxin thng c chn oan trn lm sang vi cac triu chng
gm bun nn, au bung, thay i th giac, l m va m sang. Thng gp
nhng bnh nhn co suy chc nng thn hoc nhng bnh nhn ang dung
cac thuc lam tng nng digoxin (verapamil, diltiazem, erythromycin,
cyclosporine..). Nhp nhanh nh kch phat kem block nh tht cac mc
khac nhau va nhp nhanh tht hai chiu la nhng ri loan nhp ph bin
nht i kem ng c digoxin. Cac bin phap iu tr mang tnh h tr, bng
cach dng thuc, t may tao nhp tam thi vi block nh tht va tim tnh
mach phenytion cho nhp nhanh tht hai chiu.
Kim soat tn s tht khng dung thuc trong rung nh co th dung phng
phap trit t nut nh tht cung vi cy may tao nhp vnh vin. Chin lc nay
ch nn ap dung cho nhng bnh nhn tht bai vi vic kim soat tn s bng
thuc va nhng bnh nhn ma vic kim soat nhp khng hiu qua hoc b
chng ch nh.
La chn hng th hai
Kim soat nhp tht trong rung nh bng vic dung cac thuc chng loan nhp
thay i vic hnh thanh va truyn xung in tao ra rung nh. Cac thuc chng
loan nhp la t hiu qua hn phuc hi nhp xoang trong chuyn nhp bng thuc.
Nguy c huyt khi i kem vi chuyn nhp bng thuc nn c xem xet cn
thn trc khi bt u dung thuc chng loan nhp. Cac hng dn v s dung
thuc chng ng thao lun di y:
Chuyn nhp bng thuc nn thc hin bnh vin vi moitor theo doi in tm
lin tuc v co mt s nguy c loan nhp nhanh hoc loan nhp chm co th e
doa tnh mang. Ibutilide la thuc duy nht dung chuyn nhp c chng nhn
bi Cuc quan ly thc phm va dc phm Hoa Ky. Cac th nghim lm sang cho
thy Ibutilide c dung trong 45% trng hp chuyn nhp cua rung nh va 60%
chuyn nhp bnh nhn cung nh. Ibutilide co nguy c gy xon nh 48%,
c bit trong 24 gi u sau khi dung thuc. V nguy c nay ma bnh nhn phai
c theo doi bng monitor va may sc in kh rung co sn trong khi truyn
ibutilide va t nht trong 4 gi sau truyn. Nguy c xon nh cao nhng bnh
nhn co bnh c tim va suy tim. Ibutilide a vao qua ng tnh mach, liu 1
mg (0,01 mg/kg nu bnh nhn <60 kg), truyn chm trong 10 phut. Truyn
nhanh co th gy xon nh. Chuyn nhp bng thuc kem hiu qua hn i vi
rung nh keo dai >7 ngay. i vi rung nh co thi gian ngn, dofetilide, sotalol,
flecainide va prop AF enone co th co hiu qua trong khi amiodarone rt t hiu
qua chuyn nhp.
Duy tr nhp xoang vi cac thuc chng loan nhp co 1 s nguy c gy ra loan
nhp e doa tnh mang. V vy, iu tr thuc chng loan nhp nn dung cho
nhng bnh nhn rung nh co triu chng mc cao du a kim soat nhp tht.
Thuc chng loan nhp c chia nhom chu yu theo c ch tac dung theo phn
loai Vaughan Williams. Nhom I: c ch knh natri nhanh; nhom II: chen giao
cam; nhom III: chen knh kali la chu yu; nhom IV: chen knh canxi. Cac thuc
chng loan nhp thng c s dung, ng thai tr va liu dung c lit k
bang 76. Cac thuc hiu qua duy tr nhp xoang la flecainide, propafenone,
sotalol, dofetilite va amiodarone.
Flecainide va propafenone la hai thuc chng loan nhp thuc nhom Ic hu
ch duy tr nhp xoang nhng bnh nhn co cu truc tim bnh thng.
nhng bnh nhn co bnh tim cu truc, cac thuc nhom Ic i kem vi tng ty l
t vong (N Engl J Med 1989;321:406) va ca 2 thuc u la nhng thuc giam
co bop c tim va co th khi phat hoc lam nng thm tnh trang suy tim. Biu
hin sm cua ng c ca 2 thuc nay la thi gian QRS keo dai. Nng thuc
gy ng c co tng quan vi nhp tim do s c ch u tin trn cac knh Natri
hoat ng. Hin tng nay c goi la use dependence (vn dung s l
thuc). Co th s dung ECG gng sc cung cp thm thng tin v liu an
toan vi nhp tim cao hn. Flecainide nn c s dung mt cach thn trong khi
khng dung thm cac thuc c ch nut nh tht v co th xay ra s tng ap ng
nhp tht kch phat do thuc gy chuyn t AF thanh cung nh. Propafenone t
gy hin tng nay hn do thuc co tac dung c ch thu th -adrenergic ni tai.
Sotalol la thuc chng loan nhp nhom III hu ch trong duy tr nhp xoang.
Sotalol la hn hp cua nhiu dang ng phn quang hoc: D-sotalol chen knh
kali trong khi L-sotalol i khang thu th . Nhng tac dung phu cua thuc la
do ca 2 c ch. Ngoai vic keo dai khoang QT dn n xon nh, DL-sotalol
co th gy nhp nhanh xoang hoc bt thng dn truyn nh tht. Sotalol khng
nn s dung bnh nhn suy tim sung huyt (do no co tac dung giam co bop c
tim) hoc bnh nhn co khoang QT keo dai.
Dofetilide la thuc chng loan nhp nhom III hu ch trong duy tr nhp xoang.
Bng 76 Thuc chng lon nhp thng dng
ng dng Tc dng ph chnha/

Nhm Thuc (Thi tr)a Liu khi u/np Liu duy tr nh gi
Ia Procainamide Tnh mch 1518 mg/kg ti 20 14 mg/pht GI, CNS, +ANA/hi

(thn, mg/ pht IR: 250500 mg, 36 gi/ln; chng ging SLE,
gan) 50 mg/kg/24 gi, ti SR: 500 mg mi 6 gi; st, huyt hc, khng
Ung (thn, a 5 g/24 gi Procanbid: 1.0002.500 mg cholinergic. Theo
gan) mi 12 gi di QTc, nng
procainamide huyt
thanh (48 mg/L) v
NAPA (<20 mgmL).
Quinidine Ung (gan) Sulfate: 200400 Khng dng QT, TdP, BP,
mg mi 6 gi; gim tiu cu, bnh
Lon nhp nhanh

Gluconate: 324 ng c canh-kina
972 mg mi 812 (cinchonism), ri lon
gi tiu ha.
Disopyramide Ung (gan, 300400 mg IR: 100200 mg mi 6 gi Khng cholinergic, Suy
thn) SR: 200400 mg mi 12 gi tim.

Ib Lidocaine Tnh mch 1 mg/kg trong 2 pht 14 mg/pht HR, CNS, GI. iu chnh
Rung nh
(gan) (c th nhc li 2 liu bnh nhn suy
ln, tng liu ln ti gan.
3 mg/kg) AMI, HF hoc shock.
l
(cn tip)
303
304
Bng 76 Thuc chng lon nhp thng dng
l
Ch. 7
ng dng Tc dng ph chnha/

Nhm Thuc (Thi tr)a Liu khi u/np Liu duy tr nh gi
Lon nhp tim

Mexiletine Ung (gan) 400 mg liu dng 1 200300 mg mi 8 gi GI, CNS.
ln
Ic Flecainide Ung (gan, 50 mg mi 12 gi Tng 50100 mg/ngy mi 4 HF, GI, CNS, nhn m.
thn) ngy, ti a 400 mg/ngy
Propafenone Ung (gan) IR: 150 mg mi 8 gi IR: 150 mg mi 8 gi GI, chng mt.
ER: 225 mg mi 12 ER: c th tng trong 5 ngy,
gi ln ti 425 mg mi 12 gi
III Sotalol Ung (thn) 80 mg mi 12 gi C th tng mi 3 ngy, ln nhp tim, BP, CHF,
ti 240320 mg/ ngy, chia CNS. Hn ch s ko
23 ln/ngy di QTc <550 ms.
Dofetilide Ung (thn, CrCl (mL/pht) liu Liu c hiu chnh da vo QT, VT/TdP, au u,
gan) (mcg, 2 ln/ngy): QTc 23 gi sau liu dng 1 chng mt. Xem phn
>60: 500 n 5 cho bnh nhn ni tr. vn bn bit thm
4060: 250 Vic iu tr lu di i hi chi tit v vic khi
2039: 125 phi tnh ton QTc v CrCl u v theo di iu
<20: chng ch nh mi 3 thng v chnh liu nu tr.
cn
Ibutilide Tnh mch 1 mg (0,01 mg/kg NA QT, VT/TdP, block AV,
(gan) nu bnh nhn <60 GI, au u.
kg) trong 10 pht;
c th nhc li nu
khng p ng sau
truyn ln u 10
pht
Amiodarone Tnh mch IV: 150 mg trong 10 1 mg/pht x 6 gi, sau 0,5 huyt p, HB, HR,
(gan) pht mg/pht tng tc vi warfarin;
Ung (gan) Ung: 800 mg/ngy 100400 mg ung hng ngy xem trong bi v cc
trong 1 tun, sau tc dng trn da,
600 mg/ngy trong tuyn gip, phi, gic
1 tun, sau 400 mc, v gan.
Lon nhp nhanh

mg/ngy trong 1
tun
aCc tc dng ph ph bin hoc e da n tnh mng ca cc thuc ny u c lit k. y khng phi l danh sch y tt c cc tc dng ph c
kh nng xy ra.
MI, nhi mu c tim; ANA (antinuclear antibodies), khng th khng nhn; BP (hypotension), h huyt p; CNS (central nervous system), h thn kinh trung

ng; CHF, suy tim sung huyt; CrCl (creatinine clearance), thanh thi creatinine; ER (extended release), gii phng m rng; GI (gastrointestinal), h tiu
Rung nh
ha; H (hepatic), gan; HB (heart block), block tim; HR (bradycardia), gim nhp tim; IR (immediate release), gii phng ngay lp tc; IV, tim tnh mch; NA (not
applicable), khng p dng c; NAPA, N-Acetylprocainamide; R (renal), qua thn; SLE (systemic lupus erythematosus), lupus ban h thng; SR (sustained
release), gii phng ko di; TdP (Torsades de pointes), xon nh; VT, nhp nhanh tht.
l
305
Dofetilide c ch thanh phn nhanh cua in th kali chm, IKr. V vy,

Dofetilide lam keo dai khoang QT liu co hiu qua trn lm sang. Keo dai
QT thm do tac dung cua chm nhp tim, c goi la phuc hi hin tng giam
tun tin vn tc dn truyn khi nhp tim gia tng (reverse use dependence
[ao ngc vn dung s l thuc]). Nguy c chnh cua Dofetilide la xon
nh. Dofetilide chng ch nh bnh nhn co QT hiu chnh (QTc) >440
ms hoc 500 ms bnh nhn co block nhanh. Liu bt u s dung phu thuc
thanh thai creatinine. Ghi in tm 12 chuyn ao trc khi s dung va
12 gi sau mi liu. Nu khoang QTc keo dai 15% hoc >500 ms sau liu
u tin, th giam 50% liu. Nu QTc keo dai >500 ms sau liu th 2, dng s
dung dofetilide. Mt s thuc ngn chn s bai tit cua Dofetilide (verapamil,
cimetidine, prochlorperazine, trimethoprim, megestrol, ketoconazole) va b
chng ch nh dung vi dofetilide. u im cua Dofetilide la khng lam tng
suy tim sung huyt hoc ty l t vong bnh nhn co ri loan chc nng tht
trai (N Engl J Med 1999;341:857) va Dofetilide khng gy ra bt thng trong
dn truyn hoc ri loan chc nng nut xoang.
Dronedarone la thuc chng loan nhp mi nht c chp thun iu tr
rung nh. Thuc bt ngun t amiodarone nn ging amiodarone, thuc cung
co cac c im cua cac thuc chng loan nhp nhom I va IV theo phn loai
cua Vaughan Williams. Dronedarone a c chng minh la hiu qua hn gia
dc trong vic duy tr nhp xoang sau chuyn nhp nhng t hiu qua hn
amiodarone trong vic duy tr nhp xoang. Ty l mi mc cua cac loan nhp do
thuc la thp vi dronedarone cung nh ty l mi mc cua c tnh cac c
quan. Co xu hng tng ty l t vong nhng bnh nhn co triu chng cua suy
tim nng, va thuc b chng ch nh nhom bnh nhn nay. Dronedarone c
chuyn hoa gan va khng nn dung nhng bnh nhn co ri loan chc nng
gan ang k. Co th dung dronedarone nhng bnh nhn co ri loan chc
nng thn ang k v no c ao thai chu yu qua phn.
Amiodarone co cac c tnh cua thuc chng loan nhp t nhom I n IV va
c cho la thuc hiu qua nht duy tr nhp xoang. V amiodarone co
nhiu c tnh nn thuc khng nn la la chon u tin kim soat nhp
trong rung nh nhng bnh nhn ma cac thuc chng loan nhp khac co
th s dung mt cach an toan hn. Amiodarone dung ng tnh mach t hiu
qua trong vic chuyn nhp cp trong AF mc du a quan sat thy s chuyn
nhp sau vai ngay s dung amiodarone ng tnh mach. Do thuc c s dung
mt cach ph bin va co ty l b cac tac dung phu cao nn oi hoi phai co thao
lun chi tit hn v cac tac dung nay.
Tac dung phu cua amiodarone ng ung phu thuc mt phn vao liu lng
va co th xay ra 75% bnh nhn c iu tr liu cao trong 5 nm. Vi liu
thp hn (200300 mg/ngay), nhng tac dung phu buc phai dng thuc gp
khoang 510% bnh nhn mi nm.
c tnh trn h hp xay ra 115% bnh nhn dung thuc nhng dng nh
t xay ra hn bnh nhn dung liu <300 mg/ngay (Circulation 1990;82:580).
Bnh nhn thng co biu hin ho khan i kem vi thm nhim phi va xut
hin rale phi. Qua trnh nay co ve ao ngc c nu c phat hin sm
nhng nhng trng hp khng c phat hin co th dn n t vong n
10% s bnh nhn b anh hng. Chup X-quang ngc va thm do chc nng
h hp nn c tin hanh tai thi im ban u va mi 12 thang hoc khi bnh
nhn co triu chng kho th. Thm nhim m ke trn X-quang ngc va giam
khuch tan cn phai ngh n c tnh cua amiodarone trn h h hp.
Nhay cam anh sang la phan ng phu thng gp, va mt vai bnh nhn, co
s i mau da thanh sc hi tm vung da tip xuc anh nng. Mau da xanh
xam co th khng phuc hi hoan toan khi ngng dung thuc.
Ri loan chc nng tuyn giap la tac dung phu hay gp. Suy giap hoc
cng giap u co th xay ra, chim 25% mi nm. Hormon kch thch
tuyn giap nn c nh lng tai thi im bt u iu tr va theo doi mi
6 thang. Nu co suy giap, iu tr ng thi vi levothyroxine cho phep vic
tip tuc s dung amiodarone.
Tn thng vi giac mac c phat hin bng en khe, gp gn nh tt ca
cac bnh nhn dung thuc. Tn thng nay rt t khi anh hng n th lc
va khng phai la du hiu ngng s dung thuc. Vim thn kinh th giac,
dn n mu, him xay ra nhng cung c ghi nhn nhng bnh nhn dung
amiodarone.
Bin i in tm thng gp nht la keo dai khoang PR va nhp tim
nhanh, tuy nhin, block nh tht cao co th xay ra bnh nhn co bt
thng dn truyn t trc. Amiodarone co th gy keo dai khoang QT, mc
du thng khng qua dai, va xon nh la him gp. Tuy nhin, nn tranh
dung cac thuc khac cung keo dai khoang QT nhng bnh nhn ang s
dung amiodarone.
Ri loan chc nng gan thng biu hin bng tng men gan thoang qua
va khng co triu chng. Nu men gan tng gp ba ln gia tr bnh thng
hoc hai ln nhng bnh nhn co men gan luc u tng, nn ngng s
dung hoc giam liu amiodarone. Aspartate transaminase (AST) va alanine
transaminase (ALT) nn c theo doi mi 6 thang nhng bnh nhn ang
dung amiodarone
Tng tac thuc. Amiodarone lam tng nng trong mau cua warfarin va
digoxin, v vy nhng thuc nay nn giam mt na liu mt cach thng quy
khi bt u s dung amiodarone va phai theo doi cht che nng .
Liu php khng dng thuc khc

Phng phap khng dung thuc kim soat nhp gm trit i qua ng catheter
hoc bng phu thut ngn chn vic hnh thanh va duy tr AF.
Sc in chuyn nhp (DC CardioversionDCCV) la phng phap an toan va
hiu qua nht hi phuc nhp xoang cp tnh. Trc khi sc in, xem xet nguy
c huyt khi va vic dung thuc chng ng, nu co th, la rt quan trong,
giam thiu nhng bin chng tc mach do huyt khi co th xay ra trong qua trnh
sc in. AF co tn s ap ng tht nhanh trong bnh canh thiu mau c tim ang
tin trin, nhi mau c tim, ha ap, hoc suy h hp nn c sc in nhanh chong
bt k tnh trang dung chng ng nh th nao.
Nu thi gian rung nh <48 gi, sc in c tin hanh ngay ma khng cn
dung chng ng. Nu rung nh keo dai >48 gi ( hoc khng ro thi gian), nn
dung chng ng warfarin, vi ty l chun hoa quc t (international normalized
ratioINR) la 2,03,0; trong t nht 3 tun trc khi sc in, va chng ng
nn c tip tuc s dung vi liu tng t sau khi sc in thanh cng.
thay th cho vic dung chng ng 3 tun trc khi sc in, tin hanh siu
m qua thc quan loai tr huyt khi tiu nh trai. Phng phap nay an
toan va co li ch la sc in sm hn dung warfarin, va do o c ch nh
bnh nhn khng th ch i nhiu tun sc in. iu tr chng ng
vi warfarin c ch nh sau khi sc in trong t nht 4 tun (Am J Cardiol
1998;82:1545), du th nghim AFFIRM (N Engl J Med 2002;347:1825) gi y
rng nhng bnh nhn co nguy c t quy cao nn s dung warfarin mt cach
v han nh.
Trong thc hanh, nn an thn cho bnh nhn vi midazolam (12 mg tnh mach
mi 2 phut, ti a n 5mg), methohexal (2575 mg tnh mach), etomidate
(0,20,6 mg/kg tnh mach) hoc propofol (liu u, 5 mg/kg/gi ng tnh
mach).
Shock in ng b hp ly vi QRS la quan trong tranh gy nhp nhanh tht
do sc in vao ung giai oan d b tn thng. S ng b vi may pha rung
ngoai c th nn c khng nh bng s hin din cua du hiu ch im s
ng b chng ln phc b QRS.
Shock in cho cac ri loan nhp nh, ban in cc pha trc nn c t
ngay trn xng c v tr khoang lin sn 3 hoc 4 va in cc th hai t
ngay di pha sau xng ba vai bn trai. Cn xac nh v tr ban in cc
cach t nht 6 cm so vi may tao nhp vnh vin hoc may kh rung. Nu s
dung ban in cc, cn tao mt ap lc chc chn va bi gel dn truyn giam
tr khang tip xuc. Tranh tip xuc trc tip vi bnh nhn hoc ging bnh.
Atropine (1 mg tnh mach) nn c chun b sn x tr khi ngng xoang keo
dai. Cac ri loan nhp nghim trong nh VT, VF hoc v tm thu la him xay
Lon nhp nhanh Nhp nhanh tht l 309
ra va hu nh la do sc in khng ng b, ng c digitalis hoc dung thuc

chng loan nhp ng thi gy ra.
iu tr bng t in loai bo rung nh qua catheter co hiu qua cao bnh
nhn tre co cu truc tim bnh thng, va rung nh kch phat. Ty l khoi nhng
bnh nhn nay la khoang 80-90%. Ty l khoi giam bnh nhn co bnh tim cu
truc, tui cao va rung nh dai dng. Co 1 ty l ang k cac bnh nhn cn nhiu
hn 1 ln t in mi thanh cng. Muc tiu cua t in loai bo qua catheter
bnh nhn rung nh kch phat la c lp in loc cac tnh mach phi. bnh nhn
rung nh dai dng, thng phai kt hp ky thut trit i c lp tnh mach phi
vi chin lc thay i c cht ma do o cac vung cua tm nh c trit t
ngn can vong vao lai hoc cac xung in phat ra t ngoai tnh mach phi. V
nhiu bin chng tim n va ty l thanh cng con han ch, bnh nhn rung nh dai
dng nn c dung t nht 1 loai thuc chng loan nhp duy tr nhp xoang.
Nu khng thanh cng hoc khng dung nap thuc, co th ch nh trit i qua
catheter.
X tr phu thut
Cac ky thut phu thut iu tr AF a c anh gia t nm 1980. Trong cac
ky thut nay, thu thut Cox Maze co hiu qua cao nht va co nhiu s liu ang
k c xut ban cho thy hiu qua bn vng. Nhng bnh nhn rung nh dai dng
va co bnh tim thc tn, ty l khoi ti 90%. V la thu thut xm ln cao, iu tr
bng phu thut ch c cn nhc cho bnh nhn tht bai vi iu tr t in qua
catheter hoc bnh nhn a ln k hoach tin hanh phu thut tim ng thi.
Nhp nhanh tht

I CNG
Nhp nhanh tht cn c tip cn ban u vi gia nh rng no se co nhng giai
oan ac tnh cho n khi c chng minh la khng phai.
anh gia lm sang mt ri loan nhp tht lin quan n vic xem xet tnh trang
huyt ng, thi gian, hnh thai va s tn tai hay khng co cac bnh tim cu truc.
Cui cung, cac anh gia nay se h tr vic anh gia nguy c ngng tim t ngt
cua bnh nhn, cung nh nhu cu cn cac thit b hoc iu tr trit t.
nh ngha
Nhp nhanh tht khng bn b c nh ngha la 3 hoc nhiu hn phc b tht
(>100 nhp/phut) chm dt t nhin trong 30 giy ma khng gy anh hng huyt
ng ang k hoc cn can thip.
Nhp nhanh tht bn b n dang c nh ngha la nhp nhanh ma phc b
QRS n dang keo dai trn 30 giy hoc cn sc in do ri loan huyt ng.
Nhp nhanh tht a dang c trng bi hnh thai phc b QRS lun thay i.
Xon nh la 1 dang cua nhp nhanh tht a hnh thai ma in hnh la bt u vi
khoang QT keo dai trn nn nhp xoang. Nhp nhanh tht a dang thng gy ri
loan huyt ng.
Rung tht thng i kem vi s co bop khng ng b, ri loan huyt ng va
t t. ECG ch ra nhng song dao ng bt thng (250400 nhp/phut) co in
th rt bin i ma khng xac nh c mt phc b QRS hoc song T nao.
Rung tht la nguyn nhn chu yu gy t t do tim (sudden cardiac death
SCD). t t do tim c nh ngha la t vong xay ra trong 1 gi k khi khi
phat triu chng. My, co 350.000 trng hp SCD xay ra hang nm. Trong s
nhng bnh nhn b SCD, bnh tim thiu mau la bnh tim cu truc ph kem theo
ph bin nht. Hu ht nhng ngi sng sot sau ngng tim khng co bng chng
v nhi mau c tim cp, tuy nhin >75% co bng chng cua nhi mau c tim trc
o. Bnh c tim khng do thiu mau cung i kem vi tng nguy c b SCD.
Nguyn nhn
Nhp nhanh tht i kem vi bnh tim cu truc
Hu ht cac ri loan nhp tht u i kem vi bnh tim cu truc, in hnh la lin
quan n thiu mau ang hoat ng hoc tin s nhi mau.
Vung seo va vung quanh nhi mau thng tao ra vong vao lai gy nhp nhanh
tht dai dng n dang.
Nhp nhanh tht a dang va VF thng lin quan n thiu mau c tim va la
nguyn nhn cua phn ln trng hp SCDs ngoai bnh vin.
Bnh c tim khng lin quan n thiu mau lin quan n s gian va x hoa tin
trin cua c tim tm tht, tao ra cht nn cua loan nhp.
Bnh c tim b thm nhim (sarcoid, st, tinh bt) chim mt ty l nho hn va
nhng bnh nhn nay co nguy c cao b ri loan nhp tht ma vic iu tr vn
cha c xac nh mt cach ro rang.
Ngi trng thanh co tin s m sa cha bnh tim bm sinh thng b ca nhp
nhanh tht va nhp nhanh trn tht.
Loan san tht phai hoc bnh c tim vi s thay th cua m x m tht phai (right
ventricularRV) (i khi ca LV) gy VT n dang block nhanh trai (left bundle
branch blockLBBB) va i kem vi t t, c bit vn ng vin tre tui.
VT vong vao lai phn nhanh la 1 dang cua VT s dung h thng His-Purkinje
trong mt vong vao lai va thng i kem vi bnh c tim va h thng dn truyn
bt thng.
Nhp nhanh tht khng co bnh tim cu truc
Bt thng knh ion di truyn, nh hi chng Brugada va hi chng QT keo
dai, co th dn n VT a dang va gy t t nhng bnh nhn khng co bng
chng tn thng cu truc c tim trn chn oan hnh anh.
VT a dang lin quan h giao cam (Catecholaminergic polymorphic VT

CPVT) thng lin quan VT gia nh do gng sc lin quan n s chuyn hoa
canxi bt thng.
Nhp nhanh tht t phat la chn oan loai tr khi khng co bng chng tn
thng cu truc c tim, ri loan di truyn va nguyn nhn gy bnh co th phuc
hi (nh thiu mau c tim, bt thng v in giai hoc chuyn hoa).
Hu ht cac VT t phat bt ngun t ng ra tht phai (right ventricular
outflow tract [RVOT-VT]) va co th trit bo qua ng thng. t ph bin hn
la VT ng ra tht trai (left ventricular outflow tract [LVOT-VT]) hoc VT
phn nhanh (s dung phn nhanh trc va sau cua nhanh trai) co th phat hin
c trn EPS.
CHN ON
Biu hin lm sng
Vic anh gia nhp nhanh co phc b QRS gian rng nn lun lun bt u vi
vic anh gia kp thi cac du hiu sinh tn va triu chng lm sang. Nu ri loan
nhp dung nap kem, nn tr hoan vic anh gia chi tit va tin hanh x tr cp cu
theo hng dn ACLS. Nu bnh nhn n nh, co mt vai cu hoi quan trong co
th giup hng n chn oan co nhiu kha nng nht. Mt sai lm thng gp la
s nhn nh rng tnh trang huyt ng n nh thng ung h chn oan SVT
hn la VT.
VT la WCT thng gp nht nhng bnh nhn iu tr ni tru vi ty l c hin
mc c ghi nhn ln ti 80%. V vy cn phai tm ra cac im mu cht trong
tin s va nghin cu ky cac c im trn in tm cua loan nhp m ta
c c ch cua ri loan nhp. Bt u vi nhng cu hoi sau:
Bnh nhn co tin s co bnh tim cu truc khng?
Bnh nhn co bnh tim cu truc b WCT th nhiu kha nng la VT hn la
SVT. Trong 1 bao cao, 98% bnh nhn b WCT co nhi mau c tim trc o
c chng minh la co VT (Am J Med 1988;84:53)
Bnh nhn co cy may tao nhp, cy may kh rung (implantable cardiac
defibrillatorICD) hoc co QRS gian rng t trc khng (o la block nhanh
phai [right bundle branch blockRBBB], block nhanh trai (left BBBLBBB),
chm tr dn truyn trong tht [intraventricular conduction delayIVCD])
Nu bnh nhn co may tao nhp hoc may kh rung t ng di da, nn ngh
n WCT do may tao nhp.
WCT do may co th la do tao nhp tht vi tn s nhanh, hoc la do may i
theo nhp nhanh nh hoc nhp nhanh vong lp khng co im dng gy ra
bi s theo du cac xung nh ngc dong c tao ra bi nhp tht trc o
c phat ra t may tao nhp. Trong bt c trng hp nao th tn s cua nhp
nhanh la mt du hiu gi y c ch v tn s nay bng vi gii han trn cua tn

s (upper rate limitURL) a c lp trnh trc cua thit b. URL thng
c cai t la 120 nhp/phut. Nhp nhanh co tn s vt trn URL giup loai
tr mt cach hiu qua WCT do may tao nhp.
Co th khng nh tin s co cy thit b di da bng cach thm kham thanh
ngc (thng ngc trai i vi nhng bnh nhn thun tay phai), chup
X-quang ngc, hoc nhn thy c spike cua may tao nhp trn in tm .
in hnh la phc b QRS rng do u tao nhp tht phai co dang LBBB va
c bt u bi mt nhat spike tao nhp ngn. Hu ht cac thit b hin ai s
dung tao nhp hai bung va thng kho nhn bit trn in tm 12 chuyn
ao do xung in nhn tao co kch thc nho. V vy khng nn loai tr nhp
nhanh do may tao nhp khi khng thy spike tao nhp trong cn nhp nhanh.
Bnh nhn co RBBB, LBBB hoc IVCD t u ma b WCT th hnh thai QRS
se ging ht vi QRS ban u trong trng hp SVT. Thm vao o, vai bnh
nhn co QRS hep luc ban u se biu hin WCT do SVTs khi xay ra block
nhanh lin quan n tn s tim nhanh. Hin tng nay c goi la SVTs vi
dn truyn lch hng va co th phn bit vi VT da trn cac tiu chun
c m ta pha di.
Nhng thuc bnh nhn ang s dung?
Nn kim tra danh sach cac thuc tm bt c thuc nao co tac dung phu gy
ri loan nhp, c bit la nhng thuc co th keo dai khoang QT ban u va
lam tng nguy c b VT a hnh thai hoc xon nh. Nhng thuc nay gm
nhiu thuc chng loan nhp nhom I va III, mt vai thuc khang sinh nht
nh, chng loan thn va nhiu thuc khac. Trang web c tai tr bi ai
hoc Arizona, http://www.qtdrugs.org, cung cp danh sach y u cac thuc
gy QT keo dai.
Cac thuc co th gy ri loan in giai, nh li tiu quai hoc li tiu gi kali,
thuc ACE, thuc c ch thu th cua angiotensin... nn c xac nh chnh
xac. Ng c digoxin lun la yu t quan trong cn phai cn nhc i vi bt
ky ri loan nhp nao.
Chn on phn bit
Chn oan VT cn phai co kin thc v tip cn chung cua WCTs.
WCT co th do SVT co ng dn truyn lch hng (co block nhanh) hoc do
VT. Vic phn bit gia 2 c ch nay la iu quan trong nht. Cac thuc s dung
trong iu tr SVTs (o la adenosine, chen giao cam, chen knh canxi) co
th la nguyn nhn gy ri loan huyt ng nghim trong nu s dung nhm
cho VT. V vy, tt ca cac WCT nn c coi co ngun gc t tht cho n khi
c chng minh la khng phai.
C ch khac t ph bin hn cua WCT bao gm AVRT ngc chiu, ri loan

nhp do tng kali mau hoc nhp nhanh do may tao nhp.
Nhng du hiu nhiu khi ghi in tim t xa do in cc tip xuc kem hoc c
ng lp i lp lai cua bnh nhn (rung git, run, anh rng, tp th...) co th tao
ra nhng hnh anh ging nh nhp nhanh tht hoc rung tht.
Test chn on
Xt nghim
Cac xet nghim chuyn hoa c ban, nh lng magie, tng phn tch t bao mau,
va troponin.
in tm
Phn bit nhp nhanh trn tht lch hng vi nhp nhanh tht da trn phn
tch in tm c ban la quan trong xac nh bin phap iu tr cp va lu dai.
Chn oan VT da vao tnh trang phn ly nh tht, nhat bt c tht hoc
nhat bop hn hp, khng co hnh thai RS cac chuyn ao trc tim (V1V6),
va co LBBB vi truc lch phai. Nu khng co cac c im trn, nu trn mt
chuyn ao trc tim co hnh thai RS vi khoang RS>100 ms th coi la VT. Thm
vao o, nn tm cac c im v hnh thai QRS gi y cho VT, nh c ch ra
trong Hnh 72A va B.
Nhng im cn nh trn in tm
Dang Brugada kinh in:
in tm luc u: Gia RBBB vi oan ST chnh ln va song T ao ngc
V1, V2.
Co th bc l ra bng stress, bnh tt, st, s dung ma tuy...
Loan san RV gy loan nhp:
in tm luc u: Song epsilon (ngay sau QRS), QRS gian rng, song
T ao ngc (V1, V2).
VT: Phan anh ngun gc t RV, thng co dang LBBB. Co th biu hin VT
a hnh thai.
VT co vong vao lai nhanh:
in tm luc u: IVCD
VT: Hnh thai LBBB in hnh (xung nhanh phai, ln nhanh trai)
VT phn nhanh:
VT: Truc sau, co hnh thai RBBB
Hi chng QT keo dai:
in tm luc u: QT >50% oan RR nu nhp tim t 60100. QTc 440
ms.
VT: xon nh chuyn thanh VF.
Khng co phc b dang RS

tt ca chuyn ao trc tim?
Co Khng
VT
Khoang R n S >100 ms trn 1 chuyn ao trc tim?
Co Khng
VT
Phn ly nh tht?
Co Khng
VT
Co tiu chun hnh thai cua VT ca cac

chuyn ao trc tim V1-2 va V6?
Co Khng
VT SVT vi dn truyn
A lch hng
Hnh 72. A va B. Tiu chun Brugada phn bit nhp nhanh tht vi nhp nhanh trn tht
dn truyn lch hng trong ri loan nhp nhanh QRS rng. LBBB: block nhanh trai; RBBB:
block nhanh phai; SVT: nhp nhanh trn tht; VT: nhp nhanh tht. (T Cuculich PS. oc
in tm nng cao [ECG 201]. In: Cuculich PS, Kates AM, eds. The Washington manual
cardiology subspecialty consult. Xut ban ln th 2. Philadelphia, PA: Lippincott Williams &
Wilkins; 2009).
LBBB RBBB
VT SVT VT SVT
V1, V2 V1, V2 Song bn trai Song rsR
va bt ky : vng mt: cao hn hoc rR ba pha
(a) r 0,04 giy (a) r 0,04 giy Song RS hoc

QR hai pha
Chuyn (b) Moc song S (b) Moc song S
ao
V1
(c) Song S (c) Song S
xut hin chm xut hin chm
>0,06 giy >0,06 giy
b
hoc hoc
a
c
QS mt pha rS hai pha qRs ba pha

Chuyn
ao
V6
Hnh 72. (Tip theo).
VT ng ra:
VT: truc quay xung di, co dang LBBB. Chuyn i R/S cac chuyn ao
trc tim giup khu tru v tr. Nu chuyn i sm V1, V2 gi y ngun gc
LVOT, chuyn i mun V4 gi y ngun gc RVOT.
Chn on hnh nh
Trc tin nn anh gia xem co hay khng co bnh tim cu truc bng siu m tim
qua thanh ngc.
anh gia hnh anh su hn na (MRI tim, test gng sc khng xm ln, chup ng
mach vanh...) nn c cn nhc da trn nguyn nhn nghi ng.
IU TR
Vic phn bit SVT lch hng vi VT da trn vic phn tch in tm b
mt xac nh la rt quan trong trong vic xac nh liu phap iu tr cp va lu
dai phu hp.
iu tr cp SVT: dung thuc ng tnh mach nh adenosin, thuc chen knh

canxi, thuc chen . Tuy nhin, thuc chen knh canxi va chen co th gy ri
loan huyt ng bnh nhn VT.
V lu dai, nhiu SVTs ap ng vi RFA, trong khi hu ht VTs la ac tnh va
yu cu dung cac thuc chng loan nhp va/hoc cy may ICD.
Ngay lp tc sc in khng ng b la bin phap iu tr ban u cho VT va VF
khng co mach.

ICDs cung cp s nhn din va iu tr t ng cac ri loan nhp tht. Cy may
ICD giup cai thin ty l sng con bnh nhn sng sot sau ri loan nhp tht (d
phong SCD th phat) va nhng bnh nhn khng co nhng triu chng nhng co
nguy c cao b SCD (d phong SCD tin phat).
D phong SCD th phat vi cy may ICD c ch nh cho hu ht nhng
bnh nhn con sng sot sau SCD ngoai tr giai oan xung quanh nhi mau.
Tnh nng vt tri trong iu tr ICD so vi s dung thuc chng loan nhp
keo dai a c chng minh (th nghim AVID. N Engl J med 1997;337:1576).
D phong SCD tin phat vi cy may ICD c ch nh cho nhng bnh
nhn co nguy c cao b SCD. Hiu qua cua vic cy ICD d phong SCD tin
phat nhng bnh nhn co bnh c tim a c chng minh trong nhiu th
nghim lm sang tin cu (xem Th nghim cy may pha rung t ng a trung
tm ([Multicenter Automatic Defibrillator Implantation TrialMADIT], N
Engl J Med 1996;335:1933); Th nghim nhp nhanh khng bn b a trung
tm ([Multicenter Un-Sustained Tachycardia TrialMUSTT], N Engl J
Med 1999;341:1882); th nghim MADIT II, N Engl J Med 2002;346:877);
SCD-HeFT, N Engl J Med 2005;352(3):225. Hu ht cac bnh nhn co suy
giam chc nng tht trai (LV ejection fractionLVEF) <35% trn 3 thang du a
iu tr ni khoa ti u la ch nh cho cy ICD d phong.
Cac ch nh khac cua ICD:
Mt s trng hp bnh co tim ph ai (HCM), bnh c tim tht phai gy
ri loan nhp, hi chng QT keo dai bm sinh, hoc hi chng Brugada
co nguy c cao SCD. Cy may ICD ch nh bnh nhn co mt trong cac
hi chng trn a tng b ngng tim va a c hi sc hoc c ghi nhn
la co ri loan nhp tht. Cy may ICD d phong cho nhng bnh nhn khng
co triu chng thng c coi la phu hp c bit la nhng bnh nhn a
tng b ngt hoc co tin s t t trong gia nh.
Bnh nhn ch ghep tim ma co nguy c cao b SCD, c bit nu ho dung
thuc tr tim ng tnh mach. Cy ICD d phong la hp ly phong nga
SCD trc khi ghep tim.
ICDs b chng ch nh nhng bnh nhn co VT khng ngng, nhi mau c

tim gn y <40 ngay trong trng hp phong SCD tin phat, bnh ly tm thn
ang k hoc thi gian sng thm t hn 12 n 24 thang.
iu tr VT bng song cao tn qua catheter c tin hanh thanh cng nht
bnh nhn VT t phat huyt ng n nh ma khng co bnh cu truc tim i kem.
Ty l khoi bnh lu dai nhng bnh nhn nay tng t nh t qua catheter vi
SVT. Nu co bnh tim cu truc va c bit la VT co huyt ng khng n nh,
t qua catheter thng c danh cho VT khng ap ng vi thuc do thu thut
trit t nay co hiu qua thp hn va ty l mc bnh cao hn.
VT t phat thng i kem vi cu truc tim bnh thng nhng cung co
nhng trng hp nhp nhanh do bnh c tim c m ta.
VT ng ra tht phai (Right ventricular outflow tractRVOT-VT)
thng biu hin la VT lp lai, khng bn b va co th do gng sc gy
ra. RVOT-VT thng ap ng vi thuc chen giao cam, diltiazem hoc
verapamil va adenosine.
LVOT-VT thng ap ng vi verapamil.
Ca hai dang VT t phat u c cho la lanh tnh khi khng co bnh cu truc
tim. V vy cy may ICD la khng thch hp. Tt ca cac dang VT t phat u
thch hp iu tr RFA hoc dung thuc.
BBRVT la 1 dang cua VT ma co vong vao lai h thng bo His-Purkinje.
BBRVT co th iu tr thanh cng bng cach t nhanh phai qua catheter. V
BBRVT thng xay ra bnh nhn co bnh c tim va h thng dn truyn bt
thng, ICD thng c cy kt hp vi vic trit t.
VT i kem vi bnh tim thiu mau cung co th iu tr bng trit t qua
catheter, tuy nhin ty l thanh cng thp hn VT t phat. Ly do cua ty l thanh
cng thp hn bao gm s bt n nh v huyt ng cua VT va VT thng co
nhiu vong vao lai. Trit t bng catheter iu tr VT thiu mau nhng
bnh nhn co VT khng ap ng vi thuc chng loan nhp va a c cy may
ICD a giam thanh cng tn s sc cua ICD (Circulation 1997;96:1525).
Trit t VT khng lin quan n bnh tim thiu mau cung hp ly, c bit
la nhng bnh nhn khng ap ng vi thuc, nhng nhng vong vao lai cua
VT co th trong c tim hoc thng tm mac. V vy, ty l thanh cng thp
hn so vi VT i kem vi bnh tim thiu mau va nn cn nhc vic chuyn bnh
nhn n mt trung tm tin hanh t ca ni tm mac va ngoai tm mac mt
cach thng quy.
Thuc
VF khng ap ng vi may pha rung ngoai c th oi hoi phai s dung thm cac
thuc chng loan nhp ng tnh mach.
Thng s dung lidocaine ng tnh mach; tuy nhin, amiodarone tnh mach
to ra co hiu qua hn trong vic tng ty l sng sot cua VF khi dung phi hp
vi may pha rung (N Engl J Med 2002;346:884).
Sau khi chuyn nhp thanh cng, nn tip tuc duy tr truyn tnh mach cac thuc
chng loan nhp hiu qua cho n khi cac nguyn nhn co th ao ngc c
sa cha.
iu tr bng thuc chng loan nhp lu dai c ch nh cho iu tr cac ri loan
nhp tht tai phat co triu chng. i vi ri loan nhp tht huyt ng khng n
nh a c cy ICD, iu tr phi hp bng thuc chng loan nhp giup giam
s ln shock in cua ICD.
La chn hng u
Amiodarone an toan, dung nap tt trong iu tr ri loan nhp tht cp tnh. Dc
ng hoc cua thuc phc tap va c tnh cua no tng ln nu iu tr keo dai (Am
Heart J 1993;125:109).
Sau khi dung liu nap ng ung, amiodarone ngn can s tai phat cua VT bn
b va VF ln ti 60% bnh nhn. Liu ung, thi gian ngm thuc trn 5 ngay
mi co tac dung chng loan nhp va tac dung ri loan nhp y u co th khng
xay ra trong 4-6 tun sau khi bt u iu tr. Va khng may la s tai phat cua
cac ri loan nhp tht khi theo doi dai han la ph bin.
Amiodarone la thuc chng loan nhp c nghin cu nhiu nht iu tr
SCD va la thuc chnh c so sanh vi ICD trong cac th nghim d phong
tin phat va th phat.
S cn bng gia nhiu th nghim lm sang tin cu khng ung h vic s
dung amiodarone d phong SCD nhng nhng bnh nhn co bnh c tim.
Thuc nhom II, chen giao cam la nhom duy nht ch ra la cai thin c ty l
sng con bnh nhn sau MI.
Chen giao cam giam ty l t vong sau nhi mau 25-30% va giam ty l SCD
t 32-50% (Lancet 1981;2:823; Lancet 1999;353:9; Lancet 1999;353:2001; N
Engl J Med 2001;344:1651; Lancet 2001;357:1385).
Sau khi iu tr VT/VF cp tnh va giai oan n nh, nn bt u s dung thuc
chen giao cam va iu chnh liu thuc theo huyt ap va nhp tim.
VT t phat thng ap ng vi thuc block nut AV.
Thuc c ch men chuyn a c chng minh la lam giam ty l t t va ty l t
vong chung nhng bnh nhn co bnh ng mach vanh hoc suy tim sung huyt.
La chn hng th hai

Sotalol la thuc nhom III c ch nh cho iu tr lu dai VT/VT man tnh.
Sotalol ngn nga s tai phat cua VT bn b va VF 70% bnh nhn (N Engl J
Med 1993;329:452) nhng phai thn trong bnh nhn suy tim sung huyt.
Thuc nhom I nhn chung khng giam c ty l t vong bnh nhn VT/VF.
Thc t, thuc nhom Ic, flecainide va B con lam tng ty l t vong bnh nhn
ri loan nhp tht (N Engl J Med 1991;324:781).
Lidocaine la thuc nhom Ib, ch co dang dung ng tnh mach, co hiu qua
iu tr VT bn b va tai phat/VF. Dung lidocaine d phong c ch PVCs va
VT khng bn b sau MI khng bin chng khng c ch nh va co th lam
tng ty l t vong do nhp chm (Arch Intern Med 1989;149:2694). c tnh
cua lidocaine bao gm cac tac dung trn thn kinh trung ng (co git, l m,
choang vang, va him gp hn, ngng h hp) va u mt i khi ngng s dung
thuc. Tac dung lam giam sc co bop c tim ch thy khi dung liu cao.
Mexiletine tng t nh lidocaine nhng thuc co dang ung. Mexiletine
thng c dung kt hp vi amiodarone hoc sotalol iu tr cac ri
loan nhp tht khang tr. Mexiletine co th co tac dung han ch trong nhng
trng hp co hi chng QT keo dai bm sinh. c tnh trn h thn kinh trung
ng bao gm run, chong mt va nhn m. Liu cao hn co th gy loan ngn,
nhn i, rung git nhan cu va thay i y thc. Bun nn va nn la ph bin.
Phenytoin c s dung chu yu trong iu tr ri loan nhp tht lin quan
n digitalis. Thuc co th co tac dung han ch trong iu tr ri loan nhp tht
lin quan n hi chng QT keo dai. Liu nap ng tnh mach 250 mg trong
10 phut (tc ti a 50 mg/phut). Nhng liu tip theo la 100 mg mi 5 phut
nu cn va huyt ap n nh, tng liu ti 1.000 mg. Cn phai theo doi thng
xuyn in tm , huyt ap va tnh trang thn kinh. Truyn thuc ng tnh
mach lin tuc khng c khuyn cao (Xem chng 26, Bnh ly thn kinh).
LU C BIT
Thuc nhom IV khng co vai tro trong iu tr lu dai VT. Khng bao gi s
dung thuc chen knh canxi ng tnh mach iu tr cp VT v chung gy ri
loan huyt ng. Thuc chen knh canxi ng ung khng co hiu qua trong
iu tr VT. Nifedipine tac dung ngn co xu hng lam tng ty l t vong khi s
dung cho nhng bnh nhn sau MI (Arch Intern Med 1993;153:345).
VF tin phat xay ra trong vong 72 gi sau MI cp khng i kem vi s tng nguy
c tai phat va khng oi hoi phai dung thuc chng loan nhp lu dai
Trong xon nh lin quan n hi chng QT keo dai, iu tr cp cu la sc
in ngay lp tc.
Bolus IV magie sulfate 12 g, tng dn ti 46 g co hiu qua cao.
Trong trng hp hi chng QT keo dai mc phai, xac nh va iu tr nhng
nguyn nhn c ban nu co th.
Co th loai bo cac chui kch thch dai-chm va lam ngn oan QT bng cach
tng nhp tim ti ngng 90 n 120 nhp/phut hoc bng isoproterenol truyn
tnh mach (tc ban u 1 n 2 mcg/phut) hoc s dung may tao nhp tam
thi ng tnh mach.
LON NHP CHM
I CNG
Loan nhp chm la loan nhp thng gp nhng bnh nhn ang iu tr ni tru
vi tn s tht <60 nhp/phut.
Loan nhp chm co th do ri loan chc nng vung nao o cua h thng dn
truyn t nhin, v vy vic xem lai s dn truyn cua cac song kh cc, mach
cp mau tng ng cho tng vung va s anh hng bn trong va bn ngoai ln h
thng dn truyn la rt hu ch.
Giai phu h thng dn truyn
Nut xoang la tp hp cac t bao tao nhp chuyn bit nm vung cao cua tm
nh phai. Trong iu kin bnh thng, no khi phat song kh cc, song nay se
lan rng v pha sau va sang trai thng qua c tim tm nh va ng dn truyn
bn trong nut, dn n thi ky tm thu cua nh.
Nhp nut xoang bnh thng khi ngh ngi la 5090 nhp/phut, va thng ty
l nghch vi tui, va c xac nh bi s cn bng tng i gia hoat ng
giao cam va pho giao cam.
ng mach nut xoang cung cp mau cho nut xoang, co bt ngun giai phu
khac nhau ng mach vanh phai (right coronary arteryRCA), 65%; ng
mach mu, 25%; hoc ca hai (RCA va ng mach mu), 10%.
Song kh cc sau o n mt nhom t bao chuyn bit khac, nut nh tht, bn
phai vach ngn tm nh. Bnh thng nut nh tht la kt ni in duy nht cua tm
nh va tm tht.
Dn truyn qua nut AV b giam bt, tao ra s chm tr khoang 55110 ms va
chim phn ln khoang PR o c trn in tm .
Nut nh tht cha cac si ap ng chm, ging nut xoang, co c tnh tao nhp
vi tn s 4050 nhp/phut. V nut nh tht co tn s kh cc chm hn nn
no ch tr nn co y ngha v mt lm sang trong bnh canh co ri loan chc
nng nut xoang hoc block nh tht hoan toan.
ap ng cua tht vi s kh cc nh c iu chnh thng qua cac tac ng
cua thn kinh t ng ln nut nh tht.
Mau cung cp cho nut nh tht chu yu thng qua ng mach nut nh tht,
thng xut phat t phn gn ng mach lin tht sau (posterior descending
arteryPDA, 80%), nhng cung co th t ng mach mu (10%) hoc ca hai
(10%). Thm na, no cung nhn s cp mau t pha bn cua ng mach lin
Lon nhp chm l 321
tht trc (left anterior descendingLAD). iu nay lam cho nut nh tht
c bao v mt cach tng i khi co tn thng mach mau.
T nut nh tht, song kh cc i xung bo His, nm vach lin tht phn mang,
chia lam 2 nhanh trai, phai trc khi i vao cac si Purkinje kh cc nt
cac c tm tht.
Bo His va nhanh phai nhn mau t ng mach nut nh tht va t cac nhanh
xuyn vach cua LAD.
Nhanh trai chia thanh phn nhanh trai trc va sau: Phn nhanh trai trc
nhn mau t ng mach xuyn vach va phn nhanh trai sau, chay sau va di
nhanh trai trc, nhn mau t nhanh cua ng mach PDA va nhanh xuyn
vach cua LAD.
Nguyn nhn
Nguyn nhn thng gp cua nhp chm c lit k Bang 77.
CHN ON
Biu hin lm sng
Khi nghi ng loan nhp chm, nn anh gia tin s, kham lm sang va nhng triu
chng co sn nhm n phng cach 5 ch S x ly nhp tim chm:
STABLE N NH: Bnh nhn co ri loan huyt ng hay khng?
SYMPTOMS TRIU CHNG: Bnh nhn co nhng triu chng g, va triu
chng co lin quan n nhp chm khng?
SHORT TERM NGN HAN: Cac tnh hung xung quanh loan nhp phuc hi
c hay thoang qua?
SOURCE NGUN GC: H thng dn truyn b ri loan u? Co bt c
ri loan nhp chm khi theo doi in tm hay khng?
SCHEDULE A PACEMAKER T MAY TAO NHP: Bnh nhn co cn may
tao nhp vnh vin khng?
Khm thc th
Nu nhp chm ang tip din, vic khai thac tin s va kham lm sang nn c
rut ngn, tp trung vao anh gia s n nh v huyt ng cua loan nhp
Nu bnh nhn co cac du hiu cua ti mau kem (ha ap, l m, ri loan y thc,
tm tai...) th ngay lp tc bt u x tr theo phac ACLS.
Nu n nh, co th tin hanh anh gia chi tit hn.
Biu hin lm sang cua nhp chm rt thay i, t khng co triu chng n
triu chng khng c hiu (chong mt, mt moi, yu c, khng gng sc
c), cho n triu chng ro rang (ngt). Biu hin cua nhp chm chu yu
c quyt nh bi ap ng lam tng cung lng tim cua bn nhn khi nhp
tim giam xung.
Bng 77 Nguyn nhn gy nhp chm
Ni sinh
Bnh bm sinh (c th biu hin mun)
Bnh thoi ha t pht (lo ha)
Nhi mu hoc thiu mu
Bnh c tim
Bnh thm nhim: sarcoidosis, thm nhim tinh bt, nhim st
Bnh collagen mch mu: lupus ban h thng, thp khp, x cng b
Chn thng do phu thut: phu thut van, ghp
Bnh truyn nhim: vim ni tm mc, bnh Lyme, bnh Chagas
Ngoi sinh
Qua trung gian thn kinh t tr
Ngt do nguyn nhn thn kinhtim mch
Xoang cnh qu mn cm
Tng trng lc thn kinh ph v: ho, nn, tiu tin, i tin, t ng
Thuc: chn , chn knh canxi, digoxin, cc thuc chng lon nhp
Suy gip
H thn nhit
Cc bnh l thn kinh: tng p lc ni s
Mt cn bng in gii: tng kali mu, tng magie mu
Tng CO2 mu/ngng th khi ng do tc nghn
Nhim trng huyt
T Cooper DH. Lon nhp chm v my to nhp vnh vin. In: Cuculich PS, Kates AM, eds. The Washington
manual cardiology subspecialty consult. Xut bn ln th 2. Philadelphia, PA: Lippincott Williams &
Wilkins; 2009.
Cn chu y xac nh xem triu chng lm sang co lin quan trc tip n nhp
chm hay khng. Cac im khac trong tin s cn chu y bao gm:
Bnh tim thiu mau cuc b , c bit lin quan vong tun hoan bn phai, co th
thuc y mt s loan nhp chm. V vy, phai lun tm cac triu chng cua hi
chng vanh cp.
Cac tnh hung trc khi ri loan nhp (luc tiu, ho, ai tin, ngi kh c
hai) xung quanh cn nhp chm co th giup xac nh nguyn nhn nao-tim.
Ri loan nhp nhanh, c bit nhng bnh nhn co ri loan chc nng nut
xoang, co th theo sau la oan ngng xoang dai do nut xoang b c ch trong
nhp nhanh. V vy triu chng anh trng ngc co th lam bc l s hin din
cua hi chng nhp nhanh-chm. Do cac thuc s dung iu tr ri loan nhp
nhanh c thit k thuc y s giam nhp tim, hi chng nay khin cho vic
iu tr tr nn kho khn.
Lon nhp chm l 323
Nn hoi tin s co bnh tim cu truc, suy giap, ngng th khi ngu, bnh
collagen mach mau, nhim khun (nhim khun huyt, vim ni tm mac,
Lyme, Chagas), bnh do thm nhim (tinh bt, nhim st va sarcoid), bnh thn
kinh-c, va co tin s phu thut tim (thay van, sa cha bnh tim bm sinh).
Cac thuc cung nn c xem lai, c bit cac thuc anh hng n nut xoang
va nut nh tht (nh thuc chen knh canxi, chen giao cam, digoxin).
Sau khi khng nh tnh trang huyt ng n nh, tin hanh kham toan din hn
vi s tp trung c bit vao thm kham h tim mach va bt c du hiu nao phu
hp vi cac bnh ly kem theo c nhc ti trn la thch hp (Hnh 73).
Test chn on
Xt nghim
Cac xet nghim phong th nghim bao gm: in giai mau va xet nghim chc
nng tuyn giap hu ht moi bnh nhn. Nng digoxin va troponin nn c
lam nu co biu hin lm sang thch hp.
in tm
in tm 12 chuyn ao la nn tang chn oan bt ky ri loan nhp nao:
Cac chuyn ao nhn ro nht hoat ng tm nh cn phai kim tra (DII, III,
ART, V1).
Nn xac nh bng chng cua ri loan chc nng nut xoang (thi gian song P)
hoc bt thng dn truyn AV (khoang PR).
Bng chng cua thiu mau c tim cu va mi nn ng tm kim la tt nht.
Phn tch in tm trong nhp chm nn tp trung xac nh v tr ri loan cua
h thng dn truyn. Bn canh cac triu chng lin quan n loan nhp, vic nh
khu v tr b block se giup xac nh xem liu co cn thit phai cy may tao nhp
hay khng.
Ri loan chc nng nut xoang hoc hi chng suy nut xoang la l do chu yu
nht cy may tao nhp Hoa Ky. Biu hin lm sang cua suy nut xoang gm
(Hnh 74):
Nhp chm xoang c nh ngha la nhp u vi song P i trc phc b
QRS (II, III, AVF) vi tn s <60 nhp/phut. Ngi tre va vn ng vin thng
co nhp chm xoang khi ngh va dung nap tt. Nhp tim ban m thng thp
hn bnh thng tt ca bnh nhn nhng ngi gia co thng co nhp tim luc
ngh cao hn va nhp chm xoang la mt bin i rt t gp.
Chm xoang va ngng xoang dung ch nut xoang khng kh cc c, biu
hin thanh nhng oan v tm thu nh (khng co song P). Co th co v tm thu
tht i kem hoc nhp thoat t b ni hoc t c tm tht. oan ngng 23 giy co
th gp ngi khoe manh, khng co triu chng, c bit la trong khi ngu. Ngng
>3 giy, c bit vao ban ngay, nn nghi ng co ri loan chc nng nut xoang.
Muc ch
324
Khng nh nhp chm
Xac nh nu bnh nhn khng co triu chng Vic iu tr cp cu oi hoi da vao
Cung cp liu phap iu tr ngay lp tc nu cn phac nh chun Hi sc tim phi nng cao (ACLS)
Xac nh co cn may tao nhp vnh vin khng Atropine 0,42,0 mg IV
l
Tao nhp qua da hoc qua ng tnh mach
Ch. 7
Khi n nh, nn xem xet may tao nhp vnh vin
Co
Cac du hiu cua nu thch hp
c tnh lm sang
ti mau kem hoc
Bnh s hin tai

huyt ng khng
Chong mt, vang vt, gn ngt, ngt n nh
Lon nhp tim

Kho th khi gng sc, kha nng gng sc, va m hi Nguyn nhn thoang qua Co Quan sat mt thi gian ri
au ngc, kho th, toat m hi Khng hoc co th ao ngc anh gia lai (Nhit , tao
Ngay, bun ngu vao ban ngay, ngng th khi ngu c nhp nu cn)
Thay i thuc/liu gn y
Cac tnh hung kch thch
Khng
Bnh s trc kia
Tin s bnh tim
Ri loan nhp (nhanh va chm), may tao nhp tim vnh vin
Suy tim sung huyt/Bnh ng mach vanh Ch nh cua may tao nhp vnh vin
Phu thut van
Bnh thm nhim: sarcoid, st, tinh bt Ch nh mc I Ch nh mc II
Tin s bnh tuyn giap Nhp chm xoang hoc block nh tht co triu chng Nhp chm khng co triu chng vi:
Vim ni tm mac, bnh Lyme, bnh Chagas Nhp chm xoang la hu qua cua mt iu tr thuc cn thit Block nh tht cp III vi nhp tim >40, c bit la co chc nng
Khac: bnh mach mau nao, ngng th khi ngu, Glaucoma Khng tng nhp tim thch hp co triu chng tht trai
Thuc Block nh tht nng vi: Block nh tht cp 2 type II vi QRS thanh manh
Chen , chen knh canxi, digoxin, clonidine V tm thu 3 giy nhng bnh nhn tnh Block nh tht cp 2 type I tai hoc di bo His trn EPS
Cac thuc chng loan nhp khac Nhp thoat <40 nhp/phut Block 2 hoc 3 phn nhanh va EPS tnh c phat hin ra:
Thuc nho mt t nut nh tht qua catheter oan HV keo dai >100 ms bnh nhn khng co triu chng
Kham lm sang Bnh thn kinh c Vic tao nhp gy ra block trong bo His
Sinh hiu: nhit , nhp tim, huyt ap, SaO2 (thiu oxy) Block nh tht sau phu thut khng mong i se hi phuc Block 2 hoc 3 phn nhanh va ngt nu cac nguyn nhn khac c
Toan trang: bun ngu, l m Block hai phn nhanh hoc ba phn nhanh man tnh vi: loai tr
Tim mach: tn s, u, ting thi Block tim hoan toan cach quang Ngt khng giai thch c co ri loan chc nng nut xoang trn EPS
Chi: tm, mach Block nh tht cp 2 type II Nhng bnh nhn nguy c cao vi hi chng QT keo dai bm sinh
Khac: bu c, thiu hut thn kinh, giam phan xa Block nhanh xen ke Ngt tai phat vi:
Xet nghim chn oan Block nh tht cp 2 type II vi QRS rng ap ng qua mn vi s c ch tnh mach
in giai: K (tng kali mau), Mg (tng magi mau) Nhp nhanh tht bn b phu thuc oan ngng Nhp chm c ghi nhn khi lam test nghing ban
Nu c ch nh: Trop, TSH, kh mau ng mach (CO2), nng Digoxin Ngt tai phat va nghim phap xoa xoang canh gy v tm thu
in tm /Theo doi t xa 3 giy
Ghi in tm lin luc (chuyn ao II, III, AVF hoc V1)
Xac nh mi quan h P-QRS
Bng chng cua bnh tim thiu mau cp hoc cu (thay i cua ST, song Q)
Xac nh block
anh gia dai thi gian v tm thu tht
Kt ni cac triu chng vi thi gian nhp chm
Hnh 73. X ly loan nhp chm. EPS, thm do in sinh ly; TSH, hormone kch thch tuyn giap. (Theo Cooper DH. In: Cuculich PS, Kates
AM, eds. The Washington manual cardiology subspecialty consult. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.)
Lon nhp chm l 325
Nhp chm xoang
Block ng ra xoang nh
Nhp xoang vi ngoai tm thu nh b block
Hi chng nhp nhanh-chm vi oan ngng xoang keo dai
Hnh 74. Cac v du v ri loan chc nng nut xoang. A. Nhp chm xoang. Tn s cua nut
xoang la khoang 45 ck/p. B. Block ng ra xoang nh. Chu y rng khoang PP khi co oan
ngng bng ung 2 ln khoang PP khi khng co oan ngng. C. Ngoai tm thu nh b block.
Chu y rng song P n sm va khng c dn truyn ln trong song T lam khi ng lai nut
xoang va gy ra oan ngng quan sat c trn in tm . D. Hi chng nhp nhanh-chm.
Chu y rng kt thuc cua mt oan ri loan nhp nhanh khng u la mt oan dng keo dai 4,5
giy trc nhp xoang u tin (T Cooper DH. Ri loan nhp chm va may tao nhp vnh vin.
In: Cuculich PS, Kates AM, eds. The Washington manual cardiology subspecialty consult,
xut ban ln th 2, Philadelphia, PA: Lippincott Williams & Wilkins; 2009.)
Block ng ra nut xoang dung ch nut xoang vn phat nhp bnh thng
nhng song kh cc khng dn truyn qua c m quanh nut. Kho phn bit
vi ngng xoang trn in tm ngoai oan RR la bi s cua oan RR trc
oan nhp chm.
Hi chng nhp nhanhchm xay ra khi loan nhp nhanh xen ke vi loan nhp
chm, c bit AF. Nhp nh nhanh ngn can u ra nut xoang dn n ri loan
chc nng nut xoang va sau o chm dt loan nhp nhanh.
Khng co kha nng tng nhp tim la mt kha nng lam tng nhp tim mt cach
thch hp ap ng vi nhu cu chuyn hoa cua c th.
Ri loan dn truyn nut nh tht
Dn truyn qua nut nh tht co th b lch hng (block nhanh hoc phn
nhanh), chm tr (block nh tht cp 1), i khi b gian oan (block nh tht
2), thng xuyn nhng khng phai lun lun b gian oan (block AV
cao), hoc b mt hoan toan (block nh tht cp 3). Vic phn loai cac ri loan
nhp chm thanh mt trong cac loai trn giup bac s xac nh tin lng tt hn
va v vy giup ch cho vic iu tr.
Block nh tht cp 1 la s dn truyn chm tr, thng khu tru nut nh tht,
biu hin trn in tm co oan PR >200 ms. Block la 1 tn goi sai v nh
ngha v khng co nhat nao khng dn (lun song P trc moi phc b QRS).
Block nh tht cp 2 tn tai khi co s gian oan theo chu ky (cac nhat khng
dndropped beats) trong dn truyn nh tht. Phn bit gia Mobitz I va II
la rt quan trong v qua trnh tin trin t nhin dn n block tim hoan toan cua
chung la khac nhau.
Block nh tht Mobitz I (Wenckebach) la s chm tr tin trin trong dn
truyn nut nh tht vi cac xung nh dn cho n khi mt xung khng dn,
tip sau o la lp lai tng t qua trnh trn. Trn ECG b mt, biu hin cua
block nh tht kiu Wenckebach kinh in la:
oan PR cua cac nhat dn keo dai dn ra cho n trc nhat khng dn.
oan RR ngn lai trc nhat khng dn. V vy oan RR cua nhat khng
dn se bng hot t hn 2 ln oan RR ngn nht trn oan ghi ECG.
Phc b QRS i thanh nhom khng u mt cach u t (nhom cac nhat
p).
Block typ 1 thng trong nut nh tht, thng lanh tnh hn va t kha nng
tin trin thanh block nh tht hoan toan.
Block Mobitz II co tin lng kem hn, c trng bi s block nh tht t
ngt ma khng co bng chng cua gian oan dn truyn t t.
Trn ECG, oan PR khng thay i trc oan song P khng dn.
Block typ II, c bit la khi co block nhanh, thng sm gy block tim.
S tn tai block nh tht 2:1 lam cho kho phn bit gia c ch Mobitz I hoc
II. Cac du hiu chn oan v tr b block bao gm:
Block nh tht 1 ng thi, cac giai oan block nh tht kiu Wenkebach,
hoc dn truyn c cai thin (1:1) vi khi tng nhp xoang hoc cng
giao cam gi y s gian oan dn truyn oan gn (c ch Mobitz 1).
Block nhanh hoc phn nhanh kem theo, dn truyn ti hn (3:1, 4:1) khi
cng giao cam gi y v tr block dn truyn ngoai vi hn (c ch Mobitz
2).
Block nh tht cp 3 (hoan toan) la khi tt ca cac xung t nh u khng dn
truyn c xung tht. Co s phn ly nh tht hoan toan (nhp nh > nhp tht).
Cn phn bit vi phn ly do co s canh tranh tai nut nh tht (nhp tht > nhp
nh).
Block nh tht cao la khi co nhiu hn 1 song nh lin tip khng xung
Lon nhp chm l 327
c tht (block 3:1 hoc nhiu hn). Trn ECG, co th nh thy nhiu song P
lin tip ma khng co phc b QRS theo sau. Tuy nhin, se co th m ta c
dn truyn P:QRS mt oan ghi nao o tranh chn oan thanh block nh
tht cp 3 (Hnh 75).
Chn on hnh nh
Vic co hay khng co bnh tim cu truc nn c anh gia u tin bng siu m
qua thanh ngc.
Nhng xet nghim hnh anh su hn nn cn c tng nguyn nhn nghi ng.
IU TR
Thuc
Loan nhp chm dn n triu chng ang k va huyt ng khng n nh c
coi la cp cu tim mach va nn c x tr theo hng dn cua ACLS (xem Phu
luc C).
Atropine, thuc khang cholinergic dung vi liu 0,52,0 mg ng tnh mach, la
thuc c ban iu tr cp cu nhp chm.
Ri loan dn truyn oan gn trong h thng dn truyn (nhp chm xoang
co triu chng, block nh tht cp 1, block nh tht cp 2 Mobitz I) thng ap
ng vi atropine.
Ri loan oan xa thng khng ap ng va co th tr nn xu hn khi dung
atropine.
Nn xac nh cac nguyn nhn gy nhp chm co th phuc hi c nh m ta
trn va nn dng cac thuc gy ra hoc lam tng ln ri loan nhp (digoxin, thuc
chen knh canxi, thuc chen giao cam).
Loan nhp chm do cac nguyn nhn khng th sa cha c hoc th phat do
cac thuc cn thit cho iu tr th nn xem xet vic s dung may tao nhp.
May tao nhp tam thi c ch nh block nh tht cp hai hoc cp ba co triu
chng gy ra bi ng c thuc thoang qua hoc mt cn bng in giai va
block nh tht hoan toan hoc block nh tht cp 2 Mobitz II trong bnh canh
MI cp.
Nhp chm xoang, AF vi tn s ap ng tht chm hoc Block nh tht cp 2
Mobitz I nn c iu tr bng cy may tam thi ch khi co triu chng ang
k hoc co huyt ng khng n nh.
Vic tao nhp tam thi thng c tin hanh bng cach lun sonde tao nhp
qua ng tnh mach. Co th s dung may tao nhp ngoai c th qua lng ngc
mc du no co tin cy thm hn va gy kho chu cho bnh nhn khin cho no
ch la phng tin c la chon th hai.
Block nh tht cp 1
Block nh tht cp 2 Mobitz I (kiu Wenkebach)
Block nh tht cp 2 Mobitz II
Block nh tht cp 2
Block nh tht cp 3 (hoan toan)
Hnh 75. Cac v du v block nh tht. A. Block nh tht cp 1. Khng co nhat khng dn nao
va khoang PR>20 ms. B. Block nh tht cp 2 Mobitz I 3:2. Song P th 3 trong chui song P ln
vao trong song T cua nhat trc o. C. Block nh tht cp 2 Mobitz II. Chu y rng co s block
dn truyn qua nut nh tht ma khng co bng chng cua s chm tr dn truyn tin trin. D.
Block nh tht 2:1. Dang block nh tht nay khin cho vic phn bit gia c ch Mobitz I va
II tr nn kho khn. Chu y rng phc b QRS thanh manh gi y rng block dn truyn xay ra
oan gn hn (c ch type I). Phc b QRS rng hn (co block nhanh hoc phn nhanh kem
theo) gi y c ch type II. E. Block nh tht hoan toan. Chu y rng co s u ng mt cach
khng phu thuc ln nhau cua ca nhp nh va nhp tht (nhp thoat b ni) va khng co s lin
h ro rang vi nhau trn ban ghi in tm . (T Cooper DH. Ri loan nhp chm va may tao
nhp vnh vin. In: Cuculich PS, Kates AM, eds. The Washington manual cardiology subspe-
cialty consult. xut ban ln th 2. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.)
Khi tnh trang huyt ng a n nh, s chu y chuyn sang cac ch nh cy may
tao nhp vnh vin.
bnh nhn co triu chng, yu t quan trong quyt nh gm nhng nguyn
nhn tim n co th sa cha c va mi tng quan v thi gian cua triu
chng va loan nhp.
Bnh nhn khng co triu chng, yu t quyt nh da trn vic liu ri loan
Lon nhp chm l 329
dn truyn c phat hin co s tin trin t nhin thanh block cao hn

hay khng, la yu t tin lng xu.
Tao nhp vnh vin
Tao nhp vnh vin lin quan n vic t mt u tao nhp trong tim vi muc
ch duy tr nhp tim u tranh c cac triu chng nhc n trn va cac
hu qua v huyt ng cua mt vai ri loan nhp chm nht nh. Thm vao
o, nhng tin b trong cng ngh ch tao may tao nhp cho phep may tao nhp
ng thi, thng qua vic ng b nut nh tht va lp trnh da theo nhp
bt chc ngay cang ging nhp tim sinh ly bnh thng.
Cac ch nh nhom I (tt ca u ng y/bng chng co li ch) va nhom IIa
(nhiu y kin ng y/bng chng ung h cho co li ch) cho tao nhp vnh vin
c lit k Hnh 73.
May tao nhp c thit k tao ra mt kch thch in n tim bt c khi
nao khi nhp giam xung di gii han thp a c lp trnh cua may. V vy
biu hin trn ECG cua may tao nhp vnh vin bin i phu thuc vao mc
phu thuc vao may tao nhp cua tn s tim cua bnh nhn.
Spike tao nhp tao ra bi cac may tao nhp ng thi co in th thp, nhon
va i ngay ng trc song P hoc phc b QRS th hin s dn cua cac
bung tim.
in cc nh thng c t tiu nh phai va do o tao ra song P co hnh
thai bnh thng (nh cua nut xoang).
Tuy nhin, phc b QRS c tao ra do in cc bung tht phai thng
rng va co hnh thai ging vi block nhanh trai.
Hnh 76 minh hoa mt vai biu hin ph bin cua may tao nhp hoat ng
bnh thng va bt thng.
Ngun in cua may tao nhp thng c t di da vung ngc bn tay
khng thun. in cc c t bung tim thng qua tnh mach trung tm.
Bin chng cua cy may gm tran kh mang phi, nhim trung dung cu, chay
mau, va him khi, thung tim gy ra ep tim.
Trc khi cy may, bnh nhn phai khng co bt ky nhim trung nao va cac
vn v chng ng phai c cn nhc mt cach cn thn. Tu mau trong
tui may tao nhp xut hin chu yu bnh nhn s dung heparin tnh mach
hoc heparin trong lng phn t thp tim di da. Trong nhng trng hp
nng, phai phu thut di chuyn v tr cua may tao nhp.
Sau cy may, chup ngc thng va nghing khng nh xng tao nhp v
tr thch hp. May tao nhp phai c kim tra vi khoang cach thch hp: thng
thng la trc khi ra vin, 2 n 6 tun sau khi ra vin va sau o la mi 6 n
12 thang.
Ch tao nhp c phn loai bng mt chui 3 n 5 ch cai. Hu ht cac
may tao nhp s dung ma co 3 ch cai.
V1
A
A V A V P V P V P V P V
V2
B
V V V V V V V V V V
C
P VR P V P VR P V P VR P V P VR
D
0.5 V 2.5 V
Hnh 76. Nhp cua may tao nhp. A. May tao nhp 2 bung bnh thng. 2 phc b u tin
la chui tao nhp t nut nh tht, theo sau o la nut xoang vi cam nhn nh va tao nhp tht.
B. May tao nhp 1 bung bnh thng. Nhp nn la rung nh (khng co song P ro rang), vi
tao nhp tht vi tn s 60 l/p. C. May tao nhp b b li. Nhp nn la nhp xoang (P) vi tn
s 80 l/p vi block tim 2:1 va block nh tht cp 1 (PR dai). Tht cac spike tao nhp tht sau
mi song P, th hin s cam nhn va theo du song P mt cach thch hp; tuy nhin lai khng
dn c. D. Ri loan nhp nhanh gy ra do may tao nhp. A, tao nhp nh; V, tao nhp
tht; P, cam nhn xung ng nh; R, cam nhn xung ng tht. (AC. Theo Cooper DH,
Faddis MN. Ri loan nhp tim. Trong: Cooper DH, et al., eds. The Washington manual of
medical therapeutics. xut ban ln th 32. Philadelphia, PA: Lippincott Williams & Wilkins;
2007; D. Theo Cooper DH. Ri loan nhp chm va may tao nhp vnh vin. In: Cuculich PS,
Kates AM, eds. The Washington manual cardiology subspecialty consult. Xut ban ln th 2.
Philadelphia, PA: Lippincott Williams & Wilkins; 2009.)
Ch cai th nht biu th v tr bung tim c tao nhp: A cho tm nh,

V cho tm tht va D cho ca hai bung (A + V).
Ch cai th hai dung ch bung tim c cam nhn: A cho tm nh, V cho
tm tht, D cho ca hai bung (A + V) va O cho khng bung tim nao.
Ch cai th ba th hin loai ap ng cua may tao nhp vi tn hiu ma
Lon nhp chm l 331
no cam nhn c: I cho c ch, T cho kch hoat, D cho ca hai (I + T), va O
cho khng lam g.
Ch cai th t c dung ch kha nng phat nhp thch ng vi tn s
tim (R) ap ng vi vic tng nhu cu chuyn hoa. Gn nh toan b may tao
nhp hin thi u co kha nng iu chnh theo nhp tim.
Ch cai th nm th hin s co mt hay vng mt cua s tao nhp nhiu
v tr: O (khng co), A (nhiu v tr tao nhp nh), V (nhiu v tr tao nhp
tht) hoc D cho ca hai (A+V). Tao nhp hai bung tht iu tr tai ng b
c tim trong suy tim la ng dung.
Cac h thng tao nhp ph bin nht hin nay bao gm VVIR, DDDR, hoc
AAIR.
H thng AAI ch nn c s dung cho cac ri loan chc nng nut xoang ma
khng co bt ky ri loan dn truyn nh tht nao.
May tao nhp hai bung (disease makes a dual chamber deviceDDD) la
thch hp hn trong trng hp co bnh ly nut nh tht hoc h thng His-
Purkinje.
Bnh nhn co AF man tnh nn cy may mt bung vi lp trnh VVI.
Hng dn ACC/AHA/HRS 2008 liu phap iu tr s dung thit b cung cp
mt phac hng dn vic a ra quyt nh la chon h thng tao nhp.
May tao nhp hin ai ngay nay co kha nng chuyn i mode. iu nay rt
hu ch may tao nhp DDD dung cho bnh nhn co nhp nhanh kch phat. Khi
bnh nhn co nhp nh nhanh hn mc cai t cua may, may se t ng chuyn
sang mode (VVI) ma khng i theo tn hiu t nh na. May se t ng tr lai
mode DDD khi loan nhp nhanh c giai quyt.
May tao nhp b li la mt tnh hung co kha nng e doa n tnh mang bnh
nhn, c bit nhng la nhng bnh nhn phu thuc may tao nhp. Khi nghi ng
may tao nhp b li, cn phai ghi ACG 12 chuyn ao.
Nu khng thy hoat ng tao nhp, t 1 thoi nam chm trn may tao nhp
anh gia u ra va kha nng dn cua may. Thoi nam chm co tac dung
chuyn mode may tao nhp sang khng ng b. V du, mode VVI se
chuyn sang VOO (tao nhp tht khng ng b), va mode DDD chuyn sang
DOO (tao nhp nh tht khng ng b).
Nu ro rang la may b li hoc ECG khng ro va vn con nghi ng, th nn
tin hanh kim tra may tao nhp mt cach y u. Bnh nhn se c cp 1
cai the khi cy ghep may xac nh vic cy ghep va ch cai t may,
tao iu kin cho vic kim tra khi co s c.
Nn chup X-quang ngc ( 2 mt phng) anh gia cac bng chng cua
cac bt thng ro rang (di lch v tr, gay, chuyn i ch...).
Nhng li cua may tao nhp thng gp phai bao gm tao nhp tht bai (li u
ra), khng dn c, khng cam nhn c (cam nhn di mc), va ri loan

nhp do may tao nhp.
Khng tao nhp c dung ch tnh trang may tao nhp khng tao ra kch
thch ma ang ra no phai tao ra.
Nhay cam qua mc vi nhiu cua mi trng, in th cua c, hoc cac
nhiu in hoc do lead b li co th dn n cac oan ngng keo dai nhng
bnh nhn phu thuc may tao nhp.
Hoat ng cua nh co th b may giai ngha sai hoc may co th qua nhay
cam vi s kh cc cua tht dn n hoat ng cua nh b han ch, goi la
cross-talk (ting noi xen ln).
Lead b v hoc b tut, yu pin, may phat in yu la nhng nguyn nhn
t ph bin hn gy li u ra.
Khng dn c la nhng trng hp may tao nhp phat nhp nhng khng
nhn thy s kh cc cua c tim (song P hoc phc b QRS).
Ngng in ap bt u song kh cc phu thuc cac m xung quanh
ban in cc, thng hay mc li v tr nay. Hin tng nay goi la block
ng ra.
Nhn cam di ngng xay ra khi bin c lp trnh sn va hoc ngng
cam bin qua cao may co th phat hin ra c hoat ng t nhin cua tim.
iu nay co th dn n vic nhn thy spike tao nhp trn nh cua song
P, QRS hoc song T t nhin.
Nhp nhanh do may tao nhp thng la WCT do tao nhp tht vi tn s
nhanh hoc la do thit b ui theo nhp nhanh nh hoc la do nhp nhanh co
vong vao lai khng co im dng gy ra bi s theo du cua song nh ngc
chiu gy ra bi nhp tht c tao ra trc o.
Tn s cua loan nhp cung cp mt du hiu cho chn oan v thng tn
s nay bng hoc thp hn URL c cai t. Tn s vt qua URL giup
loai tr chn oan.
Tng t nh vy, may tao nhp co chng trnh iu chnh nhp co th b
phn giai sai do st, rung ng bn ngoai, tng thng kh va nhng kch
thch khac bn ngoai va gy ra nhp nhanh co may tao nhp thng qua
cam bin.
LU C BIT
Thng thng cac cn nhp chm thng thoang qua va thanh tng cn; v vy
ch mt ECG luc ban u la khng u bt c cn nhp chm. i khi cn
phai theo doi lin tuc.
nhng bnh nhn iu tr ni tru co th ap dung bin phap theo doi lin tuc
t xa tai trung tm.
Ngt l 333
bnh nhn ngoai tru, nu cac cn xay ra thng xuyn co th s dung eo

Holter 24-72 gi. Nu khng thng xuyn, nn cn nhc s dung may ghi s
kin hoc ILR.
Vic lin h cac triu chng vi cac ri loan nhp phat hin trn monitor lin
tuc la ht sc quan trongmt nhim vu d dang tin hanh khi chm soc bnh
nhn ni tru nhng kho khn hn vi cac bnh nhn ngoai tru. V vy, nn nhn
manh tm quan trong cua vic ghi chu chnh xac cac triu chng khi hoat ng
i vi bnh nhn.
anh gia ap ng cua nut xoang vi gng sc (nghim phap tng nhp tim),
cho bnh nhn i b hanh lang hoc i ln cu thang di s giam sat thch hp
la d dang va khng tn kem. Co th ch nh ECG gng sc thng quy (formal)
nu cn thit.
EPS co th s dung anh gia chc nng nut xoang va dn truyn nh tht,
nhng no t khi cn thit nu cac ri loan nhp a c phat hin ra bng cac thu
thut khng xm ln.
Test nghing ban se c thao lun phn di khi anh gia bnh nhn ngt.
NGT
I CNG
Ngt la mt biu hin lm sang thng gp va muc tiu u tin khi anh gia la phai
xac nh xem bnh nhn co tng nguy c t vong hay khng.
nh ngha
Ngt la tnh trang mt y thc va trng lc t th mt cach t ngt va t khoi do
thiu mau toan b nao thoang qua va hi phuc t nhin, hoan toan va nhanh chong.
Phn loi
Ngt c phn lam 4 nhom da vao nguyn nhn:
Nguyn nhn naotim (nguyn nhn ph bin nht): cng ph v, xoang canh
tng nhay cam, thay i t th t ngt.
Ha huyt ap t th: giam th tch, thuc (gy ra do bac s), ri loan thn kinh
thc vt.
Tim mach:
Loan nhp: ri loan chc nng nut xoang, block nut nh tht, may tao nhp b
li, VT, SVT, hi chng WPW va hi chng QT keo dai.
C hoc: HCM ph ai, hep van, boc tach ng mach chu, u nhy, nhi mau
phi, tng ap phi, nhi mau c tim cp, mt mach di on.
Nguyn nhn khng ro rang khac (khng phai ngt tht s): ng kinh, t
quy/TIA, ha ng mau, thiu oxy, tm ly...
X va ng mach nao la nguyn nhn him gp cua ngt thc s tr khi co s
tc nghen nng ca 4 mach nui nao (hy vong phat hin c du hiu thn kinh
khu tru trc khi ngt).
Dch t hc
Ph bin trong dn s noi chung: 6% nhng trng hp nhp vin va 3%
nhng phong cp cu.
Ty l tng t nhau gia nam va n, mt trong nhng nghin cu ln nht v dch
t cho thy ty l mi mc la 11% khi theo doi vi thi gian trung bnh trong 17
nm, vi ty l tng ang k sau 70 tui (N Engl J Med 2002;347:878).
Sinh l bnh
Hai yu t gy ngt lin quan n naotim bao gm s c ch tim, trong o nhp
chm hay v tm thu la kt qua cua tng kch thch thn kinh ph v n tim, va
giam ap lc mach mau do mach mau ngoai vi gian v giam cac kch thch giao
cam n cac ng mach ngoai vi. Hu ht tt ca cac bnh nhn s phi hp cua ca
2 thanh phn nh la c ch gy ngt.
Nhng kch thch c bit co th kch hoat c ch nao-tim, dn n ngt do tnh
hung c bit (v.d., i tiu, ai tin, ho, nut).
Yu t nguy c
Bnh tim mach, tin s t quy hoc TIA, va HTN. Ch s khi c th thp, ung
nhiu ru va tiu ng cung i kem vi ngt (Am J Cardiol 2000;85:1189; N
Engl J Med 2002;347:878).
CHN ON
Ngt co th bao trc mt bnh ma chung ta khng ngh n, co th la yu t gy
t vong lin quan n tim mach, v vy cn anh gia mt cach cn thn nhng
bnh nhn b ngt.
Kham lm sang va khai thac ky tin s la yu t then cht chn oan chnh xac
nguyn nhn cua ngt. Co ti 40% nhng cn ngt ma c ch cua no vn khng
giai thch c (Ann Intern Med 1997;126:989).
Biu hin lm sng
Bnh s
Nn tp trung chu y n nhng s kin hoc triu chng c bit xay ra trc va
sau ngt, s ln co ngi chng kin cn ngt, thi gian mt va phuc hi y thc
(t ngt hay t t), va tin s bnh tt cua bnh nhn.
Ngt l 335
Triu chng tin triu c trng nh bun nn, va m hi, thay i th giac, o
bng mt gi y n ngt do nao-tim, ma yu t khi phat thng sau mt xuc cam
c bit hoc thay i mi trng va mt moi sau o.
Cac du hiu tin triu khac: Tiu khng t chu hoc tng dn cac mc giam
y thc th chn oan co kha nng nht la ng kinh.
Loan nhp tht thoang qua thng gy t ngt mt y thc vi s phuc hi y thc
nhanh chong.
Ngt theo t thng lin quan n bnh tim co cu truc, tng ap ng mach phi,
va CAD.
Khm thc th
Kim tra tim mach va thn kinh nn la tp trung chnh cho anh gia ban u.
Kim tra du hiu sinh tn t th ng la quan trong anh gia ha huyt ap t
th. Tt ca cac bnh nhn nn c kim tra huyt ap ca 2 tay.
Kham tim phat hin bnh van tim, ri loan chc nng tht trai, bnh phi HTN.
Kham thn kinh thng b bo qua, nhng nu kham co th tm ra nguyn nhn
thn kinh gy ngt.
Xoa xoang canh trong 510 giy ma gy ra cac triu chng va hu qua la ngng
tht >3 giy c coi la hi chng xoang canh tng nhay cam. iu nay rt quan
trong co bin phap phong nga thch hp bng vic giam sat t xa, co th iu
tr nhp chm va tranh cac thu thut bnh nhn a c bit hoc nghi ng co
bnh ng mach canh.
Test chn on
Co bnh tim cu truc, ECG bt thng, tui >65, co du hiu thn kinh khu
tru va ha huyt ap t th nng gi y nguyn nhn ang lo ngai hn. V vy,
nhng bnh nhn nay cn nhp vin ngay tranh s chm tr va kt qua bt li.
Sau khi kham lm sang va hoi tin s, ECG la cng cu chn oan quan trong co
gia tr anh gia bnh nhn. 50% trng hp co bt thng trn ECG, nhng ch
mt mnh ECG th ch co gia tr chn oan 5% bnh nhn.
Nu bnh nhn khng co tin s bnh tim hoc ECG a co bt thng t trc,
test tilt-table (nghing ban) co th dung bng vic anh gia ap ng huyt
ng cua bnh nhn khi chuyn t t th nm nga sang thng ng, chn
oan. Trong qun th ngu nhin, gia tr tin oan cua test nay la thp.
Tham khao Hnh 77 co phng cach chn oan ngt.
IU TR
Nhn chung, iu tr da theo nguyn nhn gy ngt vi muc tiu phong tai phat va
giam nguy c chn thng hoc t vong.
Ngt
336
Bnh s, kham, in tm
l
Ch. 7
Chn oan hoc gi y Ngt khng giai thch c

MRI tim hu ch
Lon nhp tim

cho vic chn oan
ECG, test vn ng
Situational
Hoan canor h Thay i t ECG bt Kham thn kinh phn bit ARVD,
va anh gia thiu mau.
ho c tin triu
prodrome th dng tnh thng bt thng sarcoid, v.v... nu cac
test trc o gi y
Thn kinh tim Ha huyt ap Loan nhp Thn kinh

t th Bnh thng Nu tm thy, iu tr bnh tim cu truc va
thiu mau. anh gia loan nhp, xem xet thm do
Consider
Xem xet testtilt- in sinh ly nu co tin s nhi mau c tim.
nghing ban,
table testing, Xem xet may pha rung cy di da nu co ri loan
n u tai phat
if recurrent chc nng tht trai, co tin s nhi mau c tim
Mt cn n Cn thng xuyn Cn khng hoc khng.
c, lanh tnh thng xuyn
anh gia Kt ni cac triu Cy may ghi

hoan thanh chng vi nhp in tim Nhp xoang co Ri loan nhp
tim vi Holter hoc triu chng co triu chng
may ghi s kin, hoc
may ghi in tm
cy di da anh gia tim iu tr
tuy trng hp. hoan thanh
Hnh 77. Phac anh gia ngt. ARVD (arrhythmogenic right ventricular dysplasia), loan san tht phai gy loan nhp; ECG, in tm ;
MRI (magnetic resonance imaging), cng hng t. (S liu t Holley C. anh gia ngt. In: Cooper DH, va cng s., eds. The Washington
manual of medical therapeutics. Xut ban ln th 32. Philadelphia, PA: Lippincott Williams & Wilkins; 2007; va Strickberger SA, Benson
DW, Biaggioni I, va Nhom nghin cu kt qua cua nhiu nganh; Hi trng tim mach Hoa Ky; Hip hi nhp tim; Hip hi thn kinh t chu
Hoa Ky. Thng bao khoa hoc cua AHA/ACC v anh gia ngt; t Hi ng Hi tim mach Hoa Ky v Tim mach lm sang. iu dng tim
mach, bnh tim mach ngi tre, va t quy, va Cht lng chm soc va Nhom nghin cu kt qua nhiu nganh; va Hi trng tim mach Hoa
Ky, phi hp vi Hip hi nhp tim; c ng thun boi Hip hi thn kinh t chu Hoa Ky. Circulation. 2006;113[2]:316327.)
Ngt l 337
Ngt do naotim:
T vn bnh nhn thc hin cac bc phong nga tranh tn thng bng
vic nhn bit cac triu chng tin triu va duy tr t th nm nga thi
im o.
Tranh cac yu t kch thch a bit va duy tr lng dch thch hp.
S dung co c ng trng khi co du hiu tin triu loai bo cn.
Cac bng chng gi y rng thuc chen giao cam co th khng co ch
(Circulation 2006;113:1164); thuc c ch hp thu chon loc serotonin
(Selective serotonin reuptake inhibitorSSRI), chng trm cam va
fludrocortisone co tac dung con gy tranh cai; midodrine (bt u vi liu
ung 5 mg 3 ln/ngay va co th tng ln 15 mg 3 ln/ngay) co th hu ch
iu tr ngt do nguyn nhn nao-tim (Am J Cardiol 2001;88:80; Heart
Rhythm 2008;5:1609).
Nhn chung, cy may tao nhp vnh vin cha c chng minh la co li ch
(JAMA 2003;289:2224); tuy nhin, may tao nhp 2 bung vnh vin vi chc
nng tr lai nhp tao (tao nhp vi tn s cao khi phat hin ra nhp tim giam thp
mt cach t ngt) a c chng minh co hu ch nhng bnh nhn c la
chon ky cang co ngt do nao-tim tai phat nhiu ln vi thanh phn c ch tim
mach ni bt (J Am Coll Cardiol 1990;16:165).
Tao nhp tim la ch nh thch hp cho nhng bnh nhn ngt do nguyn nhn
xoang canh tng nhay cam.
Nhn chung, ngt do nao-tim khng thy i kem vi tng ty l t vong.
Ha huyt ap t th:
Duy tr lng dch u va loai bo cac thuc gy anh hng.
B sung thm mui, i tt ap lc va t vn ng ln t t.
Midodrine va fludrocortisone co th co ch bng cach tng huyt ap tm thu va
tng th tch huyt tng, nn co hiu qua khi s dung.
Ngt do nguyn nhn tim mach (loan nhp hoc nguyn nhn c hoc):
iu tr nhng ri loan c ban (thay van, thuc chng loan nhp, tai ti thng
mach vanh...).
Tao nhp tim cho trng hp ri loan chc nng nut xoang hoc block nh tht
cao.
Dng cac thuc gy QT keo dai.
Trit t qua catheter s dung bnh nhn ngt i kem nhp nhanh trn
tht.
May kh rung cy trong c th cho nhng trng hp nhp nhanh tht khng
co nguyn nhn khng sa cha c va trng hp ngt co EF (ejection
fractionphn sut tng mau) <35% ma khng cn co ri loan nhp nao c
tm thy.
IU TR TI NG B C TIM
I CNG
Suy tim sung huyt co bin chng dn truyn chm tr ang k gia hai tht
khoang 30% bnh nhn suy tim. Trong nhom bnh nhn nay, co bop tht khng
ng b vach va thanh bn tht gy ri loan chc nng tm thu. Hu qua cua
s mt ng b tht bao gm mt nng lng c hoc tng mau do co mt
thanh tim a gian mt phn, keo dai thi gian cua giai oan ng tch cua thi
ky tng mau tm thu va y tht tm trng, va sc cng thanh tim c bit
cng co th ong gop vao s thay i c tim bnh ly. Kt qua la bnh nhn co
tin lng xu hn nhng bnh nhn suy tim khng co bin chng cua h thng
dn truyn.
Tao nhp 2 bung tht ln u tin c a ra khi phuc lai, mc nao
o, s ng b vach va thanh bn cua tht trai trong bnh canh co s chm dn
truyn gia hai tht cai thin chc nng tm thu tht trai va triu chng suy
tim trn lm sang. Cac th nghim lm sang ngu nhin a u ch ra nhng li
ch va cung cp nhng bng chng v s thay i qua trnh din bin t nhin cua
suy tim nng nhng bnh nhn c iu tr vi phng phap c coi la biu
tng cua ngh thut bng vic giam ty l t vong va giam ty l mi mc suy tim
mt bu (N Engl J Med 2004;350:2140; N Engl J Med 2005;352:1539).
Kt qua la tai ng b c tim (cardiac resynchronization therapyCRT) a tr
thanh 1 tiu chun trong iu tr bnh nhn co chm dn truyn qua tht trai va
ng thi co suy tim tm thu khng ap ng iu tr ni khoa.
nh ngha
CRT c ch nh iu tr nhng bnh nhn co chc nng tm thu tht trai <35%
va thi gian QRS >0,12 giy nhng bnh nhn co triu chng suy tim tin trin
khang thuc phn loai theo NYHA la nhom 3, 4. CRT cung co th cn nhc
bnh nhn co EF tht trai <35% va tng i khng co triu chng. nhom bnh
nhn nay, cac li ch co ve ch gii han nhng bnh nhn co thi gian QRS >150
ms (N Engl J Med 2009;361:1329). Bnh nhn co ch nh tao nhp tht va chc
nng tm thu tht trai <35% co NYHA nhom 1, 2 hoc co triu chng cua suy tim
co th cn nhc cy CRT.
CRT co th c a vao qua h thng may tao nhp hoc qua h thng may tao
nhp/ ICD. V hu ht nhng bnh nhn co ch nh CRT u co th cy ICD
d phong tin phat SCD, v vy thng cy ng thi may tao nhp CRT va ICD.
Cn bng
12
nc v in gii
Judy L. Jang, Steven Cheng
CN BNG DCH V RI LON TH TCH
I CNG
Tng lng nc trong c th (Total body waterTBW). Nc chim khoang
60% trong lng c th nam gii va khoang 50% trong lng c th n gii.
Nc c phn b hai khu vc chnh: hai phn ba la dch ni bao (Intracellular
fluidICF) va mt phn ba la dch ngoai bao (Extracellular fluidECF). Dch
ngoai bao bao gm dch trong long mach va dch tai khoang ke c phn b
theo ty l 1:4. S phn b nay cho phep chung ta c tnh lng nc trong mi
khoang cua c th.
V.d., Mt ngi nam gii nng 70 kg,
TBW = 0,6 70 = 42 L
ICF = 2/3 TBW = 2/3 42 = 28 L
ECF = 1/3 TBW = 1/3 42 = 14 L
Dch trong long mach = 0,25 ECF = 0,25 14 = 3,5 L
Dch khoang ke = 0,75 ECF = 0,75 14 = 10,5 L
S phn b dch trong long mach va khoang ke cung b anh hng bi nhng
thay i trong cn bng Starling. Giam ap lc keo huyt tng (v.d., giam
albumin mau) va tng ap lc thuy tnh (v.d., tng gi lai natri mau) se lam dch
trong long mach i ra ngoai khoang ke. o la c ch gy ra phu.
V dch phn b trong c th phn ln la trong t bao nn nu mt nc n thun
(khng mt natri) thng khng lam thay i huyt ng. Thay vao o, ri loan
TBW se lam thay i ap lc thm thu huyt tng va nng cac cht in giai.
Khi chc nng thn con bnh thng, no se iu chnh nhng thay i cua
TBW bng cach tng bai tit hoc tai hp thu nc ng ln xa thng
qua tac ng cua hormon chng bai niu (Antidiuretic hormoneADH;
vasopressin). Mc du s bai tit vasopressin ap ng chu yu vi cac tn hiu
thm thu nhng giam th tch cung gy ra cac tn hiu bai tit vasopressin,
dn n giam bai tit nc qua thn.
503
504 l Ch. 12 Cn bng nc v in gii
Tng lng natri cua c th. 85 n 90% tng lng Na+ cua c th nm khu
vc ngoai bao ong vai tro cht tan chu yu trong dch ngoai bao. Thay i tng
lng Na+ cua c th thng la kt qua t s mt hoc tng thm cua Na+ trong
dch ngoai bao, dn n s giam hoc tng th tch cua dch ngoai bao. Trn lm
sang, giam th tch co biu hin mach nhanh, huyt ap ha, tng th tch co biu
hin phu ngoai vi, phu phi.
Nng Na+ khac vi lng Na+. Nng Na+ phan anh mt s lng natri
phn phi trong mt lng nc c nh. Nh vy, s gia tng TBW co th lam
giam nng Na+ ngay ca khi tng lng Na+ khng thay i.
Chc nng thn bnh thng co th ap ng vi thay i lng Na+ trong dch
ngoai bao bng cach tng hoc giam tai hp thu Na+. S iu chnh nay thng
qua hoat ng cua h tim mach, thn, gan va cam ng thn kinh trung ng vi
th tch tun hoan hiu dung.
Bnh nhn ng th tch

I CNG
Cn bng dch
nhng bnh nhn ng th tch, muc tiu cua cung cp dch va in giai la
duy tr s hng nh ni mi. Con ng cung cp tt nht la thng qua n ung
ma khng phai la dch truyn tnh mach (intravenousIV). Tuy nhin, nhng
bnh nhn khng th dung nap ng ming truyn dch la cn thit thay th
dch mt qua thn, qua ng tiu hoa va mt nc kn ao (qua m hi, hi
th,...).
Quyt nh truyn dch ng tnh mach (IV fluidIVF) cn c xem xet cn
thn ch khng thc hin mt cach may moc. Cn anh gia lai vic truyn dch t
nht la hang ngay, cn nng bnh nhn la mt ch s anh gia cn bng dch cn
c theo doi cn thn.
Khi ch nh truyn dch ng tnh mach cn xem xet nc va in giai tach bit.
Yu cu nc ti thiu cho cn bng dch hang ngay xp x bng tng lng
nc tiu, nc trong phn, nc mt qua m hi, hi th.
Lng nc tiu ti thiu cn thit bai tit cac cht tan tiu thu hang ngay,
n gian no c tnh bng lng cht tan tiu thu hang ngay (trung bnh
khoang 600 n 800 mOsm/ngay) chia cho lng cht tan ti a c ao thai
qua 1 lt nc tiu (khoang 1.200 mOsm/L vi chc nng thn bnh thng),
kt qua la lng nc tiu bt buc hang ngay t nht la 0,5 L.
Lng nc mt qua phn thng thng khoang 200 mL/ngay.
Lng nc mt kn ao qua m hi, hi th hang ngay khoang 400 n
500 mL. Lng nc c sinh ra t chuyn hoa ni sinh khoang 250 n 300
Cn bng dch v ri lon th tch Bnh nhn ng th tch l 505
mL/ngay la ang k. Lng nc mt kn ao qua m hi, hi th co th thay

i phu thuc va nhp th, tnh trang chuyn hoa va thn nhit (khi thn nhit
trn 37C, tng ln 1 lam mt nc thm 100 n 150 mL/ngay).
Lng dch dn lu cung la mt phn ang k.
Do o, lng dch ti thiu cn thit duy tr hng nh ni mi la khoang
1.400 mL/ngay hoc 60 mL/gi.
Cac cht in giai c s dung trong iu tr cn bng dch la Na+ va K+, yu
cu phu thuc vao lng bt buc ti thiu va lng ang mt, thng thng la.
Khoang 75 n 175 mEq Na+/ngay, v.d., NaCl (2 g mui n mi ngay cung
cp khoang 86 mEq Na+).
Noi chung, khoang 20 n 60 mEq K+/ngay nu chc nng thn bnh thng.
Carbohydrate trong cac dch dextrose, cn khoang 100 n 150 g/ngay giup
giam d hoa protein va ngn chn nhim toan ceton.
Bang 121 cung cp danh sach cac dang dch truyn tnh mach va thanh phn,
bng cach kt hp cac thanh phn cn thit, co th mang lai cac phac phu
hp vi tng bnh nhn.
V.d., Mt bnh nhn nhp vin, khng n ung qua ming. hng nh ni
mi, ban phai cung cp 2 L nc, 154 mEq Na+, 40 mEq K+, va 100 g dextrose
cho nhu cu 24 gi tip theo (cac gia tr v nhu cu nc va in giai trc o).
2 L nc: Liu 85 mL/gi
154 mEq Na+: S dung NaCl 0,45% (77 mEq Na+/L)
40 mEq K+: Thm 20 mEq/L KCl mi lt dch truyn
Bng 121 Dung dch tim truyn thng s dng
Nng HCO3-
thm thu [Glucose] [Na+] [Cl-] Tng ng
Truyn tnh mch (mOsm/L) (g/L) (mEq/L) (mEq/L) (mEq/L)
Glucose 5% (D5W) 278 50 0 0 0
NaCl 0,45%a 154 __b 77 77 0

NaCl 0,9%a 308 __b 154 154 0
NaCl 3% 1,026 __ 513 513 0
Ringers Lactatedc 274 __b 130 109 28
aNaCl 0,45% v 0,9% theo th t l dung dch mui na bnh thng v bnh thng.
bCng c th vi dextrose 5%.
cCng cha 4 mEq/L K+, 1,5 mEq/L Ca2+, v 28 mEq/L lactate.
D5W: 5% dextrose trong nc, D50W: 50% dextrose trong nc, IV: ng tnh mch.
100 g dextrose: S dung Glucose 5% (50 g dextrose/L)

Ch nh: Glucose 5% va NaCl 0,45% pha thm 20 mEq/L KCl truyn
tnh mach 85 mL/gi
Bnh nhn gim th tch
I CNG
Nguyn nhn
Giam th tch thng la kt qua cua s thiu hut tng lng natri cua c th, do
mt Na+ dch ngoai bao qua thn hoc ngoai thn. Mt nc n thun cung co
th la nguyn nhn gy giam th tch nhng s lng thng phai u ln, nguyn
nhn do mt nc t dch ni bao ch khng phai dch ngoai bao, ni co th anh
gia c s giam th tch.
Mt dch qua thn co th th phat do tng cng li tiu, cac bnh thn giam tai
hp thu mui nc (suy vo thng thn), hoc cac bnh thn tc nghen.
Mt dch ngoai thn bao gm mt dch qua ng tiu hoa (nn, tiu chay, hut
dch da day, ro tiu hoa, ...), qua ng h hp, qua da (c bit trong trng hp
bong), xut huyt va mt dch vao khoang th ba.
Chn on
Biu hin lm sng
Cac triu chng bao gm khat, mt moi, yu c, chut rut va chong mt khi thay
i t th. i khi, co th ngt va hn m nu giam th tch nghim trong.
Cac du hiu cua giam th tch bao gm giam ap lc qua tnh mach canh, ha
huyt ap t th, nhp tim nhanh t th, khng co m hi nach. Da kem an hi,
nim mac kh la du hiu giam dch khoang ke. Giam th tch nhe co th khng
phat hin c trn lm sang, trong khi giam th tch nhiu co th ri loan y thc,
thiu niu va sc giam th tch.
Test chn on
Xt nghim
Thm do cn lm sang la rt hu ch nhng cn kt hp cht che vi lm sang.
Natri niu la du n phan anh tnh trang oi Na+ cua thn.
Na+ niu <15 mEq trong giam th tch, tng ng h s bai tit Na (FeNa) <1%.
H s nay c xac nh bng: [(Na+ niu Creatinin huyt thanh) (Na+
huyt thanh Creatinin niu)] 100.
Nhim kim chuyn hoa kem theo co th tng bai tit qua Na+ nc tiu mc du
giam th tch v s bai tit Na+ vi HCO3 la bt buc. Trong trng hp nay,
mc giam Cl <20 mEq la giup xac nh tnh trang giam th tch.
Cn bng dch v ri lon th tch Bnh nhn ng th tch l 507
Ap lc thm thu niu va HCO3 huyt thanh co th tng.

Hematocrit va albumin huyt thanh co th tng do s c c mau.
IU TR
Rt kho c tnh chnh xac lng dch mt, va iu tr chu yu la theo kinh
nghim, oi hoi cn phai anh gia thng xuyn tnh trang th tch khi cac bin
phap hi sc ang tin hanh.
Giam th tch nhe co th c iu chnh qua ng ung. Tuy nhin, nu xut hin
tnh trang huyt ng khng n nh, hoc mt dch co triu chng, hoc khng
dung nap vi vic bu dch qua ng ung th cn ch nh truyn tnh mach.
Muc tiu iu tr chnh la n nh huyt ng, b sung th tch ni mach (trong
long mach), u tin dch ngoai bao. iu nay co th thc hin vi cac dch Na+
c ban, Na+ se c gi lai dch ngoai bao.
Dch ng trng, NaCl 0,9% cha lng mui tng t nh huyt tng trong
dch ngoai bao, va nh vy no khi phuc hoan toan nh dch ngoai bao. No la
la chon ban u cho vic b sung th tch ni mach.
Nc khng co cht tan phn ln khng hiu qua v nc se chu yu phn b
tai dch ni bao.
Dung dch NaCl 0,45% co 77 mEq Na+/L, gn bng mt na lng Na+ trong
dch ngoai bao, do vy mt na lng dch nay se lai khu vc dch ngoai
bao, mt na se theo phn b cua nc.
Co th bu mt lng dch ln trong thi gian ngn (bolus) hoc vi mt tc
duy tr n nh. nhng bnh nhn giam th tch co triu chng, truyn nhanh
1 n 2 L dch la thch hp nht bi phu cho khu vc dch ni bao. Ngay sau
o cn anh gia lai tnh trang th tch cua bnh nhn. Co th lp lai truyn dch
nhanh tng t nu cn thit; tuy nhin, cn chu y cht che cac du hiu cua qua
tai dch. Truyn dch nhanh vi lng nho hn co th s dung cho nhng bnh
nhn suy tim hoc phu. Khi bnh nhn n nh, co th duy tr dch truyn bi
phu lng dch mt. nhng bnh nhn co chay mau hoc xut huyt tiu hoa,
truyn mau va giup bi phu th tch va iu chnh thiu mau.
Bnh nhn tng th tch

I CNG
Nguyn nhn
Biu hin lm sang cua tng th tch la kt qua cua tng tng lng natri cua c
th. Na+ c gi lai co th do cac ri loan tai hp thu Na+ cua thn. Ngoai ra, no
co th la th phat do giam th tch tun hoan hiu dung nh suy tim, x gan, hoc
giam albumine mau.
CHN ON
Biu hin lm sng
Tha dch khoang ke dn n cac biu hin phu, c trng, tran dch mang phi.
Tha dch trong ni mach co th co ran phi, tnh mach c ni, phan hi gan tnh
mach c dng tnh, nhp nga phi vi ting S3 va tng huyt ap.
Du hiu tng th tch co th khng biu hin ro rang cho n khi tha 3 n 4
L dch. Tha dch tng dn thng la du hin sm nht cua tnh trang gi mui.
Triu chng lm sang co th bao gm kho th, c trng va phu chi.
Test chn on
Xt nghim
Nhn chung, cac xet nghim chn oan la khng cn thit, chn oan tha th tch
chu yu da trn lm sang.
Na+ niu co th thp (<15 mEq/L), vi giam th tch tun hoan hiu dung phan
anh tnh trang thn tng tai hp thu Na+.
Chn on hnh nh
X-quang ngc co th thy hnh anh phu phi hoc tran dch mang phi, nhng nu
X-quang ngc bnh thng cung khng cho phep loai tr tnh trang tha dch.
IU TR
iu tr cn phai giai quyt tnh trang d tha dch ngoai bao ng thi giai quyt
bnh ly nn. Giam lng Na+ d tha bng cach s dung ung n cac thuc li
tiu va han ch cung cp Na+.
Thuc
Thuc li tiu tng cng s bai tit Na+ qua nc tiu bng cach ngn chn s
tai hp thu Na+ thn.
Li tiu Thiazide ngn chn tai hp thu Na+ ng ln xa. Ngi ta s dung
Thiazide trong nhng trng hp tng Na+ man tnh mc nhe. Bi v li tiu
Thiazide lam giam kha nng pha loang nc tiu (kha nng bai tit nc) va
thng kch thch ap ng tng tai hp thu ng ln gn.
Li tiu quai ngn chn vn chuyn Na+-K+-2Cl n quai Henle. Chung
thng c s dung trong trng hp cn phai li tiu nhanh va ngay lp tc
nh trong qua tai dch cp tnh. Li tiu quai lam giam nng nc tiu (thn
tng bai tit nc) va tng cng bai tit cation hoa tr hai (Ca2+, Mg2+).
Li tiu gi kali hoat ng bng cach giam tai hp thu Na+ ng gop, hiu
qua li tiu cua cac thuc nay la tng i nho, nn chung c s dung nh
tac nhn b tr. Hn na, nh cac thuc khang aldosteron khng bai tit ng
Cn bng dch v ri lon th tch H natri mu l 509
thn, no c bit hu ch trong trng hp giam ti mau thn, hoc chc nng
ng thn suy giam.
iu tr bnh ly nn la rt quan trong ngn chn tai hp thu Na+ tip tuc tai
thn. Hi chng thn h c trnh bay trong Chng 13, Bnh ly thn. iu tr
suy tim c trnh bay trong Chng 5, Suy tim va bnh c tim. Va x gan c
trnh bay trong Chng 19, Bnh ly gan.
Ri lon nng natri

I CNG
Tng va giam natri mau chu yu lin quan n ri loan cn bng nc hoc phn
b nc. C th co th thch nghi c vi tnh trang thiu hoc tha nc thng
qua s iu chnh cua thn va c ch khat. Mt bt thng v nng Na+ keo dai
se gy ra nhng ri loan cn bng nc cung nh cac ap ng thch nghi.
H natri mu
I CNG
nh ngha
Ha natri nau la khi [Na+] mau <135 mEq/L.
Nguyn nhn
duy tr nng [Na+] mau n nh, lng nc vao va ra khoi c th phai
cn bng nhau. Bt ky nguyn nhn nao lam tng lng nc a vao hoc giam
lng nc ao thai khoi c th u co th dn n ha natri mau.
S giam natri mau do pha loang co th gp trong nhiu trng hp khac nhau:
Gia ha natri mau ch mt hin tng trong phong xet nghim, khi lng protein
va lipid trong mu mau qua cao dn n bao cao kt qua sai lch v nng
[Na+] thp trong dch ngoai bao. iu nay co th khc phuc vi vic s dung
in cc nhay Na+, va nng bnh thng cua [Na+] trong dch ngoai bao co
th c xac nhn bng mc ap lc thm thu bnh thng cua huyt tng.
Ha natri mau vi tng ap lc thm thu: ch nhng trng hp do tng nng
cua cac cht tan khac trong dch ngoai bao dn n keo nc vao dch ngoai bao
gy pha loang nng Na+ mau. Nguyn nhn ph bin la tng ng huyt,
tng mc Glucose mau ln 100 mg/dL se lam giam nng [Na+] mau 1,6
n 2,4 mEq/L (Am J Med 1999;106:399). Nhng cht tan khac nh glycine,
mannitol, va sorbitol co th hp thu vao dch ngoai bao gy ha natri mau thoang
qua nh trong hi chng sau ct bo tuyn tin lit. Thuc y hoat ng bai
tit cua thn va chuyn hoa cac dch hp thu co th iu chnh nhanh chong tnh
trang ha natri mau, mc du triu chng ha natri mau i khi co th thy c

trong nhng trng hp suy thn.
Him hn, tng dch ngoai bao co th xay ra khi lng nc a vao c th vt
qua kha nng sinh ly bai tit nc cua thn. iu nay co th thy trong mt s
ri loan tm thn (chng ung qua nhiu), ng c nc trong cac cuc thi, tro
chi ung, ch n tea and toast (tra va banh m). Thc t, thn co ngng
thanh thai nc. Nc tiu khng th pha loang hn nng thm thu di 50
mOsm/L, do o khi ung qua nhiu nc co th se vt qua ngng thanh thai
cua thn. c bit nhng ngi dinh dng kem, ngheo cht tan. Khi o nc
se b gi lai, Na+ b pha loang, va kt qua la ha natri mau.
Giam thanh thai nc cua thn cung co th xay ra trong mt s trng hp.
Nh a cp, kha nng thanh thai nc cua thn phn ln c kim soat bi
ADH (hoc vasopressin). Hormon nay c kch thch khi co s giam th tch.
Mc du co nhng trai ngc v quan im thm thu (no lam giam hn na
thanh thai nc, tng gi lai nc), hormon nay ap ng thch nghi khi co s giam
th tch, thiu dch m va giam huyt ng. Cac iu kin kch thch tng tit
ADH c goi la khng thch hp khi ADH b kch thch tng tit khng do cac
thay i thm thm cung nh thay i v th tch.
Tit ADH thch hp khi co s sut giam th tch tun hoan hiu dung. Luc nay
cam giac khat va c ch gi nc c kch thch, n nh tnh trang th tch trn
c s n nh lai tnh trang thm thu. Nhom nay c phn chia da trn anh
gia tnh trang dch ngoai bao.
Ha natri mau vi giam th tch co th do mt Na+ thc, chng han nh dung
li tiu thiazide va hi chng mt Na+ trong chn thng so nao hoc u nao.
Ha natri mau vi tng th tch gp trong suy tim sung huyt , x gan, hi chng
thn h nng. Mc du dch khoang ke tng ln nhng th tch tun hoan lai giam.
Theo cn bng Starling, dch se chuyn t trong long mach ra khoang ke.
Tit ADH khng thch hp c c trng bng c ch bao tn nc c
hoat hoa mc du khng co cac kch thch v thm thu hoc th tch. Bi v ap
ng cua thn vi tng th tch vn con nguyn ven, nn nhng bnh nhn nay
thng ng th tch. Tuy nhin, do s gia tng cua tng lng nc trong c th
(TBW), nng Na+ trong mau giam.
Nguyn nhn ph bin nht la hi chng tit ADH khng thch hp (Syndrome
of inappropriate ADHSIADH), mt ri loan do phong thch mt cht ging
vasopressin t thuy sau tuyn yn hoc mt m bt thng. Nhng nguyn nhn
cua SIADH bao gm: cac bt thng tm thn kinh (vim nao, vim mang nao,
loan thn cp, tai bin mach nao, chn thng so nao), cac bnh h hp (vim
phi, lao phi, thng kh ap lc dng, suy h hp cp), cac bnh ly ac tnh (ung
th phi loai t bao nho).
SIADH c chn oan da vao cac du hiu sau:

Ha natri mau vi giam ap lc thm thu
Ap lc thm thu niu >100 mOsm/L
ng th tch
Khng co cac iu kin kch thch tng tit ADH nh giam th tch, nn,
bnh ly tuyn thng thn, tuyn giap
Mt s thuc cung co th gy ra SIADH nh thuc chng trm cam (loai c
ch tai hp thu chon loc serotonin [selective serotonin reuptake inhibitors
SSRIs]), thuc an thn, thuc chng loan thn, Chlorpropamide, va mt s
thuc chng vim giam au khng steroid (non-steroidal anti-inflammatory
drugsNSAIDs).
Cai t lai trung tm iu hoa thm thu la hin tng khi gii han bnh
thng cua ap lc thm thu huyt tng b cai t lai mc thp hn. Khi o,
ADH va phan ng khat se giup duy tr ap lc thm thu huyt tng mc mi
thp hn o. iu nay gp hu ht nhng phu n mang thai (co le do ap ng
vi cac thay i ni tit t) va i khi nhng ngi co giam th tch tun hoan
hiu dung man tnh.
CHN ON
Biu hin lm sng
Triu chng lm sang cua ha natri mau lin quan n thay i ap lc thm thu
trong t bao dn n phu nao. V vy, chu yu la cac triu chng thn kinh, mc
nghim trong phu thuc vao mc va tc giam [Na+] huyt tng. Trong
ha natri mau cp (v.d., tin trin <2 ngay), bnh nhn co th nn, mt moi vi
mc [Na+] ~125 mEq/L. Nu [Na+] huyt tng giam hn na, bnh nhn co th
au u, ngu ga, lu ln. Co git, hn m co th xay nu mc [Na+] huyt tng
<115 mEq/L. Trong ha natri mau man tnh (din bin >3 ngay). C ch thch
nghi se bao v th tch t bao va co xu hng giam thiu s gia tng th tch dch
ni bao va cac triu chng.
Nguyn nhn cua ha natri mau co th c xac nh thng qua vic hoi bnh va
kham lm sang mt cach t m, bao gm ca vic anh gia th tch dch ngoai bao
va th tch tun hoan hiu dung.
Test chn on
Xt nghim
B ba xet nghim bao gm (a) ap lc thm thu huyt tng, (b) ap lc thm
thu niu, va (c) nng Na+ niu co th giup chn oan phn bit cac nguyn
nhn ha natri mau (Hnh 121).
Ap lc thm thu huyt tng
>290 mOsm/L 275290 mOsm/L <275 mOsm/L
Tng ng huyt Tng protein mau Ap lc thm thu niu

Mannitol Tng lipid mau
Tng sau TURP
<100 mOsm/L
>100 mOsm/L
Chng ung nhiu

Th tch dch ngoai bao Chng ung bia v
Sau TURP
Tha dch Bnh thng Thiu dch
[Na+] niu >20 mEq/La

[Na+] niu <10 mEq/L
[Na+] niu <10 mEq/L [Na+] niu >20 mEq/L
[Na+] niu >20 mEq/L
Nn
Li tiu Mt mui qua
Thiu nng thn Mt nc ngoai thnb thn bao gm
mt mui naob
Suy tim Khang cortisol Dung li tiu
S gan Suy giap gn y
Hi chng thn h SIADH Suy thng thn
Nguyn nhn khac cua Bicarbonaturiac
tng hoat ng ADHb Ceton niu
Khi phuc lai trung tm
iu hoa thm thud
Hnh 121. Phac din giai phng cach chn oan ha natri mau. ADH, hormone chng
bai niu; ECF, dch ngoai bao; SIADH: hi chng tit ADH khng thoa ang; post-TURP
(posttransurethral resection of the prostate syndrome), sau ct tin lit tuyn qua niu ao.
a[Na+] niu co th <20 mEq/L vi n ung t Na+. bXem bai ly thm thng tin. cT mt
kim qua nn hoc toan hoa ng ln gn. dAp lc thm thu niu co th <100 mOsm/L sau
khi qua tai nc.
Ap lc thm thu huyt tng. Hu ht cac bnh nhn ha natri mau u co ap

lc thm thu huyt tng thp (<275 mOsm/L). Nu ap lc thm thu huyt
tng khng thp, cn ngh n gia ha natri mau hoc ha natri mau vi tng
ap lc thm thu.
Ap lc thm thu niu. Thn ap ng vi tnh trang giam ap lc thm thu mau
bng cach pha loang nc tiu ti a (ap lc thm thu niu <100 mOsm/L va
ty trong <1,003). Mu nc tiu khng c pha loang cho thy s giam bai tit
nc do tng tit ADH thch hp hoc khng thch hp.
Nng [Na+] niu cho phep anh gia th tch tun hoan hiu dung va phn
bit mt Na+ tai thn hay ngoai thn. ap ng phu hp vi giam tun hoan hiu
dung la tng tai hp thu Na+ ng thn, do vy nng [Na+] niu <10 mEq/L.
Mc [Na+] niu >20 mEq/L cho thy th tch tun hoan hiu dung bnh thng
hoc tnh trang mt Na+. i khi, mt Na+ do bai tit bt buc vi mt anion
khac (HCO3, ceton) mc du th tch tun hoan giam.
IU TR
Trong iu tr, cn xac nh tc iu chnh, cach thc iu chnh va s co
mt cua cac ri loan tim tang khac.
Tc iu chnh ha natri mau phu thuc vao tc tin trin cua no va s hin
din cua cac ri loan chc nng thn kinh.
Ha natri mau cp co triu chng. Ha natri mau nng co cac ri loan chc nng
thn kinh cn c iu chnh ngay bng mui u trng. Tuy nhin, bt ky dung
dch mui nao lam tng nng Na+ trong nc tiu (nu ap lc thm thu niu
a bit thi im bt u truyn dch) u co th tng nng Na+ mau khi kem
theo han ch nc ng ung.
Nguy c khi iu chnh tnh trang ha natri mau qua nhanh la qua tai th tch
va co th tn thng t bao thn kinh trung tm cu nao (Central pontine
myelinolysisCPM) do thay i ap lc thm thu qua nhanh. CPM c m ta
vi cac triu chng lit mm, kho noi, kho nut, va co th c xac nh thng
qua chup ct lp vi tnh hoc chup cng hng t so nao. Nguy c xay ra CPM
nu tc iu chnh Na+ >12 mEq/L trong vong 24 gi (J Am Soc Nephrol
1994;4:1522). Ngoai vic do iu chnh Na+ qua nhanh, nhng nguy c khac
co th phat trin CPM la ha kali mau t trc, suy dinh dng va nghin ru.
nhng bnh nhn ha natri mau nng, vic tng nng Na+ ngay lp tc la
cn thit co th iu chnh Na+ ln 1 n 2 mEq/L trong vong 3 n 4 gi. Tuy
nhin, sau o nn giam dn tc iu chnh, tt nht la khng qua 10 n 12
mEq/L trong vong 24 gi.
Ha natri mau man tnh khng triu chng. Nguy c cao b cac thng tn do
iu tr. Bi v cac t bao a dn dn thch ng vi tnh trang ap lc thm thu
thp, vic t ngt bnh thng hoa ap lc thm thu se gy ra nhng thay i gy
tn thng t bao. Do o, mt tc iu chnh khim tn hn c ch nh, tt
nht la khng qua 5 n 8 mEq/L trong vong 24 gi.
Ha natri mau nng co triu chng. nhng bnh nhn nay, vic iu chnh
bng mui u trng c chun ngay lp tc la cn thit nng mc Na+
huyt tng ln ng thi tranh cac bin chng do iu chnh qua mc.
Cach iu chnh ha natri mau chnh xac nht oi hoi phai xac nh chi tit cac
cht tan, lng nc vao, ra khoi c th. Trong thc hanh lm sang, iu o
khng kha thi.
thay th, ngi ta s dung phng trnh sau y c tnh s thay i nng
Na+ mEq/L sau khi truyn 1 lt dch:
[Na+] = {[Na+i] + [K+i] [Na+s]} {TBW + 1}
Trong o: [Na+i] va [K+i] la nng natri va kali trong dch truyn, [Na+s] la
nng natri huyt tng ban u (Intensive Care Med 1997;23:309). TBW
c c tnh theo khi lng c th 0,6 vi nam gii (va 0,5 vi n gii). Cng
thc nay khng tnh n lng in giai va nc ang mt i.
Cach chia tc iu chnh theo bin thin [Na+] (mEq/L/L dch) cho
phep quan ly tc hp ly (s lt dch cho mi gi).
Phng trnh nay khng tnh n lng in giai va nc ang mt nn cn
phai kim tra lai cac kt qua xet nghim, t o tip tuc iu chnh tc
am bao bnh nhn c cai thin mt cach thch hp.
V.d., mt phu n 80 kg vao v co git. Co mc [Na+] huyt tng la 103 mEq/L.
Tc iu chnh: Bnh nhn co cac triu chng lm sang cua ha natri mau,
do o cn iu chnh lp tc vi tc 1 n 2 mEq/L trong 3 n 4 gi u
nhng khng qua 12 mEq/L trong vong 24 gi.
Cach iu chnh:
Bnh nhn cn c truyn mui u trng, trong o co 513 mEq Na+ cho
mi lt dch.
Mi lt dch nay cho phep tng nng [Na+] ln 10 mEq/L.
[Na+] = {513 108} {80 0,5 + 1} = 10 mEq/L
Liu mui u trng la 200 mL/gi cho n khi cac triu chng cai thin.
Tc = [2 mEq/L/gi] [10 mEq/L cho 1 L dch] = 200 mL/gi
s thay i khng vt qua 10 n 12 mEq/L, khng truyn qua 1 lt dch
trong 24 gi.
Ha natri mau khng triu chng
Ha natri mau vi giam th tch. nhng bnh nhn nay, co th s dung mui
ng trng khi phuc lai th tch trong long mach. Khi phuc lai trang thai
ng th tch se lam giam xu hng gi nc cua thn, dn n bnh thng hoa

nng [Na+]. Nu khng xac nh c thi gian giam natri mau, co th s
dung 1 L NaCl 0,9%, kim soat tc , tranh iu chnh qua mc.
Ha natri mau vi tng th tch. Ha natri mau trong suy tim sung huyt
(congestive heart failureCHF) va x gan thng nng. Tuy nhin, nhng
bnh nhn nay thng khng xut hin triu chng. Mc du th tch tun hoan
hiu dung giam, vic thm dch co th lam nghim trong hn tnh trang qua tai
th tch. iu tr trit oi hoi cn phai iu tr bnh ly nn, mc du han ch
nc vao va tng bai niu co th giup giam mc ha natri mau.
Lng nc vao phai t hn nc tiu hang ngay
Tng ao thai nc bng cach s dung li tiu quai, giam tai hp thu nc
ng ln xa. Thuc li tiu khang vasopressin cung co th hu ch trong
trng hp ha natri mau ng th tch (SIADH) va ha natri mau tng th tch
(c bit la CHF). Khi dung cac thuc lam tng bai niu, cn theo doi cht
che xet nghim nc va in giai v lng nc va in giai ang mt khng
th d oan mt cach chnh xac.
SIADH cn c phn bit vi cac nguyn nhn gy tng tit vasopressin.
iu tr ban u nn la han ch nc va iu tr cac yu t thuc y (nn, vim
phi, thuc,...). Nu khng ap ng hoc xut hin triu chng do ha natri
mau th mi ch nh cac thuc tng bai niu.
Han ch nc. S lng dch cn thit han ch phu thuc vao mc ao
thai nc. Mt hng dn hu ch mc han ch dch nh sau:
Nu (Na+ niu + K+ niu)/Na+ huyt tng <0,5 han ch <1 L/ngay.
Nu (Na+ niu + K+ niu)/Na+ huyt tng t 0,5 n 1, han ch <500 mL/
ngay.
Nu (Na+ niu + K+ niu)/Na+ huyt tng >1, bnh nhn co h s thanh
thai nc cua thn m va ang tch cc tai hp thu nc, do o cn la chon
cac bin phap sau tng bai tit nc.
Ch n giau cht tan. Th tch nc tiu c iu chnh bi 1 thm
thu nc tiu c nh. Do o, ch n nhiu mui, nhiu protein, hoc s
dung ur ng ung (30 n 60 g) co th lam tng kha nng bai tit nc va
cai thin tnh trang ha natri mau.
Thuc
Li tiu quai giup lam giam c ch c c nc tiu giup tng ao thai nc.
Thuc khang Vasopressin thuc y li tiu co th s dung trong iu tr SIADH.
Ca hai ch phm ng tnh mach (conivaptan) va ng ung (tolvaptan) u
c ph duyt iu tr ha natri mau ng th tch. Tuy nhin, han ch
nhng nguy c iu chnh qua mc, cac thuc nay ch nn dung cho cac bnh
nhn iu tr ni tru, c theo doi cht che.
Lithium va demeclocycline ngn can kha nng hp thu nc ng ln gn ap

ng vi ADH nhng t c s dung v nhiu tac dung phu. Chung ch c cn
nhc s dung trong nhng trng hp ha natri mau nng ma khng ap ng vi
cac phng phap iu tr khac.
Tng natri mu
I CNG
nh ngha
Tng natri mau la khi [Na+] mau >145 mEq/L va ai din cho tnh trang tng ap
lc thm thu (xem phn Ri loan nng natri, muc ai cng).
Nguyn nhn
Tng natri mau co th do tng tng lng natri trong c th nhng phn ln la
do thiu nc. Thng thng, tng natri mau se kch thch khat va c c nc
tiu vi nng ti a. Trong tng natri mau keo dai, mt trong hai c ch o se
giam.
Suy giam ap ng khat co th xay ra trong trng hp bnh nhn han ch tip
cn ngun nc, thng la nhng han ch v mt th cht (tan tt, sau phu thut,
t ni kh quan) hoc khim khuyt v mt tinh thn (m sang, mt tr nh).
Tng natri mau do mt nc. Xay ra s mt nc nhiu hn mt in giai, dn
n nng [Na+] tng cao.
Mt nc khng do thn co th mt nc qua da, hi th (kn ao) hoc
mt nc qua ng tiu hoa. Tiu chay la nguyn nhn mt nc qua ng
tiu hoa ph bin nht gy tng natri mau. Tiu chay thm thu (gy ra bi
lactulose, sorbitol, kem hp thu carbohydrate) va vim da day rut do virus, c
bit la mt nc va in giai khng cn xng.
Mt nc do thn gp trong tng bai niu thm thu hoc ai thao nhat.
Tng bai niu thm thu thng lin quan n glucose niu hoc thc n co
thm thu cao. Ngoai ra, tng tng hp ure t d hoa thc n giau protein
va steroid nn co th gy ra 1 li tiu thm thu.
Tng natri mau th phat do mt nc khng thm thu gp trong nhng trng
hp sau: (a) giam bai tit vasopressin (ai thao nhat trung ng), (b) vi cac
tac ng cua vasopressin (ai thao nhat do thn). Phn ln nguyn nhn do
mt trong hai c ch trn, t khi ca hai.
Nguyn nhn ph bin nht cua ai thao nhat trung ng la s pha huy cua
tuyn yn do chn thng, sau phu thut thn kinh, bnh u hat, tai bin mach
nao hoc nhim trung. Trong nhiu trng hp, ai thao nhat trung ng
khng xac nh c nguyn nhn.
Cn bng dch v ri lon th tch Tng natri mu l 517
ai thao nhat do thn co th la di truyn hoc mc phai. Nguyn nhn mc

phai thng la s pha huy kha nng c c nc tiu do thuc (lithium,
demeclocycline, amphotericin), do ri loan in giai (tng canxi mau, ha kali
mau), thuc li tiu quai hoc cac bnh thn ni tai.
Tng natri mau tin phat do tng Na+ thng do thn tng gi lai Na+, him
hn la do truyn lp i lp lai nc mui u trng hoc tng tit qua mc
mineralocorticoid man tnh.
Vn chuyn nc t dch ngoai bao vao trong t bao co th xay ra trong trng
hp tng ap lc thm thu thoang qua trong t bao, nh co git hoc tiu c vn.
CHN ON
Biu hin lm sng
Tng natri mau lam cac t bao thn kinh b teo lai do nc b chuyn ra khu vc
ngoai bao co ap lc thm thu cao. Do o, nhng du hiu nghim trong trong
tng natri mau la cac triu chng thn kinh, bao gm: thay i trang thai tinh thn,
suy nhc, kch thch thn kinh c, du hiu thn kinh khu tru, i khi co git
hoc hn m. Cung ging nh giam Na+, mc nng phu thuc vao cp tnh
va mc tng Na+ trong huyt tng. Tng Na+ man tnh thng co t triu
chng v c ch thch nghi c thc hin nhm bao v th tch t bao.
ai thao nhat (trung ng va do thn) thng co biu hin a niu va khat. Du
hiu cua giam th tch va ri loan chc nng thn kinh thng t gp, tr khi bnh
nhn co ri loan cam giac khat.
Test chn on
Xt nghim
Ap lc thm thu niu va nghim phap ap ng vi Desmopressin acetate
(DDAVPdeamino-8-D-arginine vasopressin) co th giup nh hng chn oan
nguyn nhn tng natri mau (Hnh 122).
Thn ap ng vi tng natri mau bng cach tng kha nng c c nc tiu, ap
lc thm thu niu >800 mOsm/L. Ap lc thm thu niu ti a <800 mOsm/L
phan anh s suy giam trong chc nng c c nc tiu cua thn.
Ap lc thm thu niu <300 mOsm/L hng ti nguyn nhn ai thao nhat
trung ng hoc do thn.
Ap lc thm thu niu trong khoang 300 n 800 mOsm/L co th thy trong ai
thao nhat hoc do li tiu thm thu. nh lng nng cht tan trong nc
tiu hang ngay cho phep phn bit hai nguyn nhn trn (c tnh bng ap lc
thm thu niu nhn vi th tch nc tiu 24 gi). Lng cht tan bai tit hang
ngay >900 mOsm/L xac nh tnh trang bai niu thm thu.
Th tch dch ngoai bao
Qua tai dch Thiu dch hoc bnh thng
Truyn Na+ u trng Th tch nc tiu

Cng Aldosterol hoc
hi chng Cushing
<800 mL >1.000 mL
Ap lc thm thu Ap lc thm thu niu
>800 mOsm/L 300800 mOsm/L <300 mOsm/L
[Na+] niu <10 mEq/L Bai niu thm thu ap ng vi DDAVP?
Mt nc v hnh + CDI hoan toan

(hay kn ao) NDI hoan toan
Mt qua ng >900 mOsm/ngay <900 mOsm/ngay (di truyn, lithium)
tiu hoa
Li tiu (quai hoc
thm thu) Li niu thm ap ng vi DDAVP?
Chng giam khat thu (glucose
niu, mannitol,
tng ure, dch + ai thao nhat trung ng
truyn nhiu) hoan toan vi giam th tch mau
+ ai thao nhat trung ng
mt phn
ai thao nhat do thn mt phn
(di truyn, bnh ng thn,
thuc, K+/ Ca+,
tn thng u trng k ca do
dung thuc li tiu quai thn)
Hnh 122. Phac din giai phng cach chn oan tng natri mau. BUN (blood urea nitrogen),
ure mau; Ca+, (hypercalcemia), tng canxi mau; CDI (central diabetes insipidus), ai thao nhat
trung ng; DDAVP, desmopressin acetate; ECF, dch ngoai bao; GI (gastrointestinal), ng
tiu hoa; NDI (nephrogenic diabetes insipidus), ai thao nhat do thn, K+ (hypokalemia), ha
kali mau; (+): tnh trang tng ap lc thm thu niu trong ap ng vi desmopressin acetate,
(): tnh trang tng nhe ap lc thm thu niu trong ap ng vi desmopressin acetate.
Cn bng dch v ri lon th tch Tng natri mu l 519
Nghim phap ap ng vi Desmopressin acetate (DDAVP). Cho phep phn

bit ai thao nhat trung ng va ai thao nhat do thn. Bnh nhn c xt mui 10
mcg Desmopressin acetate sau khi a c han ch nc, ap lc thm thu tng
trn 50% trong ai thao nhat trung ng va khng thay i trong ai thao nhat do
thn. Chn oan phn bit i khi kho khn nu ch suy giam chc nng tuyn
yn va thn mt phn.
IU TR
Trong iu tr, cn xac nh tc iu chnh, cach thc iu chnh va s co
mt cua cac ri loan tim tang khac.
Tc iu chnh tng natri mau phu thuc vao tc tin trin cua no va s
hin din cua cac ri loan chc nng thn kinh.
Tng natri mau co triu chng. Tng t nh trong iu tr ha natri mau,
iu chnh qua tch cc co th mang lai nhng rui ro. S vn chuyn dch nhanh
chong vao trong t bao co th dn n nguy c co git hoc tn thng thn kinh
vnh vin. Do o, tnh trang thiu dch nn c iu chnh giam dn 10 n 12
mEq/L/ngay.
Tng natri mau man tnh co triu chng, tng nguy c bin chng lin quan
n iu tr do t bao nao a thch nghi vi tnh trang tng ap lc thm thu man
tnh, do o nng [Na+] nn c iu chnh vi tc giam va phai, khoang
5 n 8 mEq/L/ngay.
Can thip
Muc tiu la kim soat nc, tt nht la ung hoc bm qua sonde da day. Ngoai
ra, co th truyn tnh mach dung dch Glucose 5% hoc nc mui sinh ly.
Theo kinh in, iu chnh tnh trang tng natri mau c thc hin da trn
cng thc tnh lng nc thiu:
Lng nc thiu = {([Na+] 140)/140} (TBW)
iu nay la hu ch trong xac nh gn ung lng nc thiu hut nhng khng

cho phep hng dn tc va loai dch truyn. Ngoai ra, chung ti ngh x
ly iu tr ging nh trong ha natri mau. S thay i nng Na+ theo dch
truyn c c tnh nh sau:
[Na+] = {[Na+i] + [K+i] [Na+s]} {TBW + 1}
Trong o: [Na+i] va [K+i] la nng natri va kali trong dch truyn, [Na+s] la
nng natri huyt tng ban u (Intensive Care Med 1997;23:309). V tng
natri mau phan anh tnh trang thiu nc, TBW c c tnh theo khi lng
c th nh sau: 0,5 vi nam gii (ch khng phai la 0,6) va 0,4 vi n gii.
V.d., Mt ngi an ng cn nng 70 kg b tiu chay (2 L/ngay) do lam

dung thuc nhun trang, xut hin l m va [Na+] = 164 mEq/L, [K+] = 3,0
mEq/L. Bnh nhn c ch nh truyn Glucose 5% va 20 mEq KCl/L.
Chnh lch nng [Na+] cho 1 L dch truyn nay la 4 mEq/L
{0 + 20 164} {(70 0.5) + 1}= 4 (mEq/L)
3 L dch la cn thit [Na+] 12 mEq/L/24 gi

(12 mEq/L/ngay) (4 mEq/L/L) = 3 L
Tc truyn la 125 mL/gi (3 L/24 gi = 0,125 L/gi). Tuy nhin, vic
truyn dch cn c theo doi cht che v no khng tnh n lng nc
ang mt i qua ng tiu hoa va mt nc kn ao (m hi, hi th) co
th ln n 1,4 L/ngay gi cho nng [Na+] n nh.
iu tr trong mt s trng hp cu th
Tng natri mau vi giam th tch. nhng bnh nhn giam th tch nhe, dung
dch NaCl 0,45% co th s dung b sung dch ngoai bao cung nh tnh trang
thiu nc. Nu bnh nhn giam th tch nghim trong hoc co triu chng, vic
iu chnh th tch bng cac dch ng trng c u tin hn vic iu chnh
tnh trang tng thm thu. Khi tnh trang huyt ng n nh, cac dch nhc
trng se c ch nh cai thin tnh trang thiu nc.
Tng natri mau nguyn phat do gi Na+ thng khng cn iu tr, ngng
cac bin phap cung cp Na+ la u.
ai thao nhat khng tng natri mau. ai thao nhat c iu tr tt nht bng
vic loai bo cac nguyn nhn c ban. Mc du mt nc qua thn, ai thao nhat
khng gy tng natri mau nu c ch khat con nguyn ven. V vy, vic iu tr
cn hng n triu chng a niu.
ai thao nhat trung ng. a niu la do giam tit vasopressin, iu tr tt
nht la s dung Desmopressin acetate (DDAVP), cht co tac dung tng t
vasopressin.
ai thao nhat do thn. Mt ch n giam Na+ kt hp vi thuc li tiu
thiazide se lam giam tnh trang a niu thng qua giam nhe th tch. iu nay
giup tng cng tai hp thu mui va nc ng ln gn, do o lam giam s
mt nc qua nc tiu. Ch n giam protein cung giup lam giam lng
nc tiu do giam lng cht tan ao thai ra ngoai.
RI LON KALI MU
I CNG
Kali la cation chnh trong t bao. Trung bnh co khoang 3.000 n 4.000 mEq
Ri lon kali mu H kali mu l 521
K+ trong c th, trong o 98% nm trong t bao. Bnh thng, nng K+ trong
dch ngoai bao khoang 3,5 n 5,0 mEq/L, trong khi nng K+ trong t bao la
150 mEq/L. S chnh lch nng K+ trong va ngoai t bao c duy tr bi hoat
ng cua bm Na+/K+/ATP (Adenosine triphosphatase).
Nhu cu K+ trong ch n cua ngi phng Ty khoang 1 mEq/kg/ngay, 90%
trong s o c hp thu qua ng tiu hoa. duy tr n nh nng K+ oi
hoi cn bng lng K+ a vao va c ao thai khoi c th.
Kali c ao thai chu yu tai ng ln xa. Bai tit K+ c tng cng vi tai
hp thu Na+ tao nn mt bin thin m.
Thn kim soat K+ thng qua ap ng vi aldosterone, kch thch bi knh Na+
ng ln xa va nng K+ mau. Tit aldosterone ln lt do ap ng vi
angiotensin II va tng kali mau.
H kali mu
I CNG
nh ngha
Ha kali mau la khi nng [K+] huyt tng <3,5 mEq/L.
Nguyn nhn
Gia ha kali mau co th thy trong tnh hung co rt nhiu t bao ang hoat ng
chuyn hoa trong mu mau dn n hp thu kali trong dch ngoai bao.
Ha kali mau thc s gp trong nhng trng hp sau y: (a) giam cung cp, (b)
tng vn chuyn vao trong t bao, (c) tng ao thai.
Giam cung cp him khi la nguyn nhn chnh dn n ha kali mau v thn
co kha nng giam bai tit K+ xung di <15 mEq/ngay. Tuy nhin, ch n
ung thiu kali co th lam nng thm tnh trang ha kali mau do mt qua ng
tiu hoa hoc qua thn.
Tng vn chuyn K+ vao trong t bao. Co th gy ha kali mau thoang qua
nhng khng lam thay i tng lng kali cua c th. Cac nguyn nhn co th
gp la nhim kim, insulin, va catecholamine. Lit gc chi co chu ky la mt ri
loan him gp do s vn chuyn kali qua mang t bao. Ri loan nay c m ta
ca trong tng va ha kali mau.
Mt kali khng do thn. Ha kali mau co th xay ra do mt dch giau K+ qua
ng tiu hoa thp. Ha kali mau do mt K+ t ng tiu hoa cao thng lin
quan n thn tng bai tit K+ do cng aldosterone th phat. Him gp hn,
trong bai tit m hi qua nhiu, mt K+ co th gy ra ha kali mau.
Mt kali qua thn. Chim hu ht cac trng hp ha kali mau man tnh. iu
nay co th gy ra bi cac yu t lam tng bin thin m, do o lam tng bai tit
K+ hoc lam tng tc dong nc tiu xa.
Tng tc dong qua ng ln xa thng xay ra khi s dung thuc li tiu
hoc li tiu thm thu (glucose niu). Hi chng Bartter_Gitelman co c ch
tng t gy mt K+ qua thn.
Mt loat cac ri loan gy mt K+ qua thn bng cach tng bin thin m
gy bai tit K+. iu nay co th at c vi s tai hp thu mt cation (Na+)
hoc s hin din cua mt anion khng c hp thu.
Tai hp thu Na+ ng ln xa phn ln b anh hng bi hoat ng cua vo
thng thn.
Cng aldosterone nguyn phat gp trong u thng thn hoc qua san
thng thn.
Cortisol cung co ai lc vi thu th mineralocorticoid nhng thng c
chuyn i mt cach nhanh chong thanh cortisone, t b anh hng bi
hoat ng cua mineralocorticoid. Tuy nhin, nu tng cortisol (hi
chng Cushing) hoc khng chuyn i thanh cortisone (hi chng tha
mineralocorticoid) se biu hin ging nh cng aldosterone.
Cng aldosterone th phat co th thy trong nhng trng hp giam th
tch tun hoan hiu dung.
Hoat hoa cu truc knh Na+ biu m ng ln xa, c lp vi aldosterone,
xay ra trong hi chng Liddle.
Tng nng mt anion khng hp thu ng ln xa cung co th tng bin
thin m gy tng bai tit K+. V du nh HCO3 (nhim kim chuyn hoa hoc
toan hoa ng thn [renal tubular acidosisRTA] type 2), ceton va hippurate
(nhim c toluene hoc ht hi keo).
CHN ON
Biu hin lm sng
Biu hin lm sang cua ha kali mau rt a dang, mc nghim trong phu thuc
vao mc ha K+ mau. Thng him xut hin triu chng khi [K+] mau trn
3,0 mEq/L.
Triu chng hay gp la mt moi, au c, yu c, chut rut. Chc nng c trn
cung co th b anh hng vi biu hin tao bon, thm ch lit rut. Ha kali mau
nng co th dn n lit hoan toan, giam thng kh hoc tiu c vn.
Test chn on
Xt nghim
Khi nguyn nhn khng ro rang, anh gia K+ bai tit qua thn va tnh trang
acid-base co th giup xac nh nguyn nhn (Bang 122).
Ri lon kali mu H kali mu l 523
Bng 122 Nguyn nhn dn n ri lon kali mu
H kali mu Tng kali mu
Vn chuyn t Insulin, kim chuyn ha, Ly gii t bo, gim Insulin, toan
bo catecholamines, lit chu k h chuyn ha, chn , lit chu k
kali mu tng kali mu
Thay i lng Dx: [K+] <25 mEq/ngy Dx: TTKG >10
K+ (nguyn hoc TTKG <2 V d: Mui thay th, c chua,
nhn ngoi V d: Cung cp thiu hoc mt khoai ty, chui, cam.
thn) qua ng tiu ha
Thay i lng Dx: TTKG >4 Dx: TTKG <7
K+ (nguyn V d: Tng bi tit, tng chnh V d: Bnh thn cp hoc mn,
nhn do thn) lch nng ng thn suy thng thn, RTA type 4
(cng aldosterol, hi chng
Liddles, khng ti hp thu
anion)
Dx, diagnosis, chn on, GI: ng tiu ha, RTA: Toan ha ng thn, TTKG, transtubular potassium
gradient, cn bng vn chuyn kali ng thn.
K+ niu. ap ng vi tnh trang ha kali mau la bai tit <25 mEq/ngay K+ trong
nc tiu. Xac nh K+ niu tt nht da vao nc tiu 24 gi hoc co th c
lng thng qua mt mu nc tiu. Mt mu nc tiu co K+ <15 mEq/L cho
thy s duy tr K+ phu hp cua thn, tuy nhin kt qua co th b anh hng bi
nhiu yu t. Ngoai ra, bin thin nng K+ trao i qua ng thn (Transtubular
potassium gradientTTKG) co th c tnh nh sau:
TTKG = (K+ niu/K+ huyt tng) (Ap lc thm thu niu/Ap lc thm
thu huyt tng)
Nu TTKG <2: Mt K+ khng do thn, TTKG >4: Mt K+ do thn.

Tnh trang acid-base. Vn chuyn qua mang t tao va bai tit K+ thn lin
quan cht che n tnh trang acid-base. Ha kali mau thng lin quan n tnh
trang nhim kim chuyn hoa va co th ong mt vai tro quan trong trong nhim
kim chuyn hoa. Phat hin nhim toan chuyn hoa bnh nhn ha kali mau se
giup thu hep chn oan phn bit, gp trong nhng trng hp sau: mt K+ qua
ng tiu hoa thp, toan hoa ng thn, hoc s bai tit cua mt anion khng
c hp thu co ngun gc t mt acid hu c (toan ceton do ai thao ng,
hippurate t nhim c toluene).
in tm
Hnh anh in tm bnh nhn ha kali mau co th thy song T det hoc m, xut
hin song U, oan ST chnh xung, va khoang thi gian QU keo dai. Ha kali mau nng
co th thy khoang thi gian PR keo dai, giam in th va phc b QRS gian rng.
IU TR
Muc tiu iu tr la iu chnh s thiu hut kali mt cach an toan va giam thiu tnh
trang mt K+ ang din ra thng qua iu tr cac nguyn nhn c ban. Phat hin va
iu chnh tnh trang tng magie kem theo se giup iu chnh ri loan ha kali mau
hiu qua hn.
Thuc
iu tr tnh trang ha kali mau co th qua ng ung hoc truyn tnh mach.
Bu kali qua ng ung. Nhn chung bu kali qua ng ung la an toan trong
nhng trng hp ha kali mau nhe, bnh nhn co th dung nap c. Liu ung
40 mEq c dung nap tt va co th cung cp thng xuyn mi 4 gi. Thng
thng, giam 0,1 mEq kali mau se c bu bng 10 mEq mui kali. Tuy nhin,
trong trng hp ha kali mau nng, vic bu kali bng ng ung la khng u
at mc kali bnh thng. Hn na, vic kali vn tip tuc i vao dch ni bao
co th lam anh hng n vic iu chnh kali mau dch ngoai bao. Mc du
iu nay co th xut hin nhng no ch n gian phan anh mc thc s cua
ha Kali mau. Trong trng hp nay, tng b sung kali cho n khi nng c
mc Kali mau v bnh thng.
Bu Kali ng tnh mach. Nhng bnh nhn ha kali mau nng e doa tnh
mang va nhng ngi khng th bu c bng ng ung cn c bu kali
ng tnh mach. Nng ti a trong iu chnh K+ khng qua 40 mEq/L vi
ng truyn ngoai vi va khng qua 100 mEq/L vi ng truyn trung tm.
Khng nn bu qua 20 mEq/gi tr trng hp lit hoc co ri loan nhp tht do
ha kali mau. Ly tng nht, KCl c pha trong nc mui sinh ly bi v dung
dch huyt thanh ngot co th lam trm trong thm tnh trang ha kali mau (kt
qua cua insulin vn chuyn kali vao trong t bao). Vic bu kali ng tnh mach
nhanh cn phai c s dung thn trong va theo doi cht che.
Tng kali mu
I CNG
nh ngha
Tng kali mau la khi nng K+ huyt tng >5,0 mEq/L.
Ri lon kali mu Tng kali mu l 525
Nguyn nhn
Gia tng kali mau la tnh trang tng kali mau mt cach gia tao do kali di chuyn
ra khoi t bao ngay trc hoc sau v tr ly mau tnh mach. Nhng yu t gop
phn tao nn hin tng nay co th do nm tay qua cht, tan mau, tng bach cu
hoc tng tiu cu.
Tng kali mau thc s la kt qua cua (a) s thay i vn chuyn kali qua mang,
(b) tng lng kali vao c th, va ph bin nht (c) giam bai tit kali qua thn.
S kt hp gia cac c ch nay thng la c s dn n tng kali mau trong thc
hanh lm sang, va giam bai tit kali thn lun la mt thanh phn trong c ch
bnh sinh.
S thay i vn chuyn qua mang. Thiu hut insulin, tng ap lc thm thu,
thuc chen giao cam khng chon loc, digoxin, nhim toan chuyn hoa (tr
cac nguyn nhn axit hu c), thuc gian c kh cc (v.d., succinylcholine),
kali c vn chuyn t khng gian ni bao ra ngoai bao. Tng kali mau do qua
trnh luyn tp th duc la do tng lng giai K+ t c. Bnh lit c chu ky co
tnh cht gia nh a c cp la mt nguyn nhn him gp cua tng kali
mau. Pha huy mt lng ln t bao, nh trong hi chng ly giai khi u cung giai
phong 1 lng kali vao dch ngoai bao.
Tng cung cp kali vao c th him khi la nguyn nhn duy nht gy tng kali
mau, tr khi co s suy giam bai tit thn. Thc phm co ham lng kali cao
bao gm mui thay th, trai cy kh, cac loai hat, ca chua, khoai ty, rau dn,
chui, cam. Nc ep co ngun gc t cac thc phm nay thng mang mt ham
lng kali cao.
Giam bai tit kali qua thn. Trong cac trng hp tng kali mau, thn co kha
nng tng cng bai tit kali qua nc tiu. Qua trnh nay co th b suy yu
bi mt s nguyn nhn, bao gm bnh thn ni tai, giam dch loc ng ln
xa, suy thng thn, giam aldosteronedo giam renin (type 4 toan hoa ng thn
[RTA]).
Thuc cung co th lin quan n cn nguyn tng kali mau thng qua nhiu
c ch. Nhng thuc ph bin gy tng kali mau nh thuc c ch men
chuyn angiotensin, thuc li tiu gi kali, NSAIDs, cyclosporine. Heparin va
ketoconazole cung co th gy ra tng kali mau thng qua vic giam san xut cua
aldosterone, mc du cac thuc nay dung mt mnh thng khng u gy tng kali
mau co y ngha lm sang.
CHN ON
Biu hin lm sng
Anh hng nghim trong nht cua tng kali mau la ri loan nhp tim th phat do
vai tro quan trong cua kali vi mang t bao. Bnh nhn co th co biu hin trng
ngc, ngt, thm ch t vong do ngng tim.
Tng kali mau nng gy kh cc mt phn cua mang t bao c vn gy yu c, co
th tin trin n lit mm, giam thng kh nu co anh hng n cac c h hp.
Test chn on
Xt nghim
Nu nguyn nhn khng ro rang va bnh nhn khng co triu chng, gia tng
kali mau cn c loai tr bng cach xet nghim lai kali.
anh gia kha nng bai tit kali cua thn va truc renin-angiotensin-aldosterone
co th giup thu hep chn oan phn bit khi nguyn nhn khng phai ngay lp
tc ro rang.
S bai tit kali cua thn co th c anh gia thng qua chnh lch nng kali
qua ng thn (The trans-tubular potassium gradientTTKG).
TTKG >10 cho thy kha nng bai tit kali cua ng thn con nguyn ven. Tng
kali mau dai dng mc du ap ng cua thn la nguyn ven cho thy co giam
dong mau c phn b ti ng ln xa ni K+ c bai tit, nh trong trng
hp giam th tch tun hoan hiu dung.
TTKG <7 cho thy s suy giam bai tit kali do giam aldosterone, khang
aldosterone hoc giam aldosterone do giam renin. anh gia truc renin-
aldosterone co th giup phn bit cac nguyn nhn nay.
Mc aldosterone thp cho thy hoc la bnh tuyn thng thn (mc renin
cao, TTKG cai thin vi fludrocortisone), hoc la giam aldosterone do giam
renin (mc renin thp, xay ra type 4 cua toan hoa ng thn nh shunt
Clorua hoc hi chng Gordon).
Mc aldosterone cao, thng i kem vi mc renin cao cho thy tnh trang
khang aldosterone hoc cung co th thy khi dung cac thuc li tiu gi
kali.
in tm
Thay i trn in tm bao gm tng bin song T, T cao nhon, i xng.
Nghim trong hn co th dn n keo dai thi gian PR va phc b QRS, chm
dn truyn nh tht, mt song P. S m rng phc b QRS cung vi tng bin
song T tao nn hnh anh song hnh sin. Hu qua cui cung la rung tht, ngng
tim.
IU TR
Tng kali mau nng vi nhng bin i trn in tm la mt cp cu cn
phai c iu tr ngay lp tc vi muc ch giam thiu s kh cc t bao va giam
Ri lon kali mu Tng kali mu l 527
nhanh kali dch ngoai bao. iu tr cp co th bao gm mt s hoc tt ca nhng

iu tr sau y:
Thuc
S dung calcium gluconate lam giam kch thch mang nhng khng lam giam
nng kali. Liu thng thng la 10 mL dung dch 10% truyn trong 2 n 3
phut. Hiu qua bt u trong vong vai phut nhng khng tn tai lu (30 n 60
phut). Co th lp lai nu khng thy s cai thin trn in tm trong vong 5
n 10 phut.
Insulin lam tng vn chuyn kali vao trong t bao va tam thi lam giam nng
kali huyt tng. Mt s kt hp thng c s dung la 10 n 20 n v insulin
va 25 n 50 g glucose tim tnh mach. Bnh nhn tng ng huyt nn c s
dung insulin n c.
NaHCO3 co hiu qua cho nhng trng hp tng kali mau nghim trong lin
quan n nhim toan chuyn hoa. Trong cac trng hp cp tnh, no co th s
dung vi mt dung dch ng trng tnh mach (3 ng NaHCO3 pha trong 1 L
dung dch dextrose 5%).
Kch thch 2 giao cam lam tng vn chuyn kali vao trong t bao. Bt u co
hiu qua sau 30 phut, co th giam kali mau 0,5 n 1,5 mEq/L va tac dung trong
vong 2 n 4 gi. Co th s dung Albuterol liu 10 n 20 mg kh dung lin tuc
30 n 60 phut.
iu chnh giam kali mau dai han.
Tng phn phi natri ng ln xa lam tng bai tit kali. iu nay co th at
c bng cach truyn NaCl cho nhng bnh nhn giam th tch. Nu khng, co
th s dung cac thuc li tiu nu chc nng thn bnh thng.
Nha trao i ion nh sodium polystyrene sulfonate (Kayexalate) thuc y
trao i Na+ va K+ trong ng rut. Co th ung liu 25 n 50 g trn vi
100 mL sorbitol 20% ngn nga tao bon. iu nay co th lam giam kali
mau 0,5 n 1,0 mEq/L trong vong 1 n 2 gi va keo dai 4 n 6 gi. Sodium
polystyrene sulfonate cung co th c thut hu mn vi liu 50 g pha trong
150 mL nc. Thut hu mn nn tranh nhng bnh nhn sau phu thut v
tng ty l hoai t rut, c bit la sau ghep thn.
Loc mau nn danh cho cac bnh nhn suy thn va nhng trng hp tng kali
mau nghim trong e doa tnh mang va khng ap ng vi nhng bin phap
khac.
iu tr dai han co th lin quan n iu chnh ch n ung tranh cac thc
phm cha nhiu kali, iu chnh toan chuyn hoa bng kim qua ng ung,
thuc y bai tit kali bng thuc li tiu va/hoc s dung cac mineralocorticoid
ngoai sinh trong nhng giam aldosterone.
RI LON CANXI MU
I CNG
Canxi la cn thit cho s hnh thanh xng va chc nng cua thn kinh c.
Khoang 99% canxi trong c th nm trong xng; 1% con lai phn ln trong
dch ngoai bao. Khoang 50% canxi mau dang ion hoa (t do), trong khi phn
con lai dang kt hp vi albumin (40%) va cac ion nh phosphate (10%).
Cn bng canxi c iu chnh bng hormon tuyn cn giap (Parathyroid
hormonePTH) va calcitriol.
PTH gy tng canxi mau do kch thch tng huy xng, tng gi lai canxi
thn va thuc y thn chuyn vitamin D thanh calcitriol. Canxi mau iu hoa
tit PTH theo c ch iu hoa ngc m tnh: giam canxi mau kch thch bai tit
PTH va ngc lai tng canxi mau lam giam bai tit PTH.
Calcitriol (1,25-dihydroxycholecalciferol, 1,25-dihydroxyvitamin D3, hoc
1,25 (OH)2D3) la dang hoat ng cua vitamin D. No kch thch s hp thu
canxi rut la mt trong nhiu yu t cung cp thng tin phan hi n tuyn
cn giap.
Tng canxi mu
I CNG
nh ngha
Canxi mau >10,3 mg/dL vi mc albumin mau bnh thng hoc canxi ion mau
>5,2 mg/dL c goi la tng canxi mau.
Nguyn nhn
Tng canxi mau trn lm sang oi hoi ca tng canxi dch ngoai bao va giam
thanh thai canxi cua thn. Ri loan chuyn hoa canxi thng b che lp bi c ch
bu tr cho n khi bnh nhn ri loan ng thi, nh la giam thanh thai thn
do suy giam th tch. Hn 90% cac trng hp tng canxi mau trn lm sang la do
cng tuyn cn giap nguyn phat hoc cac bnh ac tnh.
Cng tuyn cn giap nguyn phat la nguyn nhn hu ht cua tng canxi
mau trong cp cu. y la mt ri loan thng gp, c bit phu n cao tui,
trong o ty l mc hang nm la khoang 2 trong 1.000. Khoang 85% cac trng
hp la do u tuyn (adenoma) cua 1 tuyn ni tit n le, 15% do qua san cua
ca 4 tuyn, va khoang 1% do ung th biu m (carcinoma) cua tuyn cn giap.
Bnh ac tnh c xac nhn hu ht cac bnh nhn tng canxi mau oi hoi phai
Ri lon canxi mu Tng canxi mu l 529
nhp vin. Bnh nhn thng co bnh canh lm sang ro rt. nhng bnh nhn
o, tng canxi mau co th do cac san phm tit ra t t bao ung th kch thch hoat
ng cua t bao huy xng gy giai phong canxi hoc do khi u tit peptide ging
PTH (PTH related peptidesPTHrPs) va u san xut calcitriol.
Cac nguyn nhn t gp chim khoang 10% cac trng hp tng canxi mau:
Tng hoat hoa vitamin D xay ra khi s dung vitamin D ngoai sinh hoc tng
sinh calcitriol trong cac bnh u hat man tnh (v.d., bnh sarcoit, bnh lao).
Hi chng sa-kim m ta s tng canxi mau cp hoc man tnh, nhim kim
va suy thn, co th la kt qua cua vic tiu thu mt lng ln thuc khang axit
co cha canxi.
Nguyn nhn khac. Cng giap, suy thng thn, bt ng keo dai, bnh
Paget, bnh to vin cc co th lin quan n tng canxi mau. Tng canxi mau
kt hp vi giam canxi niu co tnh cht gia nh la mt ri loan di truyn
gen tri trn nhim sc th thng him gp lin quan n thu th nhay cam
canxi, c c trng bi tng canxi mau khng triu chng t thi nin thiu
cung tin s gia nh co tng canxi mau.
CHN ON
Biu hin lm sng
Triu chng lm sang thng ch xut hin khi canxi mau >12 mg/dL va co xu
hng nghim trong hn nu tng canxi mau tin trin nhanh. Hu ht cac bnh
nhn cng tuyn cn giap tin phat tng canxi khng triu chng, c phat hin
mt cach ngu nhin.
Biu hin thn bao gm a niu va soi thn. Nu canxi mau tng trn 13 mg/dL,
suy thn co th xay ra do vi hoa thn (nephrocalcinosis) va co th xut hin vi
hoa m mm.
Cac triu chng tiu hoa bao gm chan n, nn, tao bon, va him gp hn la vim
tuy.
Biu hin thn kinh bao gm suy nhc, mt moi, lu ln va hn m.
Tha xng va gay xng thng xay ra do xng hp thu canxi khng ng
u trong cng cn giap. Him gp, vim xng x nang hoa co th xay ra khi
cng cn giap manh va keo dai, dn n u xng (brown tumors) va thay
th tuy.
Hoi bnh va kham thc th nn tp trung vao (a) din bin cac triu chng cua
tng canxi mau, (b) bng chng lm sang cua bt ky nguyn nhn nao cua canxi
mau, va (c) cac triu chng, du hiu cua bnh ac tnh (hu nh lun co trong
tng canxi mau ac tnh). Nu tng canxi mau hn 6 thang ma nguyn nhn
khng ro rang, cng tuyn cn giap gn nh la nguyn nhn chc chn.
Test chn on
Xt nghim
Phn ln chn oan co th thc hin thng qua hoi bnh, kham lm sang va mt
vai xet nghim n gian.
Canxi mau c c hiu chnh vi albumin mau hoc tnh nng canxi ion
hoa. Canxi hiu chnh = [Ca++] = [Ca++] + {0,8 (4,0 [Albumin])}. Nhiu
bnh nhn cng tuyn cn giap nguyn phat se co mc canxi mau gii han bnh
thng cao man tnh.
Xet nghim PTH mau la bt buc trong anh gia tng canxi mau. Xet nghim
PTH nguyn ven nn c s dung v no c lp vi chc nng thn.
Tng canxi trong dch ngoai bao thng dn n c ch PTH. V vy, phat hin
mc PTH mau bnh thng hoc tng cao trong tng canxi mau se gi y nguyn
nhn do cng tuyn cn giap nguyn phat.
Khi PTH b c ch mt cach thch hp, PTHrP co th c o lng chn
oan tng canxi mau trong bnh ac tnh. Mc 1,25(OH)2D3 tng trong cac bnh
ly u hat, cng tuyn cn giap nguyn phat, qua liu calcitriol hoc bnh to u
chi. Mc 25(OH)D3 tng trong nhim c vitamin D khng calcitriol.
nh lng phospho mau co th giup xac nh cac ri loan tim n cua canxi
trong hng nh ni mi. Cng tuyn cn giap thng lam giam phospho mau
do kch thch tng phospho niu. Trong khi ca bnh Paget va nhim c vitamin
D u co xu hng tng phospho mau.
Canxi niu co th tng trong cng tuyn cn giap nguyn phat do mc loc canxi
vt qua kha nng tai hp thu cua thn. Nu tin s gia nh va bnh canh lm
sang gi y, tng canxi mau kt hp vi giam canxi niu co tnh cht gia nh co
th c phn bit vi cng cn giap nguyn phat bng thanh thai canxi thp
trong nc tiu 24 gi (<200 mg/ngay) hoc bai tit phn oan cua canxi (<1%).
in tm
in tm co th cho thy khoang QT ngn lai, vi tng canxi mau nng co th
thy block nh tht (Block atrioventricularBAV) vi cac cp khac nhau.
IU TR
iu tr cp tng canxi mau: Cn c am bao nu xut hin cac triu chng
nghim trong hoc canxi mau >12 mg/dL. Cac bin phap sau y nn c s
dung theo th t.
iu chnh tnh trang giam th tch bng dung dch nc mui sinh ly 0,9% la
bt buc vi nhng bnh nhn giam th tch, v giam th tch ngn chn bai tit
canxi hiu qua. Co th duy tr dch sau khi a at c tnh trang ng th tch
am bao duy tr mt lng th tch nc tiu 100 n 150 mL/gi. Bnh nhn cn
c theo doi cht che cac du hiu cua qua tai th tch.
Ri lon canxi mu Tng canxi mu l 531
Thuc
Thuc li tiu quai co th c s dung nu co du hiu qua tai th tch trong
khi vic bu dch b gii han ma tnh trang tng canxi mau vn con. Li tiu quai
lam giam tai hp thu canxi quanh t bao trong quai Henle v vy co th lam tng
bai tit canxi. Tuy nhin, khng s dung li tiu trong nhng trng hp ng th
tch hoc giam th tch v chung co th tip tuc lam giam th tch dch ngoai bao
va ngn chn s phuc hi th tch.
Bisphosphonate ng tnh mach co th c s dung giam giai phong canxi
t xng trong tng canxi mau dai dng. Pamidronate 60 mg truyn tnh mach
trong 2 n 4 gi cho trng hp tng canxi mau nng (>13,5 mg/dL), 60 mg
truyn tnh mach co th c s dung trong khoang thi gian tng t. ap ng
giam canxi mau co th thy trong vong 2 ngay, keo dai 2 tun hoc lu hn. iu
tr co th c lp i lp lai sau 7 ngay nu tng canxi mau tai phat. Zoledronate
la mt bisphosphonate manh hn c s dung, liu 4 mg c truyn tnh mach
trong t nht 15 phut. Nn truyn dch trc khi s dung bisphosphonate. Suy thn
la chng ch nh tng i.
La chon khac
Calcitonin c ch huy xng va lam tng bai tit canxi. Calcitonin ca hi 4 n
8 IU/kg tim bp hoc tim di da mi 6 n 12 gi lam giam canxi mau 1 n
2 mg/dL trong vong vai gi 60 n 70% bnh nhn. Mc du no yu hn so vi
cac thuc c ch huy xng khac nhng no t c tnh, an toan cho bnh nhn
suy thn va co tac dung giam au nhng bnh nhn co di cn xng.
Glucocorticoid co hiu qua trong tng canxi mau trong bnh mau ac tnh va
cac u hat san xut calcitriol. Liu khi u la 20 n 60 mg/ngay prednisone
hoc tng ng. Khi canxi mau n nh, nn giam liu ti thiu cn thit
kim soat cac triu chng cua tng canxi mau. c tnh (xem Chng 25, Vim
khp va bnh ly khp) lam han ch tnh hu dung cua corticoid khi s dung
keo dai.
Gallium nitrate c ch huy xng mt cach hiu qua nh Bisphosphonate
truyn tnh mach va khi phat chm sau 2 ngay. Liu 100 n 200 mg/m2/ngay
c truyn lin tuc cho n 5 ngay, hoc co th dng sm hn khi canxi mau
tr v bnh thng. Tuy nhin, no co nguy c gy c cho thn nn chng ch
nh khi creatinine huyt thanh >2,5 mg/dL.
Loc mau. Thn nhn tao va thm phn phuc mac co hiu qua trong nhng
trng hp tng canxi mau nng (>16 mg/dL) hoc kem theo suy thn.
iu tr lu dai tng canxi mau
Cng tuyn cn giap tin phat. nhiu bnh nhn, ri loan nay tin trin
lanh tnh vi bin ng nng canxi mau rt t va khng gy hu qua ro rang
trn lm sang. Ct tuyn cn giap c ch nh nhng bnh nhn (a) Canxi
mau hiu chnh >1 mg/dL so vi gii han trn cua mc bnh thng, (b) Canxi
niu >400 mg/ngay, (c) suy thn, (d) giam mt xng (T-score 2,5), (e) tui
<50, va (f) khng th theo doi lu dai (J Bone Miner Res 2002;17(suppl 2):N2).
Phu thut thng co ty l thanh cng cao (95%) va ty l ty vong thp.
iu tr ni khoa la mt s la chon hp ly nhng bnh nhn khng co triu
chng va khng co ch nh phu thut. iu tr bao gm ung nhiu nc va
ch n nhiu mui, tng cng hoat ng th cht giam bt tiu xng va
tranh dung cac thuc li tiu thiazide. Thuc bisphosphonate ng ung hoc
liu phap thay th estrogen hoc raloxifene nhng phu n man kinh co th
c xem xet trong nhng bi canh lm sang thch hp. Cinacalcet, mt thuc
kch thch thu cam canxi cung c chng minh la lam giam tit PTH va nng
canxi huyt thanh.
Tng canxi mau ac tnh. Bisphosphonate va liu phap glucocorticoid kt hp
vi ch n han ch canxi (<400 mg/ngay) co th s dung mc du cac th
nghim cho thy khng mang lai hiu qua lu dai, tr khi cac khi u ac tnh ap
ng vi iu tr.
H canxi mu
I CNG
nh ngha
Canxi mau <8,4 mg/dL vi mc albumin mau bnh thng hoc canxi ion mau
<4,2 mg/dL c goi la ha canxi mau.
Nguyn nhn
Gia ha canxi mau la trng hp lng canxi mau toan phn b giam do giam
albumin mau nhng canxi mau hiu chnh (xem thm phn tng canxi mau) va
canxin ion hoa bnh thng.
Anh hng cua suy tuyn cn giap. Giam hoat ng cua PTH co th la kt qua
cua t min dch, vim, hoc sau iu tr (v.d., sau ct tuyn giap) lam pha huy
tuyn cn giap. Mt s nguyn nhn him gp la do suy tuyn cn giap bm sinh,
nh trong hi chng DiGeorge hoc ha canxi mau co tnh cht gia nh. Giam
tit PTH cung gp trong ca 2 trng hp ha magie mau (<1 mg/dL) va tng magie
mau nng(>6 mg/dL).
Thiu vitamin D lam giam tng lng canxi cua c th nhng thng khng anh
hng ti nng canxi mau tr khi thiu hut nghim trong. Do xut hin cng
tuyn cn giap th phat sau khi [Ca+] giam, mc canxi mau thng xuyn c
iu chnh. Thiu vitamin D ang k co th xay ra nhng ngi ln tui hoc
t tip xuc vi anh sang mt tri, bnh gan tin trin (do giam tng hp cac tin
Ri lon canxi mu H canxi mu l 533
cht), va trong hi chng thn h. Giam hoat hoa vitamin D thng qua hoat ng
cua 1--hydroxylase co th gp trong coi xng do thiu vitamin D hoc suy thn
man.
Canxi mau co th giam nhiu trong trng hp tng cao phospho mau lin quan
n s gn canxi cac m. Canxi cung co th b gn bi citrate (trong qua trnh s
dung cac ch phm mau cha citrate hoc cac thuc chng ng mau trong thn
nhn tao) hoc mt s thuc nh foscarnet va fluoroquinolone. Tng cng gn
vi albumin cung xay ra trong trng hp nhim kim do lam tng s tip xuc vi
v tr lin kt in tch m cua albumin.
Khac. Nng canxi t do trong mau thp gp kha ph bin nhng bnh nhn
hi sc co le do giam cytokine trung gian trong giai phong PTH va calcitriol ng
thi giam hiu qua cua chung trn c quan ch.
CHN ON
Biu hin lm sng
Biu hin lm sang a dang tuy theo mc giam canxi mau va tc khi phat.
Trng hp cp tnh, giam canxi mau mc trung bnh co th lam tng cac kch
thch thn kinh c, dn n cac biu hin t quanh ming, d cam u chi hoc co
qup chn tay (tetany).
Du hiu Trousseau: Co qup c-ban tay khi bm bng o huyt ap ln trn mc
huyt ap tm thu trong vong 3 phut. Du hiu Chvostek co cac c mt khi go
nhe vao vung trc tai. S biu hin cua cac du hiu nay nh la du hiu tetany
tim n.
Trng hp cp tnh, giam canxi mau mc nng co th gy co tht thanh quan,
ln ln, co git hoc co mach vi nhp chm va suy tim mt bu.
Du hiu gi y chn oan co th la (a) tin s phu thut vung c (suy tuyn cn
giap sau phu thut), bnh h thng (t min dch, bnh u hat), (c) tin s gia nh
co ngi giam canxi mau, (d) s dung cac thuc gy giam canxi mau, (e) co nguy
c thiu hut vitamin D.
Test chn on
Xt nghim
Xet nghim phn tch anh gia truc canxi-PTH va cac in giai khac.
nh lng albumin huyt thanh cn lam trong moi trng hp bt thng canxi
mau loai tr gia ha canxi mau. Nh a trnh bay trn, canxi mau co th c
hiu chnh bng {0,8 (4 [albumin])} canxi mau toan phn.
PTH huyt thanh thp hoc khng bnh thng trong ha canxi mau la du hiu
gi y suy tuyn cn giap. PTH tng thng gp nhng bnh nhn thiu vitamin
D hoc tng phospho mau.
nh lng phospho mau giup ch cho vic xac nh thiu hut vitamin D (giam
canxi va phospho mau), hoc thai canxi ni mach (tng canxi va phospho mau).
anh gia tnh trang vitamin D bng cach o 25(OH)D3 v calcitriol (1,25(OH)2D3),
co th bnh thng thng qua gia tng hoat ng bu tr cua 1--hydroxylase.
Giam magie mau lun cn c loai tr trong cac nguyn nhn gy ha canxi mau.
in tm
in tm cho thy hnh anh keo dai khoang QT va nhp chm.
IU TR
Ha canxi mau co triu chng oi hoi phai c iu tr kp thi va tch cc.
Thuc
Trc tin cn kim tra phospho mau. Trong trng hp tng phospho mau
nng, vic b sung canxi se lam tng cac san phm cua canxi-phospho va co th
thuc y hnh thanh vi hoa m ngoai xng. Trong trng hp cp tnh, ha canxi
mau co triu chng kem theo tng phospho mau nng, loc mau co th cn thit
kim soat tnh trang ri loan cht khoang nay. Nu ha canxi mau khng co triu
chng, nn ha phospho mau trc khi b sung canxi.
Ha magie mau, nu co, phai c x ly u tin co hiu qua khc phuc giam
Canxi mau. 2 g magie sulfate co th c tim tnh mach trong 15 phut, sau o
truyn duy tr (xem thm phn magie).
B sung canxi. Canxi ng tnh mach nn c ch nh trong nhng trng
hp ha canxi mau nng hoc co triu chng, co th s dung canxi clorua hoc
canxi gluconat. Canxi gluconate thng c u tin la chon hn do giam nguy
c gy c cho m khi thoat mach. Canxi gluconate thng c pha trong dung
dch 10% (100 mg canxi gluconate trong mi mL). Mt ng canxi gluconate (10
mL) cha 1.000 mg canxi gluconate va 90 mg canxi.
Khi cn thit iu tr tnh trang ha canxi mau nng hoc co triu chng, liu
khi u 90 n 180 mg canxi co th at c vi 1 n 2 g canxi gluconate
(tng ng vi 10 n 20 mL hoc 1 n 2 ng canxi gluconate).
Hiu qua iu tr ban u ch la thoang qua, duy tr nng canxi cn phai
truyn lin tuc 0,5 n 1,5 mg/kg/gi canxi. Mt dung dch 1 L huyt thanh
ngot 5% vi 100 mL dung dch canxi gluconate 10% cha khoang 900 mg
canxi, tng ng co khoang 1 mg canxi trong mi mL dung dch c truyn
tnh mach vi tc 50 mL/gi (tng ng 50 mg canxi mi gi), co th tng
liu ln khi cn thit.
iu tr lu dai. oi hoi phai b sung canxi va vitamin D hoc cht chuyn hoa
co hoat tnh cua no tng hp thu canxi rut.
Ri lon phospho mu l 535
B sung canxi ng ung. Canxi carbonate (cha 40% canxi) hoc canxi
acetate (cha 25% canxi) co th c s dung vi muc tiu b sung 1 n 2
g canxi 3 ln mi ngay. canxi nn c ung xa ba n giam gn kt vi
phospho va hp thu ti a rut. Cn kim tra canxi mau 1 n 2 ln mi tun
hng dn iu tr.
Vitamin D. Thiu hut do ch n co th c bu bng ergocalciferol 400 n
1.000 n v/ngay. Tuy nhin, trong trng hp kt hp vi giam canxi mau
khac, liu cao hn co th c s dung. Mt phac b sung vitamin D 50.000
n v trong vong 6 n 8 tun c ch nh cho nhng trng hp khim khu-
yt c ban trong chuyn hoa vitamin D (v.d., suy thn), hoc hang ngay nhng
bnh nhn suy dinh dng nng hoc kem hp thu.
Trong khi o, calcitriol khi phat tac dung nhanh. Liu khi u la 0,25 mcg
mi ngay, va phn ln cac bnh nhn c duy tr liu 0,5 n 2 mcg mi ngay,
Liu co th tng ln trong khoang thi gian 2 n 4 tun. Calcitriol lam tng hp
thu canxi va phospho rut, va do o cn theo doi phospho mau va thuc gn
phospho co th s dung khi lng phospho mau vt qua ngng bnh thng.
Bin chng
Tng canxi mau. Trong trng hp bin chng tng canxi mau xut hin, cn dng
b sung canxi va vitamin D. Khi canxi mau tr v mc bnh thng, b sung canxi
va vitamin D cn c khi ng lai vi liu thp hn. Tng canxi mau do calcitriol
thng t hi phuc trong vong 1 tun.
RI LON PHOSPHO MU
I CNG
Phospho rt cn thit cho s hnh thanh xng va chuyn hoa nng lng trong
t bao.
Khoang 85% tng lng phospho trong c th trong xng va hu ht lng
con lai nm trong t bao. Do o lng phospho trong huyt thanh khng phan anh
ht c d tr phospho cua c th.
Cn bng phospho c quyt nh chu yu bi 4 yu t:
PTH quy nh s hnh thanh va giai phong cac cht khoang d tr trong xng,
giam tai hp thu phosphate ng ln gn, tng thai phospho.
Ban thn nng phosphate t iu hoa s tai hp thu cua thn mt cach phu hp.
Insulin lam giam nng phosphate huyt thanh bng cach chuyn phosphate
vao trong cac t bao.
Calcitriol (1,25(OH)2D3) lam tng nng phosphate huyt thanh bng cach
tng hp thu phospho rut.
Tng phosphate mu
I CNG
nh ngha
Tng phosphate mau khi nng phosphate mau >4,5 mg/dL.
Nguyn nhn
Tng phosphate mau co th do (a) s vn chuyn t trong t bao ra, (b) do
tng hp thu phosphate, va ph bin nht la (c) do giam chc nng bai tit cua
thn. Trong thc hanh lm sang, suy thn la nguyn nhn thng gp dn n
tng phosphate mau.
Vn chuyn phosphate t trong t bao ra ngoai khoang ke xut hin trong tnh
trang tiu c, hi chng tiu huy khi u, tan mau ln. Toan chuyn hoa va ha
insulin mau lam giam lng phosphate vao trong t bao gy nn tnh trang tng
phosphate mau, i khi co th gp trong toan ceton do ai thao ng.
Tng hp thu dn n tng phosphate mau thng gp trong bi canh bnh suy
thn hoc do ch n khng king khem vi bnh nhn b bnh thn man tnh
hoc do bin chng cua vic iu tr nh thut thao bng Phospho-Soda (v.d., Fleet)
hay dung cac thuc co hoat tnh tng t nh vitamin D cho bnh nhn suy thn.
Giam chc nng bai tit thng gp nht trong suy thn. i khi suy tuyn cn
giap hoc gia suy tuyn cn giap cung gy giam thanh thai cua phospho.
CHN ON
Biu hin lm sng
Cac du hiu, triu chng thng gp la ha canxi mau va canxi hoa m mm. i
khi lng ong tai da co th dn n nga nhiu. Tnh trang tng mn cam canxi
m ta s thiu mau cuc b m co th la kt qua cua s canxi hoa cac mach mau
nho va huyt khi.
Tng phospho mau man tnh gop phn vao s phat trin loan dng xng do
thn (xem Chng 13, Bnh l thn).
Test chn on
Xet nghim phospho mau cao co th kt hp vi nng canxi mau giam do tao
phc hp vi phospho trong long mach.
IU TR
Tng phosphate cp tnh c iu tr bng cach tng bai tit phospho qua thn,
phng phap nay b gii han bi tnh trang suy thn.
Ri lon phospho mu H phosphate mu l 537
Khi phuc chc nng thn se iu chnh tnh trang tng phosphate mau trong
vong 12 gi. Huyt thanh mn va/hoc acetazolamid (15 mg/kg/4 gi) co th
c s dung thuc y bai tit phosphate qua nc tiu trong trng hp cn
thit.
Loc mau co th c ch nh, c bit khi suy thn khng th phuc hi hoc
trng hp giam canxi mau co triu chng.
Tng phosphate man tnh thng lin quan vi suy thn man tnh. iu tr cn
giam lng phospho a vao thng qua iu chnh ch n va s dung cac thuc
gn phosphate. Vn nay c trnh bay y u hn trong Chng 13, Bnh ly
thn.
H phosphate mu
I CNG
nh ngha
Ha phosphate mau khi nng phosphate mau <2,8 mg/dL.
Nguyn nhn
Ha phosphate mau co th do (a) giam hp thu rut, (b) tng bai tit thn hoc
do (c) tng vn chuyn vao trong t bao. Thng thng co s phi hp mt s
nguyn nhn gy ra tnh trang giam phosphate mau.
Suy giam hp thu ng rut thng kt hp vi hi chng kem hp thu, s
dung cac cht gn phosphate, thiu hut vitamin D v bt c nguyn nhn nao
(xem phn canxi). Nghin ru man tnh thng lin quan n giam hp thu ca
phosphate va vitamin D dn n can kit toan b lng phospho cua c th.
Tng bai tit thn thng gp do tng PTH nh trong bnh cng tuyn cn
giap. iu nay c thy ro nhng ngi cng tuyn cn giap th phat sau
phu thut ghep thn do nng cao cua PTH anh hng nng n chc nng
ao thai phosphate ra nc tiu cua thn c ghep. Ha phosphate mau cung co
th xay ra do li tiu thm thu va cac ri loan chc nng ng ln gn nh di
truyn trong bnh coi xng giam phosphate mau co tnh cht gia nh lin quan
n nhim sc th X va hi chng Fanconi.
Tng vn chuyn phosphate vao trong t bao co th do nhim kim h hp
hoc do tng insulin. Sau o la s ap ng nghch thng gy giam phospho mau
trong iu tr suy dinh dng khng ung cach (hi chng tai nui dng). S gia
tng insulin ni sinh trong qua trnh iu tr suy dinh dng lam giam phosphate
tip tuc lan giam phospho mau cac c th suy dinh dng. Phospho cung co th
c hp thu nhanh vao xng sau phu thut ct tuyn cn giap do cng tuyn
cn giap nng (hi chng xng oi).
CHN ON
Biu hin lm sng
Cac du hiu va triu chng thng ch xut hin khi can kit tng lng phosphate
toan c th va nng phospho huyt thanh <1 mg/dL. Hu qua cui cung tai c
quan ch xay ra do khng co kha nng tao ATP, cung cp oxy m giam cung vi
s sut giam cua 2 n 3 Diphosphoglycerat trong hng cu. Chung bao gm cac du
hiu tn thng c (tiu c vn, giam chc nng c hoanh, suy tim), cac bt thng
v thn kinh (d cam, ri loan vn ngn, lu ln, co git va hn m), va him gp hn
la tan huyt va ri loan chc nng cua tiu cu.
Test chn on
Nguyn nhn thng ro rang t cac bnh canh lm sang trong o co ha phosphate
mau. Nu khng, xet nghim phospho trong nc tiu giup xac nh c ch gy
giam phospho mau. Nu phosphate trong nc tiu 24 gi >100 mg hoc bai tit
phn oan cua phosphate >5% cho thy s mt qua mc Phospho qua thn.
Nng 25(OH)D3 trong huyt thanh cho thy ch n ung thiu vitamin D
hoc kem hp thu. Nng PTH cao gp trong cng tuyn cn giap nguyn
phat hoc th phat.
IU TR
Ha phosphate mau cp tnh mc trung bnh (1 n 2,5 mg/dL) gp ph bin
cac bnh nhn nhp vin thng do tng vn chuyn phosphate vao trong t
bao, khng oi hoi iu tr khi khng co triu chng ngoai tr s iu chnh cac
nguyn nhn c ban.
Ha phosphate mau cp tnh nng khi nng phosphate mau <1 mg/dL, oi
hoi iu tr bng phosphate ng tnh mach khi co triu chng lm sang nng.
Phosphate ng tnh mach bao gm kali phosphate (1,5 mEq kali/mmol phos-
phate) va natri phosphate (1,3 mEq/mmol phosphate).
Truyn tnh mach phosphate 0,08 n 0,16 mmol/kg pha trong 500 mL dung
dch huyt thanh mn 0,45% trong 6 gi (1 mmol phosphate = 31 mg phospho).
Khi nng phospho huyt thanh >1,5 mg/dL th dng truyn phosphate va co
th chuyn sang b sung bng ng ung. V s cn thit b sung phosphate
ni bao co th phai keo dai t 24 n 36 gi.
Cn theo doi sat tranh gy tng phosphate mau co th dn n ha canxi mau.
Nu co triu chng ha huyt ap cn chu y kim tra xem co giam canxi mau
khng, nn truyn chm lai hoc ngng truyn, kim tra canxi va phospho cn
thc hin mi 8 gi.
Ha phosphate mau man tnh. Tnh trang thiu vitamin D (nu co) nn c iu
Ri lon magie mu Tng magie mu l 539
tr u tin (xem phn canxi). Tip theo b sung bng ng ming 0,5 n 1,0 g
nguyn t phospho 2 n 3 ln/ngay. Cac ch phm bao gm phospho trung tnh
(250 mg phospho va 7 mEq Na+ va K+ mi vin nang) va phospho trung tnh
K+ (250 mg phospho va 14 mEq K+ mi vin nang), vin nang nn c hoa tan
trong nc. Hn dch phospho-soda (815 mg phospho va 33 mEq natri mi 5 mL)
co th thay th nhm han ch tac dung phu nh bun nn va tiu chay khi dung
cac san phm ng ung.
RI LON MAGIE MU
Magie ong vai tro quan trong trong chc nng cua h thng thn kinh c.
Khoang 60% lng magie cua c th c d tr xng va hu ht lng con lai
trong t bao. Ch co khoang 1% lng magie dch ngoai bao. Kt qua magie
mau la yu t d bao thp cho lng d tr trong t bao va tng lng magie d
tr va co th anh gia thp lng magie thiu hut cua c th.
Magie t iu chnh s cn bng nh nng cua no trong huyt tng cung chc
nng bai tit magie cua thn. Giam magie mau kch thch ng thn tai hp thu
magie, ngc lai tng magie mau c ch qua trnh nay.
Tng magie mu
I CNG
nh ngha
Tng magie mau khi nng magie mau >2,2 mEq/L.
Nguyn nhn
Hu ht cac trng hp tng magie huyt co biu hin lm sang la do iu tr, xay
ra do s dung 1 liu ln thuc khang acid co cha magie hoc thuc nhun trang
hoc iu tr tin san git bng magie ng tnh mach. V bai tit qua thn la
cach thc duy nht lam giam nng magie huyt nn khi chc nng thn b suy
giam, ng c magie co th xay ra ngay ca vi liu iu tr cua thuc khang acid
va thuc nhun trang.
Mc tng nhe cua magie co th gp cac bnh thn giai oan cui, ng c
theophylline, nhim toan ceton ai thao ng, va hi chng ly giai khi u.
CHN ON
Biu hin lm sng
Cac du hiu va triu chng ch c nhn thy khi mc magie huyt >4 mEq/L.
Bt thng thn kinh c thng bao gm giam phan xa gn xng (thng la du

hiu u tin cua ng c magie), th , suy giam tr nh co th dn n ngu ga
va lit c. Khi c hoanh b lit co th gy ra suy h hp.
Triu chng tim mach gm co: huyt ap thp, nhp chm va ngng tim.
Test chn on
in tm co th cho thy nhp chm, keo dai khoang PR, QRS, ST vi mc
magie 5 n 10 mEq/L. Block tim hoan toan hoc ngng tim co th xay ra khi nng
magie >15 mEq/L.
IU TR
D phong. Trong giai oan suy thn, tranh dung cac thuc co cha magie
(Maalox, Magie citrate,..).
Tng magie khng co triu chng. Khi chc nng thn bnh thng, nng
magie se nhanh chong tr lai bnh thng khi dng s dung thuc cha
magie.
Tng magie co triu chng
iu tr h tr kp thi la rt quan trong bao gm th may khi suy h hp, t
may tao nhp tam thi trong ri loan nhp chm.
Cac anh hng cua tng magie mau c i khang nhanh chong bng truyn
tnh mach 10 n 20 mL dung dch canxi gluconate 10% (1 n 2 g) trong vong
10 phut.
Bai tit thn c tng cng bng s dung dung dch huyt thanh mn.
Trong trng hp suy thn, loc mau c ch nh.
H magie mu
I CNG
nh ngha
Ha magie mau khi nng magie mau <1,3 mEq/L.
Nguyn nhn
Ha magie mau thng c gy ra bi s giam hp thu ng rut va tng bai
tit qua thn.
Giam hp thu rut gp khi c th b suy dinh dng, cung ph bin nhng
ngi nghin ru man tnh hoc hi chng kem hp thu. Magie cung co th
b mt thng qua tiu chay keo dai va hut dch da day.
Tng bai tit magie qua thn co th gp khi co s gia tng lu lng ng thn
Ri lon magie mu H magie mu l 541
(anh hng cua li tiu thm thu) hoc suy giam chc nng cua ng thn (hoai
t ng thn cp, thuc li tiu quai, hi chng Bartter va Gitelman).
Thuc. Mt s thuc gy tng ao thai magie ng thn bao gm aminoglycosid,
amphotericin B, cisplatin, pentamidine, va cyclosporine.
CHN ON
Biu hin lm sng
Biu hin thn kinh bao gm hn m, lu ln, run, tht iu, rung git nhan cu,
cn tetany, va co git.
Ri loan nhp tht va nh co th xay ra, c bit la nhng bnh nhn c iu
tr vi digoxin.
Test chn on
Xt nghim
Nng thp [Mg2+] trong mau cung vi bnh canh lm sang phu hp u chn
oan ha magie mau. Tuy nhin, do s trao i Mg2+ gia xng va dch trong t
bao din ra chm nn i khi mc Mg2+ bnh thng trong mau khng phan anh
c s thiu hut tng lng magie trong c th.
nh lng magie trong nc tiu la mt xet nghim hu ch xac nh nguyn
nhn gy ha magie mau khi bnh canh lm sang khng a ra chn oan chc
chn. Magie niu 24 gi >2 mEq (>24 mg) hoc phn oan bai tit magie >2%
trong ha magie mau gi y nguyn nhn do tng bai tit qua thn. Phn oan bai
tit magie qua thn c tnh bng cng thc
(Mg2+ nc tiu/Creatinin nc tiu) {(Mg2+ mau 0,7)/Cratinin mau} 100
Ha canxi mau va/hoc ha kali mau co th gp do ri loan cn bng cac cht v c
ni mi do tnh trang ha magie mau gy ra (xem phn canxi va kali).
Bt thng in tm thng gp la keo dai khoang PR va QT, QRS m rng.
Xon nh la ri loan nhp tim c in thng gp.
IU TR
bnh nhn chc nng thn bnh thng, s bai tit magie d dang nn t gy
bin chng tng magie khi s dung magie liu khuyn cao. Tuy nhin, s dung
magie iu tr cn c cn nhc cn trong nhng bnh nhn chc nng thn
suy giam.
ng dung magie phu thuc vao biu hin lm sang gy ra do s thiu hut
magie.
Ha magie khng triu chng co th c iu tr bng ng ung. Hin
co nhiu ch phm Mag-OX 400 (240 mg magie cho mi vin nen 400 mg),
UroMag (84 mg trong mi vin 140 mg) va dang giai phong chm Slow-Mag
(vin nen 64 mg). Thng thng mi ngay khoang 240 mg magie c khuyn
cao s dung cho nhng thiu hut nhe, khi co thiu hut nng liu dung co th n
720 mg/ngay. Tac dung phu chu yu la tiu chay. Nng magie trong mau
tr lai bnh thng co th do s huy ng ngun d tr trong t bao va trong
xng. Hn na s gia tng t ngt nng trong mau co th kch thch thn
tng bai tit. Do o nng magie trong mau cn c theo doi cht che va
iu tr thay th cn c duy tr cho n khi nng magie mau bnh thng
hoa c gi n nh.
Ha magie co biu hin lm sang nng cn phai iu tr bng 1 n 2 g magie
sulfat (1 g magie sulfat = 96 mg magie) truyn tnh mach trong 15 phut. bu
lai lng magie b thiu hut trm trong trong t bao cn duy tr iu tr thay th
thng keo dai 3 n 7 ngay. Nng magie huyt nn c o mi 24 gi va
tc truyn cn c iu chnh duy tr nng magie huyt <2,5 mEq/L.
Phan xa gn xng phai c theo doi thng xuyn, giam phan xa la du hiu
cua tng magie huyt. Giam liu va theo doi cht che ngay ca vi nhng trng
hp co suy thn mc nhe.
RI LON THNG BNG KIM TOAN
I CNG
pH dch ngoai bao bnh thng la 7,40 0,03. S ri loan pH co th xay ra
khi co s thay i ty l nng [HCO3] va pCO2 nh c m ta trong phng
trnh Henderson-Hasselbalch:
pH = 6,1 + log {[HCO3] (pCO2 0,3)}
S duy tr pH la cn thit cho hoat ng chc nng bnh thng cua t bao. Co ba
c ch tn tai gi cho pH trong gii han bnh thng:
H m hoa hoc qua trung gian HCO3 trong dch ngoai bao va h m protein
va phosphate trong dch ni bao. Nng [HCO3] bnh thng la 24 2
mEq/L.
H m h hp thng kh ph nang giup lam giam thiu s bin i pH bi s
thay i ap sut ring phn cua CO2 (pCO2). Nng CO2 bnh thng la 40
5 mm Hg.
S iu chnh nng H+ thn cho phep thn thch nghi vi s thay i tnh
trang kim toan thng qua s tai hp thu HCO3 va bai tit chun axit (v.d.,
H2PO4) va NH4+.
Ri lon thng bng kim toan l 543
nh ngha
Toan hoa mau va kim hoa mau la tnh trang giam va tng pH mau bt k do c
ch nao, co th gy ra bi ri loan chuyn hoa hoc h hp:
Toan chuyn hoa c c trng bi s giam [HCO3] trong huyt tng do mt
HCO3 hoc do s tch tu cua axit.
Kim chuyn hoa c c trng bi s tng [HCO3] trong huyt tng do mt
H+ hoc tng thm HCO3.
Toan h hp c c trng bi s tng pCO2 do giam thng kh ph nang.
Kim h hp c c trng bi s giam pCO2 do tng thng kh ph nang.
CHN ON
Chn on phn bit
Phn tch cn co tnh h thng co th a ra kt lun chnh xac va iu tr ban
u ung. Mt khi tnh trang kim-toan c xac nh chnh xac, cac thm do chn
oan tip theo se c thc hin xac nh chnh xac nguyn nhn. Vic thm
do co h thng tnh trang kim-toan theo 5 bc sau: kim tra kh mau ng mach
(Arterial blood gasABG), xac nh s ri loan tin phat, anh gia s bu tr, tnh
khoang trng anion (Anion gapAG), va anh gia khoang trng delta.
Bc 1. Kim tra kh mau ng mach: toan hoa mau khi pH <7,37 va kim hoa
mau khi pH >7,43.
Bc 2. Xac nh ri loan tin phat da vao s thay i nng [HCO3] hoc
pCO2 co th tnh toan s thay i cua pH.
Trong toan hoa mau, s giam nng [HCO3] gi y toan chuyn hoa, va s
tng pCO2 gi y toan h hp. Trong kim hoa mau, s tng nng [HCO3]
gi y kim chuyn hoa trong khi s giam pCO2 gi y kim h hp.
S ri loan hn hp khi pH bnh thng nhng pCO2 va nng [HCO3] u
bt thng. S thay i ca pCO2 va nng [HCO3] co th gy ra s thay i
cua pH.
Bc 3. Xac nh ap ng bu tr co phu hp.
C ch bu tr la s thch nghi cua c th i vi ri loan kim toan tin phat
nhm muc ch n nh pH mau. Ri loan v h hp gy mt cn bng pH se
c bu tr bng qua trnh chuyn hoa cn bng lai nng pH mau.
Kt qua cua s bu tr la lam giam bt s thay i ch khng iu chnh c
hoan toan s thay i tin phat cua pH mau.
S bu tr d kin cho s ri loan kim toan tin phat c trnh bay Bang 123.
Mt ap ng bu tr khng phu hp gi y s hin din cua mt ri loan hn hp.
V.d., mt bnh nhn b toan chuyn hoa, s bu tr h hp lam giam s ri
loan chuyn hoa ln pH bng cach giam pCO2. Tuy nhin, nu pCO2 cao hn
d kin, s bu tr h hp la khng u, biu hin mt tnh trang toan h hp phi

hp vi toan chuyn hoa tin phat. Nu pCO2 thp hn d kin, s bu tr qua
mc, biu hin mt tnh trang kim h hp i kem.
Bc 4. Xac nh khoang trng anion.
nhng ngi bnh thng, tng lng cation va anion trong huyt tng bng
nhau. Tng lng cation bao gm lng cation co th o lng c (Measured
cationsMCs) va lng cation khng th o lng c (Unmeasured cations
UCs), con tng lng anion bao gm lng anion co th o lng c
(measured anionsMAs) va lng anion khng th o lng c (Unmeasured
anionsUAs). Mt s loai toan hoa mau c c trng bi s tng lng anion
khng th o lng c. Khoang trng anion n thun ch la mt cach
chng minh s tng cua cac anion nay.
AG = [Na+] ([Cl-] + [HCO3]). Gia tr bnh thng cua AG la 10 2 mEq/L.
AG = s tha cua cac anion khng o c (so vi cac cation khng o c)

= UA UC
V tng lng cation = tng lng anion:

MC + UC = MA + UA
Bng 123 p ng b tr d kin cho s ri lon kim toan tin pht
Ri lon Thay i tin pht p ng b tr
Toan chuyn ha Gim [HCO3] Gim pCO2 1,2 mm Hg cho mi 1 mEq/L, gim
[HCO3] hoc pCO2 = 2 ch s cui ca pH
Kim chuyn ha Tng [HCO3] Tng pCO2 0,7 mm Hg cho mi 1 mEq/L, tng
[HCO3]
Toan h hp Tng pCO2
Cp Tng [HCO3] 1,0 mEq/L cho mi 10 mm Hg

tng pCO2
Mn Tng [HCO ] 3,5 mEq/L cho mi 10 mm Hg
3
tng pCO2
Kim h hp Gim pCO2
Cp Gim [HCO3] 2,0 mEq/L cho mi 10 mm Hg
gim pCO2
Mn Gim [HCO3] 5,0 mEq/L cho mi 10 mm Hg
gim pCO2
Ri lon thng bng kim toan l 545
Sp xp lai phng trnh

UA UC = MC MA
MCs la Na+; MAs la Cl va HCO3.
V albumin mau la ngun gc UA, khoang trng anion cn c hiu chnh nu
co s thay i lng albumin mau:
AGhiu chnh = AG + {(4 [albumin]) 2,5}
S tng khoang trng anion gi y s hin din cua toan chuyn hoa vi s lu
hanh cua anion (Bang 124).
Bc 5. anh gia khoang trng delta.
duy tr tng lng anion n nh, moi trng hp tng UA cn tng ng vi
s giam [HCO3]. So sanh s thay i khoang trng anion (AG) vi s thay
i [HCO3] ([HCO3]) la phng phap n gian khng nh chc chn
rng mi s thay i trong khoang trng anion c giai thch.
Nu AG = [HCO3], y n thun la khoang trng anion cua toan chuyn
hoa.
Nu AG > [HCO3],
Nng [HCO3] khng giam nhiu nh d kin.
o la kim chuyn hoa va cua toan chuyn hoa tng khoang trng anion.
V.d., Mt bnh nhn b nhim toan ceton do ai thao ng (DKA) b nn
trc khi vao vin. Anh ta co khoang trng anion (AG) la 20 va [HCO3] la
20. AG =10 va [HCO3] =4, th hin mt khoang trng anion cua toan
chuyn hoa (toan ceton do ai thao ng) kem theo mt tnh trang kim
chuyn hoa (do nn).
Nu AG < [HCO3],
[HCO3] giam nhiu hn hn d kin.
o la toan chuyn hoa kt hp cua toan chuyn hoa khng tng khoang
trng anion va toan chuyn hoa co tng khoang trng anion.
V.d., Mt bnh nhn nhp vin vi triu chng st va ha huyt ap sau khi b
tiu chay keo dai. C y co AG la 15, [HCO3] la 12. AG la 5 va [HCO3]
la 12, biu hin tnh trang toan chuyn hoa khng tng khoang trng anion
(do tiu chay) va toan chuyn hoa co tng khoang trng anion (toan lactic).
Toan chuyn ha
I CNG
Nguyn nhn
Nguyn nhn cua toan chuyn hoa co th c chia thanh nhom nhng nguyn
nhn gy tng khoang trng anion va nhom nhng nguyn nhn vi khoang
trng anion bnh thng. Nhiu nguyn nhn thng gp trong thc hanh lm
sang co th thy trong Bang 124.
Nhim toan co khoang trng anion la hu qua cua vic hnh thanh va tch tu cac
Bng 124 Bn ri lon kim toan tin pht v nguyn nhn thng gp
Nhim toan Nhim kim
Chuyn ha C khong trng: Trc tip:

Toan ceton (i, nghin ru, i tho Mt H+ (mt dch ng
ng) tiu ha)
Ng c (methanol, ethylene glycol, Kim ha do gim th
salicylates) tch
Toan lactic (sc, do thuc) Dng cc cht hoc
Tng ure huyt thuc gy kim
Khng c khong trng: Gin tip (p ng duy tr):

Mt HCO ngoi thn (tiu chy)
3 Gim th tch
Mt HCO3 ti thn/RTA2 (toan ha ng Mt chloride
thn type 2)
Gim bi tit H+/RTA1 (toan ha ng thn H kali mu

type 1)
Lin quan n gim aldosterone/RTA4
(toan ha ng thn type 4)
RTA1 RTA2 RTA4
/BT /BT
[K+] mu
[HCO ] mu
3 <10 15-20 >15
pH niu >5,3 Thay i <5,3
H hp c ch trung tm h hp Kch thch h thn kinh
trung ng
Bnh l thn kinh c Thiu oxy mu
Bnh phi Lo u
RTA (renal tubular acidosis), toan ha ng thn.

Ri lon thng bng kim toan Toan chuyn ha l 547
acid, anion khng o lng c dch ngoai bao. Nhng nguyn nhn thng
gp la toan ceton do ai thao ng, toan lactic, va ng c ru.
Nhim toan khng co khoang trng anion la hu qua cua vic mt [HCO3] qua
ng tiu hoa. Nhng nguyn nhn tai thn dn n tng bai tit [HCO3] hoc
nhng ri loan ao thai axit tai thn c goi chung la toan hoa ng thn (Renal
tubular acidosesRTAs).
Mt [HCO3] tai rut xay ra ph bin trong tiu chay nng.
Ba type cua toan hoa ng thn lin quan vi ba c ch x ly axit thn: tai hp
thu bicarbonate ng ln gn, bai tit H+ ng ln xa va tao ra NH3, cht m
chnh cua h tit niu. H m tit niu lam giam s tp trung cua H+ t do trn
mang loc, do o lam giam s ro r tr lai cua H+ xay ra khi pH nc tiu thp.
Toan hoa ng thn do ng ln gn (Proximal [type 2] RTA [RTA2]) gy
ra bi s giam tai hp thu HCO3 ng ln gn. Cac nguyn nhn bao gm:
cac ri loan di truyn (bnh Wilson), ng c (kim loai nng, ifosfamide), a u
tuy xng, bnh t min (hi chng Sjgren), va dung li tiu acetazolamide.
Toan hoa ng thn do ng ln xa (Distal [type 1] RTA [RTA1]) gy ra bi
s giam bai tit HCO3 ng ln xa. iu nay co th xay ra do giam bai tit
H+ gp trong nhiu bnh ly t min (hi chng Sjgren, lupus, vim khp dang
thp) hoc cac bnh ly thn. No cung co th gy ra bi s ro r tr lai H+ do tng
tnh thm mang loc gp trong s dung Amphotericin B.
Toan hoa ng thn do tng kali mau ng ln xa (Distal hyperkalemic
[type 4] RTA [RTA4]) co th gy ra bi thiu hut aldosterone hoc khang al-
dosterone. Hu qua cua tng kali mau la lam giam hiu lc m cua NH3 vi H+
niu. S giam aldosterone va giam renin mau gp vi mt tn sut nht nh
nhng bnh nhn b ai thao ng. Mt s loai thuc bao gm NSAIDs, chen
giao cam, va cyclosporine cung co lin quan n tnh trang nay.
i khi, thn khng th bai tit u H+ do giam chnh lch nng ng thn.
Trong nhng trng hp nay, lu lng dch loc thp hoc giam tai hp thu Na+
ng ln xa la nguyn nhn dn n giam chnh lch in th, t o lam tng
bai tit H+. Tnh trang nay gp trong giam th tch tun hoan nng, tc nghen
ng tit niu, bnh thn do hng cu hnh lim, dung li tiu amiloride va
triamterene.
CHN ON
Test chn on
Bc u tin thu hep chn oan phn bit i vi toan chuyn hoa la tnh
khoang trng anion.
Nguyn nhn cu th cua tng khoang trng anion c xac nh da vao bnh
s. Tuy nhin, mt s nhng xet nghim c hiu co th giup xac nh mt
s anion nh lactate, acetoacetate, acetone va -hydroxybutyrate. (Cn lu y

la vic s dung nitroprusside phat hin ceton co th tht bai trong vic xac
nh toan ceton do -hydroxybutyrate). Cac ng c ru (methanol, ethanol,
ethylene glycol) cung co th c chn oan nh mt s xet nghim. Lm sang
nghi ng ng c ru do ung nhiu ru kem tng khoang trng ap lc
thm thu. Khoang trng nay la s khac nhau gia ap lc thm thu o c
va ap lc thm thu huyt tng tnh theo cng thc:
[Osm]meas {([Na+] 2) + ([glucose] 18) + ([BUN] 2,8)}
Nu khoang trng anion bnh thng, mt HCO3 qua ng tiu hoa co
th phn bit vi RTA da vao khoang trng anion nc tiu (Urine anion
gapUAG). Khoang trng anion niu la s chnh lch gia tng lng anion
va cation chnh o c trong nc tiu: [Na+]niu + [K+]niu [Cl]niu. V
NH4+ la cation chnh khng o lng c trong nc tiu, khoang trng anion
niu m phan anh NH4+ c bai tit nhiu, ap ng phu hp vi nhim toan
chuyn hoa. Ngc lai, khoang trng anion niu dng co ngha la NH4+ c
bai tit thp trong nc tiu, trong nhim toan chuyn hoa, gi y khim khuyt
ng thn.
Nng [K+] mau va pH nc tiu co th hu ch phn bit gia cac type
RTA.
Type 1 va 2 thng lin quan vi ha kali mau, trong khi type 4 lai c trng
bi tng kali mau.
pH niu thp (thng <5,3) RTA4 do giam tao ra NH3 m, c ch bai tit
H+ khng b anh hng. Ngc lai, pH niu cao bt thng trong RTA1 (pH
niu >5,3). RTA2, pH niu thay i: pH niu se tng khi bicarbonate trong
dch loc vt qua ngng tai hp thu cua ng thn, va giam khi tai loc thp
di ngng nay.
IU TR
Toan ceton do nghin ru hoc oi co th c iu chnh bng vic b sung
lng calo qua ng ming hoc truyn dch va iu chnh s thiu hut th tch
tun hoan. iu tr toan ceton do ai thao ng c trnh bay Chng 23,
Bnh ai thao ng va ri loan lin quan.
Toan axit lactic se c giai quyt khi bnh ly nn c iu tr va m c tai
ti mau. giai quyt tnh trang nay cn cac bin phap hi sc tch cc iu
tr sc c trnh bay Chng 8, Chm soc cp cu. Vic b sung kim khng
co li ch ro rang trong iu tr toan axit lactic, va co th dn n tnh trang nhim
kim chuyn hoa mt khi nguyn nhn bnh nn c kim soat. Vic s dung
kim trong nhng trng hp nhim toan nng con ang c tranh cai.
Ri lon thng bng kim toan Toan chuyn ha l 549
iu tr nhim toan trong trng hp ng c ng tiu hoa c m ta

(Chng 28, Ng c hoc).
Nhim toan chuyn hoa co khoang trng anion bnh thng. iu tr vi
NaHCO3 la thch hp cho nhng bnh nhn b nhim toan chuyn hoa co khoang
trng anion bnh thng. S giam HCO3 co th c tnh theo mEq:
HCO3 giam = (0,5 trong lng [24 (HCO3)])
Tuy nhin cng thc nay gia nh mt th tch thc phn phi bng 50% tng
trong lng c th. Trong thc t, s phn phi HCO3 tng theo mc nng
cua nhim toan va co th vt qua 100% tng trong lng c th trong trng
hp nhim toan rt nng. Cn chu y rng mt vin NaHCO3 chun 650 mg ch
cung cp 7 mEq HCO3, trong khi mt ng NaHCO3 tim tnh mach cha 50
mEq HCO3. Tuy nhin vic ch nh NaHCO3 ng tnh mach cn lun thn
trong v nhng tac dung phu tim tang, bao gm phu phi, ha kali mau, va ha
canxi mau.
iu tr toan hoa ng thn. iu tr nhim toan chuyn hoa mau man tnh bng
vic b sung kim ngn nga anh hng cua no i vi d hoa xng va c.
Trong toan hoa ng thn do ng ln xa (RTA1), iu chnh nhim toan chuyn
hoa oi hoi b sung HCO3 ng ung liu 1 n 2 mEq/kg/ngay vi NaHCO3
hoc natri citrate. Vic thay th kali citrate co th cn thit cho bnh nhn b ha
kali mau, soi thn, hoc bnh thn canxi hoa. Cac bnh ly nn cn c tm ra
va giai quyt.
Trong toan hoa ng thn do ng ln gn (RTA2), cn b sung lng kim ln
hn nhiu (10 n 15 mEq/kg/ngay) giai quyt tnh trang toan. Vic b sung
mui kali giup giam thiu mc ha kali mau lin quan n liu phap kim
hoa.
iu tr RTA4 oi hoi iu chnh tng kali mau. iu tr bao gm ch n ung
han ch kali (40 n 60 mEq/ngay) va co th dung li tiu quai kem hoc khng
kem NaHCO3 ng ung (0,5 n 1 mEq/kg/ngay). Dung Mineralocorticoid
(fludrocortisone, 50 n 200 mcmg ung hang ngay) nn ch nh bnh nhn
b suy thng thn tin phat va co th cn nhc trong cac nguyn nhn khac cua
giam aldosterone.
Kim chuyn ha
I CNG
Nguyn nhn
Tnh trang nhim kim chuyn hoa dai dng la do hai yu t: mt la s tao ra
(nguyn nhn khi phat) va hai la s duy tr (khim khuyt keo dai cua h thng
ap ng iu chnh thn).
S tao ra co th do tng cung cp HCO3 , hoc ph bin hn la do mt qua
nhiu H+. Mt H+ co th do mt cac dch giau H+, bao gm cac dch tit ng
tiu hoa trn. Kim hoa mau do giam th tch xay ra khi th tch long mach giam
nhng lng bicarbonate vn nguyn ven.
S duy tr tnh trang kim chuyn hoa la do giam bai tit cua thn, v thn bnh
thng co mt kha nng bai tit HCO3 rt ln. Nguyn nhn co th do giam
mc loc cu thn hoc tng kha nng tai hp thu HCO3 cua ng thn do ha
chloride mau, giam th tch va ha kali mau. S giam chloride qua mang loc
c cam nhn bi t bao Macula densa ng ln xa, tao ra tn hiu phan hi lai
v ng-cu thn, dn n giam loc HCO3 va kch thch giai phong aldosterone.
No cung han ch bai tit HCO3 ng ln xa. Kim chuyn hoa thng c
chia ra kim chuyn hoa ap ng vi chloride va kim chuyn hoa khng ap
ng vi chloride.
CHN ON
Biu hin lm sng
Nguyn nhn phat sinh ra kim chuyn hoa thng thy ro qua hoi bnh. Cac
nguyn nhn thng gp bao gm mt dch tit ng tiu hoa cao do nn hoc
tng bai tit H+ do dung li tiu.
V nhng nguyn nhn chu yu cua nhim kim chuyn hoa thng lin quan n
giam th tch (nn va dung li tiu), bnh nhn co th co cac du hiu cua giam
th tch. i khi, bnh nhn co th biu hin tng huyt ap hoc tha nhe dch
ngoai bao la hu qua cua vic s dung nhiu mineralocorticoid.
Test chn on
in giai niu co th co ch cho chn oan nguyn nhn cua kim chuyn hoa khi
bnh s va kham lm sang khng chn oan c.
[Cl] niu <20 mEq/L phu hp vi kim chuyn hoa ap ng vi chloride
va thng ch ra giam th tch. [Cl] niu >20 mEq/L gi y nguyn nhn gy
nhim kim chuyn hoa khng ap ng vi Chloride (xem Bang 124).
[Na+] niu khng ang tin cy trong vic d oan khi lng tun hoan hiu
dung trong nhng trng hp nay, v bicarbonate niu gy tng thai Na+ ngay
ca trong trng hp giam th tch.
Nng K+ mau thng thp trong kim chuyn hoa. Ha kali mau gop phn lam
kim hoa mau do lam tng bai tit H+ ng thn va mt Cl. Ha kali mau cung
la hu qua cua nhim kim do tng vn chuyn qua mang t bao.
Ri lon thng bng kim toan Toan h hp l 551
IU TR
Kim chuyn hoa ap ng vi chloride thng c iu tr hiu qua bng hi
sc vi dung dch mui ng trng n khi khi lng tun hoan c phuc
hi. S tng chloride dch loc dn n tng kha nng x ly cua thn i vi tai
bicarbonate.
Kim chuyn hoa khng ap ng vi chloride khng hiu qua vi bu dch mui
ng trng va thng co th tch dch ngoai bao bnh thng hoc tng.
Tha mineralocorticoid co th kim soat vi li tiu gi kali (amiloride hoc
spironolactone) va bu u lng kali thiu.
Nhim kim do dung nhiu cac thuc kim co th nhanh chong c giai
quyt khi ngng dung cac thuc nay, bnh nhn co chc nng thn bnh
thng.
Kali mau thp se tip tuc duy tr tnh trang nhim kim nht nh du co cac bin
phap can thip khac. Do vy, vic b sung kali cn ch nh cho tt ca cac trng
hp nhim kim chuyn hoa.
Li tiu acetazolamide co th co li trong trng hp nhim kim dai dng du a
dung cac bin phap iu tr trn, hoc nu vic truyn mui ng trng b han
ch v bnh nhn b tha dch. Acetazolamide nay lam tng thai bicarbonate qua
nc tiu, tuy vy no cung lam tng mt K+ qua nc tiu. Acetazolamide co th
dung vi liu 250 mg mi 6 gi hoc vi liu duy nhp 500 mg.
Nhim kim mau nng (pH >7,70) vi tng th tch dch ngoai bao va/hoc suy
thn co th c iu tr vi dung dch HCl ng trng (150 mEq/L) truyn qua
tnh mach trung tm. Lng HCl cn thit c tnh theo cng thc {(0,5 khi
lng nac) ([HCO3] 24)}. Vic iu chnh nn thc hin trong vong 8 n
24 gi.
Toan h hp
I CNG
Cac nguyn nhn cua toan h hp co th chia thanh giam thng kh do (a) c ch
trung tm h hp, (b) bnh ly thn kinh c, (c) giam an hi cua phi, (d)
tng sc can ng th, va (e) tng khoang cht (xem Bang 123).
CHN ON
Cac triu chng cua nhim toan h hp la do nhng thay i cua pH dch nao tuy.
Tnh trang tng CO2 rt nng co th c dung nap tt nu thn a co thi gian
bu tr va pH mau tng i bnh thng. Ngc lai, tng pCO2 du rt t nhng cp

tnh cung co th gy ra rt nhiu triu chng do thn cha kp bu tr.
Cac triu chng va du hiu ban u co th bao gm au u va bn chn, sau
o co th tin trin n tng phan xa gn xng toan thn/rung git va hn m.
IU TR
iu tr gm iu chnh cac ri loan c ban va cai thin thng kh (xem Chng
10, Bnh ly phi).
Vic dung NaHCO3 cai thin tnh trang toan mau ngc lai co th lam giam
pH nng hn trong cac trng hp co han ch thng kh. HCO3 c b sung se
kt hp vi H+ trong cac m va tao ra CO2 va nc. Khi ch thng kh nhn
tao c cai t c nh, lng CO2 tao ra thm nay khng th c thai ra ngoai
va hu qua la se lam nng thm tnh trang tng CO2 mau. Do o, nhn chung nn
tranh dung HCO3 trong trng hp ch co toan h hp n thun.
Kim h hp
I CNG
Cac nguyn nhn thng gp cua tng thng kh dn n kim h hp c trnh
bay trong (Bang 123).
CHN ON
Biu hin lm sng
S tng pH dch nao tuy xay ra vi trng hp kim h hp cp gy giam ang
k dong mau ln nao co th dn n choang va giam y thc. Tng kch thch mang
co th dn n co git va ri loan nhp. Cac triu chng va du hiu cua ha canxi
mau cp (xem phn canxi) co th la biu hin do s giam t ngt canxi ion.
Kim h hp man tnh thng khng co triu chng v pH mau vn duy tr
mc bnh thng do thn bu tr tt.
Test chn on
Tng pH trong kim h hp cp tnh co th gy ra giam canxi ion (xem phn
canxi), ha phosphate mau nng (xem phn phospho), va ha kali mau (xem phn
kali).
IU TR
iu tr kim h hp cn tp trung xac nh va iu tr bnh ly nn.
Ri lon thng bng kim toan Kim h hp l 553
nhng bnh nhn c iu tr trong n v hi sc tch cc, kim h hp co

th c iu tr bng thay i cai t may th giam thng kh (xem Chng
8, Chm soc cp cu).
iu tr
14
bnh truyn nhim
Stephen Y. Liang, Sara L. Cross, Nigar Kirmani
PGS.TS. Phan Thu Phng, TS. V Vn Gip,
TS. Duy Cng, ThS. L Hon
Nguyn tc iu tr
I CNG
Quyt nh bt u, tip tuc va ngng iu tr khang sinh nn c thc hin mt
cach cn thn. S dung ba bai khang sinh co th mang n cac tac dung phu, khang
thuc va tng cac chi ph. Khi ch nh iu tr khang sinh, cn cn nhc mt s
yu t c cp trong chng nay. Trng hp khng co khang sinh, cn tham
khao y kin cua chuyn gia truyn nhim c khuyn ngh chon thuc thay th.
CHN ON
Trong anh gia ban u, nhum Gram cua m hoc bnh phm nhim trung
thng cho phep phong oan nhanh, t o thng bao v s la chon khang sinh.
Cac m hnh bnh tt nhay cam mang tnh a phng phai c xem xet khi
la chon iu tr khang sinh theo kinh nghim bi v cac m hnh bnh tt rt khac
nhau gia cac cng ng va cac bnh vin ring re.
Nui cy cn thit chn oan xac nh va cn phai lam khang sinh . Khi nghi
ng vi sinh vt cn nui cy mi trng c bit, cac phong th nghim vi sinh
hoc nn xem xet hi chn lai am bao qua trnh nui cy thch hp.
Khang sinh giup la chon cac khang sinh phu hp iu tr ch va cn c
thc hin trn tt ca cac mu bnh phm nui cy dng tnh.
Xet nghim chn oan nhanh, chng han nh phan ng chui polymerase
(polymerase chain reactionPCR) va xet nghim phat hin khang nguyn cung
co th giup khng nh sm cn nguyn nhim trung.
IU TR
S la chon cua liu phap khang sinh ban u
iu tr theo kinh nghim nn c hng trc tip vao cac tac nhn co kha
nng gy bnh nht vi ph hep nht.
Liu phap iu tr nn c sa i phu hp vi du hiu lm sang cua bnh
nhn va kt qua nui cy.
595
596 l Ch. 14 iu tr bnh truyn nhim
anh gia ky lng trc v tin s d ng thuc cua bnh nhn va tin s iu
tr khang sinh la rt cn thit
Thi im bt u iu tr bng khang sinh
i vi bnh canh sang cp tnh, iu tr theo kinh nghim thng c bt u
ngay lp tc sau khi co kt qua nui cy thch hp. Tuy nhin, nu tnh trang
bnh nhn n nh, vic tr hoan s dung khang sinh theo kinh nghim cho phep
iu tr tp trung tch cc hn da trn xet nghim ban u va tranh c s
dung cac loai thuc khng cn thit.
iu tr khn cp c ch nh nhng bnh nhn co st va giam bach cu
hoc la ct lach. Nhim khun huyt, vim mang nao va nhim trung ky kh
nng hoai th cung cn c iu tr kp thi bng khang sinh.
ng dung
Bnh nhn nhim trung nng nn c dung khang sinh tnh mach (intravenously
IV). Trong nhng trng hp t khn cp hn, tim bp (intramuscularIM)
hoc ung (oralPO) la u. iu tr ng ung c chp nhn nu nng
thuc u co th i ti c cac m nhim trung.
Cac loai liu phap iu tr
Liu phap dit vi khun thch hp cho bnh nhn suy giam min dch hoc
nhim trung e doa tnh mang. No cung thch hp vi nhng nhim trung do
s phong v cua vt chu suy giam nh vim ni tm mac, vim mang nao va
vim tuy xng.
Chc nng thn va gan quyt nh liu khang sinh.
Tng tac thuc anh hng hiu qua iu tr va phai lun lun c anh gia
trc khi bt u dung khang sinh.
anh gia kt qua iu tr bng khang sinh
Nu co lo ngai tht bai iu tr, hay xem lai cac cu hoi sau:
Vi khun phn lp c co phai la tac nhn gy nhim trung khng?
Phac iu tr khang sinh c chon co thch hp bao phu cac vi khun
khng?
Nng khang sinh co u ti v tr nhim trung khng?
Co khang thuc xut hin khng?
Bnh nhn vn con sng co phai do bnh ly nn nao o, hay do hnh thanh ap
xe, mt tai bin iu tr, phan ng thuc, hay qua trnh khac khng?
Thi gian iu tr
Thi gian iu tr phu thuc vao din bin t nhin va mc nng nhe cua
nhim trung.
iu tr cac bnh nhim trung cp tnh khng bin chng cn c tip tuc cho
n khi bnh nhn ht st va ht cac biu hin lm sang, thng ti thiu la 72
gi.
Nhim trng gy ra bi c t Nhim trng Clostridium Difficile l 597
Nhim trung tai cac v tr c bit (v.d., vim ni tm mac, vim khp nhim
khun, vim tuy xng) th cn phai keo dai iu tr.
LU C BIT
Tnh trang bnh nhn
Tnh trang lm sang cua bnh nhn se giup cho vic xac nh phng phap iu
tr, ng dung va loai iu tr.
Bnh nhn nn c anh gia kp thi s bt n huyt ng, nhim trung tin
trin nhanh hoc e doa tnh mang va nhng thiu hut h min dch.
Bnh nhn mang thai va sau khi sinh
Mc du khng co khang sinh nao c bit n la hoan toan an toan trong thai
ky, penicillin va cephalosporin thng c s dung nht. Chng ch nh
Tetracycline va fluoroquinolones. Sulfonamides va aminoglycosides khng
nn c s dung nu co sn cac loai thuc thay th.
Nhiu khang sinh xut hin trong sa me va nn c s dung thn trong
nhng ba me ang cho con bu.
NHIM TRNG GY RA BI C T
Nhim trng Clostridium difficile
I CNG
Thng gp sau khi iu tr khang sinh toan thn.
CHN ON
Biu hin lm sng
Cac triu chng co th bao gm t tiu chay nhe hoc va cho ti vim ai trang
gia mac nghim trong, co kha nng t vong. au qun bung, st nhe va tng bach
cu thng gp. Bnh kch phat co th biu hin nh tc rut hoc phnh kt trang
do nhim c dn n thung rut.
Chn on phn bit
Tiu chay lin quan trc tip n dung khang sinh ma khng nhim phai C. difficile,
se khoi sau khi ngng s dung thuc khang sinh.
Test chn on
Phat hin cac c t C. difficile trong phn hoc bng cach phat hin gia mac qua
ni soi ai trang.
IU TR
i vi bnh t nhe n trung bnh, iu tr nn bao gm metronidazole 500
mg ng ung (thch hp hn dung IV) trong vong 10 n 14 ngay va ngng
cac thuc khang sinh la nguyn nhn nu co th (Kim soat ly nhim Hosp
Epidemiol 2010;31:431). Trong trng hp bnh nng, vancomycin 125-500
mg ng ung 4 ln/ngay (tim tnh mach khng hiu qua). (Clin Infect Dis
2007;45:302). i vi nhim trung bin chng tc rut, phnh kt trang do c
t hoc shock, vic b sung metronidazole IV va vancomycin dung thut ai trang
c xut (Clin Infect Dis 2007;45:302). Trong mt s trng hp, co th ct
bo ai trang nu cn thit.
Kt qua cui cung cua liu phap iu tr la ngng tiu chay; khng xet nghim
lai phn kim tra a ht c t cha.
Tranh cac thuc giam nhu ng rut nhng bnh nhn nng.
Bnh thng tai phat va c iu tr bng metronidazole hoc vancomycin thi
gian keo dai, tng t tn cng, hoc liu giam dn. iu tr h tr vi rifaximin
ng ung i khi c s dung (Clin Infect Dis 2007;45:302).
Fidaxomicin co vai tro iu tr va phong nga tai phat C. difficile (N Engl J Med
2011;364:422).
Un vn
I CNG
Gy ra bi nhim c c t Clostridium tetani do vt thng b nhim nha bao
un van.
Phng chng
Un van c d phong tt nht bng tim chung (MMWR 2012;61 (4):1). i
vi vt thng co nguy c cao, globulin min dch un van ngi 250 U tim bp.
(MMWR 2006;55 (Khng RR-17):1).
CHN ON
Biu hin lm sng

Cac triu chng in hnh la co cng c va co git, tip theo la ri loan thn kinh
thc vt. Cac triu chng thng bt u mt (cng ham, ci nhn) va cac c c.
Thng khng co biu hin ri loan y thc va khng st cao. Chn oan ch da
vao biu hin lm sang.
Hi chng sc c t Hi chng sc c t t cu l 599
IU TR
Min dch thu ng bng cach tim globulin min dch un van ngi 3.000 n
5.000 U (tim bp chia lam nhiu ln) trung hoa cac c t con ang lu hanh.
Min dch chu ng bng giai c t un van cn c tim tai mt v tr khac.
Cac thuc benzodiazepines hoc chen thn kinh c co th s dung kim soat cn
git. Ct loc vt thng loai bo d vt la rt quan trong. Khang sinh thng dung la
metronidazole 500 mg IV mi 6-8 gi trong 7 n 10 ngay ang c tranh lun.
iu tr chu yu la chm soc h tr.
HI CHNG SC C T
Hi chng shock c t (Toxic shock syndromeTSS) la mt bnh toan thn e

doa tnh mang do siu khang nguyn c t c san xut bi Staphylococcus
aureus hoc do cac nhim trung do lin cu khun tan huyt nhom A (group A
-hemolytic Streptococcus [GABHS]) (Bang 14-1).
Hi chng sc c t t cu
I CNG
Thng lin quan n nhim trung mu vt thng phu thut, bong, vim m ao
hoc s dung tampon phu n tre. Cac trng hp con c nhn thy sau khi nut
mui do chay mau cam.
CHN ON
Biu hin lm sng
Triu chng in hnh la st, ha huyt ap va vim da troc vay tng chm long ban
tay va long ban chn. Nn ma, tiu chay, au c, suy nhc, kho th; ri loan y
thc co th la du hiu sm cua suy a phu tang.
Test chn on
Cy mau thng la m tnh. Creatine phosphokinase (Creatine phosphokinase
CPK) thng tng. Phat hin khang th chng lai hi chng shock c t toxin-1
(toxic shock syndrome toxin-1 [TSST-1]) la hu ch giup ch nh iu tr chng
tai phat.
KT QU/TIN LNG
Ty l t vong tng i thp.
Bng 141 iu tr hi chng shock c
Liu php Liu php

Cn nguyn khng sinh phi hp Lu
Group A Penicillin G 4 triu U IVIG 1 g/kg vo ngy Phu thut can thip
-hemolytic IV + Clindamycin u tin; 0,5 g/kg hu ht c
Streptoco 900 mg IV mi 8 vo ngy 2 v th ch nh cho cc
cus (GABHS) gi trong 1014 3 (Clin Infect Dis trng hp nhim
ngy 2003;37:333) trng hoi t.
Clindamycin c
thm vo lm
gim s sn sinh
c t.
Lin cu khun Oxacillin 2 g IV 4 IVIG mi GABHS iu tr l h tr
gi/ln hoc c th hu ch ban u. Khng
vancomycin 1 g IV trong cc trng s dng tampons,
12 gi/ln trong hp nng, tuy c bit nu hiu
1014 ngy. nhin cc liu cao gi khng th
hn c th cn TSST1 l m tnh.
thit (Clin Infect Cc khng sinh
Dis 2004; 38: lm gim nguy c
836) ti pht.
IVIG, intravenous immunoglobulin, immunoglobulin ng tnh mch; TSST1, hi chng shock c

toxin1 (khng th).
Hi chng sc c t lin cu khun
I CNG
Co lin quan n nhim trung GABHS xm ln, c bit la hoai t mang c hoc
vim c (80% cac trng hp). Ty l t vong cao hn nhiu so vi hi chng shock
c t tu cu.
CHN ON
Biu hin lm sng
Cac biu hin ban u thng la khi phat t ngt cac cn au lan toa nghim
trong hoc khu tru. Cac biu hin toan thn khac tng t nh vi hi chng shock
c t tu cu, nhng vim da troc vay th t ph bin hn.
Nhim trng da, m mm v xng Vim m t bo l 601
Test chn on
Cy mau thng dng tnh va nng khang th lin cu O (antistreptolysin O
ASO) tng.
IU TR
Xem Bang 141
NHIM TRNG DA, M MM V XNG
Vic tng ty l tu cu khang methicillin lin quan ti cng ng (community-

associated methicillin-resistant Staphylococcus aureus [CA-MRSA]) a lam thay
i phng cach x tr cac nhim trung da va m mm (skin and soft tissue
infectionsSSTIs) (Clin Infect Dis 2011;52:1).
p-xe, mn nht v nht c
I CNG
Tu cu khang methicillin (MRSA) va nhay cam methicillin (methicillin-sensitive S.
aureus [MSSA]) chim 25% n 50% cac trng hp.
IU TR
Ch cn rach va dn lu ap-xe (incision and drainageI&D) la u, c bit la
i vi cac ap xe <5 cm.
iu tr khang sinh la cn thit nu nhim trung lan rng; bnh canh toan thn;
tin trin nhanh lin quan vi vim m t bao; bnh i kem (ai thao ng); suy
giam min dch; v tr trn khun mt, ban tay hoc c quan sinh duc hoc khng
ap ng vi rach va dn lu ap-xe.
iu tr khang sinh theo kinh nghim nn bao phu CA-MRSA (xem phn sau).
Thi gian iu tr khang sinh thng la 57 ngay.
Vim m t bo
IU TR
Vim m t bao dang mu (dch tit hoc dn lu mu ma khng co ap-xe) c
gy ra chu yu bi CA-MRSA (59%) hoc MSSA (17%) va oi hoi iu tr
CA-MRSA (N Engl J Med 2006;355:666). Cac la chon khang sinh ng
ung la clindamycin 300-450 mg 3 ln/ngay; trimethoprim-sulfamethoxazole
(trimethoprim-sulfamethoxazole [TMP-SMX]) 12 vin nen manh gp i

(double strengthDS) 2 ln/ngay; doxycycline 100 mg hai ln mi ngay;
minocycline 200 mg mt ln, sau o 100 mg hai ln mi ngay va linezolid 600
mg 2 ln/ngay.
Vim m t bao khng mu (khng thoat mu hoc khng co ap-xe i kem) co th
c gy ra bi lin cu tan mau nhom A (73%) va S. aureus (Medicine nm
2010;89:217). Khang sinh -lactam (cephalexin hoc dicloxacillin 500 mg ng
ung 4 ln/ngay) co th c s dung. CA-MRSA nn c thm vao nu khng
co phan ng. Clindamycin hoc linezolid cung c la chon cho tr liu n.
TMP-SMX co th c s dung nu c kt hp vi mt khang sinh -lactam
(v.d., amoxicillin 500 mg ng ung 3 ln/ngay) bao phu ca lin cu khun.
Tac nhn gy bnh qua ng nc: Vim m t bao nghim trong i khi gp
sau khi tip xuc vi nc ngot (Aeromonas hydrophila) hoc nc mn (Vibrio
vulnificus). iu tr ban u nn bao gm ceftazidime 2 g 8 gi/ln IV, cefepime
2 g 8 gi/ln IV hoc ciprofloxacin 750 mg ung 2 ln/ngay. Doxycycline 100
mg IV/PO 12 gi/ln nn c b sung iu tr nhim khun do Vibrio, trong o
c bit phu hp i vi nhng bnh nhn x gan.
Chng vim qung
I CNG
Vim qung biu hin la tn thng nng b mt, au, dang hng ban, tn thng
manh gii han thng c tm thy chn. ngi bnh thng, GABHS gy ra
nhim trung nay.
IU TR
Penicillin V 250 n 1.000 mg PO 4 ln/ngay hoc penicillin G 1,02,0 triu U IV
6 gi/ln, tuy thuc vao mc nghim trong cua bnh. nhng bnh nhn ang
b d ng vi penicillin th macrolides va clindamycin la cac la chon thay th.
Nhim trng phc tp da v m mm
I CNG
Nhim trung su m mm, nhim trung vt thng trong phu thut va sau chn
thng, ap-xe ln, vim m t bao phc tap va loet do nhim trung va bong thuc
phn loai nay.
Nhim trng da, m mm v xng Vim m hoi t l 603
CHN ON
Nui cy mu bnh phm cac ap-xe va cac mang vun phu thut nn c thc
hin nhng bnh nhn nm vin.
IU TR
Bnh nhn cn c nhp vin c tim khang sinh tnh mach va thc hin
phu thut can thip khi cn thit. Vancomycin 15-20 mg/kg IV mi ngay hai
ln, linezolid 600 mg PO/IV mi ngay hai ln, daptomycin 4 mg/kg mi ngay,
telavancin 10 mg/kg ngay mt ln, clindamycin 600 mg ba ln ngay va ceftaroline
600 mg hai ln ngay la cac la chon khang sinh c chp thun.
Rifampin khng c khuyn cao iu tr n c hoc kt hp vi cac khang
sinh khac.
Lot t th nm v lot bn chn bnh nhn i tho ng
I CNG
Thng la nhim tap khun; phn lp vi khun b mt khng ang tin cy. Vim
tuy xng la mt bin chng thng xuyn va cn c loai tr.
IU TR
Chm soc vt thng va ct loc la liu phap quan trong hang u.
Nhim trung t trung bnh n nng oi hoi phai dung khang sinh toan thn
bao phu S. aureus, vi khun ym kh va vi khun Gram m ng rut. Cac la
chon bao gm vancomycin cng vi mt -lactam/-lactam kt hp thuc c ch,
carbapenem (ertapenem, doripenem hoc meropenem), hoc vancomycin vi
metronidazole kt hp vi mt trong hai ciprofloxacin hoc mt cephalosporin
th h th ba.
Nhim trung nhe thng do tu cu (S. aureus) va lin cu (Streptococci) co th
c iu tr bng clindamycin cng vi ciprofloxacin hoc TMP-SMX cng vi
amoxicillin-clavulanate. Clindamycin va linezolid n c co th dung cho cac
bnh nhim trung nhe (Clin Infect Dis 2004;39:885).
Vim m hoi t
I CNG
La mt bnh nhim trung cp co ty l t vong cao biu hin la nhim trung m
mm lan rng va huyt khi cua vi tun hoan vi kt qua la hoai t (Clin Infect Dis
2007; 44: 705). Nhim trung ly lan nhanh chong trn b mt va co th lin quan
vi nhim trung huyt hoc TSS. Hoai t Fournier la vim da hoai t cua ay chu.
Nguyn nhn do vi khun hoc la hn hp (sinh vt hiu kh va ky kh) hoc do mt
loai vi khun (GABHS hoc S. aureus, bao gm CA-MRSA).
CHN ON
Biu hin lm sng
Cac biu hin ban u co th la vim m t bao n thun tin trin nhanh chong
n hoai t vi biu hin sm da, mt tnh an hi cua da va hnh thanh cac phong
nc i kem cn au d di.
Test chn on
Chn oan lm sang: Khi co nghi ng nn thc hin phu thut thm do ngay.
Cn cy mau va cy cac mu bnh phm phu thut. CPK co th tng.
Chup ct lp vi tnh (Computed tomographyCT) va chup phim thng co th
thy kh va phu n da sm trong qua trnh b bnh.
IU TR
Phu thut ct loc tch cc la rt quan trong, cung vi s dung thuc khang sinh
ng tnh mach va h tr th tch. iu tr khang sinh theo kinh nghim ban u
nn dung loai ph rng bao gm -lactam/-lactamase inhibitor, penicillin liu
cao, carbapenem hoc fluoroquinolone kt hp vi clindamycin. Vancomycin
cung nn c thm vao cho n khi MRSA co th c loai tr.
iu tr tr bng oxy cao ap co th hu ch.
Hoi th sinh hi (Gas gangrene)
I CNG
Bnh thng thng do Clostridium perfringens, Clostridium septicum, S. aureus,
GABHS, hoc vi khun ky kh khac gy ra. Phn bit tnh trang nay vi vim cn
mac hoai t cn phai kim tra cac c lin quan tai thi im phu thut.
IU TR
iu tr oi hoi phai phu thut ct loc ngay va kt hp iu tr khang sinh
penicillin ng tnh mach cng vi clindamycin. Nn kt hp cephalosporin th
h III, ciprofloxacin hoc aminoglycoside cho n khi vt Gram khng co s hin
din cua vi khun gram m.
Nhim trng da, m mm v xng Vim ty xng l 605
Vim ty xng
I CNG
Vim tuy xng la mt qua trnh vim gy ra bi mt loai vi khun co th dn n
s pha huy xng. No nn c ngh n khi nhim trung da hoc m mm bao phu
pha ngoai cua xng va khi co au xng cuc b kem theo st hoc nhim trung
huyt (Lancet 2004;364:369).
Nguyn nhn
Vim tuy xng ng mau cp tnh thng c gy bi tu cu.
Vim tuy xng ct sng co th la do tu cu, trc khun gram m hoc vi khun
lao.
Vim tuy xng kt hp vi mt nhim trung ln cn co th la do S. aureus,
trc khun gram m, tu cu khng sinh coagulase (nhim trung vt m), hoc vi
khun ky kh (loet decubitus xng cut).
Vim tuy xng co s hin din cua thit b chnh hnh thng c gy ra bi
S. aureus va cac loai tu cu khng sinh coagulase.
Vim tuy xng lin quan n bnh ly khoa hoc c gy ra bi tu cu hoc
Salmonella.
Vim tuy xng man tnh thng c lin quan n hoai t xng va co th
lin quan n cac mm bnh vi khun gram m cung nh tu cu.
CHN ON
Chn oan bng cach phat hin xng nhim trung thng qua vt loet da hoc
bng chn oan hnh anh nh chup phim thng, ghi xa hnh xng, hoc chup
cng hng t (magnetic resonance imagingMRI) (Clin Infect Dis 2008;47:
519).
Cn sinh thit va cy xng b vim (trc khi s dung khang sinh).
Tc mau lng va protein co phan ng thng tng cao ro rt va co th c s
dung theo doi ap ng iu tr.
IU TR
Nu khng xac nh c cn nguyn, nn iu tr theo kinh nghim bao phu
tu cu va tt ca cac cn nguyn gy bnh co kha nng khac (nh a c lit k
trc o).
Tim khang sinh -lactam (oxacillin, cefazolin) co hiu qua chng lai MSSA.
Vancomycin, daptomycin va linezolid c s dung iu tr vim tuy xng
MRSA. Cac thuc ung co kha nng at c nng xng hp ly bao gm

trimethoprim-sulfamethoxazole, clindamycin va doxycycline.
Vim tuy xng do vi khun gram m co th c iu tr bng fluoroquinolon
tim hoc ung va thuc phai thm thu vao xng tuyt i va sinh kha dung
cao hoc iu tr bng cephalosporin th h th ba.
iu tr khoi cn t nht 46 tun bng khang sinh liu cao. Ban u cn phai tim,
sau 23 tun co th xem xet chuyn sang ung nu cac tac nhn gy bnh nhay
cam va nng dit khun u co th at c. (Clin Infect Dis 2012;54:403).
Vim tuy xng cp ng mau. Trong trng hp khng co thiu ti mau
hoc co d vt, bnh co th c iu tr bng liu phap khang sinh n thun.
Vim tuy xng lin quan n ti mau (v.d., nhng bnh nhn ai thao
ng) him khi c cha khoi bng thuc iu tr n thun; tng cng ti
mau, ct loc, thm ch ct cut chi c t ra. Nhim trung thng la do tap
khun, bao gm vi khun ky kh.
Vim tuy xng tuy co mt cua thit b chnh hnh rt him khi c loai bo
bng khang sinh n thun va thng oi hoi phai loai bo cac thit b. Khi khng
th loai bo, b sung rifampin 300 mg ung ba ln mi ngay. Liu phap khang sinh
c ch dai han, co th cn.
Vim tuy xng man tnh. Tiu dit vi khun oi hoi s kt hp gia iu tr ni
khoa kt hp phu thut loai bo cac nhim trung dai dng. Liu phap khang
sinh c ch dai han co th c s dung. Nu phu thut khng kha thi th iu tr
h tr oxy cao ap co th hu ch.
NHIM TRNG H THN KINH TRUNG NG
Vim mng no
I CNG
Vim mang nao la tnh trang vim cua mang bao boc xung quanh nao va/hoc tuy
sng. Tnh trang nay co th gy ra bi vi khun, hoc virus, hoc do cac nguyn
nhn khng nhim trung nh thuc.
CHN ON
Biu hin lm sng
Vim mang nao nn c cn nhc trong bt ky bnh nhn nao co du hiu st va
cng c hoc kem cac triu chng thn kinh, c bit la nu ng thi co nhim
trung khac hoc kem theo chn thng so.
Nhim trng h thn kinh trung ng Vim mng no l 607
Vim mang nao do vi khun la mt trng hp cp cu. iu tr khng nn tr

hoan i cho cac bin phap xac nh chn oan v tin lng phu thuc vao
vic bt u ngay iu tr bng khang sinh.
Vim mang nao v khun thng nhe hn vim mang nao do vi khun va co
th c bt u bng cac triu chng ng h hp trn hoc vim hong. Virus
la nguyn nhn ph bin, cung co th la vim do thuc (v.d., thuc chng vim
khng steroid [nonsteroidal anti-inflammatory drugsNSAIDs], TMP-SMX).
S khac nhau gia cac nguyn nhn gy bnh vi khun, virus va cn nguyn
khng nhim trung trn lm sang kho co th phn bit c.
Test chn on
Chn oan oi hoi phai choc do tuy sng cung vi vic o ap sut m, kim tra
protein dch nao tuy (cerebrospinal fluidCSF), glucose va cng thc bach cu,
nui cy nhum Gram. Cy mau nn lun lun c thc hin. Chup CT so nao
trc khi choc dch nao tuy ang c tranh lun, tuy nhin nhn chung khng
bt buc thc hin ngi tre tui, bnh nhn suy giam min dch co biu hin
thn kinh khu tru, co git, hoc y thc xu dn (Clin Infect Dis 2004;39:1267).
Cac kt qua dch nao tuy in hnh trong vim mang nao do vi khun bao gm
tng bach cu a nhn trung tnh, protein CSF cao ro rt va nng glucose giam.
Trong vim mang nao do virus, tng bach cu lympho dch nao tuy ph bin
(mc du bach cu trung tnh co th chim u th rt sm trong qua trnh bnh).
Xat nghim PCR dch nao tuy co th phat hin enterovirus, virus herpes simplex
(herpes simplex virusHSV) va HIV.
Tuy thuc vao bnh canh lm sang, cac xet nghim dch nao tuy khac co th c
lam bao gm xet nghim rapid plasma reagin (rapid plasma reaginRPR), nhum
AFB phat hin khang nguyn ngng kt latex khang nguyn, khang nguyn
cryptococcus va khang th arbovirus.
IU TR
iu tr bao gm cac bin phap h tr va iu tr khang sinh (Clin Infect Dis 2004;
39:1267). Bt c khi nao nghi ng vim mang nao cp do vi khun, nn iu tr
bng tim khang sinh liu cao cang sm cang tt. Khi nao cac nguyn nhn cua
bnh vim mang nao c xac nh th phac iu tr thc nghim nn c da
trn cac yu t nguy c cua bnh nhn va nhum Gram cua CSF:
Nu khng phat hin c vi khun nao, cephalosporin th h th ba liu cao
(ceftriaxone 2 g IV mi 12 gi) va vancomycin 1 g IV mi 812 gi c khuyn
khch trong cac kt qua cy ang c ch x ly.
Ampicillin 2 g 4 gi/ln IV nn c b sung cho cac bnh nhn suy giam min
dch va ln tui (>50 tui) chng lai Listeria monocytogenes.
Sau phu thut thn kinh hoc sau chn thng u hoc ct sng th bao
phu liu cao vancomycin va ceftazidime hoc cefepime 2 g 8 gi/ln IV ph rng.
Phac iu tr theo kinh nghim nn c thay i khi bit c kt qua nui
cy va khang sinh .
Dexamethasone 10 mg 6 gi/ln IV dung ngay trc khi hoc cung vi khang sinh
ban u va keo dai 4 ngay se lam giam nguy c biu hin thn kinh nhng bnh
nhn vim mang nao do ph cu (Streptococcus pneumoniaeS.pneumoniae).
Steroids khng c chng minh co li bnh nhn vim mang nao do vi khun
gy bi cac sinh vt khac va nn ngng s dung nu co mt tac nhn gy bnh
khac c phn lp (N Engl J Med 2002;347:1549).
iu tr cho cac nhim trung cu th
iu tr ph cu, penicillin G IV 4.000.000 iu tr 4 gi/ln trong 14 ngay la
thch hp khi mu phn lp nhay cam hoan toan vi penicillin. Ceftriaxone hoc
cefotaxime liu cao (nh m ta trn) c s dung iu tr cac chng nhay cam
hoc khang penicillin trung gian va vancomycin c thm vao nu co khang
ceftriaxone hoc khang penicillin nng cao. Cac la chon cho trng hp
bnh nhn d ng nng vi penicillin la vancomycin cng vi rifampin 300 mg
PO 3 ln/ngay hoc chloramphenicol 1 g IV 6 gi/ln. Vancomycin khng nn
c s dung mt mnh. Dexamethasone, nh m ta trn, co th hiu qua nu
c s dung sm.
iu tr nao m cu (N.meningitidis), ceftriaxone hoc cefotaxime liu cao
c tip tuc trong t nht 5 ngay sau khi bnh nhn ht st, tng liu trnh
thng la 7 ngay. Chloramphenicol c chon nu bnh nhn d ng penicillin.
Bnh nhn cn c t trong mt phong cach ly h hp trong t nht 24 gi u
iu tr. Nhng ngi co tip xuc gn (v.d., nhng ngi sng trong cung h gia
nh va nhng can b y t co tip xuc gn vi dch tit cua bnh nhn nh t
ni kh quan) c iu tr d phong bng ciprofloxacin 500 mg ng ming
mt ln; rifampin, 600 mg PO 2 ln/ngay trong 2 ngay; hoc ceftriaxone 250
mg tim bp. S thiu hut thanh phn b sung Terminal (C5 qua C9) nn c
loai tr nhng bnh nhn b nhim trung nao m cu tai phat.
Vim mang nao do Listeria monocytogenes gp ngi ln suy giam min
dch va ngi gia. iu tr bng ampicillin 2 g 4 gi/ln IV kt hp vi mt
khang sinh nhom aminoglycoside dung toan thn trong t nht 3-4 tun.
Trimethoprim-sulfamethoxazole (Trimethoprim-sulfamethoxazole-TMP-SMX;
TMP 5 mg/kg IV 6 gi/ln) hoc meropenem (2 g 8 gi/ln IV) la mt la chon
thay th cho cac bnh nhn d ng penicillin.
Vim mang nao mu do trc khun gram m thng la mt bin chng cua
chn thng u hoc sau ca phu thut thn kinh. Ceftazidime hoc cefepime
liu cao 2 g 8 gi/ln IV c s dung cho hu ht cac mm bnh bao phu ca
Nhim trng h thn kinh trung ng Vim no l 609
trc khun mu xanh (Pseudomonas aeruginosaP. aeruginosa). Ceftriaxone

hoc cefotaxime liu cao co th c s dung cho cac tac nhn gy bnh nhay
cam. Cac la chon thay th gm meropenem va ciprofloxacin.
Vim mang nao do tu khun thng la kt qua cua nhim vi khun mt
cao, trc tip khuch tan t mt vim nhim ln cn mang nao hoc sau thu
thut phu thut thn kinh gn y. Oxacillin va nafcillin 2 g IV 4 gi/ln la cac
thuc c la chon. Cephalosporin th h u khng ang tin cy s dung
trong thm nhp vao dch nao tuy. Vancomycin nn c s dung cho bnh
nhn d ng penicillin va khang methicillin khi co kha nng hoc a c xac
nhn. Rifampin cung co th s dung khi cn thit.
i vi bnh vim mang nao do enteroviral, iu tr thng la chm soc h tr.
Acyclovir, 10 mg/kg IV 8 gi/ln c s dung cho bnh nhn vim mang nao
do HSV t trung bnh n nng.
Nhim trng no tht v no tht shunt bng
I CNG
Thng thy nhng bnh nhn trai qua phu thut thn kinh, gy bi tu cu khng
sinh ra coagulase, tu cu vang va cac loai Propionibacterium.
IU TR
iu tr vancomycin IV co kem hoc khng rifampin hoc vancomycin tim vao
trong nao tht. Cn loai bo cac shunt nhim trung cha bnh.
Vim no
I CNG
Vim nao la tnh trang vim cua t chc nhu m nao, thng lin quan ti nhim
virus HSV-1 la nguyn nhn ph bin nht va quan trong nht cua vim nao gy
dch le te. Nguyn nhn khac bao gm virus Dengue va vim nao mang nao do
arbovirus nh virut West Nile (West Nile virusWNV) (xem phn Nhim trung
ly truyn qua mui t).
CHN ON
Biu hin lm sng
Bao gm st va cac bt thng v thn kinh, c bit la cac ri loan y thc hoc co
git ma thng khng kem theo du hiu mang nao.
Test chn on
Chn oan xac nh bng cach phat hin HSV-1 trong CSF bng PCR. Tuy nhin,
kt qua PCR m tnh khng loai tr kha nng vim nao do HSV. Tng tn hiu thuy
thai dng thng thy trn chup MRI nao.
IU TR
iu tr bng acyclovir 10 mg/kg IV 8 gi/ln truyn keo dai hn 1 gi vi bu nc
y u, iu nay cn c bt u sm ngay khi co nghi ng va tip tuc keo dai
trong 1421 ngay, cho ti khi nao chn oan c loai tr. Tr hoan bt u iu
tr lam tng ang k nguy c dn n kt qua iu tr kem (Clin Ifect Dis 2008;47:
303).
p-xe no
I CNG
Ap-xe nao cac bnh nhn co h min dch y u thng la do vi khun tai v tr
ban u va la kt qua cua s ly lan t mt nhim trung ln cn hoc t s thuyn
tc mach do nhim khun vim ni tm mac. Nhim trung thng la hn hp, vi
lin cu khun rng ming, tu cu va vi khun ky kh la tac nhn gy bnh ph bin
nht.
CHN ON
Chn oan bng chup X-quang: Vi cac tn thng tng tn hiu dang vong nhn
thy trn chup MRI hoc chup CT co thuc can quang.
Xac nh cn nguyn vi sinh vt bng cach hut, sinh thit, hoc tai thi im phu
thut xet nghim.
IU TR
iu tr theo kinh nghim nn dung khang sinh bao phu cac tac nhn co kha nng
gy bnh nht da trn nhim trung nguyn phat. Khi khng nhn thy trc cn
nguyn nhim trung th s dung phac kt hp cephalosporin th h th ba vi
metronidazole va vancomycin la mt tr liu hp ly cho n khi co kt qua nui cy
(Int J Surg 2011;9:136). iu tr thng la phu thut va kt hp s dung b sung
khang sinh toan thn.
Nhim trng tim mch Vim ni tm mc nhim khun l 611
u trng sn dy ln no (neurocysticercosis)
I CNG
Bnh c gy ra bi cac nang cua Taenia solium trong nao. Nhim bnh khi n
tht ln cha nu chn co cha trng cua T. solium, la bnh ph bin Mexico va
Trung My. Ty l mc bnh u trung san nao cac nc phat trin gn y tng ln
do ngi nhp c mang mm bnh n t cac vung co dch.
CHN ON
Biu hin lm sng
Co th biu hin khi phat bi cn co git, nao ung thuy hoc bt thng v thn
kinh khu tru.
Test chn on
Bnh u trung san dy ln nao nn c nghi ng nhng bnh nhn co cn ng
kinh mi khi phat ma khng ro nguyn nhn va i n vung dch t lu hanh. Kt
qua chup nao cho thy c trng nhiu nang co th co hoc khng th tng tn hiu.
Phat hin bach cu ai toan trong dch nao tuy la mt gi y cho vic chn oan. Xet
nghim huyt thanh hoc co sn tai Trung tm kim soat dch bnh (Centers for
Disease ControlCDC).
IU TR
iu tr co th cn phai phu thut va/hoc s dung liu cao albendazole hoc
Praziquantel, tuy thuc vao v tr cua nang va mc nghim trong. Thuc chng
co git, theo doi ap lc ni so va steroid co th cn kim soat cac triu chng
(Lancet 2003;362:547).
NHIM TRNG TIM MCH
Vim ni tm mc nhim khun
I CNG
Dch t hc
Ty l vim ni tm mac nhim khun cp tnh (acute bacterial endocarditisABE)
va vim ni tm mac do chm soc y t (lin quan n ng thng IV, cac thu thut
xm ln) ang gia tng (Arch Intern Med 2009;109:463).
Vim ni tm mac do van gia (Prosthetic valve endocarditisPVE) xay ra
1%4% bnh nhn co van tim gia.
Nguyn nhn
Vim ni tm mac nhim khun (Infective endocarditisIE) thng la do cu
khun gram dng. Tu cu la tac nhn thng gp nht ng sau lin cu viridans,
vi khun rut va tu cu khng sinh coagulase.
Vim ni tm mac vi khun do vi khun gram m va nm xay ra t hn va thng
lin quan n vic s dung ma tuy hoc van tim gia.
Thu thut nha khoa va nhim khun t cac nhim trung xa la nhng mm mng
cua cac nhim trung.
Vim ni tm mac do van gia (prosthetic valve endocarditisPVE). Nhim
trung sm (trong vong 2 thang phu thut), gy bi S. aureus, tu cu khng sinh
coagulase, trc khun gram m va cac loai Candida. S. aureus, tu cu khng sinh
coagulase, cu khun ng rut va lin cu la nhng nguyn nhn ph bin nht
cua khi phat PVE mun.
Yu t nguy c
Bnh tim cu truc, s dung ma tuy, van tim gia va co tin s vim ni tm mac la
yu t gi y quan trong chn oan vim ni tm mac.
CHN ON
Tiu chun Duke sa i (Bang 142a va b) chn oan vim ni tm mac vi
khun, kt hp vi sinh, giai phu bnh, siu m tim va du hiu lm sang c s
dung rng rai (Clin Infect Dis 2000;30:633).
Biu hin lm sng

Bnh nhn co ABE co th biu hin trong vong 310 ngay sau khi khi phat
nhim trung vi bnh him ngheo.
Vim ni tm mac ban cp do vi khun (Subacute bacterial endocarditis
SBE) co biu hin trong vai tun n vai thang vi cac triu chng toan thn (st,
mt moi, chan n), bnh phc hp min dch (vim thn, au khp, cac hat Osler)
va hin tng tc mach (thn, lach va nhi mau nao, xut huyt; cac tn thng
Janeway).
PVE phai c ngh n bt c bnh nhn nao co nhim khun huyt dai dng
sau khi phu thut van tim.
Bng 142a Tiu chun Duke (sa i) chn on vim ni tm mc nhim khun
Tiu chun chnh
I. Cy mu dng tnh
1. Hai mu cy mu ring bit vi viridans streptococci, Streptococcus bovis, Staph-
ylococcus aureus, nhm HACEK, hoc cu khun rut mc phi cng ng
(khng phi nhim trng nguyn pht)
2. Cy mu dng tnh lin tc t mu mu ly cch nhau t nht 12 gi hoc tt c
3 hoc 4 mu mu ring bit c ly ra cch nhau 1 gi.
3. Cy mu dng tnh 1 ln i vi Coxiella burnetii
II. Bng chng c s lin quan ca ni tm mc
1. Siu m tim c du hiu IE
2. Dao ng tim hng lot mt van hoc cc cu trc h tr, trong dng chy tro
ngc hoc trn cc vt liu cy ghp m khng th gii thch do cc phu thut.
3. p-xe
4. Mt phn mi xut hin ca van gi
5. Tro ngc van mi xy ra (thay i t ting thi trc l nhng khng )
Tiu chun ph
1. Tin s c bnh tim hoc tim chch ma ty
2. St 38C (100,4F)
3. Hin tng mch: Thuyn tc ng mch, nhi mu phi nhim khun, phnh
mch do nm, xut huyt ni s, tn thng Janeway
4. Hin tng min dch: Vim cu thn, cc ht ca Osler, im Roth, yu t dng
thp
5. Bng chng vi sinh: Vt cy mu dng tnh nhng khng p ng c tiu chun
chnh hoc bng chng huyt thanh ca vi khun gy nhim khun ph hp vi IE.
HACEK, Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella; IE, vim ni tm mc nhim

khun.
Test chn on
Tiu chun chn oan ang tin cy nht cua IE la s hin din cua vi khun trong
mau lin tuc trong mt bi canh lm sang tng thch. Nn cy mau 3 ln t cac
v tr ring bit t nht 1 gi trc khi iu tr khang sinh theo kinh nghim. Cy
mau thng dng tnh t nht 90% s bnh nhn nhng co th m tnh nu bnh
nhn a c dung khang sinh.
Phn bc chn on vim ni tm mc nhim khun theo

Bng 142b
tiu chun Duke (sa i)
Vim ni tm mc nhim khun chc chn
Tiu chun gii phu bnh:

Nt si hoc p-xe trong tim c khng nh bi m bnh hc cho thy vim mng
trong tim hot ng V mt vi sinh vt c lin quan c khng nh bi nui cy
hoc m bnh hc
Tiu chun lm sng:
2 tiu chun chnh HOC
1 tiu chun chnh v 3 tiu chun ph HOC
5 tiu chun ph
Vim ni tm mc nhim khun c th
1 tiu chun chnh v 1 tiu chun ph HOC
3 tiu chun ph
Loi tr vim ni tm mc nhim khun
Chn on xc nh thay th HOC
Phn gii ca cc biu hin bng liu php 4 ngy HOC
Khng c bng chng bnh l lc phu thut hoc phu tch bnh phm sau khi iu tr
khng sinh 4 ngy.
IE, vim ni tm mc nhim khun.

Trch t Li JS, Sexton DJ, Mick N v cng s. Proposed Modifications to the Duke Criteria for the
Diagnosis of Infective Endocarditis. Clin Infect Dis 2000;30:633638.
Siu m tim ong mt vai tro quan trong trong vic chn oan IE va xac nh s
cn thit cua vic cn phai can thip phu thut.
Bnh nhn IE va sui van c nhn thy bng siu m tim qua thanh ngc
(transthoracic echocardiographyTTE) co nguy c thuyn tc cao, suy tim, t
dy chng van. Tuy nhin, TTE m tnh th khng th loai tr IE.
Khi co bng chng lm sang cua IE, siu m tim qua thc quan (transesoph
- ageal echocardiographyTEE) cai thin nhay cua cac tiu chun Duke,
c bit la bnh nhn van tim gia.
IU TR
Bt buc dung khang sinh tim tnh mach liu cao, keo dai (thng 46 tun).
Cn thit lam khang sinh i vi vi khun gy bnh iu tr ti u.
ABE thng oi hoi phai iu tr khang sinh theo kinh nghim trc khi co kt
qua nui cy. iu tr ban u cho S. aureus nn bao gm vancomycin 15 mg/kg
IV 12 gi/ln. Liu phap nay cn phai c iu chnh trn c s d liu nui cy
va khang sinh . i vi cac chung nhay cam methicillin, dung oxacillin 2 g IV
4 gi/ln tt hn vancomycin.
SBE gy ra bi vi khun nhay cam cn c iu tr bng penicillin, do bnh nay
thng co ty l cha khoi >90%. iu tr co th b tr hoan cho n khi nui cy
khng nh mt vi khun cu th va khang sinh .
PVE nn c iu tr tch cc keo dai v nguy c gia tng tht bai iu tr va tai
phat. Ch nh thay van c m ta chi tit bn di.
o thnh lc trc khi iu tr c khuyn ngh cho bnh nhn iu tr trn 7
ngay bng aminoglycoside, o lai trong qua trnh iu tr hoc co triu chng v
tai.
iu tr khang sinh cho cac loai vi khun cu th (Bang 143)
iu tr viridans streptococciy la cac chung nhay cam vi penicillin: Dung
penicillin G hoc ceftriaxone trong 4 tun c khuyn ngh. Mt l trnh iu
tr ngn 2 tun kt hp vi gentamicin co th cn nhc nhng se kem theo nguy
c c tnh thn va tai va khng nn s dung cho PVE hoc cac bnh nghim
trong. Streptococci vi khang penicillin trung bnh hoc cao nn c iu tr
kt hp keo dai. Giai mn cam penicillin thng lanh hn so vi vancomycin
khi bnh nhn d ng penicillin.
S. pyogenes va S. pneumoniae nn c iu tr bng penicillin G 24.000.000
iu tr IV 4 gi/ln trong 46 tun. Ph cu khang Penicillin nn iu tr bng
ceftriaxone 2 g IV 24 gi/ln trong 46 tun. Nhim khun huyt va vim ni
tm mac do Streptococcus bovis co lin quan n bnh ly ng tiu hoa thp
(gastrointestinalGI), bao gm nhng khi u. Vim ni tm mac do lin cu
nhom B va G cung co th c kt hp vi bnh ly ng tiu hoa thp.
Cac chung Enterococcus gy ra 5% n 20% cac trng hp SBE. Cac chung
phn lp t bnh nhn vim ni tm mac cu khun ng rut nn c sang loc
vi cac san phm -lactam va th nhay cam vi vancomycin, quinupristin/
dalfopristin, linezolid va gentamicin. Vim ni tm mac nhim khun do
enterococcus khang vancomycin (Vancomycin-resistantenterococcusVRE)
IE rt kho iu tr; cac hi chn vi cac chuyn gia vic bnh truyn nhim
c khuyn khch.
Tu cu (MSSA) nn c iu tr bng oxacillin. Penicillin vt tri hn so vi
vancomycin va giai mn cam c khuyn ngh nu co th (Medicine (Baltimore)
2003; 82: 333). Cefazolin co th c thay th nhng bnh nhn d ng
penicillin khng co tin s shock phan v. IE ngi nghin chch ma tuy co
th iu tr 2 tun bng oxacillin kt hp vi mt aminoglycoside. Vancomycin,
linezolid va daptomycin co th c s dung cho MRSA. Gentamicin liu thp

ban u tng sc khang trong cac van cha b tn thng gy suy thn
khng c chng minh la co li (Clin Infect Dis 2009,48:713).
Vim ni tm mac do tu cu khng sinh coagulase (v.d., tu cu da) xay ra
chu yu bnh nhn co van tim gia, mc du bnh nhn vim ni tm mac trn
bnh nhn co van tim bnh thng ngay cang tng, c bit la trong cac c s y
t. Vim ni tm mac do vi khun Staphylococcus lugdunensis lin quan vi s
gia tng biu hin quanh van va di bnh. Nhng vi khun nay ngay cang tr
nn khang vi thuc khang sinh -lactam.
PVE oi hoi phai phi hp iu tr tch cc trong t nht 6 tun. iu tr kinh
nghim ban u trong khi ch nui cy bao gm vic thm rifampin vao
vancomycin va gentamicin tng tnh thm mang sinh hoc. Thay th oxacillin
cho vancomycin nu co kt qua nui cy va khang sinh . Tht bai iu tr
hoc tai phat la ph bin.
HACEK la mt t vit tt cho mt nhom vi khun gram m ken chon vt chu,
phat trin chm (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella va
cac loai Kingella), gy nhim trung cac van tim.
Nui cy IE m tnh thng khi a iu tr khang sinh trc o hoc trng
hp him la vi cac mm bnh ken vt chu, chng han nh lin cu khun thiu
hut dinh dng, cac vi khun HACEK, Coxiella burnetii (st Q), Bartonella,
Brucella, Tropheryma whippelii (bnh Whipple) va nm. Co th iu tr theo
kinh nghim mc du cac mu nui cy la m tnh (xem Bang 143).
ap ng vi iu tr bng khang sinh
Cai thin lm sang thng c ghi nhn trong vong 310 ngay k t ngay bt
u iu tr.
Cy mau nn c lam hang ngay cho n khi khng con bng chng cua vi
khun trong mau.
St dai dng hoc tai phat thng la do nhim trung tim lan rng nhng cung
co th la do thuyn tc, qua mn thuc hoc bi nhim do nhim trung bnh
vin (Circulation 2005;111:e393).
X tr phu thut
i vi vim ni tm mac van bnh nhn con nguyn ven, ch nh phu thut
khi co suy tim dai dng, sa van ng mach chu hoc van hai la co bng chng
huyt ng cua ap lc cui tm trng tht trai cao; cac bin chng nh nghen
tim, ng mach chu hnh khuyn hay ap-xe, ro, hoc thung; nhim nm hoc vi
khun khang cao. Nghen mach tai phat va nhim khun huyt keo dai cung
c ch nh phu thut.
i vi PVE, cac ch nh bao gm suy tim, nt van, tng tc nghen van hoc sa
Bng 143 iu tr vim ni tm mc c gy ra bi cc mm bnh c tha
Mm bnh Phc khng sinh Thi gian iu tr Lu
Nhim trng tim mch

Viridans streptococci
MIC <0,12 mcg/mL [Penicillin G 1218 triu IV 24 gi/ln 4 tun (2 tun nu kt hp 2 tun khng hiu qu cho
hoc ceftriaxone] + gentamicin (liu vi gentamicin) trng hp van gi, cc triu
thp) Vancomycin nu d ng vi PCN chng tc mch ln hoc lan
rng
MIC 0,120,5 mcg/mL [Penicillin G 4 triu IV 4 gi/ln hoc 4 tun vi 2 tun s dng Vancomycin n c bnh
ceftriaxone] + gentamicin gentamicin nhn d ng.

Vancomycin nu d ng vi PCN

MIC>0,5 mcg/mL Ampicillin/sulbactam gentamicin 46 tun
(nu sn xut lactamase)
Vancomycin gentamicin
Cc loi Enterococcus
Nhy cm vi Penicillin Vancomycin gentamicin 46 tun Khng gentamicin mc cao,
Vancomycin thay th bng streptomycin
hoc ceftriaxone
(cn tip)
l
617
618
l
Bng 143 iu tr vim ni tm mc c gy ra bi cc mm bnh c tha (Tip theo)
Ch. 14
Mm bnh Phc khng sinh Thi gian iu tr Lu

iu tr bnh truyn nhim
Khng penicillin lactamase: Ampicillin/ 6 tun Tham kho kin ca chuyn
sulblactam + gentamicin gia truyn nhim
Khng ni ti
Vancomycin + gentamicin
Khng Vancomycin v Linezolid hoc daptomycin 8 tun

ampicillin Quinupristin/dalfopristin
doxycycline
Cc chng t cu
Van nguyn vn, MSSA Oxacillin 6 tun Bt u 35 ngy gentamicin
Cefazolin nu d ng penicillin m tng tc dng hip ng c th
khng c phn ng phn v khng c li
Van ba l, MSSA (tim Oxacillin + gentamicin 2 tun
chch ma ty)
Van nguyn vn, MRSA Vancomycin hoc daptomycin hoc 6 tun
linezolid (cng iu tr cho MSSA nu
d ng qu mn)
Cc chng t cu (van gi)
MSSA/MSSE Oxacillin + rifampin + gentamicin 6 tun (2 tun dng
Nhim trng tim mch

gentamicin)
MSSA/MSSE Vancomycin + rifampin + gentamicin

Vi khun HACEK v Ceftriaxone hoc ampicillin 4 tun HACEK l vit tt ca
nui cy IE m tnh sulbactam hoc ciprofloxacin Haemophilus, Actinobacillus,
Cardiobacterium, Eikenella,
Kinggella.

Liu dng: Ceftriaxone 2 g IV mi 24 gi; gentamicin 2 g mi ngy hoc 1 mg/kg mi 8 gi; vancomycin 15 mg/kg mi 12 gi; ampicillinsulbactam 3 g
IV mi 6 gi; ampicillin 2 g IV mi 4 gi; oxacillin 2 g IV mi 4 gi; rifampin 300 mg PO mi 8 gi; cefazolin 2 g IV mi 8 gi; daptomycin 6 mg/kg/ngy;
linezolid 600 mg IV mi 12 gi; ciprofloxacin 400 mg IV mi 12 gi.
o thnh lc ban u v hng tun cho bnh nhn dng khng sinh nhm aminoglycosides nu 7 ngy. Theo di nng aminoglycoside v vancomycin.
Nng y ca vancomycin l gn 1520 g/mL.
aXem Circulation 2005; 111: e393.
IE, vim ni tm mc nhim khun; IV, tim tnh mch; MIC (minimum inhibitory concentration), nng c ch ti thiu; MRSA (methicillinresistant
Staphylococcus aureus), t cu khng methicillin; MRSE (methicillinresistant Staphylococcus epidermidis), t cu da khng methicillin; MSSA, t cu nhy
cm methicillin; MSSE (methicillinsensitive Staphylococcus epidermidis), t cu da nhy cm methicillin; PCN, penicillin.
l
619
van nghim trong, cac bin chng nh hnh thanh ap-xe, nhim khun huyt dai
dng hoc tc mach tai phat va tai phat nhim trung (J Am Coll Cardiol 2006;
48: e1).
LU C BIT
Cac khuyn cao cua Hip hi Tim mach Hoa Ky d phong cho IE a c xem
xet va c trnh bay trong Bang 144.
Vim c tim
I CNG
La khi tim b anh hng bi qua trnh vim, do mt tac nhn nhim trung gy ra.
Vim c tim co th xay ra trong va sau khi nhim mt loai virus, rickettsia, vi
khun, nm va ky sinh trung.
Virus la nguyn nhn thng gp nht bao gm enterovirus (Coxsackie B va
echovirus), adenovirus, virus herpes 6, parvovirus B-19, va nhiu chung khac.
Vim c tim cung co th la mt bin chng him gp sau khi tim phong bnh
u mua.
CHN ON
Xet nghim pht mui hong va huyt thanh hoc co th c thc hin phat hin
nhim virus.
Sinh thit mang trong tim lam m bnh hoc va lam PCR virus cung co th giup
chn oan.
IU TR
Phac iu tr nn da vao cn nguyn nhim trung c xac nh. Vai tro cua
globulin min dch tnh mach va cac thuc khang virus trong iu tr vim c tim
do virus vn con cha ro rang.
Vim mng ngoi tim
I CNG
Vim mang ngoai tim cp tnh la mt hi chng vim cua mang ngoai tim, c
trng bi au ngc, nghe co ting co mang ngoai tim, va ST chnh ln ng loat khi
lam in tm (electrocardiogramECG). Nguyn nhn truyn nhim ph bin
Nhim trng tim mch Vim mng ngoi tim l 621
Bng 144 iu tr d phng vim ni tm mca
Bnh cnh lm sng Thuc v liu lng
I. D phng vim ni tm mc c khuyn co cho cc bnh l tim mch sau y:

van gi; vim ni tm mc trc ; bnh tim bm sinh khng c cha tr, bao
gm c t ng dn, iu tr tim bm sinh vi cht liu gi trong 6 thng u tin
sau khi phu thut, hoc b d tt cn st li ti hoc tip gip vi cc v tr ca cc
b phn gi; v bnh van tim do ghp tim.
II. Phc iu tr cho cc phu thut nha khoa, ng ming hoc ng th (bao
gm c vic nh rng, nu v phu thut ni nha, lm sch rng, sinh thit qua ni
soi ph qun, ni soi ph qun ng cng, phu thut nim mc ng h hp, ct
amidan).
D phng chun Amoxicillin 2 g ung 1 gi trc phu thut
Khng c kh nng ung Amoxicillin 2 g tim bp hoc tim tnh mch hoc
cefazolin hoc ceftriaxone 1 g tim bp hoc tim
tnh mch 30 pht trc phu thut
Bnh nhn d ng vi Clindamycin 600 mg ung hoc cephalexin 2 g ung
penicilin hoc clarithromycin hoc azithromycin 500 mg
ung 1 gi trc khi phu thut
Bnh nhn d ng vi Clindamycin 600 mg tim tnh mch hoc cefazolin
penicilin v khng c kh hoc ceftriaxone 1 g tim tnh mch 30 pht trc
nng ung thuc khi phu thut
III. Phu thut d dy-rut v ng sinh dc khng bt but phi d phng. Cc bnh
nhn c nguy c cao b nhim trng hoc phu thut ni c vi khun enterococci
c tr nn c nhn amoxicillin hoc vancomycin tiu dit cc mm bnh trc
thao tc k thut ng tit niu.
IV. D phng c khuyn co vi cc th thut c nhim trng da, cu trc da hoc
m c xng CH P DNG cho nhng bnh nhn c cc bnh l tim mch nu
trn. Nn dng penicillin hoc cephalosponrin khng t cu.
aXem Circulation 2007;116:1736
IM, tim bp; IV, tim tnh mch; PO, ung.
nht la virus, con nguyn nhn do vi khun thng la tu cu va ph cu. Bnh lao
(TuberculosisTB) hoc bnh nm histoplasmosis la nguyn nhn co th gp (xem
phn Lao).
IU TR
Vai tro cua liu phap khang virus trong vim mang ngoai tim do virus vn cha ro
rang. Cac thuc giam au nhom NSAID co th c s dung giam au.
NHIM TRNG NG H HP TRN
Vim hng
I CNG
Vim hong thng la do virus, nhim trung do GABHS va cac vi khun khac gy
ra tnh trang nay vi ty l t hn.
CHN ON
Biu hin lm sng
St, bnh ly hach vung c, xut tit dch t hach hanh nhn, trng hp khng b ho
co th b au hong. Kho khn khi chn oan vim hong do virus da vao lm sang.
Chn on phn bit
Nhim HIV cp tnh cn c ngh n trong trng hp b vim hong vi tng
t bao lympho khng in hnh, kem theo xet nghim m tnh vi lin cu va
virus Epstein-Barr.
Vim thanh quan nn c ngh n khi bnh nhn co st vi au nng hong,
nut au, du hiu vim long ng h hp cp tnh, va kho nut, tuy nhin ti
thiu cn ni soi tai mui hong.
Bin chng gy vim mu nh ap-xe amidal mu hoc ap-xe vung hu hong t trc
nn c ngh n cac bnh nhn au nghim trong mt bn, kho noi, cng
ham va kho nut.
Test chn on
Xet nghim chn oan thng danh ring cho cac bnh nhn co triu chng khi
tip xuc vi bnh nhn b vim hong do lin cu, cac ca nhn co du hiu nhim
trung ang k (nh st, du hiu vim long va co hach vung c), bnh nhn co
triu chng khng ro rang mc du a iu tr triu chng va bnh nhn co tin s
thp khp.
Th nghim phat hin khang nguyn nhanh chong (Rapid antigen detection
testingRADT) la hu ch cho vic xac nh GABHS-oi hoi phai iu tr
ngn nga bin chng mu va st thp khp. Xet nghim m tnh cung khng chc
chn loai tr GABHS, tao ra mu nui cy dch hu hong la cn thit khi RADT
m tnh.
Huyt thanh virus Epstein-Barr (v.d., heterophile agglutinin hoc monospot) va
kim tra tiu ban mau ngoai vi cho cac t bao lympho khng in hnh nn c
thc hin khi nghi ng bnh bach cu n nhn nhim trung.
Nhim trng ng h hp trn Vim thanh qun l 623
IU TR
Hu ht cac trng hp vim hong t thuyn giam va khng oi hoi phai s dung
khang sinh iu tr.
iu tr GABHS c ch nh khi mu nui cy dng tnh hoc RADT, nu bnh
nhn co nguy c cao b st thp khp hoc nu chn oan nghi ng trong khi ch
i kt qua cua mu nui cy. Cac la chon iu tr bao gm penicillin V 250 mg
ung 4 ln/ngay hoc 500 mg ung 2 ln/ngay trong vong 10 ngay, clindamycin
t 300 ti 450 mg ung mi 68 gi/ln trong vong 5 ngay, azithromycin 500 mg
ung trong ngay th nht, tip theo la 250 mg vao ngay th hai ti th nm hoc
benzathine penicillin G 1,2 triu U tim bp mt liu mt ln (Clin Infect Dis
2002;35:113; Circulation 2009;119:1541).
Vim hong do lu cu iu tr bng ceftriaxone 250 mg tim bp vi liu duy
nht.
Vim thanh qun
I CNG
Haemophilus influenzae type B, Streptococcus pneumoniae, S. aureus va GABHS
la cac vi khun ph bin gy ra vim thanh quan, mc du cac tac nhn virus va nm
co th gy bnh.
CHN ON
Biu hin lm sng
St, au hong, kho nut, vim long ng h hp, kho noi va nut kho bnh nhn
kham hong bnh thng nn ngh ngay chn oan lm sang vim thanh quan.
Test chn on
Mu nui cy dch hong va mau rt hu ch trong vic xac nh nguyn nhn.
Chup X-quang tia mm vung c co th h tr vic thit lp chn oan.
Chn oan xac nh qua ni soi thanh quan
IU TR
iu tr tc th bao gm t vn nhp vin va c xut trong tt ca cac trng
hp co nghi ng. Liu phap khang sinh nn bao gm mt tac nhn co hoat tnh
chng H. influenzae nh ceftriaxone 2 g IV 24 gi/ln hoc cefotaxime 2 g IV 68
gi/ln.
Vim xoang
I CNG
Vim xoang c gy ra bi s tc nghen phc tap tai mui hong.
Vim mui xoang thng c gy ra bi virus ng h hp trn. Vi khun gy
bnh, nh S. pneumoniae, H. influenzae, Moraxella catarrhalis, vi khun ky kh
lin quan di 2% trng hp va cn c xem xet nu cac triu chng la nng
hoc nu keo dai trn 10 ngay.
Vim mui xoang man tnh co th c gy ra bi bt ky cac nhom tac nhn nao
gy ra vim xoang cp tnh, cung nh S. aureus, Corynebacterium diphtheria
va nhiu vi khun ky kh (v.d., Prevotella spp., Veillonella spp.) Cac yu t gop
phn co th bao gm bnh hen suyn, polyp mui, d ng hoc suy giam min dch.
CHN ON
Biu hin lm sng
Vim mui xoang cp tnh la mt chn oan lm sang ma thy xut hin mu khi
chay nc mui, tc mui, xoang va au vung xoang co hoc khng kem theo st,
keo dai t hn 4 tun.
Vim mui xoang man tnh c xac nh bi cac triu chng keo dai hn 12
tun, gm chay mu, tc mui, au vung mt hoc tng tnh nhay cam mui va giam
khu giac vi nhng du hiu cua triu chng vim.
Test chn on
Chn oan oi hoi bng chng khach quan cua bnh nim mac, thng la vi ni
soi xoang va ni soi mui hoc chup CT xoang. Chup X-quang khng chun b
(khng co thuc can quang) khng c khuyn khch.
Nui cy dch xoang co th thu c t vic ni soi mui xoang hoc choc hut
xoang. Gac mui khng mang lai hiu qua.
IU TR
Cac muc tiu cua iu tr ni khoa cho vim mui xoang cp tnh va man tnh la
kim soat nhim trung, giam phu n m, dn lu mu, duy tr xoang thng thoang
va iu tr nguyn nhn.
Vim mui xoang cp tnh
iu tr triu chng la c s cua vic iu tr, k ca thuc ung va thuc giam
au vi hoc khng vi mt liu trnh iu tr ngn han cua thuc thng mui tai
ch hoc xt glucocorticoid (Otolaryngol Head Neck Surg 2007;137:S1).
Nhim trng ng h hp trn Nhim virus gy cm l 625
iu tr khang sinh theo kinh nghim c ch nh ch cho cac triu chng

nng dai dng (10 ngay) hay tht bai cua iu tr triu chng. Phac iu tr
hang u nn bao gm mt liu trnh t 57 ngay bng amoxicillin-clavulanate
875 mg/125 mg ung 2 ln/ngay. Doxycycline hoc fluoroquinolone h hp
(v.d., moxifloxacin, levofloxacin) co th c s dung nh mt tac nhn hang
th hai trong trng hp d ng -lactam hoc tht bai iu tr. TMP-SMX
va macrolides khng c khuyn cao cho iu tr theo kinh nghim do ty l
khang cao (Clin Infect Dis 2012;54:e72).
Vim mui xoang man tnh. iu tr thng bao gm glucocorticoid tai ch va/
hoc h thng; vai tro cua cac khang sinh la khng ro rang. Nu chung c
s dung th amoxicillin-clavulanate c s dung trong iu tr ban u, vi
clindamycin cho bnh nhn d ng penicillin. Mt s trng hp vim man tnh
co th cn phai phu thut ni soi.
Nhim virus gy cm
I CNG
Bnh cum d ly lan va co nguy c cao bung phat vi cac mc khac nhau trong
nhng thang mua ng.
CHN ON
Biu hin lm sng
Bnh cum co biu hin cp tnh, st cao theo t nht nh kem au u, au c,
ho va n lanh.
Test chn on
Trong mua cum, nu co cac triu chng lm sang,cn dung tm bng ly dch vung
hu hong lam test nhanh khang nguyn, PCR, hoc phng phap khang th huynh
quang va nui cy.
IU TR
iu tr thng la iu tr cac triu chng.
Cac thuc khang virus co th rut ngn thi gian b bnh, nhng phai c bt u
trong vong 24 n 48 gi sau khi khi phat triu chng va cho thy hiu qua
bnh nhn suy giam min dch (MMWR 2011;60 (1):1). Co y kin cho rng liu
phap khang virus nn iu tr trong vong 48 gi sau khi khi phat triu chng
nng cn nhp vin hoc co nguy c cao b bin chng (xem muc Bin chng).
Cac cht c ch neuraminidase (oseltamivir 75 mg ung 2 ln/ngay hoc
zanamivir 10 mg ht hai ln mt ngay, trong vong 5 ngay) c s dung trong

iu tr va d phong cum A va B.
Adamantanes (amantadine va rimantadine, mi 100 mg ung 2 ln/ngay)
khng co hiu qua chng lai cum B.
Chung lu hanh thay i hang nm vi thay i m hnh khang cho ca hai
loai thuc khang virus. Quyt nh iu tr phai c da trn s liu khang
hang nm, co sn t CDC tai http://www.cdc.gov.
Tim chung la chin lc phong nga ang tin cy nht. Tim chung hang nm
c khuyn khch cho tt ca moi ngi t 6 thang tui tr ln (MMWR 2011;60
(33):1128).
BIN CHNG
Ngi ln trn 65 tui, nhng ngi sng trong vin dng lao va cac c s chm
soc trong thi gian dai khac, phu n mang thai (va nhng phu n sau sinh 2 tun),
va nhng bnh nhn mc bnh man tnh (v.d., bnh phi, bnh tim mach, bnh ac
tnh ang hoat ng, ai thao ng, suy thn man tnh, bnh gan man tnh, suy
giam min dch bao gm ca HIV va cy ghep b phn trn c th, beo ph) co
nguy c b bin chng cao.
Bnh vim phi do cum va vim phi do bi nhim vi khun la cac bin chng
thng gp nht cua bnh cum.
Trao i khang nguyn gia cac typ co th dn ti s xut hin cua cac chung lam
tng s lng virus hay kha nng ly lan dch bnh cao, oi hoi phai thay i iu
tr hoc cac bin phap kim soat nhim khun cao.
NHIM TRNG NG H HP DI
Vim ph qun cp
I CNG
Vim ph quan cp tnh la bnh ly vim nhim tai ph quan. Cac nguyn nhn gy
bnh thng la cac tac nhn virus, chng han nh coronavirus, rhinovirus, cum
hoc parainfluenza. Nguyn nhn ph bin bao gm Mycoplasma pneumoniae,
Chlamydophila pneumoniae, va Bordetella pertussis.
CHN ON
Biu hin lm sng
Cac triu chng bao gm ho co hoc khng khac am keo dai trn 5 ngay va co
Nhim trng ng h hp di Vim phi nhim phi t cng ng l 627
th khng phn bit c vi mt nhim trung ng h hp trn giai oan sm.

Thng khng co triu chng st.
Test chn on
Chn oan c da trn lm sang. Mu nui cy m khng c khuyn
khch.
nhng bnh nhn co st, bnh h thng, hoc ln tui, vim phi nn c loai
tr da trn lm sang hoc X-quang va xet nghim chn oan cum nn c thc
hin tuy thuc vao mua va xu hng bnh tai a phng.
Ho keo dai >2 tun ngi ln nn c xem xet vi bnh ho ga bng mt ming
gac ly mui hong nui cy va PCR.
IU TR
iu tr triu chng va cn c hng vao vic kim soat ho (dextromethorphan
15 mg ung mi 6 gi).
S dung khang sinh thng xuyn khng c khuyn ngh tr khi a c chn
oan bnh ho ga (Ann Intern Med 2001;134:521).
iu tr bnh ho ga bao gm clarithromycin 500 mg ung 2 ln/ngay trong vong
14 ngay hoc azithromycin 500 mg ung mt liu duy nht tip theo sau o la 250
mg ung hng ngay trong vong 4 ngay tip theo.
Trng hp bnh ho ga nn c bao cao cho c quan y t a phng tm kim
cac h tr va c quan ly iu tr d phong sau phi nhim vi azithromycin khi
co ch nh.
Vim phi nhim phi t cng ng
I CNG
Cn nguyn chu yu la S. pneumoniae trong o khang a thuc ang gia tng nhanh
chong. Vim phi c gy ra bi cac tac nhn khng in hnh, chng han nh
Legionella pneumophila, C. pneumoniae, M. pneumoniae hoc khng th xac nh
c mt cach chnh xac v mt lm sang. Cum va virus h hp khac cung co th
gy bnh vim phi ngi ln. MRSA la mt nguyn nhn quan trong cua bnh
vim phi nng, hoai t.
CHN ON
Biu hin lm sng
St va cac triu chng h hp, bao gm ho khac am, kho th va au ngc kiu
mang phi, la cac du hiu ph bin nhng bnh nhn suy giam min dch. Du
hiu bao gm th nhanh, ting ran, hoc nghe phi co hi chng ng c.
Test chn on
Tt ca cac bnh nhn ni tru cn c anh gia bnh phm m nhum Gram
hoc nui cy va cy mau trc khi iu tr bng khang sinh.
Nu mt tac nhn khng in hnh b nghi ng th cn tm khang nguyn
Legionella trong nc tiu. Bnh phm h hp co th c gi i xet nghim
min dch enzyme (enzyme immunoassayEIA), min dch huynh quang, hoc
PCR phat hin mm bnh khng in hnh hoc do virus khac (bao gm ca
cum). Xet nghim huyt thanh giai oan cp tnh va hi phuc co th hi cu
xac nh tac nhn vi khun khng in hnh bao gm C. pneumoniae, C. burnetii
(st Q), va Hantavirus.
Chup X-quang ngc nn c thc hin va co th cho thy s x cng cua thuy
phi, thm nhim ke hoc tn thng khoang, nhm xac nh chn oan.
Soi kh ph quan c s dung phat hin cac sinh vt t ph bin, c bit la
nhng bnh nhn suy giam min dch, cung nh xac nh tn thng giai phu
co lin quan, thc hin sinh thit m bnh hoc va co mu nui cy cht lng.
IU TR
Hu ht cac bnh nhn co th c iu tr ngoai tru, mc du tt ca phai c anh
gia mc nghim trong cua bnh, bnh ly kem theo va nng oxy mau. Hng
dn cho phac iu tr theo kinh nghim chi tit a c cng b, vi trong tm
nhm muc tiu ti cac tac nhn gy bnh co kha nng nht trong cac nhom nguy
c cu th (Clin Infect Dis 2007;44:S27). iu tr khang sinh cn c thu hep mt
khi a c xac nh c nguyn nhn vi sinh cu th.
Bnh nhn ngoai tru gn y khng co tip xuc vi khang sinh va khng co
bnh i kem nn s dung macrolide nh azithromycin 500 mg ung mt liu duy
nht theo sau o la 250 mg ung hang ngay trong vong 4 ngay tip theo, hoc
doxycycline 100 mg ung trong vong t nht 5 ngay.
Bnh nhn ngoai tru co phi nhim khang sinh hoc co cac bnh i kem khac
nn c iu tr bng nhom fluoroquinolone h hp (v.d., moxifloxacin) n
tr liu hoc macrolide (azithromycin hoc clarithromycin) vi hoc khng vi
amoxicillin liu cao 1 g ung 3 ln/ngay trong vong t nht 5 ngay.
Cac bnh nhn nhp vin nn c iu tr bng ceftriaxone 1 g IV hang ngay
hoc cefotaxime 1 g IV 8 gi/ln cng vi mt macrolide (azithromycin hoc
clarithromycin), hoc tr liu n bng nhom fluoroquinolone h hp. Thi gian
ti thiu cua vic iu tr nn la 5 ngay, nhng thng la dai hn, cac bnh nhn
phai ht st trong vong 48 n 72 gi co du hiu cai thin lm sang iu tr trc
khi ngng thuc.
Nhim trng ng h hp di p-xe phi l 629
nhng bnh nhn b bnh nng, vic b sung cac azithromycin hoc nhom
fluoroquinolone h hp kt hp vi -lactam (ceftriaxone, cefotaxime, ampicillin-
sulbactam) la cn thit cung cp iu tr chng lai L. pneumophila. iu tr
MRSA vi vancomycin hoc linezolid cung nn c cn nhc. Penicillin G IV
ma at nng cao trong m phi, vn con la mt iu tr hiu qua cho trng
hp nhay cam vi S. pneumoniae c phn lp (Clin Infect Dis 2003; 37: 230).
chng lai Pseudomonas aeruginosa, th s dung -lactam khang pseudomonas
(cefepime, piperacillin-tazobactam, meropenem, imipenem) kt hp vi mt
nhom fluoroquinolone khang pseudomonas (ciprofloxacin, levofloxacin) c
khuyn ngh s dung.
Choc dch mang phi phai c thc hin, cung vi s phn tch pH, s lng t
bao, nhum Gram va nui cy vi khun, protein va lactate dehydrogenase (xem
Chng 10, Bnh ly phi). Vim mu mang phi cn c dn lu.
p-xe phi
I CNG
Ap-xe phi thng kt qua t vic ht vao h vi sinh vt ng ung. Nhim a
khun rt ph bin va co th lin quan n vi khun ky kh ng ming (Prevotella
spp., Fusobacterium nucleatum, Actinomyces spp., va vi khun ky kh, cu trc
khun vi hiu kh), trc khun rut gram m (K. pneumoniae), va S. aureus. Cac
yu t nguy c bao gm bnh rng ming va iu kin ma khin bnh nhn ht vao
cac cht dch hu hong.
CHN ON
Biu hin lm sng
Bnh m va co th tng t lao phi, vi kho th, st, ret run, va m hi m, sut
cn va ho m hoc mau trong vai tun.
Test chn on
Chup X-quang ngc la nhay va thng cho thy thm nhim vi tn thng dang
hang va mc nc-hi trong nhu m phi nh cac thuy di hoc cac phn oan sau
cua thuy trn. Chup CT co th ro hn v cac tn thng.
IU TR
iu tr khang sinh nn bao gm fluoroquinolone chng ph cu (moxifloxacin,
levofloxacin) kt hp vi clindamycin, hoc tr liu n bng -lactam/cht
c ch -lactam (ampicillin-sulbactam, piperacillin-tazobactam, amoxicillin-

clavulanate) hoc mt carbapenem (meropenem, imipenem). MRSA co th
gy tn thng khoang phi tng t nh ap-xe, trong o mt s trng hp th
vancomycin hoc linezolid nn c s dung.
Dn lu qua da hoc phu thut ct bo nhim trung c danh ring cho nhng
ngi co bnh ly dai dng, thng lin quan n ap-xe ln (>8 cm) hoc nhim
vi khun khang.
Lao phi
I CNG
Lao phi la mt bnh h thng c gy ra bi M. tuberculosis. Hu ht cac trng
hp la kt qua cua s kch hoat cua nhim trung trc. Ty l mc bnh lao, c
bit la a khang thuc (multidrug-resistant forms [MDR-TB]), a tng ln trong s
nhng ngi nhp c t ng Nam A, cn Sahara , chu Phi, tiu luc a n , va
Trung My. Ty l ln bnh lao khang thuc (Extensively drug resistant TB [XDR-
TB]) ang ngay cang tr nn ph bin cn Sahara chu Phi. Ngi co nguy c
cao nht la nhng ngi b nhim HIV, bui phi silic, ai thao ng, suy thn man
tnh, bnh ac tnh, suy dinh dng va cac bnh suy giam min dch khac, bao gm
ca iu tr cht i khang vi yu t hoai t khi u (tumor necrosis factorTNF) nh
infliximab va etanercept (Clin Infect Dis 2004;39:300).
CHN ON
Biu hin lm sng
Biu hin lm sang thng gp nht la bnh ly v phi. Triu chng thng tin
trin chm va co th bao gm ho, ho ra mau, kho th, st, ra m hi m, sut cn
va mt moi.
Bnh ngoai phi co th biu hin nh hach vung c, bnh tit niu, vim tuy
xng, lao k, vim mang nao, vim phuc mac, hoc vim mang ngoai tim.
Test chn on
X-quang ngc co th cho thy thm nhim nhiu , dang nt, dang hang, lao k,
tran dch mang phi hoc bnh ly hach vung rn phi. Trong nhim trung, thm
nhim thuy gia va di la ph bin hn. Bnh canh tai hoat ng in hnh la
tn thng cac thuy trn.
Chn oan xac nh lao phi khi co xet nghim m dng tnh vi fluorochrome
hoc soi m co vi khun lao (vi khun khang a-xt, acid-fast bacteriaAFB). Tuy
nhin, vi khun lao khng in hnh (nontuberculous mycobacteriaNTM) va
mt s loai Nocardia cung co th cho kt qua dng tnh vi nhng ky thut nay.
Nhim trng ng h hp di Lao phi l 631
Vi khun lao co th mt vai tun phat trin mu nui cy, v vy nu trn lm

sang nghi ng, iu tr lao nn c ch nh ngay ca khi soi m m tnh, cho
n khi kt qua mu nui cy tra li m tnh. S dung h thng nui cy phong
xa va phng phap c hiu xac nh DNA cua vi khun co th cung cp kt qua
nhanh hn so vi cac phng phap truyn thng.
Th nghim tnh nhay cam vi thuc nn c thc hin trn tt ca cac mu phn
lp ban u cung nh cac mu phn lp thu c t bnh nhn khng ap ng vi
iu tr chun.
IU TR
iu tr (MMWR 2003;52(RR-11):1; Clin infect Dis 2000;31(3):633) khng nht
thit phai nhp vin, nhng bnh vin la ni cung cp iu tr ban u cho bnh
nhn. Nu mt bnh nhn c nhp vin, cach ly trong phong ap lc m la iu
cn thit.
Cac c quan y t a phng cn nhn c thng bao cua tt ca cac trng hp
mc bnh lao va quan ly co th am bao c vic xac nh va tun thu iu
tr y t qua liu phap iu tr ngn ngay co kim soat trc tip (directly observed
therapyDOT).
Phac iu tr lao phai bao gm t nht hai loai thuc ma cac sinh vt co kha
nng khang thuc khng cao, va lam giam nguy c khang thuc. iu tr keo dai
la cn thit v vi khun lao co i sng keo dai. Do vic tun thu phac a thi
gian keo dai gp kho khn, DOT nn c s dung cho tt ca cac bnh nhn.
iu tr tn cng (trong 8 tun u) cho lao phi khng bin chng nn bao
gm bn loai thuc: isoniazid (INH 5 mg/kg; ti a, 300 mg PO hang ngay),
rifampin (RIF, 10 mg/kg; ti a, 600 mg PO hang ngay ), pyrazinamide (PZA,
1530 mg/kg; ti a, 2 g PO hang ngay), va hoc ethambutol (EMB, 1525 mg/
kg PO hang ngay) hoc streptomycin (SM, 15 mg/kg; ti a, 1 g IM hang ngay).
Pyradoxine (vitamin B6) 2550 mg PO hang ngay nn c s dung vi INH
ngn chn bnh thn kinh. Nu phn lp vi khun chng minh la nhay cam hoan
toan vi INH va RIF, sau o EMB (hoc streptomycin) co th c giam xung
va INH, RIF, PZA va tip tuc hoan thanh giai oan u tin nay.
iu tr duy tr ph bin nht bao gm thm 16 tun INH va RIF, at c
mt tiu chun toan b cua 6 thang iu tr bnh lao phi. Bnh nhn co nguy
c tai phat cao (lao hang hoc mu nui cy dng tnh sau 2 thang iu tr) nn
c iu tr vi tng s 9 thang.
Sau t nht 2 tun iu tr hang ngay, dung thuc ngt quang (hai hoc ba ln mt
tun liu iu chnh) co th c cn nhc nh la mt phn cua s giam sat DOT
cua cac s y t cng cng.
Nu khang INH la d liu tai bt ky im nao, th nn ngng s dung INH; va
RIF, PZA va EMB tip tuc s dung trong sut thi gian con lai cua iu tr. Vi
khun ch khang INH co th c iu tr hiu qua vi mt phac 6 thang nu
co s dung ngay t u, bn thuc tiu chun gm INH, RIF, PZA va EMB hoc
streptomycin.
iu tr cho bnh lao a khang thuc c nghin cu t hn, vic tham khao
y kin mt chuyn gia trong vic iu tr bnh lao c khuyn khch manh me.
Bnh ngoai phi ngi ln co th c x ly theo cach tng t nh bnh phi,
vi phac 6 n 9 thang. Lao mang nao nn c iu tr 912 thang.
Phu n co thai khng nn dung PZA hoc streptomycin va cn c iu tr vi
phac 9 thang. INH, RIF, va EMB, vi pyridoxine, nn c dung trong giai
oan 8 tun u. Nu phn lp vi khun chng minh la INH nhay cam, EMB co
th dng lai vi s tip ni cua INH va RIF cho phn con lai cua iu tr.
Glucocorticoids vn con gy nhiu tranh cai trong vic quan ly bnh lao nhng
no a c s dung kt hp vi cac thuc chng lao iu tr cac bin chng e
doa tnh mang nh vim mang ngoai tim (Circulation 2005;112:3608) va vim
mang nao (N Engl J Med 2004;351:1741). Cac phac a bao gm prednisone 1
mg/kg (ti a 60 mg) ung hang ngay hoc dexamethasone 12 mg IV hang ngay
giam dn liu sau vai tun.
Theo doi ap ng iu tr. Nhng bnh nhn co AFB m dng tnh trc khi
iu tr cn phai gi mu m AFB va nui cy trong mi 12 tun cho n khi
xet nghim m tm AFB tr nn m tnh. m nn c ly sau o hang thang
cho n khi hai mu nui cy m tnh lin tip. Vic chuyn ao mu nui cy
t dng tnh sang m tnh la ch s ang tin cy nht cua ap ng iu tr. Cac
triu chng khng giam hay xet nghim dng tnh vi AFB m keo dai hoc
cac mu nui cy sau 3 thang iu tr nn tng nhng nghi ng v s khang thuc
hoc khng tun thu iu tr va nn tham khao mt chuyn gia trong vic iu tr
bnh lao.
Theo doi cac phan ng bt li. Hu ht bnh nhn nn lam cac xet nghim
c ban khi bt u iu tr bao gm cac enzym gan, bilirubin, cng thc mau
(complete blood counCBC) va creatinine huyt thanh. Theo doi v cn lm sang
thng xuyn la khng cn thit vi nhng bnh nhn co gia tr ban u bnh
thng, ngoai tr trong trng hp nhim HIV (c bit nu c iu tr khang
virus ng thi), lam dung ru, bnh gan man tnh hoc mang thai. anh gia
lm sang hang thang vi yu cu cu th v cac triu chng cua nhim c thuc
la rt cn thit. Bnh nhn dung EMB nn c kim tra th lc va nhn thc mau
o-xanh hang thang.
Nhim bnh lao tim n
Nhim lao tim n (Latent TB infectionLTBI) xay ra khi mt ngi nao o a
c tip xuc vi khun lao, khi c ch ra bng mt xet nghim tuberculin
da (tuberculin skin testTST) dng tnh hoc xet nghim giai phong interferon
Nhim trng ng h hp di Lao phi l 633
gamma (interferon gamma release assayIGRA) nhng khng co du hiu hoc

triu chng cua bnh hin ang hoat ng.
Cac tiu ch cho mt xet nghim dng tnh da vao ng knh ti a cua cuc
sn (khng ban o):
Cuc sn 5-mm c xem la dng tnh bnh nhn b nhim HIV hoc la mt
khim khuyt khac cua h min dch trung gian t bao, cac tip xuc gn vi
trng hp mc lao phi, nhng bnh nhn chup X-quang ngc co biu hin
cua bnh lao c cha lanh va nhng ngi co cy ghep ni tang hay c ch
min dch khac.
Cuc sn 10-mm c xem la biu hin dng tnh vi nhng ngi nhp c t
cac khu vc co ty l cao (chu A, chu Phi, My Latinh, ng u), cac tu nhn,
nhng ngi v gia c s dung ma tuy, ngi sng trong vin dng lao, ngi
co thu nhp thp, cac bnh nhn mc bnh man tnh va nhng ngi co s chnh
lch gia sc khoe va tnh trang v kinh t va nhng ngi co tip xuc thng
xuyn vi cac nhom nay (v.d., nhn vin chm soc sc khoe, bao v nha tu).
Cuc sn 15-mm c xem la du hiu TST dng tnh nhng ngi khoe
manh khng nm trong mt nhom ty l cao.
Nu khng iu tr, khoang 5% s ngi co bnh lao tim n phat trin thanh
bnh lao thc trong vong 2 nm nhim bnh. Bnh lao xay ra thm 5% s
ngi co bnh lao tim n nhng nm sng con lai cua ho. iu tr d phong
y u co th lam giam ang k nguy c mc bnh.
Thuc phong ly nhim bnh lao tim n
iu tr d phong cho LTBI nn c dung ch sau khi loai tr c giai oan
bnh ang hoat ng bi mt anh gia phu hp (chup X-quang ngc, ly m,
hoc ca hai). INH 300 mg ung hang ngay trong 9 thang nn dung cho ngi co
LTBI co yu t nguy c tin trin thanh bnh lao hoat ng, bt k tui nao.
Cac yu t nguy c cho s tin trin bao gm s chuyn i TST trong vong 2
nm cua mt TST m tnh; mt tin s cua bnh lao khng c iu tr hoc
bng chng chup X-quang ngc cho thy tn thng bnh cu; nhim HIV, ai
thao ng, bnh thn giai oan cui, bnh thiu mau ac tnh hoc khi tn sinh
dang li lympho ac tnh, cac tnh trang gy ra sut cn nhanh, suy dinh dng
man tnh, bui phi silic, hoc bnh nhn ang c iu tr liu phap c ch
min dch va cac thanh vin trong gia nh va ngi thn cn khac cua bnh
nhn co mt phan ng TST.
Ngi nhim HIV hay cac bnh suy giam min dch nghim trong khac (v.d.,
cy ghep), ma co tip xuc vi mt bnh nhn b bnh lao nn c iu tr cho
LTBI bt k co TST hay khng.
Phac thay th mi mt thi gian ngn hn nhng c tnh co cao nn c
trao i vi cac chuyn gia v bnh lao (N Engl J Med 2011;365:2155).
Gii thiu n cac c quan y t cng cng i vi nhng ngi iu tr d phong

bnh lao tim n c khuyn cao am bao s tun thu va giam sat i vi
cac bin chng lin quan n thuc.
NHIM TRNG NG TIU HA V D DY
Vim phc mc
I CNG
Vim phuc mac nguyn phat hoc t phat do vi khun (spontaneous bacterial
peritonitisSBP) la mt bin chng thng gp cua bnh x gan c trng va cn
c loai tr trong bt ky bnh nhn tran dch mang bung va st hoc bnh ly mt
bu khac bao gm bnh nao, suy thn va chay mau ng tiu hoa. M. tuberculosis
va Neisseria gonorrhoeae (hi chng Fitz-Hugh-Curtis phu n) cung i khi
gy ra vim phuc mac nguyn phat nhng bnh nhn co nguy c.
Vim phuc mac th phat c gy ra bi mt v tr thung tang trong ng tiu
hoa hoc ng sinh duc hoc lan truyn t mt nhim trung ni tang, thng
cn mt phu thut ngoai khoa bung cp cu. Tn thng do rt nhiu loai vi
khun khac nhau.
Vim phuc mac lin quan ti loc mang bung c cp Chng 13, Bnh ly
thn.
CHN ON
Biu hin lm sng
Cac du hiu va triu chng co th khng xut hin nhng bnh nhn SBP, do
vy, vic choc hut chn oan nn c thc hin tt ca nhng bnh nhn nhp
vin do x gan c trng hoc chay mau ng tiu hoa, bnh ly nao gan hoc giam
chc nng gan/thn. (Gut 2012;61:297).
Test chn on
Chn oan SBP c thc hin bi vic gi dch c trng nui cy (ly bnh
phm trc tip tai ging), m t bao va vi phn. SBP c chn oan khi dch
c trng co >250 neutrophils.
Chn oan vim phuc mac th phat c thc hin trn lm sang, b sung bng
nui cy mau (dng tnh t 20% ti 30%) va chn oan hnh anh anh gia kh
t do (thung) hoc nguyn nhn nhim trung khac.
Nhim trng ng tiu ha v d dy Nhim trng gan mt l 635
IU TR
iu tr ban u SBP, nui cy dch c trng kt qua m tnh (culture-negative
neutrophilic ascitesCNNA) khng co bng chng nhim khun trong dch
c chng (khi co di 250 t bao a nhn trung tnh trong dch c trng
[polymorphonuclear neutrophilsPMNs]) nn c thu hep nu cn nguyn gy
bnh c phn lp. Thi gian iu tr la 7 ngay, tuy nhin nn c keo dai
ti 2 tun nu vi khun vn tn tai. Tim albumin b sung tnh mach vao ngay
th nht va th ba cua iu tr co th cai thin kha nng sng sot (N Engl J Med
1999;341(6):403). Nu choc hut lp lai cho thy <250 PMNs va mu nui cy
tip tuc m tnh th iu tr co th rut ngn xung 5 ngay. D phong vim phuc
mac tin phat nn c bt u sau ln u mc vim phuc mac tin phat hoc
sau khi chay mau do gian tnh mach.
Vim phuc mac th phat chu yu oi hoi phai can thip phu thut. Cn iu tr
khang sinh ph rng va phu hp vi cn nguyn ngh n trong khi ch i cac
kt qua nui cy. iu tr chng nm theo kinh nghim thng khng c ch
nh. Vic hnh thanh ap-xe trong bung la mt bin chng cua vim phuc mac
th cp thng oi hoi phai dn lu. Khang sinh thng c tip tuc s dung
cho n khi khng thy cac ap-xe theo chn oan bng hnh anh (Bang 145).
Nhim trng gan mt
I CNG
Vim tui mt cp tnh thng c bt u bng cn au qun mt lin quan
n soi mt va cac biu hin c trng la st, goc phn t pha trn bn phai (right
upper quadrantRUQ) tng nhay cam vi du hiu Murphy va oi ma. Vim tui
mt khng do soi xay ra 5% n 10% cac trng hp. Cac sinh vt nay thng
la h vi sinh vt ng rut bnh thng. Tng bach cu va tng nhe cua bilirubin,
transaminase va phosphatase kim la co th.
Vim ng mt thp co th tc mt cp tnh, thng keo theo vim tuy hoc
vim tc mt.
CHN ON
Biu hin lm sng
Cac biu hin in hnh la tam chng Charcot vi st, au ha sn phai va vang
da va mt; cac triu chng ngoai ra khac cua mt nhn thc va ha huyt ap (ngu
chng Reynolds) canh bao cn can thip nhanh chong. Nhim trung huyt va
shock la biu hin ph bin.
Bng 145 iu tr theo kinh nghim vim phc mc
Liu php tim

tnh mch
Bnh Tc nhn ph bin kinh nghim Lu
Vim phc mc th pht H vi khun ng lactam/ Lun lun

(au bng cp) rut (vi khun cht c ch theo di
ng rut gram lactama hoc cc v tr v
m, gram dng, cephalosporin cn nguyn
vi khun ym kh) th h th 3 nhim
hoc th 4 + trng; iu
metronidazole/ tr trong
clindamycinb vng t 5
hoc ti 7 ngy
carbapenemc sau phu
thut.
Vim phc mc do nm Candida spp. Anidulafungin hoc iu tr trong

hoc p-xe voriconazole vng 2 tun
hoc
itraconazoled
Lao mng bng Mycobacterium iu tr tng t
tuberculosis nh lao phi
Vim phc mc do vi khu- Xem chng 19,
n nguyn pht hoc Bnh l gan
th pht
Vim phc mc lin quan Xem chng 13,
ti lc mng bng Bnh l thn
Hi chng Fitz-Hugh- Xem chng cc
Curtis bnh ly truyn
qua ng tnh
dc trong iu
tr Neisseria
gonorhea lan ta
aTicarcillimclavulanate 3,1 g 6 gi/ln; piperacillintazobactam 3,375 g 6 gi/ln hoc 4,5 g 8 gi/
ln; ampicillinsulbactam 3 g 6 gi/ln.
bV d, ceftriaxone 1 g 24 gi/ln cng vi metronidazole 500 mg 8 gi/ln hoc clindamycin 600 ti
900 mg 8 gi/ln.
cErtapenem 1 g 24 gi/ln; imipenem 500 mg 6 gi/ln; meropenem 1 g 8 gi/ln; doripenem 500 mg
8 gi/ln.
dAnidulafungin 200 mg x 1, sau l 100 mg IV 24 gi/ln; voriconazole 6 mg/kg IV 12 gi/ln 1 ngy,
sau 4 mg/kg IV 12 gi/ln; itraconazole 200 mg ung 12 gi/ln.
TB, bnh lao.
Nhim trng khc Vim ti tha l 637
Tng tnh nhay cam va chng lai khi thm kham ha sn phai la du hiu ph
bin. Du hiu Murphy co th hu ch nu khi kham khng thy tng tnh nhay
cam vung bung.
Test chn on
Xet nghim chc nng gan (Liver function testLFT) bt thng la nghim trong.
Chn oan nhim trung ng mt thng c thc hin bng cac ky thut
hnh anh, siu m la cac phng thc chnh. Quet axit Technetium-99m-hydroxy
iminodiacetic, chup CT co th cung hu ch (N Engl J Med 2008;358(26):2804).
Ni soi mt tuy ngc dong (Endoscopic retrograde cholangiopancreatography
ERCP) cho phep chn oan cung nh can thip iu tr trong trng hp co tc
ng mt chu va cn c xem xet nhng bnh nhn co ng mt chu b gian,
vang da va vang mt hoc LFT bt thng.
IU TR
X tr vim tui mt cp bao gm truyn dch, nhn n ung, giam au va phu
thut. Hay cn nhc vic s dung khang sinh sau khi phu thut nhng bnh nhn
nhe khi ho co th giam cac nguy c nhim trung sau phu thut, c bit nhng
trng hp tui cao, bnh nng va cac bin chng nh thiu mau hoc thung tui
mt, vim phuc mac, nhim khun huyt phai dung khang sinh ph rng. Phu
thut cp cu thng cn thit nhng bnh nhn nng, tuy nhin phu thut cung
co th tr hoan ln ti 6 tun nu co ap ng ban u.
C s chnh cua vic iu tr i vi vim ng mt la chm soc h tr tch cc
va phu thut hoc ni soi va dn lu. S dung khang sinh ph rng la bt buc.
S tin trin cua ap-xe la mt bin chng va oi hoi cn phai lam phu thut
dn lu. (Bang 146).
NHIM TRNG KHC
Tiu chay do nhim khun (xem chng 18, Bnh ly ng tiu hoa).
Vim gan virus (xem chng 19, Bnh ly gan).
Bnh co lin quan tiHelicobacter pylori (xem chng 18, Bnh ng tiu
hoa bnh).
Vim ti tha
I CNG
Cn nguyn la trc khun ng rut gram m va vi khun ky kh.
Bng 146 iu tr theo kinh nghim vim ng mt v vim ti mta
Tc nhn Liu php tim tnh mch

Bnh ph bin kinh nghim Lu
Vim ti mt Escherichia coli lactam/cht c iu tr trong

Klebsiella ch lactamb hoc vng 34 ngy
Enterococcus fluoroquinolonec hoc sau phu thut
Enterobacter cephalosporin th h 3 + hoc 57 ngy
metronidazole/clindamycind nu khng c
hoc carapeneme nu nng ct ti mt.
hoc c nguy c khng
cao
Vim ng mt E. coli lactam/lactam hoc i hi s gii p
Klebsiella carbapenem hoc ng mt
Enterococcus tigercyclin (100 mg x 1, iu tr 47 ngy
Enterobacter sau 50 mg mi 12 gi) sau khi gim
tc nghn
aClin Infect Dis 2003;37:997.
bTicarcillinclavulanate 3,1 g mi 6 gi; piperacillintazobactam 3,375 g mi 6 gi hoc 4,5 g mi 8
gi; ampicillinsulbactam 3 g mi 6 gi.
cCiproflacin 400 mg mi 12 gi; levofloxacin 500 mg mi 24 gi; moxifloxacin 400 mg mi 24 gi.
dV d, ceftriaxone 1 g mi 24 gi cng vi hoc metronidazole 500mg mi 8 gi hoc clindamycin 600
ti 900 mg mi 8 gi.
eErtapenem 1 g mi 24 gi; imipenem 500 mg mi 6 gi; meropenem 1 g mi 8 gi; doripenem 500
mg mi 8 gi.
CHN ON
Vim tui tha biu hin ban u la au bung di goc phn t bn trai va st. Tao
bon la du hiu ph bin.
Chn oan da vao lm sang, tuy nhin chup CT bung/chu hng co th hu ch
loa tr cac ap-xe canh ai trang va c khuyn cao la phng phap chn oan
hnh anh ban u.
IU TR
Phac iu tr tiu chun cho vim tui tha nhe la TMP-SMX (Trimethoprim-
sulfamethoxazole) 160 mg/800 mg DS ung 2 ln/ngay hoc ciprofloxacin 500
ung 2 ln/ngay kt hp vi metronidazole 500 mg ung 2 ln/ngay trong vong 7
ti 10 ngay. Khang sinh ph rng s dung (vim phuc mac th phat), trong o co
th bao gm mt -lactam/cht c ch -lactam va phu thut can thip c cn
nhc trong trng hp nng hn (N Engl J Med 2007;357(20):2057).
Nhim trng ng sinh dc Nhim trng ng tit niu di l 639
Vim rut tha
CHN ON
Cac du hiu in hnh vi au bung m h kem theo la cn au tai ch goc
phn t pha bn phai (right lower quadrantRLQ) cua bung va cac du hiu va
triu chng cua vim phuc mac th cp.
Cung nh chn oan vim tui tha, chn oan thng da vao triu chng lm
sang.
IU TR
iu tr la phu thut, thng iu tr liu phap khang sinh b tr nh i vi vim
phuc mac th cp.
NHIM TRNG NG SINH DC
Phng phap chn oan va iu tr nhim trung niu sinh duc ngi ln c xac
nh bi s khac bit gia gii tnh, s phi nhim khang sinh trc va can thip
cua cac dung cu y t.
Nhim trng ng tit niu di
CHN ON
Biu hin lm sng
Nhim trung ng tit niu di (urinary tract infectionsUTIs) c c trng
bi hin tng ai mu va nhim khun, thng kho tiu, tnh trang cn i tiu
gp, hoc tn sut i tiu nhiu. Thng khng co st tr khi vim thn-b thn.
Tiu kho nhng khng i tiu ra mu trong bnh nhn co hoat ng tnh duc canh
bao cac nhim trung ly truyn qua ng tnh duc.
Test chn on
Chn oan gia nh nhanh chong co th c thc hin bng vic phn tch nc
tiu (urinalysisUA) hoc soi ti mu, keo si, mu nc tiu v khun gi y co
mu (leukocyte esterase dng tnh hoc >8 leukocytes mi vi trng phong ai
ln [high-power field]) hoc nhim khun (nitrit dng tnh hoc >1 sinh vt mi
vi trng vt knh ngm du [oil-immersion field]). Mt mu nc tiu nhum
Gram co th hu ch trong vic hng dn la chon khang sinh ban u. Mu nui
cy nh lng thng >105 vi khun/mL, tuy nhin m khun lac co 102 ti 104
vi khun/mL co th ch ra nhim trung phu n b kho tiu cp tnh.
Mt phat hin ngu nhin tm thy nhim khun tit niu khng triu chng
co y ngha lm sang han ch ngoai tr phu n co thai hoc bnh nhn a trai qua
phu thut niu (Clin Infect Dis 2005;40:643).
Vim bang quang khng bin chng phu n. Mu nui cy nc tiu trc
khi iu tr c khuyn ngh cho nhng bnh nhn tiu ng, cac bnh nhn co
triu chng trn 7 ngay, cac bnh nhn co tai phat nhim trung ng tiu, phu n
s dung mang chn tranh thai va nhng ngi trn 65 tui. iu tr nn keo dai
trn 7 ngay trong nhom bnh nhn nay. Nhim trung chu yu gy ra bi E. coli
(80%) va Staphylococcus saprophyticus (5% n 15%).
Vim bang quang tai phat phu n. Cac nhim trung lp lai thng la tai
nhim hn la do tai phat, cac yu t do t chc phu thuc vao cac yu t nguy c,
iu nay khac nhau gia phu n tre, phu n man kinh khoe manh va nhng ngi
ln tui.
Nhim trung ng tiu bin chng. UTIs kt hp vi cac bt thng giai phu;
chc nng trao i cht, va cac bt thng v h min dch; mang thai; tiu trong
ng thng hoc cac mm bnh khac thng c goi la bin chng. Cy nc
tiu trc va sau iu tr la cn thit va cn iu tr khang sinh ph rng trong 10
n 14 ngay. Cn rut bo nhng vt liu nhn tao.
UTIs nam gii. Vim bang quang khng ph bin nam gii tre tui. Co th
khng cn thit phai tm cac bt thng giai phu va cac nhim trung qua ng
tnh duc nn c cn nhc khi chn oan thay th. Cac yu t nguy c bao gm
giao hp qua ng hu mn va khng ct bao quy u. Vim tin lit tuyn la
nguyn nhn thng gp cua nhim trung tiu tai phat nam gii.
Nhim trung lin quan ti ng thng (cathete). La mt ngun nhim khun
gram m ph bin nhng bnh nhn iu tr ni tru va thng do a vi khun.
Thi gian t ng thng la yu t nguy c ln nht.
Hi chng vim niu ao cp tnh la mt hin tng xay ra phu n nhng
ngi co cac nhim trung ng tiu di va ai ra mu vi <105 vi khun/mL
nc tiu. Nhng bnh nhn nay co th b vim bang quang do vi khun hoc
vim nim ao do Chlamydia trachomatis, Ureaplasma urealyticum hoc N.
gonorrhoeae vi tn sut t hn. Mu nui cy dch trong c t cung cho cac bnh
ly truyn qua ng tnh duc nn c thc hin (xem muc cac bnh ly truyn
qua ng tnh duc). Nu khng co nguyn nhn cu th nao c ghi nhn, iu
tr theo kinh nghim vi doxycycline 100 mg ung 2 ln/ngay trong 7 ngay hoc
azithromycin 1 g ung mt liu duy nht c khuyn ngh.
Vim tuyn tin lit cp tnh thng la mt cn bnh h thng nghim trong
c c trng bi cac triu chng st, n lanh, kho tiu, mm va au tuyn tin
lit khi thm kham. Chn oan thng c da trn kham bnh va nhum Gram
mu nc tiu va nui cy. S nn tuyn tin lit khng cn thit hoc khng
c khuyn ngh chn oan vim tin lit tuyn cp tnh. Vi khun gram m
ng rut la nhng vi sinh vt gy bnh thng thng.
Vim tin lit tuyn man tnh co th biu hin nh au lng di, m h, au
tng sinh mn, tinh hoan, dng vt; kho tiu, au khi xut tinh, nhim trung
ng tiu tai phat vi cac sinh vt tng t hoc tinh dch co mau. Vim tin lit
tuyn thng do vi khun; chn oan oi hoi phai xac nh c nguyn nhn gy
bnh t cac mu nui cy nc tiu trc va sau khi co bop tuyn tin lit (Tech
Urol 1997;3:38). Cn nguyn gy bnh tng t nh vim cp. Siu m qua trc
trang la ch hu ch nu b nghi ng co ap-xe.
Vim mao tinh hoan biu hin nh au bu mt bn vi mao tinh hoan sng va
mm khi kham. Khun gy bnh thng la N. gonorrhoeae va C. trachomatis
nam gii tre tui co sinh hoat tnh duc va sinh vt ng rut gram m nhng
ngi an ng ln tui. Chn oan va iu tr nn c hng dn theo dch t
hoc nay vi ceftriaxone va doxycycline nam gii tre tui va TMP-SMX hoc
ciprofloxacin nam gii trn 35 tui.
IU TR
Xem chi tit tai Bang 147
Vim bang quang khng bin chng phu n. Mt liu trnh iu tr 3 ngay bng
khang sinh theo kinh nghim c khuyn cao cho nhng phu n co triu chng
ai mu.
Vim bang quang tai phat phu n
Phac iu tr vim bang quang n gian la se thanh cng trng hp tai
phat. Tai phat bnh do cac sinh vt nhim mm bnh xay ra trong vong 2 tun
ngng iu tr th nn c iu tr trong 2 tun va co th ngh ti bt thng
ng tit niu
iu tr d phong cho bnh nhn tai nhim thng xuyn nn c bt u ch
sau khi co kh trung nc tiu vi mt phac iu tr chun. Mt bin phap
tranh thai co th lam giam tn sut tai nhim phu n a s dung mt mang va/
hoc cht dit tinh trung. Phac iu tr d phong co th c s dung lin tuc,
sau khi co hoat ng tnh duc, hoc t bt u.
Nhim trung ng tiu nam gii. iu tr bng mt phac khang sinh
thng thng nh iu tr vim bang quang phu n nn c duy tr y u
trong vong 7 ngay. Nu nh co ap ng vi iu tr ngay tc thi, th vic anh
gia h tit niu la co th khng hu ch. Cac nghin cu v h tit niu la phu hp
khi khng co yu t nguy c tim n c xac nh, khi iu tr tht bai, trong
trng hp nhim khun tai phat hoc khi vim b thn xay ra.
Bng 147 iu tr theo kinh nghim vi nhim trng ng niu
Bnh Liu php iu tr Lu
Vim bng quang Hng u: TMPSMX DS PO La chn khng sinh da vo cc

n gin (Clin 2 ln/ngy hoc TMP (nu du hiu nhy cm ti ch.
Infect Dis 2011; d ng sulfa) 100 mg PO 2 iu tr thng trong 3 ngy.
52: e103) ln/ngy; duy tr s dng Liu php m rng ti 7 ngy
nitrofuratoin 100 mg PO 2 cho nhng bnh nhn i tho
ln/ngy (x 37 ngy) hoc ng v ln tui, trnh s
fosfomycin 3 g PO liu n. dng TMPSMX ph n ln
Thay th: Ciprofloxacin 250 tui.
mg PO 2 ln/ngy hoc Fosfomycin c hiu qu thp hn
nofloxacin 400 mg PO 2 cc nhm thuc oc khuyn
ln/ngy vi cc triu chng ngh khc; cn trnh nu nghi
nng hoc da vo cc du ng vim thnb thn cp
hiu khng thuc. tnh.
Vim bng quang Nh vim bng quang n Thn trng vi vim ng tit
n ng (J gin ph n vi ngoi tr niu ti pht hay vim thn-b
Antimicrob nitrofurantoin, khng nn thn.
Chemother s dng (khng t c
2000; 46 (suppl nng m ng tin cy).
1); 23-27) iu tr trong 7 ngy.
Vim bng quang D phng sau quan h: TMP Ung nc p qu cranberry (nam
ti pht (N SMX SS x 1 hoc cipro- vit qut), estrogen t ti m
Engl J Med floxacin 250 mg x 1 hoc o ph n mn kinh, v bi
2003;349:259) nitrofurantoin 100 mg x 1. tit sau khi giao hp c th
D phng tip tc: TMPSMX c tc dng ngn nga UTI ti
0,5 SS 1 ln/ngy hoc cch pht.
ngy x 6 thng hoc nitrofu-
rantoin 50100 mg mi ti
trc khi i ng 6 thng.
T iu tr gin on: TMPSMX
DS ung 2 ln/ngy x 3 ngy
hoc ciprofloxacin 250 mg
ung 2 ln/ngy x 3 ngy.
Mang thai Nitrofurantoin 100 mg ung iu tr tt c nhim khun khng
(Cochrane 4 ln/ngy x 7 ngy hoc triu chng ph n mang
Database Syst cephalexin 200500 ng ung thai. Ly mu nc tiu vi ph
Rev 2011;19: 4 ln/ngy x 7 ngy hoc n mang thai k cui hoc tam
CD002256) cefuroxime axetil 250 mg c nguyt u tin (Clin Infect
ung 4 ln/ngy x 7 ngy. Dis 2005;40:634-654).
(cn tip)
Bng 147 iu tr theo kinh nghim vi nhim trng ng niu (Tip theo)
Bnh Liu php iu tr Lu
UTI bin chng T nh ti trung bnh: FQa th Da vo iu tr theo kinh nghim

(N Eng J Med h th hai. bao ph cc vi khun nhy cm
31993; 329; Bnh nng, FQ gn y v liu php ph hp khi mm
1328) hoc ngi gi: Cefepime bnh c xc nh. Liu php
2 g IV 12 gi/ln hoc duy tr trong 10 ti 14 ngy
cephalosporinb th h 3 nhng c th c cn nhc
hoc carbapenemc hoc rt ngn nu cc yu t bin
piperacillintazobactam th chng c gii quyt (v d:
h th 3 3,3754,5 g IV 6 loi b dng c trn c th
gi/ln. Cn nhc s dng hoc si).
thm vancomycin iu tr
theo kinh nghim vi cu
khun Gram dng.
Candida niu Candida albicans: Fluconazole Loi b ng thng nu c
(Clin Infect Dis 100200 mg ung hng Chng ch nh iu tr:
2004;38:161) ngy trong 7 ti 14 ngy. Cc triu chng ca i m,
Bnh nng hoc cc chng phn cng, mang thai, gim
khng phi albicans: bch cu, cy ghp thn, trc
amphotericin B x 510 ngy phu thut ng tit niu
hoc nguy c bnh lan ta.
Vim thnb thn Bnh nhn ngoi tr: FQa th iu tr ng tnh mch khi ht
(Clin Infect Dis h 2 st trong 48 gi, sau i
2004;38:161) Bnh nhn ni tr: FQa th h thnh ung hon ton trong 14
th 2 hoc aminoglycoside ngy. Cn nhc liu n IV, sau
hoc ampicillinsulbactam l liu php ng ming
12 g IV 6 gi/ln hoc bnh nhn ngoi tr giai
cephalosporinb th h 3 on n nh.
Mang thai: Cefazolin 1 g IV 8 Khng s dng flouroquinolones
gi/ln hoc ceftriaxone 1 trng hp mang thai.
g IV hoc tim bp 24 gi/
ln hoc piperacillin 4g IV 8
gi/ln
aQua ng ming: Ciprofloxacin 500 mg PO 2 ln/ngy; ofloxacin 200 mg PO 2 ln/ngy; levofloxacin
500 mg PO hng ngy; norfloxacin 400 mg PO 2 ln/ngy. Ngoi ng rut: Levofloxacin 500 mg IV
hng ngy; ciprofloxacin 400 mg IV mi 12 gi.
bCefotaxime 1 hoc 2 g IV mi 8 gi; ceftriaxone 1 g IV hng ngy; ceftazidime 1 n 2 g IV mi 812 gi.
cImipenem 500 mg IV mi 6 gi; meropenem 1 g IV mi 8 gi.
dGentamicin hoc tobramycin 2 mg/kg liu np IV, sau 1,5 n 3,0 mg/kg/ngy hoc chia liu.
DS, vin liu gp i; FQ, fluoroquinolone; GU, genitourinary, tit niu; IM, tim bp; IV, tim tnh mch;
PO, ung; SS, single strength, vin liu bnh thng; TMP, trimethoprim; TMPSMX, trimethoprim
sulfamethoxazole; UTI, nhim trng ng tit niu di.
Nhim khun do t ng thng

iu tr thng khng c ch nh iu tr trng hp nhim trung khng
triu chng ngoai tr trong trng hp khng co thai, suy giam min dch, hoc
a d kin phu thut h tit niu. Nhim trung ng tiu co triu chng do
t ng thng nn c loai bo ngay hoc thay i ng thng, thu thp cac mu
nui cy mau va nc tiu va iu tr trong vong 710 ngay bng khang sinh
thch hp cho cac bin chng do nhim trung ng tiu.
Nhim candida mau khng nn iu tr tr khi bnh nhn co suy giam min dch
va co nguy c cao i vi nhim candida mau, hoc co nhng triu chng nh
ai mu va khng bit v cn nguyn vi khun. Hoc mt khac ti u hoa vt chu
(v.d., kim soat ng huyt bnh nhn tiu ng, loai bo hoc thay i ng
thng Foley) la u.
Cac bin phap phong nga bao gm s dung ky thut v trung trong qua trnh
chen ng thng tiu, s dung mt h thng thoat nc khep kn, va loai bo kp
thi cac ng thng khi khng cn thit.
nhng bnh nhn co ng thng t bn trong, s phat trin cua vi khun niu
la khng th tranh khoi, va vic c ch khang sinh keo dai th ch cn chon
cho vi khun a khang thuc. Nhng bnh nhn nay ch nn c iu tr bng
khang sinh toan thn khi b nhim trung va co triu chng ai mu.
iu tr vim tuyn tin lit cp do vi khun cn t 24 tun hoc ciprofloxacin
500 mg ung 2 ln/ngay hoc TMP-SMX 160 mg/800 mg (DS) 2 ln/ngay. Mu
nui cy dng tnh cua vim tuyn tin lit man tnh do vi khun nn c iu
tr keo dai (t nht 6 tun vi fluoroquinolone hoc 3 thang vi TMP-SMX).
Vim thnb thn
I CNG
Biu hin lm sng
Bnh nhn co st, au sn va cac triu chng nhim trung ng tiu di v
nguyn nhn thng bt ngun t y.
Tiu kho ma khng ai ra mu trn bnh nhn hoat ng tnh duc nn xem xet ti
cac nhim trung qua ng tnh duc.
Test chn on
Mu nc tiu c c trng bi cac du hiu nhim khun ang k nh ai mu,
cac t bao hng cu (red blood cellsRBCs) va thnh thoang co bach cu phi.
Chn oan nn bao gm nui cy mu nc tiu trong tt ca cac bnh nhn.
Cy mau nn c ly nhng ngi phai nhp vin v nhim trung mau co
Nhim trng qua ng tnh dc, lot sinh dc Bnh herpes l 645
th co mt trong 15% n 20% cac trng hp. Tac nhn gy bnh la E. coli, S.
saprophyticus him gp hn la Proteus sp. Ban u se khng cn thm cac xet
nghim khac, tuy nhin s hin din cua cac sinh vt khac co th gi y mt bt
thng giai phu hoc s suy giam min dch.
IU TR
Xem chi tit Bang 147
iu tr cho bnh nhn t nhe ti trung bnh, nhng ngi co kha nng ung
thuc co th iu tr ban u nhng bnh nhn ngoai tru mt cach an toan.
Nhng bnh nhn nng, nhng ngi b bun nn, nn va nhng bnh nhn
mang thai nn c iu tr ban u vi liu phap tim hoc truyn tnh mach.
LU C BIT
anh gia cac bt thng giai phu nn c thc hin nhng bnh nhn khng
ap ng vi iu tr kinh nghim ban u trong vong 48 gi. S xut hin cua
mt bt thng giai phu nh ap-xe thn hoc giai phu thn nn c anh gia
bng siu m, chup CT hoc chup niu tnh mach (intravenous pyelogramIVP)
(Bang 147).
NHIM TRNG QUA NG TNH DC,

LOT SINH DC
Bnh herpes sinh dc
I CNG
Bnh herpes sinh duc c gy ra bi HSV, thng la loai 2, tuy nhin ty l HSV-1
b phn sinh duc ang tng ln.
CHN ON
Nhim trung thng co triu chng au b phn sinh duc va quanh hu mn gy
ra loet nhanh chong va hnh thanh tn thng nng tng nhay cam
Ly nhim ln u co th kem theo ni hach ben, st, au u, au c va vim
mang nao v khun; tai phat thng t nghim trong hn. Bnh nhn khng co
triu chng nn thng dn ti s truyn nhim bnh.
Khng nh nhim trung HSV oi hoi phai nui cy hoc PCR; tuy nhin, biu
hin lm sang thng la u chn oan.
IU TR
Xem bang 148 v cac la chon cua iu tr.
Bnh giang mai
I CNG
Giang mai c gy ra bi xon khun Treponema pallidum. Co mt mc ng
nhim HIV cao nhng bnh nhn mc bnh giang mai, v vy nhim HIV cn
c loai tr bng cac xet nghim thch hp (JAMA 2003; 290 (11):1510).
CHN ON
Biu hin lm sng
Giang mai nguyn phat phat trin trong vong vai tun tip xuc va biu hin nh
au mt hoc nhiu v tr, cng, loet b mt (sng).
Giang mai th phat tin trin t 410 tun sau khi ht vt sng va co th xut
hin phat ban, tn thng da va nim mac, hach va cac triu chng th tang.
Giang mai thi ky th ba gia 1 va 20 nm sau khi b nhim trung va bao gm
bnh ly tim mach, loet gm va bnh thn kinh (suy nhc c th, giang mai bin
chng thn kinh, hay giang mai mang nao cp).
Test chn on
Trong giang mai nguyn phat, soi bng knh hin vi nn en cac dch tit
v tr tn thng, co th cho thy xon khun. Mt xet nghim huyt thanh hoc
khng treponemal (v.d., trong phong th nghim RPR hay nghin cu bnh hoa
liu [venereal disease research laboratoryVDRL]) phai c xac nhn bng mt
xet nghim tm treponemal c hiu (v.d., nh huynh quang hp thu khang th
treponemail hoc ngng kt hat T. pallidum).
Chn oan bnh giang mai th phat c thc hin trn c s cac nghin cu
huyt thanh dng tnh va s hin din cua mt bnh canh lm sang tng thch.
Giang mai tim n xac nh bng mt chn oan huyt thanh trong trng hp khng
co triu chng bnh giang mai giang mai tim n gia oan u co huyt thanh
dng tnh <1 nm va giang mai giai oan cui la huyt thanh dng tnh >1 nm.
loai tr giang mai thn kinh, choc do tuy sng (lumbar punctureLP) nn
c thc hin khi co s hin din cua triu chng thn kinh hay cac du hiu mt
hoc thnh giac hay triu chng, bng chng cua bnh thi ky th ba, hoc tht
bai iu tr. Mt s chuyn gia khuyn ngh LP nhng bnh nhn nhim HIV
co RPR huyt thanh hoc VDRL 1: 32 hay vi CD4 <350 mm3 (Clin Infect Dis
2009,48:816). Dch nao tuy nn c lam VRDL.
Nhim trng qua ng tnh dc, lot sinh dc Bnh giang mai l 647
Bng 148 iu tr cc bnh ly truyn qua ng tnh dca
Bnh Phc khuyn ngh Phc thay th
Bnh lot sinh dc

Herpes simplex
Nhim ln u Acyclovir 400 mg ung 3 ln/
ngy x 710 ngy hoc 200 mg
ung 5 ln/ngy x 710 ngy
Valacyclovir 1 g ung 3 ln/
ngy x 710 ngy
Famciclovir 250 mg ung 3
ln/ngy x 710 ngy
Nhim ti pht Acyclovir 400 mg PO 3 ln/
ngy x 5 ngy hoc 800 mg PO
3 ln/ngy x 2 ngy
Valacyclovir 1 g ngy 1 ln
trong 5 ngy hoc 500 mg
ung 2 ln/ngy trong 3 ngy
Famciclovir 1 g PO 2 ln/ngy
x 5 ngy
Liu php c ch Acyclovir 400 mg ung 2 ln/
ngy
Valacyclovir 500 mg hoc 1 g
ung 1 ln/ngy
Famciclovir 250 mg PO 2 ln/
ngy
Bnh giang mai
Giai on u, th Benzathine penicillin G 2,4 triu D ng penicillin:
pht hoc tim n U tim bp liu n Doxycycline 100 mg ung
<1 nm 2 ln/ngy x 14 ngy
Tetracycline 500 mg ung
4 ln/ngy x 14 ngy
Tim n >1 nm, Benzathine penicillin G 2,4 triu Doxycycline 100 mg ung
tim n khng r U tim bp 1 ln/tun x 3 liu 2 ln/ngy x 28 ngy
thi gian Tetracycline 500 mg ung
4 ln/ngy x 28 ngy
(cn tip)
Bng 148 iu tr cc bnh ly truyn qua ng tnh dca (Tip theo)
Giang mai thn kinh Dung dch kt tinh penicillin G Procaine penicillin
1824 triu iu tr mi ngy 2,4 triu U tim bp 1 liu
1014 ngy hng ngy + probenecid
500 mg ung 4 ln/ngy x
1014 ngy
Mang thai Penicillin c khuyn co iu
trgii mn cm nu cn
Bnh h cam Azithromycin 1 g ung liu duy Ciprofloxacin 500 mg ung
nht 2 ln/ngy x 3 ngy
Ceftriaxone 250 mg tim bp Erythromycin base 500 mg
liu duy nht ung 2 ln/ngy x 7 ngy
Bnh ht xoi Doxycycline 100 mg ung 2 Erythromycin 500 mg
(Lymphogranuloma ln/ngy x 21 ngy ung 4 ln/ngy x 21 ngy
venereum)
Vim niu o/vim c t cung
Bnh lu (Gonorrhea Ceftriaxone 125 mg tim bp Nu d ng v khng c lu
GC) 1 ln hoc cefixime 400 mg hu hng, c th s dng
ung 1 ln) + (azithromycin spectinomycin 2 g tim
hoc doxycycline iu tr bp mt ln (khng c sn
chlamydia) Hoa K)
Fluoroquinolones khng
c khuyn khch
Nhim lu cu lan ta Ceftriaxone 1 g IV hng ngy
hoc cefotaxime 1 g IV mi 8
gi x 7 ngy
Chlamydia Azithromycin 1 g ung 1 liu Erythromycin base 500 mg
duy nht ung 4 ln/ngy x 7 ngy
Doxycycline 100 mg ung 2
ln/ngy x 7 ngy
Bnh vim chu hng
Bnh nhn ngoi tr Ceftriaxone 250 mg tim bp Cefoxitin 2 g tim bp +
1 ln + doxycycline 100 mg probenecid 1 g ung 1 ln
ung 2 ln/ngy x 14 ngy + c th c thay th cho
metronidazole 500 mg ung 2 ceftriaxone
ln/ngy x 14 ngy
(cn tip)
Nhim trng qua ng tnh dc, lot sinh dc Bnh giang mai l 649
Bng 148 iu tr cc bnh ly truyn qua ng tnh dca (Tip theo)
Bnh nhn ni tru (Cefoxitin 2 g IV 6 gi/ln Clindamycin 900 mg IV

hoc cefotetan 2 g IV 12 gi/ 8 gi/ln + gentamicin
ln) + doxycycline 100 mg 2 mg/kg liu ti, sau
ung 2 ln/ngy x 14 ngy + 1,5 mg/kg 8 gi/ln +
metronidazole 500 mg ung 2 doxycyline 100 mg ung
ln/ngy x 14 ngy 2 ln/ngy x 14 ngy
Ampicillinsulbactam 3 g
IV 6 gi/ln + doxycycline
100 mg ung 2 ln/ngy
x 14 ngy
Vim m o
Trichomonas Metronidazole 2 g ung liu n Metronidazole 500 mg
Tinidazole 2 g ung liu n ung 2 ln/ngy x 7 ngy
Mang thai Metronidazole 2 g ung x 1
(khng gy d dng thai)
Vim m o do vi Metronidazole 500 mg ung 2 Clindamycin 300 mg ung
khun ln/ngy x 7 ngy 2 ln/ngy x 7 ngy
Clindamycindng kem, 2% bi Clindamycin ovules
trong m o trc lc i ng 100 mg t trong m o
x 7 ngy x 3 ngy
Metronidazole gel 0,75% bi Tinidazole 2 g ung 1 ln/
trong m o 1 ln/ngy trong ngy x 2 ngy hoc 1 g
5 ngy ung 1 ln/ngy x 5 ngy
Nhim nm candida Fluconazole 150 mg ung 72 Intravaginal azoles trong
gi/ln x 23 liu 714 ngy
Nhim nm candida Fluconazole 100, 150 hoc
ti pht 200 mg ung 1 tun/ln x 6
thng
IM, tim bp; IV, tim tnh mch; PO, ung

MMWR 2010;59 (RR-12).
IU TR
Chi tit v cac loai iu tr xem Bang 148.
Bnh h cam
I CNG
Bnh ha cam c gy ra bi Haemophilus ducreyi.
CHN ON
Bnh ha cam tao ra mt vt loet b phn sinh duc gy au va sng hach ben co
mu.
Vic xac nh cac sinh vt gp kho khn va oi hoi phng tin nui cy c
bit.
IU TR
Chi tit iu tr xem Bang 148.
Bnh ht xoi
I CNG
Bnh ht xoai (Lymphogranuloma venereumLGV) c gy ra bi C. trachomatis
(serovars L1, L2, or L3).
CHN ON
Biu hin ging nh mt vt loet b phn sinh duc khng gy au, tip theo
la triu chng chng lp, hach ben. Vim trc trangai trang vi au va chay
dch co th xay ra khi giao hp qua ng hu mn (Clin Infect Dis 2007;44:
26).
Chn oan da vao lm sang khi co nghi ng va xet nghim khang th C.
trachomatis nu co sn.
IU TR
Nhim trng qua ng tnh dc, vim m o... Vim m o do vi khun l 651
NHIM TRNG QUA NG TNH DC,

VIM M O V NHIM KHUN M O
Vim m o do Trichomoniasis
CHN ON
Biu hin lm sng
Triu chng lm sang cua nhim trung do Trichomonas vaginalis bao gm chay
dch mu m ao, kho tiu va vim sinh duc.
Kham m ao cho thy chay dch nhiu va xut huyt t cung.
Test chn on
Chn oan oi hoi phai quan sat trc quan hoat lc trichomonads trn mt dung
dch mui lam t cua dch tit m ao. Khi PH dch m ao tng ( 4,5) mi co
th quan sat thy.
IU TR
Vim m o do vi khun
I CNG
Vic thay th cac lactobacilli thng thng vi nng cao cua cac vi khun ky kh
trong m ao dn n vim m ao do vi khun.
CHN ON
Ba trong s cac tiu ch sau y la cn thit chn oan:
Mu ng nht, mong, trng
S co mt cua cac t bao u mi khi kim tra bng knh hin vi
PH dch m ao tng (4,5)
Mui tanh kt hp vi chay dch m ao trc khi hoc sau khi b sung 10%
potassium hydroxide (KOH) (xet nghim mui)
IU TR
Nhim trng men nm m o
I CNG
Nhim trung nm Candida m ao (Vulvovaginal candidiasisVVC) thng khng
c coi la mt bnh ly truyn qua ng tnh duc nhng thng phat trin trong
trng hp s dung bin phap tranh thai ng ung hoc iu tr bng khang sinh.
Nhim khun tai phat co th la mt bnh canh cua ngi cha co xet nghim HIV.
CHN ON
Dch m ao day, ging nh pho mat kt hp vi vim m ao nng, nga va
thng kho tiu.
Chn oan xac nh oi hoi phai quan sat trc quan cac yu t nm dch tit m
ao a c thm potassium hydroxide.
IU TR
iu tr thng c thc hin trn c s cua cac biu hin lm sang (Bang 148).
Fluconazole tht bai co th ch ra s hin din cua cac chung nm khng phai
C. albicans.
Vim c t cung v niu o
I CNG
Vim c t cung va niu ao la cac biu hin thng xuyn cua nhim trung
N. gonorrhoeae hoc C. trachomatis va i khi la Mycoplasma hominis, U.
urealyticum va T. vaginalis. Cac bnh nhim trung thng cung tn tai va biu hin
lm sang co th ging ht nhau.
CHN ON
Biu hin lm sng
Phu n co vim niu ao, vim c t cung hoc ca hai, phan nan v vic chay dch
mu nhay m ao, au khi giao hp va kho tiu.
an ng b vim niu ao co th co kho tiu va co mu nhay chay ra dng vt.
Nhim trung lu cu lan toa (Disseminated gonococcal infectionDGI) co th
biu hin st, vim bao gn, tn thng da co mun mu va au a khp. DGI cung
co th biu hin ch nh vim khp nhim khun cua u gi, c tay hoc c chn
(xem Chng 25, Vim khp va bnh ly khp bnh).
Nhim trng qua ng tnh dc, vim m o... Bnh vim vng chu... l 653
Test chn on
Th nghim khuch ai axit nucleic dng tnh c thc hin trn tuyn mt
trong c t cung, m ao, niu ao (nam), hoc ngh ly mu nc tiu chn
oan C. trachomatis hoc nhim N. gonorrhoeae. Trong trng hp nhim N.
gonorrhoeae, nhum Gram cua dch tuyn c t cung hoc dch niu ao co hnh
anh song cu nm trong t bao vi khun gram m co th nhanh chong thit lp
chn oan. Nui cy co th c thc hin trn niu ao hoc mu gac tuyn c.
Ngoai cac nghin cu trc o, cac bnh nhn nghi ng DGI nn c ly mu
nui cy. Trong vic xac nh vim khp nhim khun, phn tch hoat dch va
nui cy c ch nh.
IU TR
Do vic gia tng sc khang, fluoroquinolones khng nn c s dung iu
tr nhim trung N. gonorrhoeae (MMWR 2010;59(RR-12):1) (xem Bang 148 cho
cac la chon iu tr).
Bnh vim vng chu hng
I CNG
Bnh vim vung chu hng (Pelvic inflammatory diseasePID) la mt bnh nhim
trung ng sinh duc trn phu n, thng bt u bng vim c t cung. Hu qua
lu dai do khng iu tr PID bao gm cn au man tnh, tng nguy c mang thai
ngoai t cung va v sinh.
CHN ON
Biu hin lm sng
Cac triu chng co th bao gm t cam giac kho chu vung chu va au khi giao hp
ti au bung d di kem theo st, trong o co th co cac du hiu phc tap cua hi
chng Fitz-Hugh-Curtis hoc ap-xe ng dn trngbung trng.
Test chn on
au c t cung khi kham hoc au phn phu va co s hin din cua t nht 10
bach cu mi vi trng phong ai thp (low-power field) trn mt mu tiu ban
cua dch m ao hoc dch c t cung a c thm dung dch mui phu hp vi
chn oan vim vung chu.
Xet nghim khuch ai axit nucleic hoc nui cy dch c t cung nn c ly
xac nh C. trachomatis hoc nhim trung N. gonorrhoeae.
Tt ca phu n c chn oan b PID nn c sang loc nhim HIV.
IU TR
Xem Bang 148.
Phu n b bnh nng, mang thai va nhim HIV co vim chu hng phai nhp vin.
Bnh nhn khng th chu ng c cac khang sinh ng ung cung cn nhp vin.
NHIM NM TON TH V VI KHUN KHNG

IN HNH
Biu hin lm sang thng hay bin i, khng c hiu. Cn ngh ti nhim nm
toan th nhng trng hp bnh nhn bnh phi man tnh, vim mang nao man
tnh, tn thng tiu xng, tn thng da man tnh, st khng ro cn nguyn, suy
giam cac dong t bao mau ma khng giai thch c cn nguyn. Trn bnh nhn
co suy giam min dch cung co th ngh ti cn nguyn nay nu co s tin trin mi
cua bnh ly phi, da, ay mt, triu chng vung u c, hoc st keo dai khng
ro cn nguyn.
Chn oan nm gy bnh cn da vao c im dch t (mt s b gii han v a
ly), v tr tn thng, ap ng vim, c im nm qua soi knh hin vi. Cac nhim
nm co th phc tap va kho iu tr, cn tham khao y kin cac nha truyn nhim.
iu tr cu th cac nhim nm, Nocardia, Actinomyces, xem Bang 149.
Nhim nm candida
I CNG
Nm candidas la nguyn nhn thng gp nht trong s cac loai nm phat trin
nhanh gy bnh ngi. Nhim trung do nm co biu hin a dang t vim nim
mac khng bin chng hoc bnh tin trin nhanh ti t vong do nhim bt c c
quan nao (Clin Infect Dis 2009;4:503). Nhim nm thng lin quan ti s dung
khang sinh, thuc tranh thai, iu tr c ch min dch va c t bao, va d vt trong
c th. Cac tn thng do nm ngoai da co th mt i nu loai bo cac yu t thun
li (v.d., iu tr khang sinh) hoc tn tai va tin trin trong trng hp c a co
suy giam min dch. Cac bin chng nng, nh nhim nm candida huyt dn ti
tn thng da, mt, ni tm mac va vim xng tuy.
CHN ON
Test chn on
Chn oan nhim nm candida da va nim mac thng thng co th da trn
kham lm sang, tuy nhin co th khng nh bng phan ng dch tit vi kali
Nhim nm ton th v vi khun... Nhim nm cryptococcus l 655
hydroxide. Trng hp bnh khng ap ng iu tr co th cy lai mu loai tr

cac nguyn nhn nm khng phai loai C. Albicans. Nhim nm candida xm ln
c khng nh bng cy mau hoc m.
IU TR
Nhim nm candida ngoai da nim mac thng ap ng tt vi iu tr tai ch,
nhng ng ung hoc thm ch ng tim cung co th c s dung phu thuc
vao mc nng va c a ngi bnh (xem Bang 149). Nhim nm candida
huyt va cac nhim nm xm nhp khac cn keo dai thi gian iu tr. Nhim
nm candida huyt lin quan ti catheter tnh mach (xem phn cac nhim trung
lin quan ti chm soc y t).
Nhim nm cryptococcus
I CNG
Cryptococcus neoformans la loai nm men phn b rng rai co trong t va phn chim
b cu. Bnh ly thng gp la vim mang nao (au u va ri loan y thc) va vim
phi (t tn thng dang nt khng triu chng ti suy h hp tin trin ti cp). Tn
thng da do nm cryptococcus cung co th gp. Thng la cac nhim trung c hi.
CHN ON
Chn oan khng nh bng nhum mc tu thy bao t nm men trong m hoc
dch c th. Xet nghim ngng kt Latex vi khang nguyn cryptococcal trong
huyt thanh hoc dch nao tuy cung co gia tr chn oan, nng khang nguyn
trong huyt thanh cao gi y nhim nm toan th. Choc dch nao tuy la cn thit
loai tr bnh ly thn kinh trung ng (central nervous systemCNS) kem theo
nhng ngi mc bnh h thng. Lun phai o ap lc dch nao tuy, nu ap lc (>25
cm nc) la mt tin lng xu va cn c x tr, thng bng choc dch nao tuy
nhiu ln hoc dn lu nao tht.
IU TR
Tuy thuc vao tnh trang min dch va v tr tn thng cua bnh nhn (xem Bang
149). X tr tng ap lc ni so rt quan trong. Nu ap lc tng >25 cm nc
cn phai lam giam 50% bng cach dn lu 30 mL dch va lam hang ngay nu cn.
Nu ban u ap lc dch nao tuy khng tng, vic choc dn lu ch thc hin nu
cac triu chng tng ln (Clin Infect Dis 2010;50:291). iu tr d phong la cn
thit bnh nhn HIV cho ti khi cai thin chc nng min dch khi iu tr bi
cac thuc khang virus.
656
Bng 149 iu tr cc nhim nm, Nocardia, Actinomyces
Cn nguyn iu tr khi u iu tr d phng Lu
l
Ch. 14
Nm Candida spp.
Nim mc (Clin Infect Topical Clotrimazole 10 mg ha tan ung 5 Khng ch nh cho

Dis ln/ngy trong 14 ngy. bnh nhn HIV,

2009; 48:503) Nm thc qun: Fluconazole 100200 mg ngoi tr trng
PO 1 ln/ngy x 14 ngy. hp hay ti pht.
m o: Topical azole x 114 ngy hoc Gim bch cu ht:
fluconazole 150 mg PO 1 ln. Fluconazole 400
mg PO 1 ln/ngy,
posaconazole 200
mg PO hng ngy.
Tip tc iu tr ti
khi s lng bch
cu >500 hoc
3 thng sau ghp
tng c.
Xm ln Fluconazole 800 mg liu tn cng, 400 mg iu tr tt c cc bnh nhn c cy
(Clin Infect Dis IV/PO hng ngy x 7 ngy. mu dng tnh vi nm nh vi
2009;48:503) Nhim nm nng, mi c iu tr bng iu tr nm xm ln, trong thi
nhm azole, nghi ng do Candidas (v.d., gian t nht 14 ngy. Cn loi b
echinocandin, anidulafungin 200 mg IV catheter tnh mch. Khng iu tr
1 ln, sau 100 mg mi ngy hoc bng echinocandin nu cy mu
amphotericin B*). dng tnh vi C.parasilosis m
trc iu tr di 14 ngy.
Lin quan ti Catheter Xem phn nhim trng bnh vin.
Cryptococcus nepformans
Khng vim mng no Fluconazole 400 mg PO hoc IV 1 ln/ngy x Suy gim min dch: Vim phi n thun bnh nhn
(Clin infect dis 2010; 612 thng. Fluconazole 200 khng c suy gim min dch cn
Nhim nm ton th v vi khun...

50:291) mg PO mi ngy. c theo di thn trng.
C. neoformans
Vim mng no ngi (Clin Infect Dis 2010;50:291).
Min dch bnh thng Amphotericin B* + flucytosine 25 mg/kg mi Khng c ch nh. Lun kim tra p lc ni s v gim
6 gi IV x 2 tun, sau Fluconazole 400 50% nu tng trn 25 cm nc
mg PO hng ngy trong 8 tun. bng cch dn lu 30 mL dch no
ty. C th tin hnh nhiu ln nu
p lc khng gim.
Suy gim min dch Amphotericin B* + flucytosine 25 mg/kg mi Fluconazole 200 mg D phng tip tc cho n khi c kh
6 gi IV x 2 tun, sao Fluconazole 400 PO mi ngy. nng min dch hoc CD4 n c
mg PO hng ngy trong 8 tun. duy tr >200 trong 6 thng.

Histoplasma capsulatum
(Clin infect Dis 2007;45:807)
Th mn tnh, mc Itraconazole 200400 mg/ngy PO ko di Khng c ch nh. Nng itraconazole huyt thanh
trung bnh, min 6 thng. cn t >1 g/mL.
dch bnh thng
Cp tnh; bnh nng; Amphotericin B* trong 2 tun ti khi ci thin Itraconazole 200 mg Tip tc duy tr iu tr d phng ti
suy gim min dch triu chng lm sng, sau Itraconazole PO mi ngy. khi CD4 >200 trong vng 6 thng.
200 mg PO 2 ln/ngy ko di >12 thng.
(cn tip)
l
657
658
Bng 149 iu tr cc nhim nm, Nocardia, Actinomyces (Tip theo)
l
Ch. 14
Blastomyces dematitidis
(Clin infect dis 2008;46:1801)

Khng vim mng Itraconazole 200400 mg/ngy PO trong Khng c ch nh.
no, bnh nh ti vng 6 thng.
trung bnh, min
dch bnh thng
Cp tnh; bnh nng; Amphotericin B* trong 2 tun ti khi ci thin Itraconazole 200
suy gim min dch triu chng lm sng, sau Itraconazole 400 mg PO mi
200400 mg PO 1 ln/ngy trong 6 thng. ngy.
Nhim trng thn kinh Amphotericin B* trong 46 tun, tip theo Khng c ch nh.
trung ng Itraconazole 200 mg 2 ln/ngy hoc
voriconazole 200400 mg 2 ln/ngy ko
di t nht 12 thng ti khi ht u hiu
thn kinh.
Coccidioides immitis
(Clin Infect Dis 2005;41:1217)
Khng vim mng no Itraconazole 200 mg PO 2 ln/ngy hoc Fluconazole 400 Theo di nng gn b th huyt
fluconazole 400 mg mi ngy trong 12 mg PO hng ngy thanh. Nu tng chng t c ti
thng. (c th iu tr d pht.
phng c i nu
nhim nm ton
th).
Vim mng no Fluconazole 400-800 mg IV/PO mi 24 gi. Fluconazole 400 mg Vi nt phi v hang khng triu
C th truyn amphotericin B 0,11,5 mg PO mi ngy sut chng, khng c ch nh iu tr.
Nhim nm ton th v vi khun...

hng ngy hoc hng tun kt hp vi cc i. Cn nhc iu tr ngoi khoa nu
azole cho vim mng no nng. tn thng dng hang tn ti >2
nm, tin trin >1 nm hoc gn
mng phi.
Aspergillus
Aspergilloma Phu thut nu chy mu nng. Khng ch nh. Dng liposomal.
Nhim nm Viconazole 6 mg/kg mi 12 gi PO/IV x 2 Tip tc hoc lp li Amphotericin B hiu qu vi c
aspergillus th xm ngy, sau 4 mg/kg mi 12 gi, tip tc iu tr nu suy mucormycosis khi khi ng iu
nhp (Clin Infect Dis 200 mg 2 ln/ngy. Lin tc trong vng gim min dch ti tr vim xoang trong khi ch kt
2008;46:327) 612 tun ti khi hi phc min dch hoc pht. qu khng nh.
tn thng thoi lui.

Sporothrix (Clin Infect Itraconazole 200 mg PO hng ngy trong Khng ch nh. Bnh nng v vim mng no:
Dis 2007;45:1255) vng 36 thng. Amphotericin B* khi u trong 6
Thay th: Dung dch kali iode bo ha, 5 git tun, sau itraconazole 200 mg
PO 3 ln/ngy c th tng ln 40 git nu 2 ln/ngy ti 12 thng.
dung np tt. Theo di nng itraconazole huyt
tng.
Mucomycosis Amphotericin B* liu ngng trn trong vng Khng ch nh.
6 thng.
(cn tip)
l
659
660
Bng 149 iu tr cc nhim nm, Nocardia, Actinomyces (Tip theo)
l
Ch. 14
Nocardia
(Clin Infect Dis 2007;44:1307)

Phi TMPSMX 15 mg/kg/ngy IV (TMP) + TMPSMX 12 DS iu tr 6 thng nu min dch bnh
imipenem 500 mg IV mi 6 gi x 34 tun, 2 ln/ngy hoc thng, 12 thng nu suy gim
sau TMPSMX 12 DS PO 2 ln/ngy. dapsone 100 mg min dch.
t trm trng: TMPSMX 12 DS 2 ln/ngy PO mi ngy hoc
cho ti 2 DS 3 ln/ngy hoc minocycline minocycline 100
100 mg PO 2 ln/ngy. mg PO 2 ln/ngy.
Thn kinh trung ng TMPSMX 15 mg/kg IV (TMP) + imipenem
500 mg IV mi 6 gi x 36 tun, sau
TMPSMX 3 vin 960 mg PO 2 ln/ngy.
Nu c suy gim min dch, cn iu tr kt
hp 2 thuc trong vng 1 nm.
Actinomyces (Penicillin G 1824 triu n v IV mi ngy Khng ch nh.
hoc clindamycin 600 mg IV mi 8 gi) x
26 tun, sau penicillin V 24 g PO mi
ngy chia 4 ln HOC doxycycline 100
mg PO 2 ln/ngy HOC clindamycine PO
trong 612 thng.
*Liu Amphotericin: Amphotericin 0,71,0 mg/kg. Liposomal amphotericin B 35 mg/kg.

ANC (absolute neutrophil count), lng bch cu tuyt i; CF, phn ng ngng kt b th; CNS: thn kinh trung ng; CSF, dch no ty; Cx (culture), nui cy;
DS (double strength), mnh gp i; dz (disease), dch bnh; IV: ng tnh mch; PO: ng ung; TMPSMX: trimethoprimsulfamethoxazole.
Nhim nm ton th v vi khun... Nhim nm blastomyces l 661
Nhim nm histoplasma
I CNG
Histoplasma capsulatum gp nhiu Ohio va vung thung lung sng Mississippi
Hoa Ky va chu My Latinh, sinh si trong t b nhim bi phn cua chim va di.
CHN ON
Biu hin lm sang rt thay i, bao gm cp tnh dang cum hoc man tnh dang u
hat phi hoc suy a phu tang ti cp bnh nhn suy giam min dch. Chn oan
da trn nui cy hoc m bnh hoc, xet nghim tm khang nguyn (nc tiu, mau,
dch nao tuy), hoc phan ng ngng kt b th (complement fixationCF) (1:16
hoc tng trn 4 ln). Xet nghim tm khang nguyn trong nc tiu co gia tr cao
trong chn oan nhim nm toan thn va theo doi ap ng iu tr.
IU TR
Vi th co biu hin lm sang ro, cn keo dai thi gian iu tr bng itraconazole.
Vi th vim phi nhe, co th theo doi ma khng cn phai iu tr c hiu
(Bang 14-9).
Nhim nm blastomyces
I CNG
Nm da do blastomyces gy thanh dch min Bc, ng nam va Trung Nam nc
My. Thng lan rng toan thn, ngay ca nhng bnh nhn co min dch bnh
thng, va co xu hng gy bnh phi, da, xng, va ng sinh duc tit niu.
Vim phi nng va bnh ly thn kinh trung ng co th xay ra ca ngi suy giam
min dch va co min dch bnh thng.
CHN ON
Cn phai phn lp c nm bng nui cy m hoc m bnh hoc. Chn oan huyt
thanh co phan ng cheo vi Histoplasma va Cryptococcus, va khng dung chn
oan ma co th dung theo doi ap ng iu tr sm nu dng tnh.
IU TR
Thng iu tr bng itraconazole trong vong 6 thang nhng cn iu tr ban u
bng amphotericin B vi cac th nng nguy c ti tnh mang hoc th bnh ly thn
kinh trung ng (xem Bang 149).
Nhim nm coccidioides
I CNG
Coccidioides immitis gy dch vung Ty Nam nc My va Trung My.
t gp hn la bnh ly vim phi man hoc nhim nm toan th tai mang nao, xng,
khp va da.
CHN ON
Chn oan xac nh bng nui cy, m bnh hoc, hoc phan ng ngng kt b th
huyt thanh dng tnh.
Hiu gia phan ng ngng kt b th ln hn 1:16 chng to co bnh ly ngoai phi.
Choc dch mang nao co th thc hin nui cy va lam phan ng ngng kt b
th nhm loai tr bnh ly thn kinh trung ng vi cac ca bnh nng, tin trin
nhanh va th bnh toan thn.
Test da ch dung trong nghin cu dch t anh gia phi nhim vi nm.
IU TR
Khng cn iu tr cho th vim phi cp, do co th t khoi. Vi trng hp bnh
toan th, bnh nhn suy giam min dch, hoc vim phi dai dng trn 6 tun, cn
iu tr bng cac nhom azole trong vong 1 nm. Theo doi hiu gia phan ng ngng
kt b th trong iu tr, nu tng ln chng to co tai phat tr lai (xem Bang 149).
Nhim nm aspergillus
I CNG
Aspergillus la loai nm tn tai rng rai trong mi trng, co th gy ra rt nhiu
th bnh, va thng gy bnh c quan h hp va cac xoang.
U nm do aspergilloma phi. Xut hin khi phi trc o a co tn thng
dang bong m va co th d dang nhn bit trn phim chup X-quang ngc va huyt
thanh chn oan Aspergillus.
Bnh nm Aspergillus xm nhp (invasive aspergillosisIA) co biu hin
nng vi xm ln mach mau, tc mach, thiu mau vung m b ky sinh va bnh ly
tin trin sau khi phat tan qua ng mau. Thng gp nhng bnh nhn co suy
giam min dch nng va biu hin lm sang thay di tuy theo tng c th bnh.
Bnh nhim nm Aspergillus ph quan phi (allergic bronchopulmonary
Nhim nm ton th v vi khun... Nhim nm sporotrum l 663
aspergillosisABPA) dang d ng. c trng bi din bin man tnh vi nhng

t tai phat, biu hin hi chng vim ng h hp lin quan ti s xm nhp
cua Aspergillus.
CHN ON
Chn oan kho khn do biu hin a dang cua bnh, co th ngh ti trong tnh
hung bnh nhn co suy giam min dch keo dai.
Hnh anh X-quang co gia tr gi y cao, nu khng phai nm phi xm nhp, nht
la hnh li lim trn film ct lp vi tnh bnh nhn suy giam min dch.
Chn oan khng nh da trn bng chng m hoc tai ni tn thng. Cy nm
t co gia tr.
Xet nghim tm galactomannan co gia tr h tr chn oan trong nhim nm xm
nhp va dung theo doi hi cu cac bnh nhn co nguy c nhim nm (Clin Infect
Dis 2004;39:797). nhay cao hn nu xet nghim lam vi dch h hp so vi
huyt thanh. (Am J Respir Crit Care Med 2008;177:27).
IU TR
U nm do aspergilome phi. iu tr bng phu thut ct thuy phi hoc nut
mach phi, ch nh khi bnh nhn co ho mau nng (xem Bang 149).
Nhim nm Aspergillus xm nhp. iu tr tai ch bng ct bo vung tn
thng. iu tr khang nm theo kinh nghim cho bnh ly vung mt c co th
gm amphotericin B nhm bao phu ca zygomycose, trong khi ch i kt qua
nh danh cn nguyn (N Engl J Med 2009;360:1870).
Vim ph quan phi do d ng aspergillus. iu tr cn ban la s dung corticoid
ngt quang; mt t itraconazole co th lam giam triu chng t cp.
Nhim nm sporotrum
A CNG
Sporothrix schenckii la loai nm gy dch lu hanh a phng, xay ra sau chn
thng do nhim nm t t hoc cac dung cu nhim nm, phn ln ca bnh co lin
quan ti ngh nghip. Bnh cung co th phat tan do meo nhim bnh hoc cac vt
cao cua ng vt khac (Clin Infetc Dis 2007;45:1255).
CHN ON
Biu hin lm sng
Bnh thm nhim bach cu lympho di da (lymphocutaneous disease) la biu hin
thng gp, vi c im khu tru ngoai da va m mm. Him gp bnh ly phi va

dang toan th him gp do ht phai nm.
Test chn on
Cn lam nui cy va m bnh hoc cho thy nm men m va dch c th.
IU TR
iu tr bnh tng bach cu lympho di da (lymphocutaneous disease) bng
itraconazole hoc dung dch kali iod bao hoa. Th nng va vim mang nao cn iu
tr bng amphotericin B (xem Bang 149).
Nhim nm mucor
I CNG
Nguyn nhn gy bnh thuc lp Zygomycetes, bao gm ca Mucor, tuy nhin hu
ht cn nguyn gy bnh la loai nm khac trong lp, nh Rhizopus. Cac nm thuc
nhom nay gy bnh vung u c, phi, ng tiu hoa, da va bnh toan th vi
xm ln mach mau, tc mach nhiu c quan. Yu t nguy c bao gm suy giam
min dch, qua tai st, iu tr corticoid liu cao, ai thao ng co toan ceton hoc
khng.
CHN ON
Biu hin a dang tuy vao c quan b bnh. Nhim nm xm ln pha huy va
hoai t m nhanh chong do xm ln mach mau va huyt khi (Lancet Infect Dis
2011;11:301).
Chn oan da trn cy m bnh va nhum bac nhm bao toan cu truc nm. MRI
co tim thuc can quang co li ch trong chn oan thay i v cu truc vung u
c do nm.
IU TR
Cn can thip ngoai khoa loai bo vung tn thng, m thng va lam sach, sau
o iu tr bng Liposomal amphotericin B 5 mg/kg mi ngay trong vong 6 thang.
Cht gn va thai st co th dung iu tr cu canh. (Xem Bang 14-9) (Antimicrob
Agents Chemother 2006;50:3768).
TIN LNG
Ty l t vong cao nhng bnh nhn suy giam min dch va nm lan toa.
Nhim nm ton th v vi khun... Nhim nm actinomyces l 665
Nhim nm nocardia
I CNG
Nocardia la nhanh vi khun dang si Gram dng nhom ai kh co mt nhiu ni
gy th bnh tai ch va lan toa nhng bnh nhn co suy giam min dch t bao
(Clin Infect Dis 2007;44:1307). Nhim trung c trng la thm nhim phi, ap-xe,
vim mu mang phi, th lan toa thng gp la nhim trung thn kinh va tao ap-xe.
CHN ON
Biu hin lm sang co th la vim phi cp, ban cp va man tnh.
X-quang ngc co th thy thm nhim, nt, tran dch mang phi, hoc dang hang
(Infection 2010;38:89).
Chn oan da vao xet nghim m hoc nhum Gram m tn thng va nui
cy (gm ca AFB), thng cn nhiu mu do kha nng phat hin thp.
Cn kim tra tn thng h thn kinh trung ng bng MRI vi cac bnh nhn
tn thng phi.
IU TR
iu tr phi hp liu cao sulfonamide va imipenem. Thi gian iu tr t 612
thang, tuy theo tnh trang min dch. iu tr d phong keo dai cho cac trng hp
suy giam min dch (xem Bang 149).
Nhim nm actinomyces
I CNG
Actinomyces la trc khun Gram dng ai kh mc thp, thng gy bnh hu
hong, phi va ng tiu hoa. Nhim khun in hnh la tn thng thm nhim
cng man tnh m mm kem theo l ro, di knh hin vi thy hat sulfur. Khng
ging nh Nocardia, nhim actinomyces khng ch gii han ngi suy giam min
dch.
CHN ON
Biu hin lm sang tuy thuc v tr tn thng. Dang ph bin nht la tn thng
vung hong ming c va mt. Him thy h thn kinh va xng. Chn oan da
vao m bnh hoc va quan sat tht hat sulfur dch r (BMJ 2011;343:d6099).
IU TR
iu tr bng amoxicillin, doxycycline hoc clindamycin keo dai. Khi u bng
liu cao penicillin IV hoc clindamycin trong 2-6 tun. i khi cn ti can thip
phu thut (xem Bang 149).
Nhim Mycobacteria khng in hnh (Nontuberculous)
I CNG
Non tuberculosis mycobacteria (NTM) gy bnh ly phi, da, m mm, va hach
lympho co mt khp ni trong mi trng. Cn lam khang sinh va tham khao
y kin chuyn khoa truyn nhim iu tr.
M.avium (MAI), M.kansasii (xem chng 16, Suy giam min dch ngi,
HIV-AIDS).
M.fortuium, M.marinum, M.ulcerans, Mhaemophilum, va M.scrofulaceum
la nguyn nhn gy bnh man tnh xng va m mm. M. Leaprae khng
c xp vao nhom NTM do chung co kha nng ly t ngi sang ngi.
BNH DO TIT TC TRUYN
Cac bnh do tit tuc truyn (tick-borne infections [TBIs]) thng xay ra vao cac
thang mua he, mt s vung trn nc My; ty l nhim bnh tuy thuc vao s lng
cac loai tit tuc va vt chu mang mm bnh. ng nhim cung luc nhiu bnh do
tit tuc co th ngh ti khi co nhiu hi chng xay ra ng thi. Yu t nguy c da
vao cac hoat ng bn ngoai vung dch hn la khai thac vic cn trung t, v hu
ht cac trng hp khng nhn bit c.
Bnh Lyme
I CNG
La mt bnh thng gp nht trong s cac bnh do vector truyn My va la bnh ly
toan thn co mc biu hin bnh rt thay i do xon khun Borrelia burgdorferi
gy nn. La bnh dch lu hanh a phng, bao gm vung duyn hai ng bc, cao
nguyn Midwest, va bc California. iu tr d phong bng Doxycyclin 200 mg
PO (liu duy nht) lam giam nguy c mc Lyme trong vung dch do b bo ve cn
(N Engl J Med 2001;345:79).
Bnh do tit tc truyn Bnh st m vng ni l 667
CHN ON
Biu hin lm sng
Biu hin qua 3 giai oan lm sang, sau thi gian u bnh 710 ngay:
Giai oan 1 (bnh khu tru giai oan sm) c trng bi ban o loang, ban chm
o trai rng dn xung quanh at kch thc >5 cm, gia thng nhat mau, kem
theo cac du hiu toan thn nhe.
Giai oan 2 (bnh lan toa giai oan sm) xut hin sau khoang vai tun cho ti
hang thang vi nhiu ban o loang, du hiu thn kinh (v.d., lit dy 7, vim nao
mang nao), du hiu tim mach (block nh tht, vim c tim ngoai vi), va vim cac
khp nho khng i xng.
Giai oan 3 (giai oan mun) xut hin sau hang thang cho ti nhiu nm vi biu
hin vim da man tnh, bnh ly thn kinh, va vim n khp hoc vim cac khp
nho khng i xng. Tnh trang mt moi man tnh khng gp thng xuyn hn
bnh nhn mc bnh Lyme so vi nhom chng.
Test chn on
Chn oan da vao lm sang trong bnh canh phu hp, h tr bi so sanh hiu gia
khang th trong 2 giai oan (sang loc enzyme-linked immunosorbent assay [ELI-
SA], tip theo la Western blot) giai oan cp va hi phuc.
IU TR
iu tr tuy theo giai oan lm sang cua bnh (Clin Infect Dis 2006;43:1089).
Khang sinh ng ung (doxycyclin 100 mg PO 2 ln/ngay, amoxicillin 500mg
PO 3 ln/ngay, hoc cefuroxime acetil 500 mg PO 2 ln/ngay trong 1021 ngay)
c ch nh giai oan sm khu tru hoc giai oan lan toa nhng khng co du
hiu thn kinh, tim mach. Cung phac khang sinh trn dung iu tr bnh giai
oan mun nhng keo dai 28 ngay. Doxycycline co th bao phu ca ng nhim
vi ehrlichiosis.
iu tr bng ng tim (ceftriaxone 2 g IV hang ngay, cefotaxime 2 g IV mi 8
gi, penicillin G 34 triu n v mi 4 gi) vi cac th co triu chng thn kinh nng
hoc bnh tim trong bt c giai oan nao cua bnh trong thi gian t 1428 ngay.
Bnh st m vng ni
I CNG
Bnh st m vung nui a (Rocky Moutain spotted feverRMSF) co cn nguyn
do Rickettsia rickettsii truyn qua vt cn cua bo ve, co th khng nhn bit c.
Bnh dch lu hanh a phng.
CHN ON
Triu chng lm sang bao gm st, au u, au c xut hin 15 ngay sau khi co
m xut huyt khi u t cac u chi, co th khng phat hin c. Chn oan
ban u co th hng ti iu tr trc mt da trn hi chng lm sang, nhng sinh
thit da va xet nghim huyt thanh giai oan cp va hi phuc co th a ra thm
iu tr h tr.
IU TR
Khang sinh la chon la doxycyclin 100 mg mi 12 gi IV hoc PO trong 7 ngay
hoc sau ht st 2 ngay. Chloramphenicol la la chon thay th (Lancet Infect Dis
2007;7:724).
KT QU/TIN LNG
Co th t vong nu iu tr mun.
Nhim ehrlichiosis v anaplasmosis
I CNG
Nhim Ehrlichiosis va Anaplasmosis la nhim trung toan th do tit tuc truyn, do
cac tac nhn ky sinh ni bao gn ging vi Ehrlichia va Anaplasma gy nn. Biu
hin bnh vi hai hi chng lm sang:
Giam bach cu n nhn (Human monocytic ehrlichiosisHME) do Ehrlichia
chaffeensis, bnh lu hanh a phng min nam va trung nam nc My.
Giam bach cu a nhn (Human granulocytic anaplasmosisHGA) do
Anaplasma phagocytophilum, cung lu hanh trong cung khu vc vi Lyme
borreliosis do co chung vector truyn bnh.
CHN ON
Biu hin lm sng

Khi u thng 1 tun sau khi b cn trung cn bng st, au u, au c. t khi
thy ban. Th bnh nng co th dn ti suy h hp, suy thn, va suy giam thn kinh.
c trng cua bnh th trung bnh va nng la giam bach cu, giam tiu cu, va tng
men gan.
Test chn on
Thy bach cu dang phi du trong bach cu n nhn hoc a nhn ngoai vi, t
gp nhng co th chn oan bng bnh canh lm sang phu hp. Chn oan khng
nh bng o hiu gia khang th giai oan cp va hi phuc.
Bnh do tit tc truyn Bnh tularemia l 669
PCR vi bnh phm la mau hoc cac dch c th la la chon u tin (Clin infect
dis 2007;45:S45).
IU TR
Khi ng iu tr khang sinh sm giup cai thin tin lng bnh th nng. Khang
sinh u tin la doxycyclin 100mg PO hoc IV mi 12 gi hoc tetracycine 25
mg/kg/ngay PO chia 2 ln trong 714 ngay. Rifampin 300 mg mi 12 gi trong
710 ngay la phac thay th dung cho nhng bnh nhn co chng ch nh vi
doxycyclin hoc tetracycline (Clin Infect Dis 2007;45:S45).
Bnh tularemia
I CNG
Cn nguyn gy bnh la vi khun gram m Francisella tularensis, bnh lu hanh
a phng min trung nam nc My. Ly truyn qua vt t cua bo ve, hoc tip
xuc vi ng vt (c bit la tho), hoc tip xuc vi khng kh cha mm bnh.
F.tularensis la mt trong nhng cn nguyn a c bit ro nht. Ch cn nhim
khoang 10 vi khun la co th phat bnh. y co th c coi la vu kh sinh hoc do
co kha nng ly nhim ln, d phat tan, co th gy bnh nng va t vong (JAMA
2001;285:2763).
CHN ON
Biu hin lm sng
St va gai ret xut hin 25 ngay sau phi nhim. Biu hin lm sang tuy thuc
vao v tr va ng vao cua vi khun. Thng gp sng au hach tai ch co kem
hoc khng loet da. Cung co th thy vim tuyn l. Bnh lan toa toan thn (dang
thng han) va vim phi d tin trin nng vi ty l t vong cao nu khng c
iu tr kp thi.
Test chn on
Chn oan khng nh bng cy mau, m, dch mang phi, tuy nhin co nhay
thp. Cn thit lp canh bao an toan sinh hoc cac phong th nghim khi bt u
nui cy bnh phm nghi ng. o hiu gia khang th giai oan cp va hi phuc co
gia tr chn oan hi cu.
IU TR
Khang sinh u tin la streptomycin 1 g IM mi 12 gi trong 10 ngay; tuy nhin
cung co th dung gentamycin 5 mg/kg IV mi 8 gi co hiu qua tng ng va d

dung hn. Doxycyclin 100 mg PO/IV mi 12 trong 1421 ngay la phac thay th
tuy nhin d tai phat. Ciprofloxacin 500750 mg PO 2 ln/ngay x 1421 ngay cung
co hiu qua (JAMA 2001;285:2763).
Nhim babesia
I CNG
Bnh ly ging vi st ret, gy ra do ky sinh trung ky sinh trong hng cu Babesia
microti truyn qua vt t cua bo ve. Dch lu hanh cung trong vung cua Lyme
borreliosis, bnh nhn co th b ng nhim.
CHN ON
Biu hin lm sang co th thay i t khng triu chng ti nng vi st, ret run,
au c, va au u. Co th kem huyt tan. Chn oan bng xet nghim tm ky sinh
trung trong hng cu trn lam giot mong. Xet nghim huyt thanh sn co CDC.
IU TR
Cn iu tr vi th trung bnh va nng, nht la vi bnh nhn a ct lach. Atovaquone
750 mg PO 2 ln/ngay kt hp vi azithromycin 600 mg mi ngay trong 710 ngay
la la chon u tin. Clindamycin 600 mg IV mi 8 gi kt hp vi quinine 650
mg PO 3 ln/ngay trong 710 ngay co th s dung vi th nng e doa tnh mang.
Truyn mau nu cn. iu tr keo dai vi nhng bnh nhn co triu chng tn
tai dai dng cho ti khi khng phat hin ky sinh trung trong mau (Clin Infect Dis
2006;43:1089).
NHIM TRNG DO MUI TRUYN
Vim no, mng no do arbovirus
I CNG
Co rt nhiu virus thuc nhom arbovirus co th gy vim nao mang nao, tuy theo vung
a ly (v.d., WNV, vim nao nga ng va ty, vim nao La Crosse, vim nao St.
Louis). Ngoai ng ly qua mui, virus cung co th ly qua truyn mau, ghep tang,
cho con bu. Bnh thng xay ra vao mua he va thng khng biu hin triu chng.
Nhim trng do mui truyn St rt l 671
CHN ON
Biu hin lm sng
Nhim West Nile virus co biu hin t st nhe cho ti vim mang nao nc trong,
vim nao ti cp, hoc biu hin dang vim a r thn kinh co lit mm. Cac th
nng co th lai di chng thn kinh lu dai.
Test chn on
Da vao lm sang hoc o hiu gia khang th giai oan cp va hi phuc. Tm
thang th IgM c hiu trong dch nao tuy chn oan giai oan cp.
IU TR
Vi cac virus thuc nhom arbovirus, iu tr h tr la chu yu.
St rt
I CNG
La bnh nhim ky sinh trung toan thn, dch lu hanh chu yu cac nc nhit i
va cn nhit i. Co nhiu loai ky sinh trung st ret.
Phng chng
S dung cac phng tin phong mui cn va cac phac s dung thuc khi i ti
vung dch co th thy http://www.cdc.gov/travel/.
CHN ON
Biu hin lm sng
Triu chng xut hin t sau vai tun hoc ln ti 612 thang sau khi nhim ky
sinh trung, biu hin bi st, au u, au c, mt moi. Cn st ret i khi xut
hin thanh cn ret run co tnh cht chu ky, ba pha gm cn ret run (mi 48 gi vi
Plasmodium ovale va Plasmodium vivax) sau o st nong kem theo au u, ho, va
nn; kt thuc bng va m hi nhiu. St ret do P. falciparum rt thng gp, thng
gy ra cac th nng. Cac bin chng hoc cac th nng do P. falciparum c chn
oan khi lng ky sinh trung mau chim (>5%) s hng cu, st ret th nao, giam
ng mau, tng axit lactic, suy thn, co hi chng suy h hp cp tin trin, hoc
bnh ly ng mau.
Test chn on
Cn nghi ng va loai tr st ret tt ca nhng bnh nhn co st, co tin s i vao
vung dch lu hanh trong vong 1 nm tr lai.
Chn oan bng soi tm ky sinh trung trn tiu ban mau nhum Giemsa giot day.
Cn lam tiu ban mau trong khi st tng kha nng bt c ky sinh trung.
Test chn oan nhanh nhm phat hin khang nguyn cua tt ca cac loai ky sinh
trung st ret, nht la P.falciparum, nhng cn c khng nh bng soi tiu ban
mau di knh hin vi.
IU TR
Phac iu tr c la chon theo loai ky sinh trung, mc nng, va tnh trang
khang chloroquine. Thng tin cp nht v vung st ret khang chloroquine va
khuyn cao iu tr co th thy http://www.cdc.gov/travel/ va http://www.cdc.
gov/malaria.
St ret do P. falciparum khng bin chng t vung con nhay vi chloroquine-
sensitive areas va P. malariae: chloroquine base 600 mg (1.000 mg chloroquine
phosphate) PO 1 liu, sau o 300 mg PO 6 gi, 24 gi va 48 gi tip.
P. ovale va phn ln P. vivax t vung con nhay vi chloroquine: iu tr nh
trn kt hp vi primaquine phospahte 15,3 mg PO mi ngay trong 14 ngay
phong tai phat. Cn lam xet nghim G6PD trc khi khi ng iu tr bng
primaquine.
St ret do P. falciparum khng co bin chng t vung khang chloroquine va
P.vivax t Australia, Indonesia, hoc Nam My: Quinine sulfate 650 mg PO
3 ln/ngay kt hp vi doxycycline 100 mg PO 2 ln/ngay trong 7 ngay. Co th
iu tr thay th bng atovaquone 1g PO mi ngay kt hp vi proguanil 400 mg
PO hang ngay trong 3 ngay, hoc mefloquine.
St ret co bin chng hoc nng do P. falciparum: Quinidine gluconate 10 mg
mui/kg (ti a 600 mg) IV trong vong 12 gi sau o giam xung 0,02 mg/kg/
phut truyn lin tuc 72 gi hoc ti khi lng hng cu ky sinh xung di 1% co
th ngng truyn va chuyn sang ng ung vi quinine sulfate nh trn. Cung
nh a dung trn toan th gii, artesunate truyn tnh mach cung sn co My tai
cac c s cp cu (http://www.cdc.gov/malaria/). Ch nh truyn loc mau khi s
lng hng cu b P. falciparum ky sinh trn 15% s lng hng cu, tuy nhin
li ch cha c chng minh.
BNH LY T TH SANG NGI
Cum gia cm va cum ln (xem phn cac bnh mi ni va khung b sinh hoc).
Bnh than (xem phn cac bnh mi ni va khung b sinh hoc).
Bnh dch hach (xem phn cac bnh mi ni va khung b sinh hoc).
Bnh ly t th sang ngi Nhim xon khun leptospira l 673
Bnh mo co (Bartonellosis)
I CNG
Cn nguyn gy bnh la vi khun Bartonella henselae. Bnh thng t khoi.
CHN ON
Biu hin lm sang thng la cac tn thng dang mun sn xut hin 310 ngay sau
khi b meo cao hoc cn, sau o la ni hach tai ch (thng la hach vung c hoc
nach) va triu chng c nng nhe. Biu hin khng in hnh la sng tuyn l, vim
nao, vim khp va bnh ly toan thn nng. Chn oan bng loai tr cac nguyn
nhn gy vim hach khac va phat hin khang th khang B. henselae hoc lam PCR
m tn thng, da, hoc mu.
IU TR
Khng cn iu tr th bnh khu tru do thng t khoi sau 24 thang. Trong trng
hp iu tr, dung azithromycin 500 mg PO liu n sau o 250 mg trong 4 ngay tip
theo. Choc hut mu co th lam giup giam triu chng (Clin Infect Dis 2005;41:1373).
Nhim xon khun leptospira
I CNG
Nhim xon khun leptospira la bnh ly nhim trung co biu hin st cp tnh kem
theo nhiu biu hin triu chng khac do xon khun Leptospira interrogans gy
nn, cn nguyn gy bnh co mt nhiu ni gy bnh cho ng vt hoang da va
vt nui trong nha, bo sat, ng vt lng c. Triu chng xut hin t 514 ngay
sau tip xuc vi vt nui b bnh hoc nc b nhim khun t nc tiu ng vt.
Nhim Leptospira th khng vang da, xay ra phn ln cac trng hp, co c
im 2 pha, khi u bng hi chng gia cum, sau o sung huyt kt mac va vim
mang nao nc trong sau mt thi ky giam st.
Mt s t cac ca tin trin trc tip thanh bnh Weil (nhim xon khun co
vang da), vi suy a phu tang biu hin bi vang da nng, ai mau, vim phi
xut huyt.
CHN ON
Khng nh bng cy nc tiu hoc mau phn lp vi khun, xet nghim PCR, o
hiu gia khang th.
IU TR
iu tr vi th khng vang da, lam giam thi gian bnh, bng doxycyclin 100 mg
PO 2 ln/ngay hoc amoxicillin 500 mg PO mi 6 gi trong 7 ngay. iu tr th
nng bng penicillin G 1,5 triu n v IV mi 46 gi hoc cephalosporin th h
th 3, trong thi gian iu tr co th xay ra phan ng JarischHerxheimer (Clin
Microbiol Rev 2001;14:296).
Nhim brucella
I CNG
Nhim Brucella co th gy nhim trung toan thn gy ra bi vi khun Gram m
Brucella coccobacilli. Nhim khun do tip xuc trc tip vi dch c th ng
vt nhim vi khun, hoc do n sa khng thc hin kh trung theo phng phap
Pasteur, hoc do ht phai hat kh dung nhim khun.
CHN ON
Biu hin lm sng
Khi u khng c hiu, thng gm cac du hiu c nng nh st, va m hi. St

cn kem ret run, cung co th tai phat va keo dai. Va m hi co mui kho chu la du
hiu c trng cua bnh. Kham lm sang co th bnh thng, tuy nhin cung co th
thy hach ngoai vi, lach to co th thng thy. Cac bin chng co th gp bt ky
c quan nao (v.d., tiu chay, vim khp, vim mang nao, vim ni tm mac, vim
phi, vim gan).
Test chn on
Phn lp vi khun bng cy mau hoc m.
IU TR
iu tr bng doxycycline 100 mg PO 2 ln/ngay trong 6 tun co th phi hp thm
gentamycin trong 23 tun hoc RIF trong 6 tun, lam giam thi gian bnh va cac
bin chng. Cn kim tra thnh lc nu iu tr bng gentamycin (N Engl J med
2005;352:2325).
Bnh ly qua vt cn Vt cn do th vt l 675
BNH LY QUA VT CN
Vt cn do th vt
I CNG
X tr bao gm ra vt thng nhiu ln, ly bnh phm nui cy vi vt thng
nhim khun, xac nh co gay xng, d vt, va tn thng khoang khp bng chn
oan hnh anh. Phn ln cac vt thng khng th t lin tr khi chung vung mt
va c ra sach hoan toan. Cn kim tra ky vt thng.
IU TR
Khang sinh c ch nh iu tr trong trng hp vt thng nhim khun
hoc d phong cac vt thng co nguy c nhim khun tuy thuc vao mc
nng, v tr (v.d., tay, vung sinh duc, gn khp), ng vt cn, tnh trang min
dch (v.d., tiu ng, ct lach, suy giam min dch), va loai tn thng (v.d.,vt
thng xuyn hay vt cao). Co th tim phong c t un van nu bnh nhn a
c tim phong un van trc o nhng cha nhc lai trong vong 5 nm.
iu tr khang sinh d phong bng amoxicillin-clavulanate 875/125 mg PO 2 ln/
ngay trong 35 ngay, tr khi vt thng khng qua ln. iu tr khang sinh hiu
qua nht vi bnh nhn n sau hn 8 gi sau khi b thng (Arch Emerg med
1989;6:251).
LU C BIT
Cho cn: Vi khun thng co trong khoang ming gm Pasteurelle multocida, lin
cu, tu cu va Capnocytophaga canimorsus. Vt thng do cho cn chim 80% s
trng hp do ng vt cn, nhng ch 5% tr nn nhim khun. Cac khang sinh
amoxicillin-clavulanate, hoc clindamycin kt hp vi ciprofloxacin co hiu qua.
Meo cn: Cac vi khun co th gp gm P. multocida va S. aureus. do hn 80% s
vt thng do meo cn co kha nng tr nn nhim khun, nn cn iu tr d phong
mt cach thng quy bng amoxicillin-clavulanate. Khng dung cefalosporins.
Nhim bartonella co th gp sau b meo cn.
Vt cn do ng vt hoang da: Phai anh gia vic cn thit hay khng tim phong
virus dai (xem di y). Vi phn ln cac vt thng, amoxicillin-clavulanate co
th am bao hiu qua d phong. Vi vt cn do kh, cn iu tr d phong nhim
Herpesvirus simiae bng acyclovir (B virus).
Bnh dai
Virus dai gy nn cac tn thng thn kinh c trng bi s nc, s gio, co tht
thanh quan, co git, va hn m.
S cn thit phai tim phong va d phong bng min dch (xem phu luc A, iu
tr sau phi nhim) cn phai c anh gia vi bt ky vt cn ng vt nao.
Nguy c nhim virus dai tuy thuc vao loai ng vt va vung a ly. My, ca
bnh ban x mi nht c phat hin do b di cn, trong khi cac nc ang
phap trin chu yu do vt cho cn.
Du bt c loai nao, nu ng vt b dai hoc nghi dai, cn tim phong dai va s
dung immunoglobulin khang dai ngay lp tc. Vi vt nui trong nha, thng
him khi cn iu tr d phong, tr khi khng ro ngun gc con vt. Vi cac
ng vt khac, cn tham khao y kin cac nha quan ly dch t.
Mt trng hp c cu sng sau khi b hn m a c bao cao (N Engl J
Med 2005;352:2508).
Vt cn t ngi
I CNG
Vt cn t ngi, c bit vt cn nghin cht, rt d dn ti nhim trung va cac
bin chng khac. Cac vi khun ky sinh trong khoang ming bnh thng gm
Streptococcus viridans, tu cu, Bacteroides spp., Fusobacterium spp., Eikenella
corrodens.
iu tr d phong bng amoxicillin-clavulanate 875/125 mg PO 2 ln/ngay
trong 5 ngay c khuyn cao.
Vi cac vt thng co nhim khun cn iu tr bng khang sinh ng tim,
nh ampicillin-sulbactam 1,5 g IV mi 6 gi; cefoxitin 2g IV mi 8 gi hoc
ticarcillin-clavulanate 3,1 g IV mi 6 gi trong 12 tun. Co th keo dai iu tr
ti 46 tun nu co vim tuy xng.
NHIM TRNG LIN QUAN TI

CHM SC Y T
Cac nhim trung lin quan ti chm soc y t gop phn ang k vao ty l mc bnh,
t vong va tng chi ph iu tr. Nhng c gng trong kim soat va d phong nhim
trung lin quan ti chm soc y t cn s tham gia cua nhiu ngun lc, quan ly, va
cam kt trong thc hanh kim soat nhim trung (xem phu luc B, kim soat nhim
trung va khuyn cao cach ly).
Nhim trng lin quan ti chm sc y t Nhim trng... t catheter l 677
Nhim trng c ngun gc t catheter
I CNG
Tu cu vang (S. aureus), tu cu trng (S. epidermidis) (tu cu khng sinh

coagulase), vi khun gram m ai kh va nm Candida la nhng nguyn nhn
chu yu lin quan ti cac nhim trung do catheter mach mau (catheter-related
bloodstream infections [CRBSIs]) (Clin Infect Dis 2001;32:1249).
Catheter tnh mach di on (central venous cathetersCVCs) t co nguy co
nhim cac tac nhn trn hn so vi tnh mach canh, trong khi catheter tnh mach
ui co nguy c nhim khun ln nht va cn c loai bo sm trong vong 72 gi
sau khi t.
Chin lc giam ty l nhim trung do cac cn nguyn trn bao gm v sinh tay,
kh trung da bng cac dung dch sat khun cha cn chlorhexidine, ti u hoa
tit khun cac dung cu, thc hin nghim ngt cac ky thut v khun, loai bo cac
dung cu tnh mach khng cn thit sm nht co th (Infect Control Epidemiol
2008;29(suppl 1):S22). Tao ng hm di da, dung cac dung cu tnh mach tm
cht dit khun co th lam giam ty l nhim khun do cac cn nguyn trn. Quy
trnh thay i cathete di on qua bng giudewire khng c khuyn cao.
CHN ON
Biu hin lm sng

Cac nhim khun co ngun gc t catheter tnh mach co th ngh ti khi co st
trn bnh nhn co t catheter. Cac du hiu lm sang lam tng nghi ng nhim
khun co ngun gc t catheter gm vim tai ch hoc vim tc tnh mach tai ch
t catheter, nhim khun huyt, vim mang b ao, khng tm thy ng vao
khac cua vi khun, va ht st sau khi g bo catheter.
Test chn on
Chn oan xac nh khi co 2 mu cy mau dng tnh t catheter tnh mach va
ven ngoai vi trc khi iu tr khang sinh.
Nui cy lai mau sau khi iu tr khang sinh anh gia thanh thai vi khun.
Siu m tim qua thc quan c khuyn cao loai tr vim ni tm mac nu
bnh nhn co mang may tao nhp hoc may kh rung, van nhn tao, vi khun
huyt hoc nm huyt dai dng, st keo dai trn 3 ngay sau iu tr khang sinh
phu hp va loai bo catheter tnh mach, cn nguyn tu cu vang va thi gian iu
tr di 4 tun.
IU TR
Cac yu t vt chu bao gm cac bnh ly kem theo, bnh nng, vi khun a khang,
nhim khun trc o, va khang sinh ang dung la nhng yu t quan trong cn
xem xet khi la chon phac khang sinh. Hng dn iu tr co trong tap ch cua
hip hi truyn nhim Hoa Ky (Clin Infect Dis 2009;49:1).
iu tr theo kinh nghim
Vancomycin 1520 mg/kg IV mi 12 gi co tac dung trn phn ln cac tu cu gy
bnh. Cn iu chnh liu at nng ay trong huyt tng t 1520 g/mL.
Cac trc khun Gram m, bao gm Pseudomonas, phai c bao phu bi cac
khang sinh ph rng cho ti khi co kt qua khng nh cn nguyn va tnh nhay
cam khang sinh. Co th kt hp khang sinh cephalosporin th h th 4 (cefepime),
carbapenems, hoc -lactam/cht c ch -lactam vi cac aminoglycoside.
Thi gian iu tr khuyn cao tuy thuc vao nhim khun co bin chng hay
khng bin chng, kt qua cy mau m tnh, thi gian rut catheter tnh mach.
iu tr c hiu: Khi xac nh c cn nguyn, iu tr khang sinh ph hep co
hiu qua tt hn.
Tu cu vang: Cac nhim trung co ngun gc catheter tnh mach do tu cu
vang nhay vi methicillin co th iu tr bng oxacillin 2g IV mi 4 gi hoc
la chon thay th bng cefazoline 12g IV mi 8 gi. La chon hang u cho
tu cu khang methicillin la vancomycin 1520mg/kg IV mi 12 gi, nng
ay cn at cho vancomycin la 1520 /mL. La chon thay th bng linezolid
600 mg PO hoc IV mi 12 gi hoc thay th bng daptomycin 6 mg/kg IV/
ngay. Kt hp thng quy gentamycin co tac dung hip ng trn tu cu
vang khng c khuyn cao (Clin Infect Dis 2009;48:722). anh gia vim
ni tm mac bng siu m tim qua thc quan. Thi gian iu tr khuyn cao
la 46 tun. Co th iu tr 2 tun vi nhim tu cu vang huyt khng co bin
chng, khng co tn thng vim ni tm mac trn siu m tim qua thc quan,
cy mau m tnh va ht st trong vong 72 gi, khng mang cac thit b nhn
tao (may tao nhp, van tim), va khng co bng chng v di bnh (Clin Infect
Dis 2011;52:1).
Nhim trung co ngun gc catheter do tu cu trng co th iu tr ging nh
vi iu tr tu cu vang khang methicillin, bng vancomycin la khang sinh la
chon u tin trong phn ln cac trng hp. Thi gian iu tr la 7 ngay nu bo
catheter va 14 ngay nu con lu lai.
Nhim trung qua catheter mach mau do cac cu khun ng rut nhay cam
co th iu tr vi ampicillin. S dung vancomycin nu khang vi ampicillin.
Nu khang vi vancomycin co th dung daptomycin hoc linezolid. Thi gian
iu tr t 714 ngay.
Vi vi khun gram m cn lam khang sinh . Thi gian iu tr 714 ngay.
Nhim trng lin quan ti chm sc y t Vim phi bnh vin... l 679
Nhim nm candida co th dung echinocandin (caspofungin 70 mg IV liu n,

sau o 50mg IV hang ngay) vi nhng trng hp bnh trung bnh hoc nng khi
ch kt qua nh danh, sau o co th thay i theo kt qua khang sinh . Vi
cac bnh nhn khng iu tr bng nhom azole trc o co th dung fluconazole
400 mg IV hoc PO hang ngay. Thi gian dung thuc keo dai 14 ngay k t
ln cy mau dng tnh cui cung (Clin Infect Dis 2009;48:503). Cn kham th
giac vi vim mang b ao do nm Candida.
Rut catheter lun c u tin. t nht cn thc hin trong cac trng hp sau:
Vi cac nhim khun do tu cu vang, cac vi khun Gram m, nhim nm
candida.
Nhim trung tai ch hoc nhim trung ng t (mu hoc du hiu vim tai ch).
Bnh nhn suy giam min dch co st, giam bach cu, va tnh trang huyt ng
khng n nh (v.d., nhim trung huyt).
Keo dai thi gian iu tr khang sinh co th la mt la chon trong mt s tnh
hung t catheter tnh mach la mt giai phap khng th thiu.
Vim phi bnh vin v vim phi do thng kh xm nhp
I CNG
Cn nguyn thng gp nht la vi khun gram m va tu cu vang.
CHN ON
Biu hin lm sng
Bao gm tn thng thm nhim phi mi hoc, tng nhu cu th oxy bnh nhn
co st, kem theo ho hoc khng ho, xut hin 48 gi sau nhp vin.
Test chn on
Chn oan da trn tiu chun lm sang va vi khun hoc. Bnh phm ti u nht
la dch c th khng nhim bn (dch mang phi hoc mau), dch hut kh ph quan
(cy nh lng), hoc dch ly t ng ni kh quan. Soi kh ph quan chn oan
(cy nh tnh) va iu tr.
IU TR
Khi ng iu tr khang sinh theo kinh nghim cn bao phu cac tac nhn thng
gp trong nhim trung lin quan ti chm soc y t, c bit la trc khn mu xanh
va tu cu khang methicillin. iu tr trung ch cn da trn kt qua khang sinh .
Cn dn lu mang phi nu co tran mu mang phi.
Nhim t cu khng methicillin
I CNG
Tu cu khang methicillin co th thy trn khun lac, nht la khi phn lp t cac bnh
phm khng v trung nh m. Thu thp bnh phm cn c chu y.
IU TR
iu tr hang u bng vancomycin (am bao at c nng ay). iu tr
thay th bng linezolid 600 mg IV hoc PO mi 12 gi, daptomycin 6 mg/kg IV
mi 24 gi, ceftaroline, va telavancin. Daptomycin khng dung iu tr vim
phi do co th bt hoat cht hoat tnh b mt (surfactant) phi.
Loai bo mang tu cu khang methicillin mui i khi co th at c vi 5 ngay
dung dang xt mupirocin 2 ln mi ngay. Ngoai ra co th s dung xa phong tm co
chloherxidine, tm ty trng, va khang sinh ng ung TMPSMX kt hp hoc
khng kt hp vi rifampin. Tuy nhin hin tng khang mupirocin co th xut
hin va tu cu co th tai lai. Vic loai bo cn hng ti nhng bnh nhn nhim
tu cu khang methicillin tai phat.
Nhim cu khun ng rut khng vancomycin
I CNG
Nn phn bit vi nhim trung do chnh cu khun khang vancomycin tai ng
rut. Phn ln cac nhim khun ng tit niu do cu khn ng rut khang
vancomycin co th iu tr vi nitrofurantoin, ampicillin, ciprofloxacin, hoc cac
thuc khac co nng trong ng tit niu cao. Ch nh phong nga khi tip xuc.
Loai bo cu khun ng rut khang vancomycin tai ng rut kho thanh cng.
IU TR
Phn ln cac bnh nhn nhim cu khun ng rut khang vancomycin trong
mau c iu tr vi linezolid, daptomycin, hoc quinupristin/dalfopristin.
Nhim vi khun gram m a khng
I CNG
Cac vi khn gram m khang khang sinh manh (v.d., Acinetobacter, Klebsiella, va
Bnh nhim trng mi ni v khng b sinh hc Bnh than l 681
Pseudomonas) la nguyn nhn chu yu lam tng ty l nhim trung lin quan ti
chm soc y t. oi hoi d phong qua ng tip xuc.
IU TR
Co s han ch trong la chon khang sinh. Ngoai kt hp khang sinh ph rng nh
-lactam/kt hp vi cht c ch -lactam, carbapenems, tigecyline, va colistin i
khi cung co hiu qua. Cn tham khao y kin chuyn khoa truyn nhim vi cac
nhim trung a khang co bin chng.
BNH NHIM TRNG MI NI V

KHNG B SINH HC
Thay i hanh vi cua con ngi va dn s, cac hin tng t nhin va s tin trin
trong th gii vi sinh vt tip tuc tao nn cac bnh mi cho loai ngi, dn ti xut
hin va lan rng cac cn bnh mi hoc cac bnh t gp trc o. Bao gm trong
nhom nay mt s cac vi sinh vt co kha nng gy t vong cao va d san xut, chung
co th c dung nh vu kh khung b sinh hoc va gy bnh cho mt s lng ln
dn s qua phi nhim ng khng kh. Phn ln chung la nhng bnh him. Mt
vu khung b sinh hoc co th c xem xet nu co s lng bt thng cac ca bnh
co cung triu chng h hp, triu chng tiu hoa, hoc hi chng st phat ban; nu
mt s ngi khoe manh mc bnh nng bt thng, hoc nu mt cn nguyn bt
thng xay n trong vung bit lp.
Bnh than (nhim trc khun than)
I CNG
Nha bao vi khun Gram dng Bacillus anthracis sinh si tai ng vao, gy nn
bnh ngoai da, nhim trung ng sinh duc, hoc bnh than do ht.
CHN ON
Biu hin lm sng
ng ly truyn t nhin qua ngi git m va n tht ng vt nhim bnh,
thng gy ra th ngoai da va nhim trung ng tiu hoa.
Bnh than ngoai da (bnh Woolsorter) c trng bi tn thng da loet hoai
t (eschar) en khng au vi vin phu n xung quanh.
Bnh than ng tiu hoa co biu hin nn, bun nn, au bung, dch c trng,
va xut huyt do loet hoai t nim mac.
Bnh than do ht (t vong 45%) phai nha bao trong khng kh t ng vt b
bnh (v.d., len hoc da ng vt), hoc phat tan co chu y (JAMA 2001;286:2549).
Biu hin ban u nh hi chng nhim cum, triu chng tiu hoa, hoc ca hai,
theo sau o la suy h hp cp va suy a phu tang.
Test chn on
Hnh anh tn thng gi y trn X-quang ngc gm trung tht gian rng, khng co
thm nhim phi. chn oan khng nh bng cy mau va PCR. Thng bao dch
nhanh chong khi phat hin ca bnh.
IU TR
Khi ng iu tr khang sinh ngay khi co nghi ng bnh than giup lam giam ty l
t vong. Khang sinh theo kinh nghim bng ciprofloxacin 400 mg IV mi 12 gi
hoc doxycyclin 100 mg mi 12 gi va mt hoc 2 khang sinh khac co tac dung vi
B.antracis (penicillin, clindamycin, vancomycin) (JAMA 2002;287:2236). iu tr
bng ciprofloxacin 500 mg PO 2 ln/ngay hoc doxycycin 100 mg PO 2 ln/ngay va
mt khang sinh co tac dung co th iu tr sau tng cng va tip tuc duy tr trong
thi gian 60 ngay giup lam giam nguy c phat trin cua cac nha bao phat trin chm.
Bnh than ngoai da khng bin chng co th iu tr bng ciprofloxacin 500 mg
2 ln/ngay hoc doxycyclin 100 mg 2 ln/ngay, thi gian iu tr nh trn. Nhim
trung ng tiu hoa co th iu tr nh vi bnh than do ht phai.
D phong sau phi nhim bng ciprofloxacin 500 mg 2 ln/ngay trong vong 60
ngay sau phi nhim. Doxycyclin va amoxicillin co th dung thay th.
Bnh u ma
I CNG
Virus u mua co th ly d dang t ngi sang ngi qua h hp, ty l t vong co
th ln ti 2530%. Bnh u mua a c thanh toan t nm 1979. Tuy nhin vn
con nguy c khung b sinh hoc t cac ngun tr virus i vi nhng ngi cha co
min dch.
CHN ON
Biu hin lm sng
St cao, au c, au lng, va au u xut hin 717 ngay sau phi nhim, tip theo
Bnh nhim trng mi ni v khng b sinh hc Bnh dch hch l 683
35 ngay sau o xut hin ban bit lp. Tn thng tin trin t giai oan vt ban,
mun nc su, v mun nc, ong vay, tao seo su. Ban xut hin t vung mt va
cac u chi, bao gm long ban tay va chn, ti thn, tt ca cac tn thng trn cung
mt vung co cung giai oan phat trin. Nhng c im nay giup phn bit u mua
vi thuy u.
Test chn on
Chn oan da vao lm sang nhng co th khng nh bng soi trn knh hin vi
in t va PCR dch t mun nc. Cn thng bao dch ngay khi phat hin ca bnh.
X ly tt ca moi bnh phm nh co nguy c ly nhim cao.
IU TR
Chu yu iu tr h tr. Khng co thuc khang virus c hiu mc du a co rt
nhiu thuc c nghin cu.
Tt ca cac bnh nhn phai c kim soat va cach ly ng hang khng, bnh
nhn con co kha nng ly cho ti khi cac tn thng dang vay bong i.
iu tr d phong sau phi nhim bng vaccin sng trong vong 3 ngay sau phi
nhim giup bao v hoan toan nhng co th xut hin cac phan ng khng mong
mun nng.
Bnh dch hch
I CNG
Cn nguyn la trc khun gram m Yersina pestis. Nhim dch hach trong t nhin
xay ra t trong vung Ty Nam My sau phi nhim vi ng vt nhim bnh (v.d.,
qua vt chy xc, vt cn cua bo chet, hoc ht phai cac cht tit ng h hp)
hoc bo chet ky sinh trn ng vt cn.
CHN ON
Biu hin lm sng
Co 3 th lm sang
Th hach: Sng au hach tai ch va st (14% t vong).
Nhim khun huyt: Gy hoai t ngoai vi va ng mau rai rac long mach (cai
cht en). Thng tin trin t dch hach th hach
Dch hach th phi: Vim phi nng co ho mau sau hi chng gia cum (t vong
khoang 57% va 100% nu iu tr chm). Dch hach th phi co th ly t ngi
qua ngi.
Test chn on
Chn oan xac nh bng phn lp Y. pestis t bnh phm mau, m, dch nao tuy.
X ly tt ca cac bnh phm nh bnh phm co nguy c ly nhim cao. Thng bao
dch ngay khi phat hin ca bnh.
IU TR
iu tr sm giup cai thin tin lng bnh, nn cn khi ng iu tr khang sinh
ngay khi co nghi ng. Khang sinh u tin hang u streptomycin 1g IM mi 12
gi; gentamycin 5 mg/kg IV/IM mi 24 gi hoc 2 mg/kg liu tn cng sau o
1,7 mg/kg IV/IM mi 8 gi, cn theo doi nng gentamycin huyt tng; hoc
doxycyclin 100 mg PO/IV 2 ln/ngay. Ciprofloxacin va chloramphenicol co th
dung thay th. Chuyn dung ng ung nu triu chng lm sang cai thin, thi
gian iu tr 1014 ngay.
iu tr d phong sau phi nhim ch nh khi co tip xuc trc tip ma khng
co dung cu bao v vi ngi khng ro hoc nghi ng dch hach th phi, bng
doxycyclin 100 mg PO 2 ln/ngay hoc ciprofloxacin 500 mg PO 2 ln/ngay
trong 7 ngay.
Ng c botulinum
I CNG
Ng c do c t botulinum tit bi vi khun Gram dng ym kh Clostridium
botulinum. Cach thc cua mhim c bao gm n phai c t t thc phm ong
hp khng ung cach hoc vt thng nhim C. botulinum t t. Ht phai c t C.
botulinum do phat tan co chu y c t vao khng kh. Ty l t vong thp nu nhn
bit sm nhng co th rt ln nu phi nhim s lng ln va thiu trang b thng gio.
CHN ON
Tam chng c in gm khng st, ri loan cam giac, va lit mm i xng t trn
xung co lin quan ti thn kinh so, khi u mi mt, nhn i, kho noi, va ri
loan chc nng c hoanh kem theo suy h hp, lit lan toa c xng. Kha nng cam
giac vn con. Tnh trang lit co th keo dai vai tun cho ti hang thang. Chn oan
khng nh bng xet nghim tm c t trong huyt thanh. Cn bao cao dch khi
phat hin ca bnh.
IU TR
u tin la iu tr h tr, thng kh nhn tao nu co suy h hp. Loai bo tn
thng co c t.
Bnh nhim trng mi ni v khng b sinh hc ...virus st xut huyt l 685
iu tr lit bng khang c t, sn co cac c s y t. Khang c t ch dung

vi nhng trng hp co nghi ng nhiu ti ng c botulism da trn lm sang
va tin s phi nhim. iu tr d phong thng quy sau phi nhim vi c t
bng khang c t khng c khuyn cao do nguy c cao xut hin phan ng
qua mn va h tr han ch.
Nhim virus st xut huyt
I CNG
y la hi chng gy ra do nhiu loai virus mang ARN, gm filoviruses (Ebola
va Marburg), flaviviruses (dengue, st vang), bunyavirus (hantaviruses, st xut
huyt Congo-Crimean [Congo-Crimean hemorrhagic feverCCHF], st thung
lung Rift [Rift Valley FeverRVF]), va arenaviruses (st xut huyt vung nam
My, st Lassa). Tt ca gy ra cac ca bnh tan phat trong vung dch lu hanh, va
phn ln co th ly truyn qua khng kh hoc tip xuc trc tip vi dch c th. Ty
l t vong rt khac nhau nhng co th ln ti 90% nh cac ca nhim Ebola nng.
CHN ON
Biu hin lm sng
Triu chng sm bao gm st, au c, kho chu, mc nng va triu chng thay
i tuy theo tng virus, nhng tt ca co th lam thay i tnh thm thanh mach va
gy nn ng mau rai rac long mach. Thng co giam tiu cu, giam bach cu va
vim gan.
Test chn on
Chn oan da trn yu t dch t, va yu t nguy c cua bnh nhn, c bit la di
chuyn ti vung dch. Khng nh chn oan bng xet nghim huyt thanh. Cn
khai bao dch khi co ca bnh c chn oan.
IU TR
Chu yu la iu tr h tr. Ribavirin (2 g IV liu khi u, sau o 1 g mi 6 gi
4 ln/ngay, tip tuc 500 mg mi 8 gi 6 ngay) c ch nh trong st xut huyt
Congo-crimean, st Lassa, RVF (JAMA 2002;287:2391); J Antimicrob Chemo-
ther 2011;66:1215).
Nhng ngi co tip xuc cn theo doi nhit 2 ln/ngay trong 3 tun. iu tr d
phong sau phi nhim bng ribavirin cho ngi tip xuc vi ngi bnh st xut
huyt Congo-Crimean, st Lassa, RVF.
Hi chng suy h hp cp nng
I CNG
Hi chng suy h hp cp nng (Severe acute respiratory syndromeSARS) la
mt bnh ly h hp ti cp dang st cum, tin trin ti vim phi va suy h hp
cp (acute respiratory distress syndromeARDS) (JAMA 2003;290:374), gy ra do
SARS kt hp vi coronavirus (SARS-associated coronavirusSARS-CoV). SARS
co th c lu y ti khi co mt chum ca bnh vi st cha c chn oan, c
bit co di chuyn qua Trung Quc ai luc, Hng Kng, hoc ai Loan trong vong
10 ngay tr lai.
CHN ON
Khng nh bng o hiu gia khang th giai oan cp va hi phuc khang th khang
SARS-CoV, hoc PCR
IU TR
Chu yu la h tr. Co th dung interferon va corticoid liu cao.
i dch cm gia cm v cm ln
I CNG
Hin tng tai t hp gen khin cho cac chung cum trc y ch co kha nng gy
bnh cho gia cm va ln co th ly nhim cho ngi, gy ra nhng bnh nng va/
hoc phat tan nhanh trong qun th ngi. Cac bin phap kim soat ly nhim va
trao i gia cac nha quan ly v dch t co vai tro quan trong khi dch ang lu
hanh. Mi chung virus mi khac nhau v c lc, kha nng gy bnh cho cac nhom
tui, biu hin triu chng, va nhay vi cac thuc khang virus. Cn theo doi cp
nht thng tin, d liu tai ch trong t bung phat dch.
18
Bnh l ng tiu ho
C. Prakash Gyawali, Amit Patel
Xut huyt ng tiu ho
I CNG
Xut huyt ng tiu hoa cp la tnh trang nghim trong lam tng ty l t vong va
chi ph iu tr, c bit trong trng hp xut huyt tiu hoa xay ra khi nm vin,
do nguyn nhn tng ap tnh mach ca hoc khi u (Gut 2011;60:1327).
Xut huyt ng tiu hoa biu hin bi nn mau hoc i ngoai phn co mau o
ti hoc o vi cac mc khac nhau.
Xut huyt ng tiu hoa ro rt khi co mau ti hoc mau i mau trong cht
nn hoc trong phn.
Xut huyt ng tiu hoa kn ao khi xet nghim phat hin co mau trong phn
(phn dnh) hoc thiu mau thiu st ma khng nhn thy mau trong phn.
Xut huyt ng tiu hoa kn ao bao gm xut huyt ng tiu hoa khng
ro nguyn nhn, xut huyt vn tn tai hoc tai phat sau khi kt qua ni soi ban
u khng phat hin c tn thng (Gastroenterology 2007;133:1697).
CHN ON
Biu hin lm sng
Bnh s
Nn ra mau, nn ra dch mau ba ca ph va sonde da day co mau hoc dch mau ca
ph la du hiu gi y chay mau t ng tiu hoa trn.
Phn en, dnh, co mui c trng, thng do nguyn nhn tai ng tiu hoa trn,
mc du xut huyt rut non va ai trang phai cung co th gp i ngoai phn en.
Mau sc khac nhau cua phn co mau la biu hin cua xut huyt oan cui rut
non hoc ai trang, tuy thuc vao s lng mau mt va nhu ng cua ai trang.
Xut huyt ng tiu hoa trn tin trin nhanh biu hin co mau trong phn va
lun co biu hin tnh trang shock do giam th tch tun hoan.
Chay mau t hu mn trc trang thng gp co mau ti phu bn ngoai phn,
kt hp vi triu chng ai trang oan di (v.d., cam giac bun ai tin khng
kim soat c, cng tc, hoc au khi ai tin).
773
774 l Ch. 18 Bnh l ng tiu ha
Thiu mau do mt mau co biu hin mt moi, suy nhc, au bung, xanh xao,
hoc kho th.
c tnh lng mau mt thng khng chnh xac. Nu mc hematocrit nn a
bit th co th anh gia s b lng mau mt da vao mc giam hematocrit. Nhn
chung, xut huyt ng tiu hoa di t gy anh hng huyt ng hn so vi
xut huyt ng tiu hoa trn.
Ri loan ng mau co th gy chay mau t cac tn thng co t trc trong
ng tiu hoa. Ri loan ng mau (v.d., bnh gan, bnh von Willebrand, thiu
vitamin K, va ng mau ni mach tin trin) co th anh hng n tin trnh xut
huyt tiu hoa (xem Chng 20, Ri loan ng mau va huyt khi).
Cac thuc co anh hng n qua trnh ng mau hoc chc nng tiu cu bao
gm warfarin, heparin, aspirin, thuc khang vim khng steroid (nonsteroidal
anti-inflammatory drugsNSAIDs), clopidogrel (Plavix), thuc tiu huyt khi,
cac thuc d phong huyt khi nh thuc i khang thu th glycoprotein IIb/IIIa
(abciximab [ReoPro], eptifibatide [Integrilin], tirofiban [Aggrastat]) va cac thuc
c ch thrombin trc tip (argatroban, bivalirudin, dabigatran etexilate). NSAIDs
va aspirin co th gy tn thng nim mac tai bt c v tr nao trn ng tiu hoa.
Khm thc th
Mau sc cua phn. Kim tra trc tip phn qua thm trc trang hoc ni soi trc
trang giup anh gia s b mc chay mau (Dig Dis Sci 1995;40:1614). Ni soi
kim tra trc trang co th xac nh bt thng hu mn trc trang nh nt hu
mn, thm kham trc trang gy cam giac rt kho chu cho ngi bnh.
Mau ti chay qua sonde da day cho thy ang co xut huyt ng tiu hoa
trn va cn c can thip ni soi cp cu (Gastrointest Endosc 2004;59:172).
Dch trong sonde da day cn c chu y khi thy co mau va dch ti mau (ba ca
ph) va xet nghim anh gia chay mau kn ao trong dch hut t sonde da
day khng c ng dung trn lm sang. Chay mau t ta trang co th khng
phat hin c qua dch hut trong sonde da day. Ra da day bng nc hoc nc
mui co th ap dung anh gia tin trin, mc nng cua xut huyt tiu hoa
trn va lam sach da day khoi mau va cuc mau ng trc khi ni soi (N Engl J
Med 2008;359:928). Sau khi chn oan xut huyt ng tiu hoa trn, sonde da
day co th c rut khi bnh nhn n nh.
Theo doi lin tuc hoc anh gia thng xuyn cac du hiu sinh tn la cn thit,
nu mach nhanh hoc tut huyt ap (blood pressureBP) t ngt co th la du
hiu sm cua tnh trang mt mau tai phat hoc mt mau vn ang tip tuc.
Nu huyt ap va mach nn nm trong gii han bnh thng, bnh nhn ngi ln
hoc ng dy co th xut hin thay i huyt ng t th (giam huyt ap tm
thu 10 mm Hg, mach tng 15 ln/phut). Thay i mach va huyt ap t th tng
ng mt 10% n 20 % khi lng tun hoan; ha huyt ap khi nm tng ng mt
Xut huyt ng tiu ha l 775
>20%. Bnh nhn xut hin tut huyt ap vi huyt ap tm thu la 100 mm Hg hoc
nhp tim nn nhanh 100 nhp/phut cho thy ri loan huyt ng nghim trong cn
bu khi lng tun hoan ngay (N Engl J Med 2008;359:928).
Test chn on
Xt nghim
Cng thc mau toan phn (Complete blood cellCBC)
Xet nghim ng mau (ch s INR, thi gian thromboplastin ban phn)
Nhom mau, xet nghim cheo t 2 n 4 n v mau
Xet nghim sinh hoa mau (gm xet nghim chc nng gan, creatinine huyt thanh)
K nng chn on
Ni soi
Ni soi thc quan da day ta trang (EGDEsophagogastroduodenoscopy)
co gia tr chn oan chnh xac cao, co vai tro trong iu tr, thu thut t gy anh
hng cho bnh nhn va la thu thut chn oan c la chon trong xut huyt
ng tiu hoa trn. Bi phu khi lng tun hoan hoc truyn mau nn c
thc hin trc khi tin hanh ni soi nhng bnh nhn co tnh trang huyt
ng khng n nh. Bnh nhn ang chay mau hoc co nguy c cao (Bang
181) cn thit phai ni soi cp cu khi tnh trang bnh nhn n nh trong bnh
vin. Tim tnh mach (IVIntravenous) erythromycin (truyn 125250 mg 30
phut trc khi ni soi thc quan da day ta trang) co tac dung lam sach mau va
cuc mau ng trong da day va giup d dang quan sat khi tin hanh ni soi thc
quan da day ta trang (Gastrointest Endosc 2011;73:245). Tin hanh ni soi thc
quan da day ta trang lai ln hai sau khi ngng xut huyt khng chng minh lam
giam s can thip cua phu thut hoc ty l t vong (J Gastroenterol Hepatol
nm 2010;25:8).
Ni soi ai trang co th thc hin sau khi thut thao nhanh nhng bnh nhn
n nh v lm sang; dung dch thut thao co th bm qua ng sonde da day khi
bnh nhn khng ung c. Mc du hiu qua chn oan cao nht khi tin hanh
ni soi trong vong 24 gi k t khi bt u co triu chng, (Am J Gastroenterol
nm 2005;100:2395), kt qua iu tr bnh nhn khng nht thit phai cai thin
trong vong 24 gi u tin (Am J Gastroenterol 2010;105:2636). Tuy nhin,
ni soi ai trang can thip co th lam giam nhu cu truyn mau, nhu cu phai
phu thut va thi gian nm vin. Tt ca cac bnh nhn xut huyt tiu hoa thp
cp tnh khng ro nguyn nhn cn phai ch nh ni soi ai trang ngay khi nhp
vin, khng phu thuc vao cach thc thm do ban u.
Soi trc trang co th giup phat hin bnh tr ni va vt nt hu mn nhng
khng thay th c ni soi ai trang.
Thang im Rockall nh gi phn tng nguy c xut huyt ng

Bng 181
tiu ha trn cp tnh
Bin s im
Tui
<60 0
6079 1
80 2
Shock
im s
lm sng Mch nhanh > 100 nhp/pht 1
Rockall
Huyt p tm thu < 100 mm Hg 2
Bnh l km theo
Bnh mch vnh, suy tim, bnh l 2
ni khoa nng
im s Suy thn, suy gan, ung th di cn 3
Rockall
y Hnh nh ni soi
Khng tm thy im chy mu, vt 0
rch Mallory Weiss
Lot d dy, vim trt, vim thc 1
qun
Ung th ng tiu ha trn 2
Du hiu va chy mu trn ni soi
lot sch, chm phng 0
C mu trong ng tiu ha, 2
ang chy mu, thy im
mch, cc mu ng
im s lm sng 0 hoc im s y 2 c nguy c thp ti xut huyt hoc t vong thp. Trch
t Gralnek IM, Barkun AN, Bardou M. Management of acute bleeding from a peptic ulcer. N Engl J Med.
2008; 359:928.
Ni soi rut non bng bong y cho phep anh gia rut non v tr su hn
so vi ni soi thc quan da day ta trang thng thng, c bit la trong trng
hp khng tm thy v tr chay mau mc du a c ni soi ai trang cn thn.
Ni soi bng vin nang co gia tr trong trng hp nghi ng nguyn nhn chay
mau t rut non trong trng hp ng tiu hoa trn va ai trang a c kim
tra ky (Gastroenterology 2007;133:1697). Ni soi bng vin nang co gia tr
chn oan trong nhng trng hp bnh nhn co xen ln nhng t xut huyt
tiu hoa cp ro rang va co luc n. Tuy nhin, hnh anh nhn c khng cung
vi thi gian xay ra do vy khng nh v chnh xac v tr tn thng rut non,
va khng tin hanh thu thut can thip c do o hiu qua chn oan khng i
lin vi cai thin kt qua iu tr (Gastroenterology 2010;138:1673).
Ni soi rut non bong n va bong kep cho phep anh gia toan b rut non
qua ca ng ming va hu mn. Bong u dy soi va overtube co th lin tuc
c bm ri xa hi khi ng soi a vao va keo ra giup rut thng ra do o cho
phep ng soi i su vao rut non. Ni soi bong kep cho phep h tr trong chn
oan va co th can thip iu tr c bit la cac tn thng phat hin qua ni soi
bng vin nang (Endoscopy 2009;41:587).
Ni soi rut non co th h tr trong m ni soi hoc m m tm v tr chay
mau rut non. Cac bac s phu thut, qua ng m bung, y ng ni soi
(a vao qua ming, hu mn, hoc ng rach rut) bng cach gp cac np
rut trn dung cu.
Chup rut non xon c va chup rut non dn ng la hai ky thut chup
rut non mi y ha hen phat hin cac tn thng rut non (Endoscopy
2011;43:477).
Phn tch hnh anh rut non trn phim chup ct lp vi tnh (CT Computed
tomography) co gia tr khi ca hai phng phap ni soi thng thng va ni soi
bng vin nang khng chn oan c nguyn nhn nhng bnh nhn co nhng
t xut huyt tiu hoa ro va n co biu hin thiu mau ro (Gastrointest Endosc
2011;73:1002).
Ky thut anh du hng cu (TRBC Tagged red blood cell) bng technetium-99m
phat tan vao trong long rut khi ang chay mau giup phat hin bng s tp trung
cht phong xa trn may quet anh gamma. Hnh thc di chuyn cua cac cum t bao
hng cu co th giup xac nh cac im chay mau nghi ng (Dis Colon Rectum
1997;40:471). Chup mach di ct lp vi tnh co th co li ch tng t trong
vic xac nh v tr chay mau trc khi chup mach bng catheter (J VASC Interv
Radiol 2010;21:848). Cac ky thut nay rt hu ch trong trng hp chay mau
tin trin khng n nh va tranh phai ni soi ai trang cp cu.
Chup mach phat hin c hin tng thoat thuc t mach vao rut khi tc
dong mau vt qua 0,5 mL/phut, do vy xac nh c v tr chay mau. Chup
mach thng c thc hin sau khi v tr chay mau c khu tru bng cac phng
phap khac. t ng thng siu chon loc va truyn vasopressin gy co mach
ang chay mau: gy tc mach la phng phap thay th khac (Am J Gastroenterol
nm 2005;100:2395). Nhum xanh Methylene oan rut ang chay mau phat
hin c nh chup mach giup bac s phu thut ct bo nu co ch nh. Trong

xut huyt tiu hoa trn, chup mach c ch nh trong trng hp xut huyt
nng kho thc hin ni soi.
IU TR
Bi phu khi lng tun hoan. t ngay hai ng truyn tnh mach c ln (16
n 18 gauge) hoc ng truyn tnh mach trung ng. Nc mui ng trng,
dung dch Ringer Lactated, hoc hetastarch 5% c ch nh truyn khi u.
Tnh trang sc do giam th tch tun hoan oi hoi tng s lng dch truyn bng
cach s dung cac thit b truyn di ap lc hoc truyn tay vi bm kim tim
ln va khoa, phu thuc tnh trang cua bnh nhn va mc khi lng tun hoan
mt (N Engl J Med 2008;359:928). Truyn khi hng cu nn c thc hin
ngay khi co th; Truyn nhom O m hoc truyn nhiu n v mau ng thi co
th c ch nh nu xut huyt at. Nn tip tuc truyn n khi huyt ng n
nh va hematocrit at 25 % n 30%. Bi phu qua nhiu dch va khi hng cu
khng cai thin kt qua va co th co hai trong trng hp chay mau do tng ap lc
tnh mach ca (Aliment Pharmacol Ther. 2010;32:215). Thuc co mach thng
khng c ch nh, mc du iu tr tng huyt ap ng tnh mach thoang qua
i khi mang lai hiu qua n khi bi phu u khi lng tun hoan.
Th oxy. Cung cp Oxy tng kha nng vn chuyn oxy cua mau cn c ch
nh trong iu tr xut huyt tiu hoa cp.
iu chnh ri loan ng mau. Ri loan ng mau ([International Normalized
Ratio] INR 1,5) lam tng ty l bnh kem theo va t vong trong xut huyt tiu
hoa cp (Aliment Pharmacol Ther. 2011;33:1010) va cn c iu chnh. Sau
khi ngng warfarin, truyn khi u 2 n 4 n v huyt tng ti ng lanh
(fresh frozen plasmaFFP), b sung vi cac dch truyn khac sau o anh gia lai
xet nghim INR. Tim vitamin K (10 mg di da hoc tim bp) giup iu chnh
thi gian prothrombin keo dai do iu tr warfarin hoc bnh gan mt trong vai
gi n vai ngay. Truyn protamine (1 mg i khang ~ 100 n v heparin) giup
hi phuc ri loan ng mau do truyn heparin. Truyn tiu cu co th c ch
nh khi s lng tiu cu di 50.000/mm3.
t ni kh quan bao v ng h hp va phong nga ht vao ng h hp trn
nhng bnh nhn khng tnh (shock, bnh nao gan) nn ra mau nhiu va bnh
nhn ang chay mau do tng ap lc tnh mach ca.
Phn tng nguy c. S dung cac cng cu phn tng nguy c a c anh gia
hiu qua nh bang im Rockall va Glasgow Blatchford xac nh bnh nhn
co nguy c tin lng nng (Aliment Pharmacol Ther. 2011;34:470). Bang im
Rockall (xem Bang 181) co cac yu t lm sang giup anh gia nhanh chong tai
thi im hin tai va khi co kt qua ni soi (Gut 1996;38:316).
Thuc
Xut huyt tiu hoa trn khng do tng ap lc tnh mach ca. Thuc c ch
bm proton ng tnh mach (proton pump inhibitorsPPIs) se lam giam ty l
xut huyt tai phat sau cm mau ban u, giam ty l phai phu thut va giam ty l
t vong trong chay mau do loet da day ta trang (peptic ulcer diseasePUD) (Am
J Gastroenterol 2004;99:1238; Br J Surg 2011;98:640). Truyn PPI tnh mach
(v.d., truyn bolus tnh mach 80 mg, sau truyn lin tuc 8 mg/gi trong 72 gi) co
th co hiu qua khi loet da day ta trang ang chay mau; Tuy nhin, cac phn tch
gp khng cho thy hiu qua khac nhau trong ty l xut huyt tai phat, can thip
phu thut, hoc t vong gia truyn tnh mach va iu tr liu bolus tnh mach
trong cac trng hp chia ngu nhin (Arch Intern Med 2010;170:751). Tuy
nhin, iu tr PPI ng tnh mach hoc ung (v.d., omeprazole 40 mg ung hai
ln/ngay hoc loai tng ng) co hiu qua hn iu tr truyn tnh mach khang
thu th histamine-2 (histamine-2 receptor antagonistH2RA). Thalidomide co
th la la chon iu tr hiu qua trong chay mau man tnh do cac d dang mach
mau ng tiu hoa trn (Gastroenterology 2011;141:1629).
Chay mau do tng ap lc tnh mach ca. Truyn octreotide lam giam ap lc
va kim soat chay mau do gian v tnh mach thc quan vi t tac dung phu,
giup cai thin hiu qua chn oan va tng ty l thanh cng cua iu tr bng ni
soi. Octreotide nn c bt u ngay (liu bolus 50 n 100 g, tip theo la
truyn 25 n 50 g/gi) va tip tuc trong 35 ngay (Hepatology 2007;46:922).
Vasopressin (0,3 n v/phuttruyn tnh mach, tng 0,1 n v/phut trong
30 phut cho n khi cm chay mau hoc xut hin tac dung phu, hoc khi at
c liu ti a 0,9 n v/phut) la thuc thay th, t c s dung do co nhiu
bin chng tim mach bao gm ngng tim va nhi mau c tim. Truyn ng thi
nitroglycerin (10 g/phut ng tnh mach, tng thm 10 g/phut mi 1015
phut cho n khi huyt ap tm thu giam n 100 mm Hg hoc khi at liu ti
a 400 g/phut). Co th lam giam tac dung phu khng mong mun v tim mach
va kim soat chay mau hiu qua hn nhng ch co th c ch nh nu huyt
ap tm thu mc 100 mm Hg. Thuc terlipressin a c chng minh la co
hiu qua nh octreotide trong kim soat chay mau do tng ap lc tnh mach ca
(Am J Gastroenterol 2009;104:617). Khang sinh d phong vi fluoroquinolone
(norfloxacin hoc ciprofloxacin) c khuyn cao dung trng hp bnh nhn
x gan co xut huyt tiu hoa do tng ap lc tnh mach ca; ceftriaxone (1 g/
ngay) la la chon thay th (Hepatology 2007;46:922).
iu tr ni soi
Ni soi co u im la kha nng iu tr cp cu va nn c thc hin sm trong

xut huyt ng tiu hoa trn (trong vong 12 n 24 gi).
Tht tnh mach thc quan qua ni soi trong trng hp gian v c thc hin
tai phong cp cu hoc n v hi sc tch cc (intensive care unitICU) va t
ni kh quan trong trng hp bnh nhn chay mau at hoc bnh nhn khng
tnh (Hepatology 2007;46:922). Tht tnh mach thc quan co gia tr trong ca
d phong tin phat hoc th phat cua chay mau do gian tnh mach vi hiu qua
tng t nh iu tr chen n thun. (Gastroenterology 2010;139:1238). Cac
bin chng bao gm loet b mt, kho nut va au ngc thoang qua.
Tim x cung co hiu qua nhng c ch nh chu yu trong trng hp khng
thc hin c ky thut tht tnh mach thc quan do nguy c cac bin chng (loet,
hep, thung, tran dch mang phi, hi chng suy h hp cp, nhim trung huyt).
Tim qua ni soi cyanoacrylate (keo) hiu qua hn iu tr -blocker trong d
phong tin phat va th phat chay mau do gian tnh mach phnh v (Gut 2010;
59:729) nhng khng hiu qua trong chay mau do gian v tnh mach thc quan.
Phng phap iu tr mi bao gm xt cac hat nano co chc nng tao cuc mau
ng trong khi ni soi cn phai nghin cu thm.
Ni thng ca chu (Transjugular intrahepatic portosystemic shuntTIPS)
la mt thu thut di s hng dn cua chn oan hnh anh t stent kim loai co
kha nng gian thng cac tnh mach gan vi tnh mach ca lam giam ap lc tnh
mach ca trong xut huyt tiu hoa do gian tnh mach thc quan/hoc chay mau
do tng ap lc tnh mach ca (Hepatology 2007;46:922). Thc hin TIPS sm co
th co hiu qua trong giam tht bai iu tr va giam t vong nhng trng hp
xut huyt cp tnh do gian tnh mach (N Engl J Med 2010;362:2370). Bnh nao
gan co th gp khoang 25% trng hp bnh nhn va c iu tr ni khoa (xem
Chng 19, Bnh ly gan). Hep TIPS ap ng vi nong bong; anh gia bng siu
m Doppler 2 chiu c khuyn cao nu xut huyt do gian tnh mach tai phat,
hoc nu tai phat gian tnh mach thc quan hoc da day.
t bong chen tnh mach ngc dong (Balloon-occluded retrograde transvenous
obliterationBRTO) la la chon iu tr mi trong xut huyt tiu hoa do gian v
tnh mach phnh v trong o tnh mach phnh v c x ly va bt thng qua mt
shunt da day va thn (J Gastroenterol Hepatol 2009;24:372).
X tr phu thut
Phu thut ct toan b ai trang cp cu rt him khi c ch nh, y la thu
thut cu sng bnh nhn trong cac trng hp xut huyt ai trang at, khng
xac nh c v tr tn thng. Ch nh nay t ra khi a loai tr c chay mau
tiu hoa cao at ngay khi co th ni soi da day. Mt s tn thng (v.d., u, tui
tha Meckel) phai iu tr bng phu thut.
Phu thut ct ai trang toan b hoc mt phn co th c ch nh trong

trng hp chay mau tui tha. Chay mau lin tuc vi nhu cu truyn mau vt
qua 46 n v trong 24 gi hoc tng s truyn 10 n v, hoc tai phat hai n
ba ln do cung mt nguyn nhn la ch nh cua phu thut.
Ct lach la phng phap iu tr chay mau da day do huyt khi tnh mach lach
gy gian tnh mach.
Phu thut tao shunt (Tnh mach ca chu hoc shunt lach - thn) cn c xem
xet nhng bnh nhn kha nng bu cua gan con tt.
LU C BIT
Bnh nhn tim mch v chy mu d dy
Trong hi chng mach vanh cp tnh (acute coronary syndromesACSs), xut
huyt tiu hoa lam tng ty l t vong gp khoang 5 ln trong vong 30 ngay va
lam gia tng ang k ty l t vong do tim va bin chng thiu mau cuc b (J Am
Coll Cardiol 2009;29:1293). Thuc chng ngng tp tiu cu phi hp (v.d.,
aspirin phi hp vi clopidogrel) la yu t nguy c quan trong nht. Trong s
bnh nhn dung aspirin liu thp co tin s xut huyt do loet da day ta trang,
iu tr keo dai aspirin lam tng nguy c xut huyt tai phat (Ann Intern Med
2010;152:1).
iu tr d phong vi thuc PPI giup giam nguy c xut huyt tiu hoa, bao gm
ca s dung thuc chng ngng tp tiu cu phi hp nhng khng anh hng mt
cach co y ngha n ty l mc vim phi bnh vin hoc t vong trong vong 30
ngay (J Crit Care 2011;26:434; Aliment Pharmacol Ther. 2011;34:519).
Mc du co mt s lo ngai rng PPI canh tranh c ch enzym cytochrome P450,
men nay co tac dung kch hoat clopidogrel, cac nghin cu ngu nhin co i
chng a khng chng minh c cac bin c mach mau gp nhiu hn khi s
dung ng thi clopidogrel va PPI (N Engl J Med 2010;11:363). Mc du d liu
con mu thun, bin th di truyn trong biu hin enzyme co th ong vai tro quan
trong trong tht bai iu tr cua clopidogrel. Trong nhom thuc PPI, pantoprazole
co tng tac dc ng hoc t nht vi clopidogrel (Eur J Gastroenterol Hepatol
2011;23:396).
Thit b h tr tm tht trai (Left ventricular assist devicesLVADs), c s
dung trong suy tim giai oan cui, co lin quan n ty l xut huyt tiu hoa cao
hn so vi iu tr chng ngng tp tiu cu hoc thuc chng ng. Chay mau
gp chu yu t ng tiu hoa trn (Gastrointest Endosc 2012;75:973; J card
Surg 2010;25:352), do vy ni soi da day hoc ni soi rut non la cac thm do
c la chon. Bnh nhn co thit b h tr tht trai se an toan hn trong qua trnh
ni soi khi dung thuc tin m.
Kh nut v nut au
I CNG
nh ngha
Kho nut hu hong la tnh trang kho chuyn thc n t ming xung thc quan,
thng lin quan vi vi trao ngc mui hong va ht.
Kho nut thc quan la cam giac kho khn khi thc n di chuyn trong thc quan.
Nut au la tnh trang au khi nut thc n va cac cht long, y co th la du
hiu gi y tnh trang vim thc quan, c bit la vim thc quan do nhim trung
va vim thc quan do thuc.
Nguyn nhn
Kho nut hu hong thng do ri loan thn kinh c hoc ri loan cu truc lin
quan n hong va thc quan oan gn (Gastroenterology 1999;116:452).
Kho nut thc quan co th xay ra khi co tc nghen thc quan (Gastroenterology
1999;117:233). Nut kho tin trin co th do khi u, trong khi cac triu chng ngt
quang co th do tn thng dang li hoc tn thng dang vong. Xut hin kho
nut cp tnh sau ba n co th do nghen thc n. Trong trng hp khng co tc
nghen c hoc, ri loan nhu ng thc quan co th la nguyn nhn cua kho nut.
CHN ON
Kh nut hu hng
Trc ht cn kham thn kinh ky. Chup barium co huynh quang (mt ky thut cai
tin cua chup ung barium) anh gia c ch nut cua hu hong va co th anh gia
c thanh quan.
Thm kham tai, mui, hong; ni soi mui ng mm; va chn oan hnh anh co th
xac nh nguyn nhn gy bnh do cu truc giai phu.
Xet nghim tm cac bnh vim a c, nhc c, va cac ri loan thn kinh c khac
co th c xem xet trong trng hp khng phai nguyn nhn do thn kinh va
cu truc.
Kh nut thc qun
Ni soi la phng phap c ch nh trong hu ht cac trng hp. Ni soi anh
gia nhng bt thng cua nim mac cho phep sinh thit t chc va anh gia kha
nng co gian nu xac nh c v tr hep (Gastroenterology 1999;117:233).
Ung Barium co gia tr anh gia v giai phu, c bit trong trng hp hep kn
ao, hep hnh nhn co th nhn thy c ch vi mt vin thuc barium hoc
barium c.
Kh nut v nut au l 783
Tc nghen thc quan cp tt nht nn anh gia bng ni soi. Khng nn s dung
Barium khi nghi ng tc nghen thc quan v phai mt vai ngay mi sach ht
barium do o thu thut ni soi b tr hoan.
o ap lc thc quan c ch nh khi cac thm do khac co kt qua bnh thng
hoc nghi ng ri loan vn ng. May o ap lc vi phn giai cao (High
resolution manometryHRM) co man hnh hin th v tr va thi gian ghi lai cac
hin tng vn ng cua thc quan hiu qua hn phng phap o ap lc thng
thng do phn tch d dang hn (Gut 2012;61:798) va giup chn oan xac nh
tc nghen thc quan (Am J Physiol 2007;293:G878)
IU TR
Thay i ch n ung va tp nut co th co hiu qua bnh nhn kho nut, c
bit la kho nut hu hong. Bnh nhn kho nut thng c khuyn la nn nhai
ky thc n va n cac loai thc n mm.
Nui n qua ng thng da day c ch nh bnh nhn thc n se vao thng vao
kh quan khi c gng nut.
Ly thc n b nghen qua ni soi giup lam nhe cn kho nut cp tnh.
Cn xem xet nhu cu dinh dng bnh nhn nut kho keo dai gy giam cn.
Thuc
Vim nim mac do bnh trao ngc co th c iu tr bng thuc c ch axit.
Nut au thng ap ng iu tr khi nguyn nhn cu th c xac nh (v.d., PPI
cho bnh trao ngc, thuc khang sinh cho vim nhim thc quan). Cac thuc co
nht cha lidocain co th giup lam giam triu chng.
Thuc khang cholinergic (v.d., scopolamine dan ngoai da) giup tng tit nc bot.
Glucagon (24 mg tim bolus tnh mach) hoc nitroglycerin ngm di li
c xet ch nh trong trng hp nghen thc n cp tnh, nhng khng nn s
dung cht lam mm tht.
Phng php ni soi iu tr
Nong thc quan c thc hin trong trng hp co tht do giai phu. Thc hin
nong theo phng phap truyn thng c thc hin khi khng xac nh c v
tr hep cung co th giup giam triu chng.
Phng phap nong chu ng c tht thc quan di (lower esophageal sphincter
LES) bng kh i khi c thc hin trong trng hp co tht tm v (xem thm
phn ri loan vn ng thc quan). Tim botulinum toxin vao c tht thc quan
di cho phep giam triu chng co tht tm v tam thi va sa cha ri loan gian
cua c tht thc quan di.
t stent thc quan co th lam giam kho nut trong trng hp u khng phu
thut c.
Bun nn v nn
I CNG
Bun nn va nn co th do tac dung phu cua thuc, bnh h thng, ri loan h
thng thn kinh trung ng (central nervous systemCNS) va cac ri loan tiu
hoa nguyn phat.
Nn xay ra trong hoc ngay sau ba n co th do hep mn v cp tnh (v.d., loet
mn v) hoc ri loan chc nng, nn trong vong 30 n 60 phut sau ba n co th
gi y bnh ly da day hoc ta trang. Nn mun sau ba n va nn ra thc n khng
tiu t ba n trc co th gi y tc hep mn v hoc lit da day.
CHN ON
Tnh trang tc rut va co thai nn c chn oan loai tr.
Danh sach thuc s dung cn c xem xet ky lng va cac bnh h thng (cp va
man tnh) cn c anh gia nh la nguyn nhn hoc yu t gop phn.
IU TR
iu chnh cn bng nc va in giai la phng phap iu tr h tr quan trong.
Ngng hoc han ch ung va n cac cht long. Nhiu bnh nhn co th kim soat
c khng cn iu tr thm.
Giai phong tc nghen da day co th cn bnh nhn tc rut hoc bun nn va
nn keo dai do cac nguyn nhn.
Bnh nhn bun nn va nn keo dai i khi co th cn ch nh nui n bng
ng rut qua hng trang hoc thm ch c nui hoan toan qua ng tnh
mach.
Thuc
iu tr thuc theo kinh nghim thng bt u trong khi cac can thip ang c
chun b tin hanh, hoc khi nguyn nhn c cho la t kim soat c.
Phenothiazine va cac thuc tng ng. Prochlorperazine (Compazine), 510
mg ung 34 ln/ngay, 10 mg tim bp hoc tim tnh mach mi 6 gi, hoc
25 mg t trc trang 2 ln/ngay; promethazine (Phenergan), 12,525 mg ng
ung, tim bp, hay t trc trang mi 46 gi; va trimethobenzamide (Tigan),
250 mg/ung 34 ln/ngay, hoc 200 mg tim bp 34 ln/ngay at hiu qua.
Tiu chy l 785
Bun ngu la tac dung phu thng gp, va phan ng loan trng lc cp tnh hoc
tac dung ngoai thap khac co th xay ra.
Thuc i khang dopamine bao gm metoclopramide (10 mg ung 30 phut
trc ba n va trc khi i ngu, hoc 10 mg tim tnh mach), thuc prokinetic
cung co tac dung chng nn trung ng. Triu chng bun ngu va ngoai thap co
th xay ra, va theo khuyn cao cua cuc quan ly dc va thc phm Hoa Ky (Food
and Drug AdministratioFDA) khi dung liu cao va keo dai co nguy c ri loan
thn kinh c vnh vin (Aliment Pharmacol Ther. 2010;31:11). Tnh trang nhn
thuc co th han ch hiu qua lu dai. Domperidone la thuc thay th, khng qua
hang rao mau nao va do o khng co tac dung phu ln thn kinh trung ng; Tuy
nhin, thuc nay khng co sn.
Cac thuc khang histamin hu ch nht trong iu tr bun nn va nn cac
bnh nhn say xe nhng cung co th hiu qua vi cac nguyn nhn khac. Cac
thuc c ch nh bao gm diphenhydramine (Benadryl, 2550 mg ung mi
68 gi, hoc 1050 mg tim bp mi 24 gi), dimenhydrinate (Dramamine, 50
n 100 mg ung hoc tim tnh mach mi 46 gi) va meclizine (Antivert, 12,5
n 25 mg, 1 gi trc khi di chuyn).
Cac thuc i khang thu th Serotonin 5-HT3. Ondansetron (Zofran, mi 4
gi 0,15 mg/kg dung ba liu hoc 32 mg truyn tnh mach trong 15 phut, bt u
30 phut trc khi hoa tr) co hiu qua trong iu tr nn do hoa tr liu. Thuc
cung ch nh trong iu tr nn do tac dung phu cua cac loai thuc khac (48 mg
ung hoc tim tnh mach mi 8 gi), c bit la dang thuc iu tr ngm di
li. Granisetron (Kytril, 10 g/kg dung ng tnh mach 13 liu/10 phut, hoc
ung 1 mg) at hiu qua.
Thuc i khang thu th Neurokinin1 (NK1). Aprepitant (ung 125 mg
ngay th nht, ung 80 mg ngay th 2 va 3) la la chon khac, hin nay c ch
nh duy nht trong iu tr bun nn va nn do hoa tr liu.
Tiu chy
I CNG
Tiu chay cp la hu qua cua qua trnh tng nhu ng va/hoc dch cua rut t
ngt. Cac tac nhn nhim trung, c t, va thuc la cac nguyn nhn thng gp
gy tiu chay cp. Vim ai trang gia mac, tiu chay do khang sinh hoc do thuc
va tao bon cn c chu y nhng bnh nhn nm vin (Gastroenterology 2004;
127:287).
Tiu chay man tnh la tnh trang i ngoai phn long co hoc khng co tng s
ln ai tin trn 4 tun.
CHN ON
Hu ht tiu chay cp do nhim trung keo dai di 24 gi va co th do virus; do vy,
xet nghim phn khng cn thit ch nh trong t bnh biu hin ngn khng st,
khng mt nc, phn khng co mau hoc mu (N Engl J Med 2004;350:38).
Cy phn, tm c t Clostridium difficile, xet nghim trng giun, ky sinh trung,
va soi ai trang sigma co th c ch nh nhng bnh nhn co cac triu chng
nghim trong va keo dai, hoc khng in hnh.
Chnh lch thm thu trong phn c tnh nhng bnh nhn b tiu chay
man tnh va i ngoai phn nc nh sau: 2902 ([Na+] phn + [K+] phn). Chnh
lch thm thu <50 mOsm/kg gp trong tiu chay tng tit va >125 mOsm/kg
gp trong tiu chay thm thu.
Ngh n tiu chay do vim nu xet nghim tm thy mau hoc bach cu trong phn.
Phn m c chn oan khi co 7 g cht beo trong phn/ngay mu phn thu
thp trong 72 gi trn nhng bnh nhn n 100 g cht beo mt ngay. Nhum
sudan mu phn la xet nghim thay th; 100 hat m trong mt vi trng (high-
power fieldHPF) la bt thng.
Nhng trng hp tiu chay man tnh cha ro nguyn nhn cn sang loc vic
dung thuc nhun trang.
Biu hin lm sng
Tiu chay cp
Nhim virus va vi khun ng rut nh E. coli, Shigella, Salmonella,
Campylobacter, Yersinia la nhng nguyn nhn thng gp nht.
Vim ai trang gia mac thng xut hin sau iu tr khang sinh va do cac c
t tit ra bi C. difficile.
Bnh do nhim Giardia c xac nh khi co Giardia lamblia trophozoites
trong phn, trong dch ta trang, hoc trong mu sinh thit rut non. Nhum
min dch huynh quang mu phn giup chn oan nhanh.
Nhim amip co th gy ra tiu chay cp, c bit nhng ngi i du lch ti
vung kem v sinh va tnh duc ng tnh nam. Xet nghim phn tm trophozoites
hoc nang cua Entamoeba histolytica hoc xet nghim khang th trong huyt
thanh giup chn oan xac nh.
Cac thuc nh thuc nhun trang, thuc khang axit, thuc tim mach (v.d.,
digitalis, quinidine), colchicine va thuc khang sinh. Triu chng thng ht
khi ngng s dung cac thuc trn.
Bnh thai ghep cn phai c chu y khi tiu chay tin trin sau cy ghep ni
tang, c bit la ghep tuy xng.
Tiu chay man sau khi khai thac ky bnh s, thm kham toan din va lam xet
nghim thng quy, tiu chay man tnh bao gm cac loai sau: tiu chay phn
Tiu chy l 787
nc (tit hoc thm thu), tiu chay do vim, hoc tiu chay m (phn m)
(Gastroenterology 2004;127:287).
IU TR
Bu u nc la iu tr khi u trong iu tr bnh tiu chay. Bu nc bng ng
tnh mach la cn thit nhng trng hp nng.
Tiu chay do khang sinh va nhim C. difficile co th ngn nga bng tranh dung
cac khang sinh co nguy c cao va ch nh thuc khang sinh da vao khang sinh .
iu tr triu chng la cn trong trng hp t khu tru la nhim trung ng tiu
hoa vi biu hin tiu chay thng xuyn hoc gy kho chu trong thi gian ang
thc hin quy trnh chn oan bnh, trong trng hp iu tr c hiu khng cai
thin triu chng, hoc khi khng xac nh c nguyn nhn cu th.
Loperamide, 24 mg ung ti a bn ln mt ngay, cac thuc opiate (cn thuc
phin, belladonna va vin nang opium) va cac thuc nhom khang cholinergic
(diphenoxylate va atropine [Lomotil], 1520 mg diphenoxylate/ngay chia liu)
la cac thuc iu tr tiu chay khng c hiu hiu qua nht.
Ch phm dang pectin va kaolin (gn cht c) va bismuth subsalicylate (co
tnh khang khun) rt hiu qua trong iu tr triu chng cua tiu chay cp.
Cac thuc gn axit mt (nh cholestyramin, 1 g ti a 4 ln/ngay) co hiu qua
trong iu tr tiu chay do axit mt.
Octreotide (100200 mg chia 23 ln khi cn) rt hiu qua trong tiu chay
dang tit do hormone nhng co th co hiu qua trong tiu chay khang thuc.
Thuc
iu tr khang sinh theo kinh nghim ch c khuyn cao nhng bnh nhn
tiu chay mc trung bnh n nng co triu chng toan thn trong thi gian
i kt qua cy phn. Thuc khang sinh co th lam tng nguy c mc hi chng
tan ur huyt do nhim Escherichia coli gy tit c t Shiga (E. coli O157:H7),
c bit la tre em va ngi cao tui (N Engl J Med 2000;342:1930). Thuc co
hiu qua gm fluoroquinolones (ciprofloxacin, 500 mg ung 2 ln/ngay trong 3
ngay, hoc norfloxacin 400 mg ung 2 ln/ngay trong 3 ngay) va trimethoprim-
sulfamethoxazole (160 mg/800 mg ung 2 ln/ngay trong 5 ngay).
Metronidazole ng ung la la chon iu tr trong vim ai trang gia mac.
Vancomycin ng ung c ch nh trong trng hp khang hoc khng
dung nap vi metronidazole. Fidaxomicin va chuyn ghep phn la nhng phng
phap mi ang c nghin cu (xem Chng 14, iu tr bnh truyn nhim).
Triu chng nhim amip c iu tr bng metronidazole 750 mg ung 3 ln/
ngay hoc 500 mg mi 8 gi, ng tnh mach t 5 n 10 ngay. Phac nay cn
c tip tuc bng paromomycin 500 mg ung 3 ln/ngay trong 7 ngay, hoc
iodoquinol 650 mg ung 3 ln/ngay trong 20 ngay iu tr ken.
iu tr nhim Giardia gm metronidazole 250 mg ung 3 ln/ngay t 5 n 7
ngay, hoc tinidazole 2 g liu duy nht. Quinacrine 100 mg ung 3 ln/ngay trong
7 ngay, la dang thuc thay th.
LU C BIT
Tiu chy bnh nhn HIV
Cac tac nhn gy nhim trung c hi nh Cryptosporidium, microsporidium,
cytomegalovirus (cytomegalovirusCMV), phc hp Mycobacterium avium va
Mycobacterium tuberculosis, co th gy tiu chay bnh nhn HIV giai oan
mun (CD4 <50 t bao/L). Trong o, C. difficile la vi khun gy bnh ph bin
nht (Gut 2008;57:861).
Nguyn nhn khac gy tiu chay trong nhom bnh nhn nay bao gm nhim trung
h sinh duc (giang mai, lu, chlamydiosis, herpes simplex virut [herpes simplex
virusHSV]) va nhim trung hoa liu khac (amebiasis, salmonella, shigella).
Lymphoma rut va sarcoma Kaposi cung co th gy tiu chay.
Xet nghim phn (trng va ky sinh trung, nui cy), ni soi sinh thit va xet
nghim huyt thanh co th giup chn oan nguyn nhn. iu tr bao gm iu tr
c hiu nu tac nhn gy bnh c xac nh; cac bin phap iu tr triu chng
trong trng hp tiu chay khng ro cn nguyn.
Bo sot tac nhn gy bnh thng gp nhng trng hp tiu chay khng chn
oan c nguyn nhn. Thuc, thuc khang sinh, HIV la cac tac nhn gy bnh,
ri loan thn kinh t ng, va nhu ng bt thng co th gop phn gy bnh.
To bn
I CNG
nh ngha
Tao bon la tnh trang ai tin khng thng xuyn (va thng khng ht phn), i
khi bnh nhn phai c rn va i ngoai phn dang vin.
Nguyn nhn
S thay i thoi quen ai tin co th la nguyn nhn c hoc, trng hp tao bon
lu dai nhiu kha nng do chc nng.
Thuc (nh cac thuc nhom chen canxi, thuc phin, thuc khang cholinergic,
st, bari sulfat) va cac bnh toan thn (nh ai thao ng, suy giap, x cng toan
thn, loan dng trng lc c) co th la nguyn nhn.
To bn l 789
N gii, tui gia, tp th duc khng thng xuyn, lng calo thp, ch n ung
t cht x va cac nguyn nhn gy au khi ai tin (v.d., nh nt hu mn, huyt
khi bui tr ngoai) la nhng yu t nguy c khac (Am Fam Physician 2011; 84:299).
CHN ON
Ni soi ai trang va chup Barit giup loai tr cac bnh v giai phu va cn thit
ch nh nhng bnh nhn >50 tui khng c sang loc ung th ai trang trc
y hoc i tng co biu hin bao ng nh thiu mau, mau trong phn, va cac
triu chng mi xut hin (Gastroenterology 2000;119:1761).
Chup chu trnh rut, o ap lc hu mn trc trang, va chup trc trang ch nh
cac trng hp bnh nhn biu hin cac triu chng dai dng va khng phat hin
c bt thng v giai phu sau thm kham ban u.
IU TR
Tp th duc thng xuyn va ung nc y u la nhng bin phap khng c
hiu.
Ch n tng cht x 20 n 30 g/ngay co th co hiu qua. Thut thao phn phai
c thc hin trc khi bt u b sung cht x. Cam lua m hoc psyllium 2-4
ln mt ngay co th c dung cung vi tng b sung nc. y hi thoang qua
thng gp.
Thuc
Thuc nhun trang
Thuc nhun trang lam mm phn nh natri docusate 50 n 200 mg ung
hang ngay va canxi docusate 240 mg ung hang ngay, giup nc va cht beo
thm nhp vao khi phn. Du khoang (1545 mL ung mi 68 gi) co th
c dung ng ung hay ng thut. Ht thuc du vao kh ph quan co th
gy vim phi do du.
Cac thuc kch thch nhun trang nh du thu du, 15 mL ung, kch thch
bai tit va tng nhu ng rut. Anthraquinones (cascara, 5 mL ung hang ngay;
senna, ung hang ngay mt n bn vin) kch thch ai trang bng cach tng
hp thu cht long va nc trong ai trang oan gn. Bisacodyl (1015 mg
ung trc khi i ngu, thuc t trc trang 10 mg) co cu truc tng t nh
phenolphthalein va kch thch nhu ng rut, iu tr hiu qua va dung nap tt
bnh nhn tao bon man tnh (Clin Gastroenterol Hepatol 2011;9:577).
Thuc nhun trang thm thu gm mui khng hp thu hoc carbohydrate gi
nc trong long ai trang. Mui magi bao gm sa magi (15 n 30 mL mi
812 gi) va magi citrate (200 mL ung), khng dung bnh nhn suy thn.
Lactulose (15 n 30 mL ung 24 ln/ngay) co th gy tac dung phu y hi.
Lubiprostone (824 mcg ung hai ln/ngay) la thuc hoat hoa knh clo rut
chon loc lam dch i vao long rut va kch thch nhu ng rut (Dig Dis Sci
2010;55:1090).
Linaclotide (145290 mcg ung 4 ln/ngay) la mt cht chu vn cua thu th
guanylate cyclase C va cung lam dch i vao trong long rut, qua o cai thin
cac triu chng cua tao bon (N Engl J Med 2011;365:567).
Thut Natri biphosphate (Fleet) (12 ln thut trc trang khi cn thit) co th c
ch nh trong trng hp tao bon nhe n trung bnh va lam sach ai trang trc
khi soi ai trang sigma, nn tranh s dung ngi suy thn. Thut bng nc (1
lt) cung rt hu ch. Cac cht thut du (hat bng Colace, hypaque) c ch nh
trong trng hp tao bon dai dng.
Cac thuc khac nh bt Polyethylene glycol (MiraLax, 17 g ung hang ngay
mt n hai ln) co th c ch nh thng xuyn hoc ngt quang iu tr
tao bon. Methylnaltrexone dung di da, mt thuc tac ng chon loc ngoai
bin i khang thu th -opioid, co hiu qua giam nhanh tao bon do opioid gy
ra (N Engl J Med 2008;358:2332). Prucalopride c chp nhn chu u trong
iu tr tao bon man tnh (Aliment Pharmacol Ther. 2010;32:1113).
Cac thuc lam sach rut. Bnh nhn nn theo ch n long trong ngay hm
trc va nhn n trong 6 gi hoc qua m trc khi thm do rut (ni soi ai
trang hoc thut barit). Tranh bnh nhn mt nc. Bnh nhn co th cam thy
kho chu nhe bung, bun nn va nn vi vic thut thao.
Dung dch polyethylene glycol ng trng-thm thu (PEG, GoLytely hoc
NuLYTELY, khoang 4 lt, cach dung ung 240 mL mi 810 phut) thng
c ch nh lam sach rut-trc khi ni soi ai trang. Cac thuc co th tch
t hn, nh PEG (khoang 2 lt) vi axit ascorbic hoc thuc nhun trang khac
la cac la chon thay th (Aliment Pharmacol Ther. 2010;32:637). Khi lng
thuc cha thch hp, co th dung thm dung dch ng trng thm thu cho
n khi sach phn.
Phosphate khng hp thu (Fleet phosphosoda, 2045 mL vi 300720 mL
nc, dung ngay hm trc va bui sang trc khi thc hin thu thut), la dung
dch u trng, thuc giup keo dch vao long rut va tao nhu ng rut trong
0,56 gi. Dang thuc vin (Visicol hoc OsmoPrep, 3240 vin, ung 34
vin mi 15 phut vi 240 mL nc). Phosphosoda co th gy mt nc nghim
trong, tng phosphat mau, giam canxi mau, ha kali mau, tng natri huyt va
nhim toan. Bin chng nng him gp la bnh thn cp do phosphate, bnh
do calcium phosphate gy ri loan chc nng khng th hi phuc cua ng thn
dn n suy thn. Do vy, phosphosoda c ch nh han ch.
Chia liu thuc. Thut thao ngay trc ni soi giup cai thin hiu qua lam sach
va quan sat d dang trong khi ni soi. V vy, tt nht qua trnh chun b chia
Ri lon ng tiu ha Tro ngc d dy thc qun l 791
thanh hai ln, mt ln vao bui ti hm trc va ln th 2 vao bui sang hm

lam thu thut (Am J Gastroenterol 2010;105:1319), c bit trong trng hp
ni soi d kin thc hin vao bui chiu.
Thut thao trong hai ngay thnh thoang c ch nh nhng ngi cao tui
hoc suy kit co chng ch nh thut thao theo phng phap thng thng,
khng dung nap, hoc khng hiu qua. Qua trnh nay gm ung magie citrate
(120300 mL ung) trong 2 ngay lin tip va bnh nhn duy tr mt ch n
ung long; Bisacodyl (30 mg ung hoc vin an 10 mg) dung trong ca hai ngay.
Thut nc (khi lng 1 lt, lp i lp lai 12 ln) co th lam sach ai trang
oan xa khi ni soi c ch nh nhng bnh nhn tc ai trang oan gn.
Nhng la chon khac: Liu phap iu tr da vao phan hi sinh hoc va kch
thch thn kinh co th hiu qua nhng trng hp tao bon v cn khng ap
ng vi iu tr thuc (Gut 2010;59:333,1288).
RI LON NG TIU HO
Tro ngc d dy thc qun
I CNG
nh ngha
Trao ngc da day thc quan (Gastroesophageal reflux diseaseGERD) c nh
ngha la co cac triu chng va/hoc cac bin chng do trao ngc dch da day vao
thc quan va cac c quan ln cn.
CHN ON
Biu hin lm sng
Triu chng in hnh thc quan cua GERD bao gm nong rat va trao ngc.
GERD cung co biu hin nh au ngc khng do tim, do vy cn loai tr cac
nguyn nhn t tim (Am J Gastroenterol 2006;101:1900).
Biu hin ngoai thc quan bao gm ho, vim thanh quan, hen suyn va mon
rng. GERD a c cho rng co mi lin quan cua vi vim xoang, x phi,
vim hong, vim tai gia tai phat trong mt s trng hp nht nh (Am J
Gastroenterol 2006;101:1900).
Giam triu chng khi iu tr th bng PPI co th giup chn oan, nhng cac trng
hp khng ap ng vi iu tr cung khng loai tr c GERD (Gastroenterology
2008;135:1392).
Chn on phn bit

Cac ri loan khac co th dn n vim thc quan bao gm:
Vim thc quan do bach cu a axit (Eosinophilic esophagitisEoE) c c
trng bi s xm nhp bach cu ai toan vao nim mac thc quan. D ng (vim
mui d ng, eczema, hen suyn) thng gp va cac cht gy d ng co trong thc
phm co th kch hoat qua trnh nay. Triu chng khi vn chuyn thc n (kho
nut) la triu chng ni bt nhng cac triu chng khac cung co th ging cac triu
chng cua GERD. Kt qua ni soi thng gp hnh anh ranh chay doc, hep long
thc quan, co np gp va mang trng nim mac thc quan. Chn oan da vao
ca lm sang va m bnh hoc, bao gm (1) cac triu chng nh nut nghen thc
n va kho nut, (2) 15 bach cu ai toan trn mt vi trng trong mu sinh thit
thc quan, va (3) loai tr cac ri loan khac bao gm GERD (Gastroenterology
2007;133:1342). Xet nghim tm cac cht gy d ng thc phm co th c cn
nhc nhng gia tr thng thp. Du vy cung nn han ch cac cht gy d ng
trong ch n ung nu xac nh c. Nu mc ng thi vi GERD cn iu
tr PPI. Cac phng phap iu tr c hiu gm iu tr tai ch (ung fluticasone,
880 n 1.760 g/ngay chia 24 ln) va corticosteroid toan thn t c ch nh
hn (budesonide 1 mg hai ln mi ngay trong 15 ngay) (Gastroenterology 2010;
139:1526). Mepolizumab, thuc khang interleukin [interleukinIL] 5 khang th
n dong, lam giam bach cu ai toan c ch nh trong trng hp EoE khang
thuc trn lm sang (Gut 2010;59:21). Phng phap nong thc quan oan hep co
th tin hanh nu iu tr steroid khng thanh cng va nguy c thung trong EoE
khng cao nh nhng anh gia trc y (Dig Dis Sci 2010;55:1512)
Vim thc quan do nhim khun thng gp nhng trng hp suy giam
min dch (AIDS, ghep tang), tr thc quan (nhu ng bt thng [nh co tht
tm v, x cng b], tc nghen c hoc [nh hep]), bnh ly ac tnh, ai thao ng
va s dung khang sinh. Tuy nhin, vim thc quan do HPV va thuy u him xay
ra ngi khoe manh. S xut hin tn thng rng ming c hiu (bnh ta
ming, mun nc Herpes) giup xac nh cn nguyn. Cac triu chng thng gp
la kho nut va nut au.
Nhim nm Candida thc quan la nhim trung thc quan thng gp nht va
thng gp trong tr thc quan, suy giam min dch qua trung gian t bao do
liu phap c ch min dch (v.d., iu tr steroid hoc cac thuc gy c t bao),
bnh ly ac tnh hoc AIDS. Hnh anh ni soi thy cac mang gia mac trng in
hnh giup chn oan vi nhay gn 100%. Cac thuc khang nm iu tr theo
kinh nghim la thch hp khi xut hin ng thi ca nm hu hong thy trn
ni soi. Fluconazole 100200 mg/ngay hoc itraconazole 200 mg/ngay trong
14 n 21 ngay c khuyn cao la iu tr ban u cho nhim nm Candida
thc quan; nystatin (100.000 U/mL, 5 mL 3 ln/ngay trong 3 tun) va troches
clotrimazole (10 mg, 45 ln/ngay trong 2 tun) la la chon thay th cho iu tr

nhim nm candida hu hong. Cac bnh nhn nhim nm khang azoles co th
c xem xet ch nh t iu tr ngn truyn amphotericin B (0,30,5 mg/
kg/ngay) (Best Pract Res Clin Gastroenterol 2008;22:639).
Vim thc quan do HSV c c trng bi cac mun nho va cac vt loet tron
hnh ay ging phat hin c khi ni soi va trn m bnh hoc co cac t bao
khng l in hnh. Khang nguyn cua virus hoc DNA co th c xac nh
bi cac khang th min dch huynh quang. iu tr gm acyclovir 400800 mg
ung nm ln/ngay trong 14 n 21 ngay hoc 5 mg/kg, tim tnh mach mi 8
gi trong 7 n 14 ngay. Famciclovir va valacyclovir la cac thuc thay th.
Tnh trang bnh thng t kim soat c cac bnh nhn co h min dch tt
(Curr Opin Gastroenterol 2008;24:496).
Vim thc quan do CMV thng ch xay ra bnh nhn suy giam min dch,
co th co cac vt trt hoc loet rng. S dung ng tnh mach ganciclovir,
foscarnet hoc cidofovir hiu qua vi nhiu loai CMV khac nhau. Ganciclovir
5mg/kg ng tnh mach mi 12 gi hoc foscarnet 90 mg/kg ng tnh
mach mi 12 gi trong 36 tun co th c s dung la liu phap u tin
Valganciclovir ng ung co th co hiu qua.
Giam triu chng co th at c khi s dung dung dch lidocain 2% ung (15
mL ung mi 34 gi) hoc sucralfate slurry (1 g ung 4 ln/ngay). c ch axit
nn c s dung cung.
Vim thc quan do cac cht hoa hoc
Ung cac thuc gy bong (kim, axit) hoc cac loai thuc nh kali ung,
doxycycline, quinidine, st, NSAIDs, aspirin va bisphosphonates co th dn
n kch ng nim mac va tn thng.
Nn thc hin ni soi sm anh gia lan rng va mc tn thng nim
mac. Khi nut phai cht n mon gy tn thng m, thi gian ti u thc
hin ni soi la sau khi nut 24 n 72 gi.
Thuc gy bnh nn ngng nu co th. Cac thuc phu nim mac (sucralfat) va
cac thuc c ch axit co th giup giam triu chng. Cht n mon th hai nhm
trung hoa cht u tin la chng ch nh.
Tn thng loet khng c hiu co th gp trong nguyn nhn do thuc, bnh
ly ac tnh va AIDS.
Khi ni soi, tin hanh chai, sinh thit va nui cy la rt cn thit.
Loet v cn bnh nhn AIDS co th ap ng vi steroid ng ung hoc iu
tr thalidomide.
Test chn on
Ni soi c ch nh tranh bo sot chn oan cac bnh co cac triu chng thc
quan (v.d., EoE), xac nh bin chng va anh gia tht bai iu tr. Cac triu
chng bao hiu nh kho nut, nut au, n mau no, giam cn hoc chay mau nn
xem xet ch nh ni soi (N Engl J Med 2008;359:1700).
o pH hoc theo doi pHtr khang c ch nh nh lng tnh trang
tip xuc axit, hin tng trao ngc, va mi tng quan gia trao ngc vi triu
chng nhng bnh nhn co cac triu chng dai dng mc du a iu tr thuc c
ch axit (c bit la trng hp ni soi khng thy tn thng) hoc nhng bnh
nhn co cac triu chng khng in hnh. Xac nh pH tr khang cung co th xac
nh hiu qua cua thuc c ch axit nhng bnh nhn GERD va cac triu chng
ang din ra.
o ap lc thc quan, c bit la HRM, co th xac nh cac qua trnh c hoc gop
phn gy ra cac triu chng dai dng.
IU TR
Thuc
Thuc khang axit, thuc i khang thu th histamine2 (histamine-2 receptor
antagonistsH2RAs), va thuc PPIs c k n ngt quang va d phong co
hiu qua bnh nhn co triu chng nhe hoc khng lin tuc.
PPI co hiu qua hn H2RA vi liu tiu chun va gia dc trong vic giam triu
chng va giup lanh tn thng phat hin c khi ni soi trn bnh nhn GERD.
Hiu qua at c han ch khi tng gp i liu PPI bnh nhn co tn thng
thc quan nng hoc triu chng keo dai. iu tr PPI keo dai, lin tuc co hiu
qua trong vic duy tr vic giam cac triu chng cua GERD, nhng liu dung cua
thuc nn c giam sau 8 n 12 tun vi liu thp nht at c giam triu
chng (N Engl J Med 2008;359:1700). Cac tac dung phu thng gp khi dung
thuc keo dai la au bung, nhc u, tiu chay. Theo kt qua cua cac nghin cu
quan sat, s dung PPI keo dai co lin quan n tnh trang loang xng, nhim
trung ng rut, vim phi cng ng va giam nng vitamin B12 trong mau
nhng li ch cua iu tr thuc PPI keo dai cao hn nguy c.
Liu chun cua H2RAs (Bang 182) at c hiu qua trong iu tr triu
chng va lin tn thng khi ni soi trn hn na s bnh nhn (N Engl J Med
2008;359:1700). Cn iu chnh liu lng bnh nhn suy thn.
Thuc c ch trao ngc cha cht chu vn thu th axit gamma-aminobutyric
(gamma-aminobutyric acidGABA), type B ngn chn tnh trang gian c tht
thc quan di thoang qua. Baclofen, loai thuc u tin, lam giam triu chng
trao ngc, nhng thuc co han ch v co tac dung phu trn thn kinh trung ng
(Am J Gastroenterol 2009;104:1764). Ca hai loai thuc Lesogaberan, thuc
nhom chu vn thu th GABAB, va arbaclofen placarbil, tin cht cua ng
Bng 182 Liu thuc c ch axit
Thuc iu tr Lot d dy GERD Tnh mch
Cimetidinea 300 mg, 4 ln/ngy 400 mg 4 ln/ngy 300 mg, mi 6 gi

400 mg, 2 ln/ngy 800 mg 2 ln/ngy
800 mg, khi i ng
Ranitidinea 150 mg, 2 ln/ngy 150300 mg 24 50 mg, mi 8 gi
300 mg, khi i ng ln/ngy
Famotidinea 20 mg, 2 ln/ngy 2040 mg 2 ln/ 20 mg, mi 12 gi
40 mg, khi i ng ngy
Nizatidinea 150 mg, 2 ln/ngy 150 mg, 2 ln/
300 mg, khi i ng ngy
Omeprazole 20 mg, hng ngy 2040 mg, hng
ngy2 ln/ngy
Esomeprazole 40 mg, hng ngy 2040 mg, hng 2040 mg, mi
ngy2 ln/ngy 24 gi
Lansoprazole 1530 mg, hng ngy 1530 mg, hng 30 mg mi 1224
ngy2 ln/ngy gi
Dexlansoprazole 3060 mg, hng
ngy
Pantoprazole 20 mg, hng ngy 2040 mg, hng 40 mg mi 1224
ngy2 ln/ngy gi hoc 80 mg
tim tnh mch,
sau 8 mg/gi
truyn tnh mch
aChnhliu khi c suy gim chc nng thn
GERD, tro ngc d dy thc qun
phn R cua baclofen co th cai thin cac triu chng dai dng khi iu tr
phi hp vi thuc PPI (Gastroenterology 2010;139:409; Am J Gastroenterol
2010;105:1266), nhng cha co sn trn lm sang.
X tr phu thut
Ch nh phu thut khi bnh nhn cn iu tr lin tuc thuc PPIs, khng tun thu
hoc khng dung nap vi iu tr thuc, trao ngc khng axit vn din ra mc du
iu tr thuc y u va bnh nhn co nguyn vong phu thut. Khi cac triu chng
c kim soat vi iu tr PPI, iu tr ni khoa va phu thut u co hiu qua.
Mc du phu thut giup kim soat triu chng tt hn va cai thin cht lng cuc
sng sau thi gian ngn (Surg Endosc 2011;25:2547), cac triu chng sau phu
thut va phu thut tht bai cung co th xay ra.
Tng s tip xuc vi axit trong thc quan va mi lin quan cua cac triu chng
trao ngc khi theo doi pH thc quan giup tin lng kha nng thanh cng cua
phng phap phu thut.
Bnh nhn tht bai khi iu tr thuc cn anh gia cn thn xac nh xem cac
triu chng co thc s lin quan n trao ngc axit trc khi quyt nh phu
thut, nhng bnh nhn nay thng co chn oan khac bao gm EoE, ri loan vn
ng thc quan, tng nhay cam ni tang va nong rat chc nng.
Bin chng co th cua phu thut bao gm kho nut, khng co kha nng , hi
chng y hi va cac triu chng ng rut nh y hi, tiu chay va au bung.
Thay i li sng/Nguy c
Cac triu chng v m bnh nhn mc GERD co th cai thin bng phng
phap nng u ging t 15 n 20 cm va tranh n trong vong 2 n 3 gi trc
khi i ngu.
Giam cn co th mang lai hiu qua nht nh cho bnh nhn tha cn mc GERD.
Tranh cac loai thc phm gy ra trao ngc (thc n co cht beo, s c la, ca ph,
coca cola) hoc cac loai thc phm gy nong rat (thc n cay, ca chua, cam quyt,
ung co ga) co th la la chon ung trong hoan canh thch hp. Cai nghin
thuc la cung co hiu qua.
Thay i li sng n thun khng co kha nng giai quyt cac triu chng phn
ln cac bnh nhn GERD va khuyn cao nn dung phi hp cac thuc.
BIN CHNG
Trt va loet thc quan (vim thc quan) him khi dn n chay mau va thiu
mau thiu st.
Tnh trang hep co th xut hin khi vim thc quan a n nh, dn n tnh
trang kho nut. Ky thut nong thc quan qua ni soi va iu tr duy tr bng thuc
PPI thng xuyn se giai quyt triu chng kho nut do hep thc quan.
Barrett thc quan (Barretts esophagusBE) la tnh trang thay i t biu m
vay thc quan bnh thng chuyn sang dang d san rut c bit do s kch thch
cua trao ngc va dn n nguy c tin trin thanh ung th thc quan dang tuyn
0,5% mi nm. Ni soi sang loc BE c ch nh bnh nhn 50 tui vi tin
s mc GERD t 5 n 10 nm (Gastroenterology 2008;135:1392). Loan san
thp trong BE co mt ty l mc ung th biu m tuyn hang nm thp tng t
nh BE khng loan san (Gastroenterology 2011;141:1179). Ch nh NSAID va
statin co th lam giam nguy c tin trin ac tnh (Gastroenterology 2011;141:
Ri lon ng tiu ha Ri lon vn ng thc qun l 797
2000). t bng song cao tn (Radiofrequency ablationRFA) la phng phap an

toan, hiu qua va bn vng i vi cac trng hp loan san va d san rut trong
BE loan san (N Engl J Med 2009;28:360 ; Gastroenterology 2011;141:460). Tuy
nhin, iu nay cn phai tip tuc nghin cu.
Ri lon vn ng thc qun
I CNG
nh ngha
Co tht tm v la ri loan vn ng d nhn thy nht cua thc quan, c trng
bi giam chc nng cua c tht thc quan di lam giam s gian n thc quan
hoan toan khi nut va gy tnh trang co tht thc quan (Am J Gastroenterol 1999;
94:3406).
Co tht thc quan lan toa la ri loan co tht c trng bi cac cn co tht khng
co nhu ng xay ra thn thc quan. Do co s gian khng hoan toan cua c tht
thc quan di, tnh trang nay co th xay ra vi cac dang khac nhau trong mt s
trng hp nht nh. Ri loan co tht khng c hiu co biu hin co tht han ch
do ri loan chc nng c ch thc quan (Gastroenterologist 1997;5:112).
Ri loan giam nhu ng thc quan c c trng bi s giam, yu, hoc
khng co nhu ng thc quan, i khi co giam vn ng cua c tht di thc
quan dn n cac triu chng trao ngc.
CHN ON
Biu hin lm sng
Cac triu chng biu hin trong co tht tm v gm kho nut, trao ngc, au
ngc, sut cn va vim phi do ht sc.
Co tht thc quan lan toa va cac ri loan co tht khac co th biu hin bi cac triu
chng tc nghen (kho nut, trao ngc) nhng cung co triu chng nhn cam (au
ngc) do thc quan tng nhay cam.
Giam vn ng c tht thc quan di lam giam chc nng bao v, giam nhu
ng thc quan anh hng n n vic lam sach cac cht trao ngc b mt
thc quan, co th dn n s phi nhim keo dai cua b mt thc quan vi cac cht
trao ngc va dn n cac bin chng trao ngc.
Test chn on
o ap lc thc quan la tiu chun vang chn oan cac ri loan vn ng. o
ap lc thc quan vi phn giai cao (High resolution manometryHRM) cho kt
qua nhn nh chnh xac hn, giup chn oan va giup phn loai cu th cac ri loan
vn ng so vi o ap lc thng thng (Neurogastroenterol Motil 2011;23:271;

Neurogastroenterol Motil 2012;24:20). Da vao c im trn HRM, co tht tm
v c chia thanh ba nhom co cac triu chng va phng phap iu tr lin quan
vi nhau (Gastroenterology 2008;135:1526).
Chup X-quang co barit co th phat hin co tht tm v in hnh vi oan thc
quan trong lng ngc gian gy giam s chuyn thc n xung da day, co mc
nc hi, khng co bong hi da day va oan thc quan xa co dang hnh non nh
mo chim. Hnh anh nh cm hoc xon c co th gp trong co tht thc quan
lan toa, i khi gp tui tha trn c hoanh. Thc quan gian vi c tht thc quan
di m va dch da day thc quan trao ngc t do co th gp trong giam nhu
ng thc quan mc nng.
Ni soi co th giup loai tr tn thng hep hoc khi u oan xa cua thc quan
bnh nhn co tht tm v va cac ri loan co tht; thn thc quan co th b gian ra
va cha cac manh vun thc n, trong khi c tht thc quan di mc du co tht
thng vn cho phep ng ni soi vao da day vi sc khang ti thiu. Giam nhu
ng co th biu hin thc quan gian, nhng co khoang trng oan ni da day
thc quan va bng chng cua bnh trao ngc.
IU TR
Thuc
Cac thuc gy gian c trn nh nitrat hoc thuc chen knh canxi dung ngay
trc ba n co th giam triu chng ri loan co tht va co tht tm v trong thi
gian ngn nhng vic duy tr giam triu chng khng at hiu qua ti u.
Tim botulinum toxin qua ni soi co th cai thin cac triu chng kho nut t
vai tun n vai thang bnh nhn co tht tm v va cac ri loan co tht do c tht
thc quan di gian khng hoan toan (Neurogastroenterol Motil 2011;. 23:139).
Cach x ly nay co th hu ch nhng bnh nhn cao tui va th lc yu do co
nguy c cao khi phu thut hoc y la bc chun b thc hin cac phng
phap iu tr trit hn (Ann Surg 2009;249:45).
Cac thuc iu hoa thn kinh (v.d., thuc chng trm cam ba vong liu thp
[tricyclic antidepressantsTCAs]) co th cai thin triu chng nhn cam (nh au
ngc) lin quan n ri loan vn ng co tht va co tht tm v.
iu tr giam tit vi thuc PPI c khuyn cao trong trao ngc lin quan n
ri loan giam nhu ng thc quan. Khng co iu tr c hiu giam nhu ng.
Phu thut chng trao ngc cn c x ly mt cach thn trong trong ri loan
giam nhu ng tin trin.
X tr phu thut
Ct c vong vung di thc quan bng nong hoc ng rach phu thut (phu
Ri lon ng tiu ha Bnh lot d dy t trng l 799
thut ct c Heller) co th lam giam triu chng lu dai trong co tht tm v (Ann
Surg 2009;249:45) khi so sanh hiu qua cai thin cac triu chng (N Engl J Med
2011;364:1807). Trao ngc da day co th c iu tr bng thuc khang axit sut
i hoc ng thi cung phu thut ct mt phn c. Thung thc quan xay ra 3%
n 5% trng hp thc hin phng phap nong va cn phai phu thut ngay
khu l thung. Phu thut ct c him khi c ch nh trong trng hp co tht
thc quan lan toa khi gian c tht di thc quan khng hoan toan la nguyn chnh
gy triu chng kho nut. Ni soi ct c tht thc quan la mt ky thut ha hen vi
kt qua ti u at c trong thi gian ngn bnh nhn co tht tm v. (Endoscopy
2010;42:265).
BIN CHNG
Cac bin chng cua co tht tm v gm vim phi do ht sc va giam cn.
Co tht tm v co lin quan n mc ung th t bao vay thc quan oan xa khoang
0,15%, nguy c cao gp 33 ln nhng ngi khng b co tht tm v.
Bnh lot d dy t trng
I CNG
nh ngha
Loet da day ta trang (peptic ulcer diseasePUD) la tnh trang nim mac trong da
day va ta trang b tn thng do tac ng n mon cua axit va pepsin vt qua cac
c ch bao v cua nim mac da day va ta trang. Cac v tr khac bao gm thc quan,
ming ni gia da day-rut non va tui tha Meckel.
Nguyn nhn
Helicobacter pylori, xon khun Gram m bai tit urease, la nguyn nhn gy
mt na cac trng hp PUD va phn ln cac tn thng loet khng phai do
NSAIDs.
PUD co th gp khoang 15% n 25% cac i tng s dung keo dai thuc
NSAID va aspirin. Tin s mc PUD, tui 60, dung ng thi corticoid hoc
thuc chng ng, dung liu cao hoc nhiu loai NSAID va mc cac bnh kem
theo nng n nh bnh thn giai oan cui la nhng i tng co nguy c cao mc
PUD (J Clin Gastroenterol 1997;24:2).
Khi u tit gastrin chim 1% trong s cac nguyn nhn loet da day ta trang.
Ung th da day hoc u lympho co th biu hin nh mt vim loet da day.
Khi khng tm c nguyn nhn gy bnh, PUD c goi la v cn. PUD v cn
co th do H. Pylori khng c chn oan hoc khng phat hin c s dung

NSAID.
Hut thuc la lam tng gp i nguy c mc PUD; lam chm lanh tn thng va
nguy c loet tai phat.
CHN ON
Biu hin lm sng
au thng v hoc kho tiu co th la triu chng tuy nhin cac triu chng khng
phai lun lun i cung s tn tai cua vt loet. Cng tc vung thng v co th phat
hin khi s bung. Mi phn trm co th biu hin bng bin chng (xem phn
sau).
Khi xut hin cac triu chng bao ng (giam cn, n mau no, chay mau, thiu
mau, nn lin tuc, khi vung thng v va ap ng kem PPI), ni soi c ch
nh anh gia bin chng hoc tm chn oan khac (BMJ 2008;337:a1400).
Test chn on
Ni soi la tiu chun vang chn oan vim loet da day ta trang. Chup vi Barit
co nhay tt chn oan loet nhng vt loet nho va trt co th b bo qua va
sinh thit tm H. pylori hay ung th khng th thc hin c.
Xet nghim khang th H. pylori huyt thanh la xet nghim khng xm ln vi
gia re va co nhay 85%, c hiu 79% trong chn oan nhim H. pylori.
Khang th vn phat hin c sau 18 thang sau khi iu tr thanh cng va xet
nghim khng c s dung chng to tit tr thanh cng vi khun (BMJ 2008;
337:a1400).
Xet nghim khang nguyn H. pylori trong phn co gia tr chn oan nhim
H. pylori vi nhay 91 %, c hiu 93% va co th giup xac nhn a tit tr
c H. pylori sau khi iu tr phac 3 thuc.
Xet nghim nhanh urease (v.d., xet nghim cac vi sinh vt ging Campylobacter
[Campylobacter-like organismCLO]) va xet nghim m bnh hoc cua mu sinh
thit ni soi thng c s dung chn oan bnh nhn khi ni soi nhng co
th m tnh gia bnh nhn iu tr PPI.
Xet nghim ur hi th gn carbon la xet nghim khng xm ln chnh xac nht
chn oan vi nhay va c hiu 95%; thng dung xac nh tit tr
thanh cng H. pylori sau iu tr (BMJ 2008;337:a1400).
IU TR
Thuc
Bt k do nguyn nhn nao, c ch axit la liu phap chnh trong iu tr PUD.
Loet da day thng c iu tr trong 12 tun va loet ta trang trong 8 tun.
Ung PPI hoc H2RA co hiu qua trong hu ht cac trng hp; iu tr PPI
ng tnh mach la cn thit khi xut huyt tiu hoa hoc khi ung khng dung
nap hoc khng th ung (xem Bang 182). Cac tac dung phu cua PPI a c
cp phn iu tr GERD. au u va trang thai tm thn bt thng (hn m,
lu ln, trm cam, ao giac) co th gp khi iu tr H2RAs, nhim c gan, giam
tiu cu va giam bach cu rt him gp. iu chnh liu lng cua H2RAs la cn
thit trong trng hp suy thn. Cimetidine co th lam giam hp thu cua nhiu
loai thuc, bao gm thuc chng ng mau warfarin, theophylline va phenytoin.
Hai thuc khang sinh va thuc PPI (phac iu tr ba thuc) la phac iu
tr chun vi H. pylori, lam lanh tn thng va lam giam tai phat mt cach
ro rt. Mt s phac khang sinh va thuc giam tit axit hin ang c s
dung (Bang 183). Phac ni tip hoc ba thuc s dung levofloxacin co th
hiu qua hn phac iu tr ba thuc chun (Clarithromycin, amoxicillin, PPI)
(Hepatogastroenterology 2011;58:1148). Phac mi c nghin cu bao
gm LOAD (levofloxacin, omeprazole, nitazoxanide, va doxycycline) trong 7
n 10 ngay va ofloxacin, azithromycin, omeprazole va bismuth trong 14 ngay
(Am J Gastroenterol 2011;106:1970). Bnh nhn trc o a s dung nhom
macrolid, nn c ch nh iu tr bng phac khng bao gm clarithromycin.
Clarithromycin co th c thay th bng furazolidone khi co s khang thuc
va cn nhc n chi ph (Helicobacter 2010;15:497). Kt qua iu tr b anh hng
bi tnh khang clarithromycin va tun thu iu tr kem; khang metronidazole
khng gy anh hng nay (Gastroenterology 2007;133:985).
NSAIDs va aspirin nn tranh nu co th; nu tip tuc dung khyn cao dung thm
PPI hoc mt thuc bao v nim mac (misoprostol, 400 n 800 g/ngay).
Thuc Sucralfate co tac dung bao boc b mt nim mac b tn thng nhng
khng lam giam tit axit, thng c s dung trong d phong loet do stress.
Tac dung phu bao gm tao bon, giam hp thu mt s loai thuc (nh cimetidine,
digoxin, fluoroquinolones, phenytoin va tetracycline) khi dung ng thi.
iu tr b sung cac thuc khang axit co th co hiu qua giam au trong iu
tr loet ng tiu hoa.
Cac bin phap khng dung thuc. Ngng hut thuc la cn c khuyn cao.
Ru vi nng cao co th lam tn thng b mt nim mac da day nhng
khng co bng chng v lin quan gia ru va loet tai phat.
X tr phu thut
Phu thut i khi vn cn thit ch nh cac trng hp khng kim soat c triu
chng, xut huyt tiu hoa, hi chng Zollinger-Ellison va loet phc tap. Phng
phap phu thut khac nhau tuy thuc vao v tr cua vt loet va s xut hin cua cac
bin chng.
Bng 183 V d v cc phc dit Helicobacter pylori
Thuc Liu dng Khuyn co
Clarithromycin 500 mg x 2 ln/ngy La chn u tin

Amoxicillin 1 g x 2 ln/ngy
PPIa 2 ln/ngy
Metronidazole 500 mg x 2 ln/ngy La chn u tin nu tin s

Amoxicillin 1 g x 2 ln/ngy dng clarithromycin
PPI 2 ln/ngy
Pepto-Bismol 524 mg x 4 ln/ngy La chn u tin nu bnh nhn

Metronidazole 250 mg x 4 ln/ngy d ng vi penicillin
Tetracycline 500 mg x 4 ln/ngy Phc cu vn khi phc 3
PPIa hoc H2RAb 2 ln/ngy thuc ung tht bi
Clarithromycin 500 mg x 2 ln/ngy La chn thay th nu phc 4

Metronidazole 500 mg x 2 ln/ngy thuc khng dung np
PPIa 2 ln/ngy
Levofloxacin 250 mg x 2 ln/ngy Phc cu vn

PPIa 2 ln/ngy
Rifabutin 300 mg dng hng ngy Phc h tr thay th

PPI 2 ln/ngy
Furazolidine 200400 mg dng hng ngy Phc h tr thay th

PPIa 2 ln/ngy
Thi gian iu tr: 10 n 14 ngy. Khi s dng phc cu vn sau khi tht bi vi iu tr ban u,
chn cc loi thuc cha c s dng trc y.
aLiu chun ca PPI: omeprazole 20 mg, lansoprazole 30 mg, pantoprazole 40 mg, rabeprazole 20 mg,
tt c cc thuc dng hai ln mt ngy. Esomeprazole c s dng mt liu 40 mg duy nht mt ln

mt ngy.
bLiu chun ca H RA: ranitidine 150 mg, famotidine 20 mg, nizatidine 150 mg, cimetidine 400 mg, tt
2
c cc thuc dng hai ln mt ngy.
H2RA, thuc c ch th th histamine-2; PPI, thuc c ch bm proton.
LU C BIT
Hi chng Zollinger-Ellison
Hi chng nay do tnh trang tit gastrin t cac t bao u khng phai t bao tiu
ao tuy hoc ta trang. a u ni tit type 1 co th lin quan n hi chng nay gp
khoang 25% s bnh nhn. Hu qua cua tng tit axit da day co th gy ra nhiu
vt loet cac v tr bt thng, cac trng hp loet khng ap ng vi phac
iu tr ni khoa chun hoc loet tiu hoa tai phat sau khi iu tr phu thut. Tiu
chay va cac triu chng cua GERD thng gp.
Nng axit da day thng la 15 m Eq/L va pH da day la 1,0. Nng gastrin
huyt thanh khi oi trong khi khng c ch axit t nht 5 ngay c coi la mt xet
nghim sang loc, nng gastrin >1.000 pg/mL gp 90% bnh nhn mc hi
chng Zollinger-Ellison. Khi nng gastrin huyt thanh tng ln nhng cha
n 1.000 pg/mL, xet nghim kch thch secretin co th thy tng 200 pg nng
gastrin huyt thanh sau khi tim tnh mach secretin bnh nhn co u gastrin
(Aliment Pharmacol Ther 2009;29:1055). PPI liu cao c ch nh iu tr. Cac
phng phap sang loc y hoc hat nhn (quet octreotide) co th hiu qua trong vic
xac nh cac tn thng ac tnh cn phu thut ct bo iu tr (Expert Opin
Pharmacother 2009;10:1145). Thi gian sng thm lu dai cua bnh nhn chu
yu lin quan n bnh ly kem theo hn la tnh trang di cn cua gastrinoma (Dig
gan Dis 2011;43:439).
BIN CHNG
Chay mau ng tiu hoa (xem phn Xut huyt ng tiu hoa)
Tc nghen da day co th xay ra vi loet gn mn v va co th co triu chng
bun nn va nn, i khi xay ra vai gi sau ba n. Chup X-quang bung cho thy
da day gian vi mc nc hi. t sonde da day nn c gi trong 2 n 3 ngay
giam ap lc da day ng thi vi bi phu nc va cht in giai bng ng
tnh mach.
iu tr thuc co th tam thi co hiu qua. Tai phat thng gp va ni soi nong
bng bong hoc phu thut thng cn thit ch nh iu tr trit .
Thung khng thng gp va oi hoi phai phu thut cp cu. Thung co th xay ra
trong trng hp khng co triu chng trc o cua loet tiu hoa va co th khng
co triu chng nhng bnh nhn iu tr bng glucocorticoid. Phim X-quang
bung thy hnh anh kh t do di c hoanh.
Vim tuy co th la kt qua cua tn thng vao tuyn tuy t vt loet thanh sau
cua da day hoc ta trang. Cn au nhiu, lin tuc, lan ra sau lng, va khng giam
khi iu tr phac giam tit. Nng amylase huyt thanh co th tng. CT scan
giup chn oan. Phu thut thng c ch nh.
GIM ST/THEO DI
Ni soi da day hoc chup phim ng tiu hoa trn nn c thc hin sau 8 n
12 tun khi a co chn oan ban u cua tt ca cac nguyn nhn gy loet co
bng chng loet da day a lanh; ni soi lai sinh thit cn c ch nh cac
trng hp tn thng loet khng lanh loai tr nguyn nhn ac tnh.
Loet ta trang hu nh khng ac tnh do vy khng cn bng chng lanh vt loet
khi khng co triu chng.
Bnh vim rut
I CNG
nh ngha
Vim loet ai trang chay mau (Ulcerative colitisUC) la mt bnh vim man
tnh v cn cua ai trang va trc trang, c trng bi tnh trang vim nim mac va
thng co biu hin i ngoai phn long ra mau. Tn thng trc trang ph bin.
Bnh Crohn (Crohns diseaseCD) c c trng bi vim xuyn qua cac lp
cua thanh rut va co th anh hng n bt ky v tr nao cua ng tiu hoa.
CHN ON
Biu hin lm sng
Ca hai bnh u co biu hin tiu chay, sut cn va au bung. Vim loet ai trang
chay mau biu hin c trng la tiu chay ra mau. Crohn cung co th biu hin
hnh thanh l ro, hep, ap-xe hoc tc rut.
Biu hin ngoai rut cua bnh vim rut (inflammatory bowel diseaseIBD) bao
gm vim khp, vim x ng mt nguyn phat, tn thng mt va da.
Test chn on
Ni soi thm do cn thc hin chn oan, c bit la trng hp vim loet ai
trang chay mau bt u t trc trang va lan rng vi mc khac nhau vao ai
trang. Ni soi anh gia tn thng cua ai trang bnh nhn Crohn (trt, loet
vi phn b khng ng u va tn thng tng oan); vao su hi trang trong khi
ni soi ai trang co th phat hin tn thng oan cui hi trang. M bnh hoc
cho thy tnh trang vim nim mac man tnh vi cac nang ap-xe va vim nang
bnh nhn vim loet ai trang chay mau va co th thy cac t bao a nhn khng
l va u hat khng co hoai t trong Crohn.
Nghin cu hnh anh ct ngang (CT va chup cng hng t [magnetic resonance
imagingMRI]) co gia tr trong vic anh gia Crohn, c bit la khi long rut b
Ri lon ng tiu ha Bnh vim rut l 805
hep hoc nghi ng cac bin chng ngoai ng tiu hoa (ap-xe, l ro). Trong khi
chup rut bng CT hoc MRI co th anh gia y u ca mc hoat ng va
cac oan rut tn thng trong Crohn, MRI co th vt tri so vi CT trong vic
phat hin hep rut va ngm thuc thanh hi trang (Inflamm Bowel Dis 2011;
17:1073). Ngc lai chup X-quang (chup rut non hang loat, chup barit) cung co
th co ch, c bit trong Crohn.
Cac du n huyt thanh co vai tro han ch trong chn oan. Khang th khang
nm men Saccharomyces cerevisiae thng c tm thy trong Crohn va khang
th t bao cht chng bach cu trung tnh (perinuclear antineutrophil cytoplasmic
antibodies [p-ANCA]) trong vim loet ai trang chay mau; s xut hin cua mt
khang th trong khi khng co khang th con lai co th giup phn bit nhng
trng hp vim ai trang khng xac nh (Gastroenterology 2002;122:1242).
Protein phan ng C va tc mau lng (erythrocyte sedimentation rateESR) co
lin quan n mc hoat ng cua bnh.
Vim ai trang do C. difficile hay gp nhom bnh nhn mc cac bnh ly vim
rut hn nhom bnh nhn khng mc; do o, cac xet nghim phn tm vi khun
nay nn c lam trong cac t bnh tin trin (Clin Gastroenterol Hepatol 2007;
5:339). CMV bi nhim co th xay ra nhng bnh nhn dung thuc c ch
min dch va co th c chn oan bng m bnh hoc trong khi ni soi (Am J
Gastroenterol 2006;101:2857).
IU TR
Thuc
Phac iu tr da vao mc nghim trong cua bnh, v tr tn thng, va cac
bin chng lin quan. Muc tiu iu tr la giai quyt tnh trang cp tnh va giam tai
phat trong tng lai. Ca hai bnh vim loet ai trang chay mau va Crohn u co th
c phn thanh ba loai mc xy dng muc tiu iu tr:
Bnh nhe n trung bnh. Bnh nhn giam cn t hoc khng giam cn, chc
nng tt va co th duy tr n ung y u. Bnh nhn vim loet ai trang ai tin
t hn bn ln hang ngay khng co chay mau trc trang hoc thiu mau, du hiu
sinh tn bnh thng va tc mau lng bnh thng, trong khi bnh nhn Crohn
co au bung t hoc khng au. iu tr thng bt u vi aminosalicylates
nhng co th bao gm thuc khang sinh va corticoid.
5Aminosalicylates (5ASA). C ch hoat ng vn cha ro nhng lin quan
n giam san xut cac cht chuyn hoa axit arachidonic, c bit la leukotrienes.
Thuc co nhiu dang bao ch, mi loai nhm muc tiu cac phn khac nhau ng
tiu hoa va co ch cho ca cua khi u va iu tr duy tr s thuyn giam bnh
nhn mc bnh nhe n trung bnh. Phan ng qua mn xay ra khng thng
xuyn bao gm vim phi, vim tuy, vim gan va vim thn.
Sulfasalazine n ai trang vn con nguyn ven, tai y thuc c chuyn

hoa thanh 5ASA va mt phn na Sulfapyridine. Do o, hiu qua at c
nhng trng hp vim loet ai trang chay mau hoc Crohn tn thng gii
han ai trang, hoc co th s dung nh iu tr ban u (0,5 g ung hai ln/
ngay, tng theo s dung nap cua bnh nhn n 0,51,5 g ung 4 ln/ngay)
hoc duy tr s thuyn giam (1 g ung 24 ln/ngay). Phn Sulfapyridine
con lai gy tac dung phu au u, bun nn, nn, va au bung, iu tr bng
cach giam liu. Phat ban da, st, mt bach cu hat, nhim c gan va gy cac
t cp vim ai trang la nhng phan ng qua mn him gp. Giam s lng
tinh trung co hi phuc co th gp nam gii. B sung axit folic c khuyn
cao do sulfasalazine co th lam giam s hp thu cua folate.
Mesalamine. Ch phm 5ASA mi khng co sulfasalazine co t tac dung
phu hn nhng t tin.
Asacol la mt cng thc ung cua 5ASA giai phong khi pH la 7 cui hi
trang. Thuc hiu qua trong vim loet ai trang va Crohn hi manh trang/
ai trang vi liu 800 n 1.600 mg ung 3 ln/ngay.
Pentasa co c ch giai phong thuc phu thuc thi gian va pH cho phep
thuc tn tai trong ca rut non va ai trang. Thuc hu ch trong trng hp
Crohn tn thng lan toa rut non nhng cung co th c s dung trong
vim loet ai trang chay mau vi liu 0,51,0 g ung 4 ln/ngay.
Apriso cung co c ch giai phong phu thuc vao pH va phn b mesalamine
trong toan b ai trang khi dung vi liu 1,5 g ung mi ngay mt ln.
Balsalazide (Colazal) c phn tach bi vi khun ai trang tao thanh
mesalamine va mt phn t tr. Do o, ch hu ch cho tn thng ai
trang vi liu 2,25 g ung 3 ln/ngay khi bnh hoat ng va 1,5 g ung 2
ln/ngay duy tr ap ng.
Thuc co h thng phn phi mesalamine (Lialda) s dung mt h thng
phn phi mi cho phep giai phong 5ASA keo dai sut toan b ai trang
trong khi giam c s ln dung thuc. Thuc hu ch trong bnh ai trang
vi liu 1,22,4 g ung 4 ln hoc 2 ln.
Olsalazine (Dipentum) la mt phn t 5ASA i c phn tach bi vi
khun ai trang va hu ch vi cac bnh ly ng rut. Tiu chay nng lam
han ch kha nng s dung thuc
Thuc khang sinh thng c s dung trn lm sang nhng trng hp
Crohn mc nhe n trung bnh cung nh khi co tn thng quanh hu mn
nhng khng s dung trong vim loet ai trang chay mau do cha xac nh c
vai tro cua vi khun. Mc du c s dung thng xuyn, cac nghin cu i
chng a khng chng minh c hiu qua i vi tnh trang vim cua ng
tiu hoa. Vai tro cua khang sinh c gii han trong Crohn tn thng ai trang
hoc hi trang-ai trang, co tn thng quanh hu mn, l ro va ap-xe. Thuc

khang sinh thng c s dung la metronidazole (250500 mg ung 3 ln/
ngay) va ciprofloxacin (500 mg ung 2 ln/ngay), thng dung cung nhau
trong 26 tun.
Budesonide (69 mg ung 4 ln/ngay) la mt corticosteroid tng hp vi qua
trnh chuyn hoa u tin qua gan han ch c tnh toan thn sau o at
c hiu qua tai ch do co ai lc cao vi cac thu th glucocorticoid, tng
t nh corticosteroid ung. Thuc hiu qua va an toan khi s dung ngn han
trong Crohn tn thng hi trang-ai trang mc nhe n trung bnh va
co th thay th mesalamine la la chon ban u at s thuyn giam (Am J
Gastroenterol 2009;104:465; Gastroenterology 2011;140:425). i vi vim
loet ai trang, hiu qua cha c ghi nhn.
iu tr tai ch rt hu ch trong bnh ly vim rut tn thng khu tru ai
trang trai. iu tr tai ch mesalamine hiu qua cao hn steroid tai ch hoc
aminosalicylates ng ung i vi vim loet ai trang chay mau mc nhe
n trung bnh hoc vim loet trc trang (Am J Gastroenterol 2010;105:501).
Tuy nhin, kt hp iu tr toan thn ng thi c ch nh trong nhng trng
hp nng (Am J Gastroenterol 2004;99:1371). Ngm nc m, thuc giam au,
cac loai kem hydrocortisone va lam m tai ch co th lam giam triu chng
trong Crohn co tn thng quanh hu mn khi kt hp vi iu tr toan thn.
Bnh nhn Crohn mc t trung bnh n nng la nhng bnh nhn khng
ap ng vi phac iu tr bnh nhe va trung bnh hoc nhng bnh nhn b
giam cn nhiu, thiu mau, st, au bung hoc cng tc, bun nn va nn lin
tuc khng do tc rut (Am J Gastroenterol 2009;104:465) hoc bnh nhn vim
loet ai trang chay mau ai tin ra mau trn sau ln mt ngay, st, thiu mau nhe
va co tc mau lng cao. Muc tiu cua iu tr la giam bnh nhanh chong vi
corticosteroid va duy tr s thuyn giam vi cac thuc c ch min dch va/hoc
thuc sinh hoc phu hp. iu tr thng c duy tr n khi bnh nhn khng
ap ng vi mt thuc cu th hoc khng dung nap c.
Glucocorticoid co hiu qua trong tao s thuyn giam bnh t trung bnh n
nng, c bit la nhng t bung phat do bnh tin trin (Gut 2011;60:571).
Biu hin ngoai rut cua bnh ly vim rut (tn thng mt, bnh ngoai da va
vim khp ngoai bin) cung ap ng vi glucocorticoid.
Prednisone c bt u bng ng ung (thng la 4060 mg ung 4 ln/
ngay n cao nht la 1 mg/kg ung 4 ln/ngay) va duy tr n khi cai thin
triu chng. Tip theo giam liu dn 5 n 10 mg hang tun cho n liu
20 mg, sau o co th tip tuc giam liu 2,55 mg hang tun. Glucocorticoid
khng c khuyn cao trong iu tr duy tr va cn tm liu phap iu tr thay
th cac bnh nhn phu thuc vao loai thuc nay.
Glucocorticoid ng ung hoc tim khng nn ch nh khi cha loai

tr c nhim trung va khng nn bt u k cho bnh nhn dung
thuc ln u tin qua in thoai.
Bnh nhn iu tr vi liu ti thiu 5 mg prednisone >2 thang cn phai
c theo doi tnh trang loang xng (JAMA 2001;285:785). Cac yu t
nguy c khac cua bnh loang xng bao gm hut thuc, trong lng c th
thp, t vn ng, tin s gia nh v bnh loang xng va suy dinh dng
Thuc c ch min dch
6-mercaptopurine (1,01,5 mg/kg/ngay, ung), mt thuc nhom purine va
azathioprine (1,52,5 mg/kg/ngay, ung), tin cht cua Simidazole, gy
c ch hoat hoa t bao T va nhn din khang nguyn va rt hiu qua trong
iu tr duy tr sau khi at c s lui bnh khi dung glucocorticoid ca hai
bnh vim loet ai trang chay mau va Crohn. Ca hai thuc azathioprine va
6-mercaptopurine co hiu qua giup at c lui bnh trong iu tr Crohn tin
trin (Cochrane Sys Rev 2010;16:CD000545). Ca hai thuc u co tac dung
phu t hn glucocorticoid va c ch nh la phac khng co steroid trong
trng hp bnh ly vim rut nng hoc hay tai phat. ap ng co th chm
sau 1 n 2 thang vi ap ng ti u xay ra khoang 4 thang sau khi bt u
iu tr. Tac dung phu bao gm c ch tuy xng co hi phuc, vim tuy va
phan ng d ng.
Xac nh hoat ng cua enzyme thiopurine methyltransferase (TPMT)
trc khi bt u iu tr se xac nh tnh a hnh v gen co th anh hng
n c tnh khi s dung cac thuc (Gastroenterology 2006;130:935).
Xet nghim t bao mau nh ky phai c thc hin, giai oan u mi 12
tun theo doi tnh trang c ch tuy xng cp tnh hoc xay ra mun. Vi
liu n nh, xet nghim co th c thc hin mi 3 thang.
Nng cht chuyn hoa 6-Thioguanine (6-Thioguanine [6-TG]) anh gia
tnh trang u liu trong khi nng 6-methyl mercaptopurine (6-methyl
mercaptopurine [6-MMP]) co th d oan s nhim c gan. B sung
allopurinol giup qua trnh chuyn hoa nghing v pha tao ra cht chuyn
hoa hoat ng (6-TG) hn la tao ra cht chuyn hoa c hai (6-MMP)
(Aliment Pharmacol Ther. 2010;31:640).
Methotrexate (15 n 25 mg tim bp hoc ung hang tun) co hiu qua khi
s dung nh phac iu tr khng co steroid i vi Crohn nhng khng co
tac dung vi vim loet ai trang. Tac dung phu bao gm x hoa gan, c ch tuy
xng, rung toc, vim phi, d ng va gy quai thai. nhng bnh nhn Crohn
ang thuyn giam, methotrexate khng at c hiu qua lam lanh nim mac
nh azathioprine hoc infliximab (Aliment Pharmacol Ther 2011;33:714).
Chup X-quang ngc (chest X-rayCXR), theo doi cng thc mau va xet
nghim chc nng gan nn c thc hin thng xuyn.
Bnh nhn co co xet nghim men gan bt thng co th cn sinh thit gan
anh gia tnh trang x hoa gan trc khi iu tr va sinh thit tip tuc
c thc hin nu nng men gan tng nhiu sau iu tr.
Khang th n dong chng yu t hoai t u alpha ([antiTNF-] antitumor
necrosis factor alpha) giup iu chnh chc nng h thng min dch va co
hiu qua trong bnh Crohn trung bnh n nng khng ap ng vi cac phng
phap khac bao gm c ch min dch va co th la chon lam iu tr ban u
hoc duy tr. Hiu qua iu tr cung c chng minh vi vim loet ai trang
mc t trung bnh n nng (Gastroenterology 2009;136:1182; Gut 2011;
60:780). Infliximab (truyn tnh mach liu 5 mg/kg tai tun 0, 2 va 6, sau o
truyn duy tr mi 8 tun), adalimumab (160 mg tim di da tun 0, sau
o 80 mg tim di da tun 2, tip theo la 40 mg tim di da mi 2 tun) va
certolizumab pegol (400 mg tim di da tai tun 0, 2 va 4 sau o s dung liu
duy tr mi 4 tun) la nhng thuc khang TNF co sn. Bn canh la la chon iu
tr u tay, adalimumab cung an toan va hiu qua cho nhng bnh nhn Crohn
a tht bai trong iu tr infliximab (Aliment Pharmacol Ther 2010; 32:1228).
Tuy nhin, khi chuyn t infliximab tnh mach sang adalimumab di da co th
co s mt dung nap va hiu qua do vy tun thu thuc khang TNF- u tin
c khuyn cao (Gut 2012;61:229). i vi Crohn mc t trung bnh
n nng, infliximab phi hp vi azathioprine hoc infliximab n tr liu co
nhiu kha nng at c thuyn giam lm sang khi khng dung steroid hn la
n tr liu azathioprine (N Engl J Med 2010; 362:1383). Bnh nhn at c
s thuyn giam vi nguy c tai phat thp co th ngng iu tr infliximab c
xac nh bng cac du hiu lm sang va sinh hoc (Gastroenterology 2012;
142:63). Vic s dung infliximab theo phac tng dn khng lam giam ty l
phai phu thut hoc tin trin cua cac bin chng (thc phm Pharmacol Co
2010;31:233).
iu tr thuc khang TNF co th lam bung phat bnh lao tim n, do o test
da va chup X-quang phi la rt cn thit trc khi bt u iu tr (Am J
Gastroenterol 2010;105:501). Tnh trang vim gan B cung cn c anh
gia. Nhim trung c hi cung nh bin chng nhim trung co th tin trin va
tnh trang suy tim sung huyt co th xu i trong qua trnh iu tr.
Phan ng qua mn cp tnh va chm, khang th khang infliximab va khang
th khang chui DNA kep co th xut hin khi truyn infliximab. Phan ng
tai ch tim a c bao cao khi s dung adalimumab va certolizumab pegol.
Natalizumab (truyn 300 mg tun 0, 4 va 8 sau o la truyn hang thang) la mt
khang th n dong cua ngi chng alpha-4 integrin, mt phn t kt dnh t
bao, c s dung cho bnh Crohn mc trung bnh n nng, khng ap ng

vi tt ca cac phng phap khac bao gm ca thuc khang TNF . Thuc nay co
th gy ra s hoat hoa virus JC polyoma ngi gy ra bnh ly cht trng nao a
tin trin (progressive multifocal leukoencephalopathyPML). Nguy c PML
co th c giam thiu bng cach tranh dung cac thuc c ch min dch ng thi
va theo doi cht che (Am J Gastroenterol 2009;104:465). Cac bin chng nhim
trung khac va phan ng qua mn cp tnh cung co th xay ra.
Bnh tin trin nng hoc ti cp la khi bnh nhn phai nhp vin do tnh trang
nng cua cac triu chng. Bnh nhn Crohn ti cp la khi co triu chng dai dng
mc du ang iu tr glucocorticoid thng ngay hoc thuc TNF hoc co
st cao, nn ma lin tuc, tc rut, ap-xe trong bung, du hiu phuc mac hoc
suy kit (Am J Gastroenterol 2009;104:465). Vim ai trang ti cp (i vi ca
Crohn va vim loet ai trang) co th biu hin i ngoai ra mau at, thiu mau
nhiu, du hiu nhim c (st, nhim trung huyt, ri loan in giai, mt nc)
va tng cac ch s vim (Arch Surg 2005;140:300). Gian ai trang nhim c
xay ra 1% n 2% bnh nhn vim loet ai trang chay mau, trong o ai trang
tr nn yu va gian kem vi triu chng nhim c toan thn nng.
iu tr h tr bao gm nhn n qua ng ming (nothing by mouthNPO) va
hut qua sonde da day nu co bng chng cua tc rut non. iu tr tch cc tnh
trang mt nc va in giai va truyn mau trong trng hp thiu mau nng.
Khang cholinergic va thuc opioid nn ngng s dung trong trng hp gian
ai trang nhim c.
anh gia ban u bao gm cac phng phap chn oan hnh anh ct ngang (CT,
MRI) anh gia ap-xe trong bung. Ni soi ai trang sigma cn nhc ch nh
thn trong co th xac nh mc nghim trong cua vim ai trang va sinh thit
loai tr vim ai trang do CMV. Cy mau va xet nghim phn loai tr
vim ai trang do C. difficile.
iu tr ni khoa tch cc vi corticosteroid ng tnh mach (methylprednis-
olone 1 mg/kg trong lng c th hoc tng ng vi 40 n 60 mg predni-
sone) va khang sinh ph rng nn c bt u.
Nu khng ap ng, truyn cyclosporine (24 mg/kg/ngay, at c nng
trong mau t 200 n 400 ng/mL) la mt la chon iu tr trong t vim
ai trang ti cp bnh nhn vim loet ai trang chay mau. Truyn tacrolimus
cung la mt la chon. Sau khi tnh trang cai thin, bnh nhn co th dn c
chuyn sang dang ung tng ng va b sung vi cac thuc c ch min dch
(Arch Surg 2005;140:300).
Tng cng dinh dng mt cach thch hp sau 5 n 7 ngay; nui dng ng
tnh mach thng ch ra nu nui dng qua ng rut khng dung nap c.
Lm sang xu i/khng cai thin sau 7 n 10 ngay iu tr tch cc, co bng
chng thung rut hoc co du hiu vim phuc mac la ch nh phu thut ct
ai trang cp cu.
anh gia ch nh phu thut nn c cn nhc bnh nhn hnh thanh ap-xe
hoc tc nghen ng tiu hoa. Khi iu tr ni khoa khng ap ng, xem xet
phu thut oan rut b tn thng. Tao hnh lai ch hep la mt la chon khi
co tn thng hep khu tru; sinh thit cn c thc hin loai tr ung th tai
cac v tr hep.
X tr phu thut
Phu thut thng c ch nh trong iu tr l ro, tc nghen, ap xe, thung hoc
chay mau khi khng ap ng vi thuc va s bt u ung th hoa (Gut 2011;60:571).
Trong bnh Crohn, tai phat gn sat v tr ct bo rut thng gp. Cn tranh thc
hin nhiu phu thut trong Crohn v nguy c cua hi chng rut ngn. Thuc c
ch min dch nn ngng trc khi phu thut va ch nh lai nu cn thit trong
giai oan hu phu.
Vi bnh vim loet ai trang chay mau, phu thut ct ai trang toan b la phng
phap trit va vi mt s bnh nhn, c la chon nhiu hn dung thuc c ch
min dch lu dai hoc liu phap sinh hoc.
Mt ch n t thc n th giup giam triu chng nhng bnh nhn mc bnh
nhe n trung bnh hoc bnh nhn co hep. Ch n cung cp cac nguyn t
a c s dung trong giai oan cp tnh cua bnh, c bit la bnh Crohn nhng
gy cho bnh nhn s kho chu va khng thch.
Bnh nhn Crohn tn thng oan cui hi trang hoc phu thut ct bo hi
trang-ai trang co th cn b sung vitamin B12. B sung bng ng ung canxi,
magie, folate, st, vitamin A va D va cac vi cht dinh dng khac co th cn thit
bnh nhn Crohn co tn thng rut non.
Bnh nhn co cac triu chng tc nghen lin tuc nn tranh nhng thc n kho tiu
hoa nh cac loai hat, vo, da, hat, va bt giy ma co th tng tnh trang tc nghen.
Nui dng ng tnh mach co th c ch nh nhng bnh nhn khng
dung nap thc n hn 4 hoc 5 ngay. rut ngh ngi khng chng minh lam
giam thi gian at c lui bnh nhng co th c s dung duy tr dinh dng
va giam triu chng trong khi ch i thuc co tac dung hoc nh bc ni
phu thut.
LU C BIT
ca nhng bnh nhn vim loet ai trang chay mau va Crohn keo dai trn 8 n
10 nm, ni soi ai trang hang nm sinh thit nim mac tm tn thng
ac tnh vi bn manh sinh thit mi 5 n 10 cm c khuyn cao. Bng chng

m bnh hoc cua loan san bt ky mc nao la ch nh cua phu thut ct ai
trang toan b. Hnh anh dai tn hep khi ni soi ai trang co th thay cho ni soi
nhum mau sinh thit trung muc tiu trong bnh ly vim rut (Gastrointest
Endosc 2011;74:840).
Cai nghin thuc la thng c tin hanh cho tt ca cac bnh nhn b vim rut.
Co bng chng dch t hoc cho thy tac dung bao v mt s bnh nhn vim
loet ai trang. Tuy nhin, nicotine a c chng minh lam tng s chuyn hoa
cua nhiu loai thuc thng c s dung iu tr vim rut do vy lam giam
hiu qua cua cac thuc nay.
Huyt khi tnh mach. Bnh nhn IBD co nguy c cao b huyt khi tnh mach
ca ln u tin va co nguy c tai phat (Gastroenterology 2011;139:779).
Kim soat triu chng quan trong nh thuc h tr iu tr nhng phai c s
dung mt cach thn trong
Thuc iu tr tiu chay co th hu ch nh la mt iu tr h tr i vi mt s
bnh nhn co t tin trin nhe hoc tiu chay sau phu thut. Thuc chng ch
nh trong t tin trin nng va gian ai trang nhim c.
Narcotics nn c s dung mt cach han ch kim soat au bi cac triu
chng man tnh co th dn n s phu thuc thuc.
Ri lon tiu ha chc nng
I CNG
nh ngha
Ri loan tiu hoa chc nng c c trng bi s hin din cua cac triu chng
bung khi khng co tn thng thc th. Cac triu chng co th t bt ky vung nao
cua ng tiu hoa.
Hi chng rut kch thch (Irritable bowel syndromeIBS), c trng chu yu
la au bung lin quan n thay i thoi quen ai tin trong thi gian t nht 3 thang,
la bnh do ri loan chc nng rut c ghi nhn nhiu nht (Gastroenterology
2006; 130:1480).
CHN ON
anh gia lm sang va cac thm do nn c tin hanh mt cach thn trong loai
tr cac nguyn nhn thc th trc khi bt u th iu tr cac triu chng c
cho la c nng.
Trong trng hp bnh nhn co cac triu chng bao ng (thiu mau, giam cn,
tin s gia nh mc bnh ung th ai trc trang, vim rut, hoc bnh celiac),
Ri lon ng tiu ha Ri lon tiu ha chc nng l 813
chn oan IBS da vao triu chng noi chung la chnh xac (Am J Gastroenterol
2009;104 (suppl 1):S1).
Xet nghim huyt thanh hoc chn oan bnh celiac c khuyn cao nhng
bnh nhn IBS. Ty l bnh celiac trong nhom bnh nhn IBS co triu chng tiu
chay chim u th c c tnh la 3,6%, so vi ty l la 0,7% dn s noi chung
(Am J Gastroenterol 2009;104 (suppl 1):S1).
Bnh nhn >50 tui mi xut hin cac triu chng rut, bnh nhn co cac triu
chng bao ng (xut huyt tiu hoa, thiu mau, giam cn, n mau no) va cac
triu chng cua bnh nhn khng ap ng vi iu tr theo kinh nghim cn
kim tra bng ni soi. Cac phng phap chn oan hnh anh ct ngang khng
c khuyn cao thng quy vi bnh nhn co cac triu chng c nng in hnh
khng co cac triu chng bao ng.
nhng ngi tre tui vi cac triu chng xut hin trong thi gian ngn va
khng giai thch c triu chng kho tiu nn anh gia tnh trang nhim H.
pylori bng cac phng phap khng xm ln (BMJ 2008;337:a1400).
IU TR
Hng dn bnh nhn, tao s yn tm, giup bnh nhn xy dng ch n ung va
thay i li sng la cha khoa cho mt mi quan h hiu qua gia bac s va bnh
nhn. Can thip tm ly nn c tin hanh cac trng hp co triu chng cp tnh
va phng phap nay at hiu qua nhiu bnh nhn.
Thuc
iu tr triu chng
Thuc chng nn rt hu ch trong cac trng hp bun nn c nng va nn
ma, bn canh cac thuc iu hoa thn kinh.
Khi au va y bung la nhng triu chng chu yu, thuc chng co tht hoc
khang cholinergic (hyoscyamine, 0,1250,25 mg ung/ngm di li co th
n 4 ln/ngay; dicyclomin, 1020 mg ung 4 ln/ngay) co th s dung trong
thi gian ngn.
S ln i ai tin cai thin vi ch n tng cht x (25 g/ngay) kem theo s
dung thuc nhun trang khi cn trong IBS th tao bon tuy nhin triu chng au
bung khng cai thin.
Loperamide (24 mg, co th n 4 ln/ngay khi cn) co th lam giam s ln i
ai tin, cam giac cng tc mun i va khng kim soat phn.
iu tr khang sinh trong thi gian ngn co th cai thin y hi va tiu chay
trong IBS; iu tr lu dai cha c nghin cu y u. Cac probiotic (v.d.,
nh bifidobacteria) i khi co hiu qua (Am J Gastroenterol 2009; 104 (suppl
1):S1).
Lubiprostone (8 g, 2 ln/ngay), mt thuc kch hoat knh chloride chon loc

va linaclotide (290 g 4 ln/ngay), cht chu vn guanylate cyclase C, co th cai
thin triu chng tao bon bnh nhn n.
Alosetron (Lotronex, 1 mg hang ngay, co th dung 2 ln/ngay), mt thuc i
vn vi 5-HT3, co hiu qua vi IBS th tiu chay phu n. Tuy nhin, tac dung
cua thuc b han ch nhng trng hp tiu chay keo dai do kha nng b vim
ai trang thiu mau du thp.
Thuc iu hoa thn kinh
Liu thp TCAs (v.d., amitriptyline, nortriptyline, imipramine, doxepin: 25-
100 mg trc khi i ngu) co tac ng iu hoa thn kinh va giam au va khng
phu thuc vao hiu ng tm thn cua bnh nhn. Co th co hiu qua, c bit la
khi triu chng au la chnh trong cac ri loan chc nng tiu hoa.
Thuc c ch tai hp thu serotonin co chon loc (SSRIs Selective serotonin
reuptake inhibitors) (v.d., fluoxetine, 20 mg; paroxetine, 20 mg; sertraline,
50 mg; duloxetine 2060 mg) cung co th co hiu qua, vi t tac dung phu hn.
Hi chng nn chu ky (Cyclic vomiting syndromCVS), la mt cn bnh
ngay cang c ghi nhn bao gm cac t nn ma nhiu va nng va co nhng
khoang thi gian gia khng co triu chng (Aliment Pharmacol Ther 2011;
34:263). iu tr vi liu thp TCAs hoc thuc chng ng kinh (zonisamide,
dung levetiracetam) co hiu qua d phong (Clin Gastroenterol Hepatol 2007, 5:
44; Am J Gastroenterol 1999;94:2855). Sumatriptan (2550 mg ng ung,
510 mg xt mui, hoc 6 mg tim di da) hoc cac triptans khac co th giup
ngn nga mt t tin trin, c bit la nu dung khi mi co tin triu hoc
trong giai oan sm (Cephalalgia 2011,31:504). Nhng t tin trin co th cn
truyn dch, truyn tnh mach thuc chng nn (ondansetron, prochlorperazine),
cac benzodiazepin (lorazepam) va kim soat au vi narcotics ng tnh mach
trong 12 ngay.
Gi tc rut cp tnh (lit rut)
I CNG
nh ngha
Gia tc rut cp tnh hay lit rut bao gm triu chng giam s vn chuyn cac cht
trong rut va co triu chng tc nghen ng rut (bun nn, nn, y bung, khng
co nhu ng) ma khng co tn thng c hoc (Med Clin North Am 2008, 92: 649).
Gia tc ai trang hoc hi chng Ogilvie m ta s gian ai trang rng ma khng
co tc nghen c hoc va co s hin din cua van hi manh trang con am bao chc
nng do s suy giam nhu ng rut (Br J Surg 2009;96:229).
Ri lon ng tiu ha Gi tc rut cp tnh (lit rut) l 815
Nguyn nhn
Lit rut thng gp trong giai oan hu phu. Thuc giam au gy nghin co th
c ch nh kim soat au sau m co th gy bnh, cac loai thuc khac co th gy
chm nhu ng rut (thuc chen knh canxi, thuc khang cholinergic, TCAs, thuc
khang histamin). Cac yu t anh hng khac bao gm can thip y t, bnh h thng
c bit e doa tnh mang, nhim trung, suy mach va bt thng in giai. Nguyn
nhn la tng t cho gia tc nghen ai trang cp tnh.
CHN ON
Hoi bnh s va kham thc th cn thn la cn thit trong anh gia ban u.
Cac xet nghim thng thng (cng thc mau, sinh hoa mau, amylase, lipase)
giup anh gia qua trnh vim nguyn phat trong bung.
Chup X-quang loai tr tc nghen (Chup X-quang bung nm nga, ng) anh
gia phn b kh trong rut va anh gia s hin din kh trong bung.
Chn oan hnh anh khac anh gia cho tc nghen c hoc va qua trnh vim va
bao gm chup CT, thut thuc can quang va chup rut non.
IU TR
iu tr h tr c ban bao gm nhn n, bu dch va iu chnh s mt cn bng
in giai. Liu phap khang sinh c ch nh ngay nu nghi ng nhim trung.
Thuc lam chm nhu ng rut (thuc chu vn adrenergic, TCAs, thuc an thn,
thuc giam au co cht gy m) nn ngng dung hoc giam liu. Bnh nhn i
lai c khuyn khch duy tr hoat ng va thc hin i b cac quang ngn.
t sonde da day hut ngn chn qua trnh nut khng kh vao ng tiu hoa.
Trong nhng trng hp keo dai, da day b chen ep, co th s dung sonde da day
hoc ng m thng da day qua ni soi, giup giam tit ng tiu hoa trn va giam
oi ma va y hi da day.
t sonde hu mn giup giam chen ep oan di ai trang; i vi cng tc
nhiu vung ai trang pha trn co th hiu qua khi hut qua ni soi ai trang, c
bit la khi ng knh manh trang ln ti 910 cm. Mt ng sonde co th t trong
ai trang vung trn trong khi ni soi. Cho bnh nhn nghing t bn nay sang bn
co th lam tng hiu qua cua hut kh trong ni soi ai trang.
Nui dng tnh mach tam thi co th c yu cu trong trng hp keo dai.
Thuc
Neostigmine (2 mg tim tnh mach chm trong 35 phut) co li mt s bnh
nhn cng chng ai trang cp tnh. Thuc nay co th gy ra tai lp nhanh chong
cua trng lc cua ai trang va chng ch nh nu tc nghen c hoc vn con cn
chn oan phn bit. Tac dung phu bao gm au bung, tit nc bot qua mc,
nhp tim chm co triu chng va ngt xu. S dung th neostigmine co th cn
nhc trc khi dung ni soi giai phong cng tc nhng bnh nhn khng co
chng ch nh (N Engl J Med 1999;341:137).
Erythromycin (200 mg tnh mach) hoat ng nh mt cht ng vn motilin va
kch thch nhu ng ng tiu hoa trn; thuc a c s dung thanh cng trong
tr liu tc nghen dai dng sau m.
Alvimopan la thuc i khang thu th -opioid ngoai vi co tac ng tng cng
chc nng cua rut sau phu thut bung (Am Surg 2011;77:1460) nhng cha
c chng minh giup rut ngn thi gian nm vin.
Mosapride citrate (15 mg ung 3 ln/ngay), thuc chu vn thu th 5HT4, co
th lam giam thi gian lit rut sau phu thut khi c dung sau phu thut (J
Gastrointest Surg 2011;15:1361).
X tr phu thut
T vn phu thut la cn thit khi hnh anh lm sang la gi y tc nghen c hoc
hoc nu co du hiu phuc mac
Phu thut ly sach phn iu tr chng ai trang cp tnh khi hut hi qua ni
soi ai trang tht bai.
Phu thut thm do c cn nhc cho trng hp cp tnh vi cac du hiu phuc
mac, rut thiu mau cuc b hoc bng chng thung.
RI LON MT TY
Vim ty cp
I CNG
nh ngha
Vim tuy cp bao gm vim tuyn tuy va m quanh tuyn tuy do hoat hoa cac men
cua tuyn tuy, c bit la trypsin.
Nguyn nhn
Cac nguyn nhn ph bin nht la ru va bnh soi mt, chim 75% n 80% cac
trng hp. Nguyn nhn t gp hn la chn thng bung, tng canxi mau, tng
triglyceride mau va mt s loai thuc. Trong mt nghin cu, hn 40% bnh nhn
nhp vin vi vim tuy cp do s dung thuc cho thy vim tuy do thuc co th
cha c chu y ghi nhn(Am J Gastroenterol 2011;106:2183). Sau ni soi mt tuy
Ri lon mt ty Vim ty cp l 817
ngc dong (endoscopic retrograde cholangiopancreatographyERCP) vim tuy

xay ra 5% n 10% bnh nhn.
CHN ON
Biu hin lm sng
Triu chng in hnh bao gm cac cn au khi phat cp tnh vung thng v,
bun nn va nn thng tng khi n. Biu hin toan thn co th bao gm st, kho
th, thay i tnh trang tm thn, thiu mau, mt cn bng in giai, c bit la vi
nhng trng hp bnh nng.
Test chn on
Xt nghim
Lipase huyt thanh c hiu hn va nhay hn so vi amylase huyt thanh, mc du
ca hai thng tng ln 23 ln so vi gii han bnh thng trn. Nhng gia tr nay
khng tng quan vi mc nghim trong hoc thuyn giam cua cac triu chng.
Bnh nhn suy thn co th co nng cac enzyme cao hn mc bnh thng.
Xet nghim cng thc mau co th co nng hemoglobin cao do tnh trang c
c mau; nitro ure trong mau (blood urea nitrogenBUN) va nng creatinin
huyt thanh co th tng.
Kim tra chc nng gan co th anh gia nguyn nhn do tc mt va xet nghim
lipid mau co th gi y tnh trang tng triglyceride mau cung la nguyn nhn gy
vim tuy cp.
Chn on hnh nh
Chup CT hai pha tuy hu ch trong vic anh gia ban u tnh trang vim tuy
cp nng nhng nhng bng chng gn y cho thy rng vic s dung CT giai
oan sm cua bnh nn c han ch (Pancreatology 2010,10:222). Cu th, CT
nn c ch nh cho cac bnh nhn co triu chng nng hoc keo dai hoc nu
chn oan khng ro rang (Med Clin Bc Am nm 2008,92:889).
MRI vi gadolinium cung co th c ch nh at hiu qua tng t, c bit la
khi chup CT b chng ch nh. Ky thut khng thch hp cho nhng bnh nhn
co tnh trang huyt ng khng n nh. MRCP rt hu ch phat hin vim tuy
do nguyn nhn ng mt trc khi ERCP c thc hin (Med Clin Bc Am
nm 2008,92:889).
IU TR
Tch cc bu dch ng tnh mach, theo doi cn thn lng nc tiu va anh gia
v kha nng hp thu lng dch vao trong bung. Theo doi tai ICU khi cn thit.
in giai , canxi va ng mau cn c theo doi va b sung khi cn thit.
Bnh nhn cn nhn n cho n khi ht au va bun nn. t sonde da day

c ch nh danh ring cho nhng bnh nhn b lit rut hoc nn keo dai.
Nui dng ng tnh mach co th cn thit khi tnh trang vim chm hi phuc
(khoang 7 ngay) hoc nu xut hin lit rut. Dinh dng qua ng rut thng
qua mt ng sonde t qua dy chng goc Treitz thng c dung nap tt, an
toan hn va hiu qua hn so vi nui dng ng tnh mach (Surg Clin North
Am 2007, 87: 1403).
Thuc c ch axit co th cn thit nhng bnh nhn nng co nguy c loet do
stress (xem phn Chay mau ng tiu hoa) mc du cha c chng minh co
hiu qua trong lam giam thi gian hoc mc triu chng (Gastroenterology
2007;132:2022).
Thuc
Thuc giam au narcotics thng la cn thit giam au.
Dilaudid thng c s dung ban u, nhng thuc giam au gy nghin khac
(v.d., meperidine) la la chon thay th. iu chnh thuc giam au tng bnh
nhn (Patient-controlled analgesiaPCA) la cn thit giam au hoan toan.
Khang sinh d phong khng c ch nh khi khng co nhim trung toan thn.
ERCP cp cu va ct c tht trong vong 72 gi co th cai thin kt qua cua vim
tuy nng do soi mt khi co tc mt va t bin chng (Ann Surg 2009;250:68). iu tr
nay se lam giam nhim trung ng mt hn la cai thin thc s tnh trang vim tuy.
X tr phu thut
Ct bo tui mt. Tr hoan ct bo tui mt sau vim tuy cp do soi mang mt nguy c
ang k bnh ng mt tai phat (Br J Surg 2011;98:1446).
BIN CHNG
Vim tuy hoai t la bin chng nghim trong cua vim tuy cp, thng c
xac nh bng chup CT co tim thuc can quang. Biu hin hoai t tuy trn cac
phng tin chn oan hnh anh lam tng ty l mc bnh kem theo va t vong cua
vim tuy cp. au bung tng, st, tng bach cu, nhim khun gi y tnh trang
vim tuy hoai t cn phai ch nh khang sinh ph rng va oi hoi phai phu
thut. Carbapenems hoc kt hp fluoroquinolone va metronidazole co kha
nng thm nhp tt vao m hoai t, nhng khang sinh iu tr d phong khng
lam giam nhim trung tuy hoc giam nguy c t vong (J Gastroenterol Hepatol
2009;24:736; J Gastrointest Surg 2009,13:768). Choc hut di hng dn cua
CT qua da nhum Gram va nui cy co th xac nh chn oan nhim trung
hoai t. Phu thut la cn thit trong trng hp nng.
Ri lon mt ty Vim ty mn l 819
S xut hin cua nang gia tuy c ngh n nu au dai dng hoc co nng
amylase mau cao. Cac bin chng bao gm nhim trung, xut huyt, v (c
trng do tuy) va chen ep cac cu truc ln cn. Cac nang gia tuy khng to ln
va khng co triu chng lm sang co th c theo doi lin tuc bng cac phng
phap chn oan hnh anh cho n khi phuc hi. Dn lu nang gia tuy co triu
chng hoc b nhim trung co th c thc hin qua da, ni soi, hoc phu thut
(Gastrointest Endosc Clin N Am 2007,17:559).
Nhim trung. Nguyn nhn cua st bao gm hoai t tuyn tuy, ap-xe, nang gia
tuy bi nhim, vim ng mt, vim phi do ht sc. Cy mau cn ch nh
va khang sinh ph rng vi vi sinh vt ng rut nn dung. Trong trng hp
khng st hoc khng co bng chng lm sang khac v nhim trung, khang sinh
d phong khng co vai tro ro rang trong vim tuy cp.
Bin chng phi. Xep phi, tran dch mang phi, vim phi va hi chng suy h
hp cp tnh co th xut hin nhng bnh nhn vim tuy cp (xem Chng 10,
Bnh ly phi).
Suy thn co th la kt qua cua s giam khi lng tun hoan hoc hoai t ng
thn cp.
Cac bin chng khac. Bin chng chuyn hoa bao gm giam canxi mau, giam
magne mau va tng ng huyt. Xut huyt tiu hoa co th do vim da day
do stress, v nang gia tuy hoc gian tnh mach da day do huyt khi tnh mach
lach.
Vim ty mn
I CNG
nh ngha
Vim tuy man tnh la tnh trang vim, x hoa va teo cac t bao tuyn nang do
vim cp tnh tai phat hoc vim man tnh cua tuyn tuy.
Hu ht thng gp trng hp nghin ru man tnh, hoc cung co th la kt
qua cua ri loan lipid mau, tng canxi mau, bnh t min va tip xuc vi cac cht
c. Trng hp do di truyn him gp (Gastroenterology 2007;132:1557).
Vim tuy t min (Autoimmune pancreatitisAIP) la mt dang cua vim tuy
t min, ngay cang c ghi nhn nhiu, c trng bi s xm nhp cua cac t
bao mau globulin min dch (immunoglobulinIg) G4 dng tnh vao trong tuyn
tuy. AIP co th kho phn bit vi ung th tuyn tuy trn CT, nhng thng c
trng bi s hep lan toa bt thng cua ng tuy chnh trn ERCP. iu tr ban u
vi prednisolone 0,6 mg/kg/ngay, sau o la liu duy tr trong 36 thang, c ch
nh khi xut hin cac triu chng (Gut 2009;58:1504).
CHN ON
Biu hin lm sng
au bung man tnh, suy tuyn tuy ngoai tit do tn thng t bao nang va x hoa
(biu hin nh giam cn, va phn m) va suy tuyn tuy ni tit do pha huy cac t
bao tiu ao (biu hin bnh tiu ng) la nhng biu hin lm sang chnh.
Test chn on
Xt nghim
Lipase va amylase co th cao nhng thng la bnh thng va khng c hiu.
Bilirubin, phosphatase kim va transaminase co th tng nu co kem tnh trang
tc mt. Xet nghim lipid va canxi huyt thanh cung nn c anh gia.
Kim tra chc nng tuyn tuy (nh kch thch secretin, xet nghim m trong
phn, va elastase trong phn) co th c ch nh nhng khng ph bin rng
rai va kho thc hin. trng hp co m trong phn, nng trypsinogen huyt
thanh la 20 ng/mL la chn oan vim tuy man tnh vi suy ngoai tit (Am Fam
Physician 2007;76:1679).
Chn on hnh nh
Vi hoa cua tuyn tuy co th c nhn thy trn phim thng va siu m. CT co
tim thuc co nhay 75% n 90% va c hiu 85% trong chn oan vim
tuy man tnh, trong khi MRCP la phng phap tng ng va thay th phu hp
(Gastroenterology 2007;132:1557). ERCP co nhay va c hiu nhng him
c ch nh v la thu thut xm ln va cac bin chng.
Siu m ni soi (Endoscopic ultrasoundEUS) co nhay cao hn (97%) vi
c hiu thp hn (60%) trong chn oan vim tuy man. No rt hu ch
anh gia cac tn thng lin quan hnh thanh khi u trn vim tuy man.
IU TR
Thuc
Thuc giam au thng c ch nh kim soat cn au, va phu thuc thuc
giam au la hin tng ph bin. Cac thuc iu hoa thn kinh (TCAs, SSRIs)
va pregabalin co th cai thin triu chng va lam giam s phu thuc vao thuc
giam au gy nghin (Gastroenterology 2011;141:536). nhng bnh nhn
giam chc nng tuy ngoai tit t mc nhe n trung bnh, vic ung b sung
enzyme tuyn tuy co th giup kim soat cn au.
B sung enzyme tuyn tuy la iu tr chu yu s suy giam tuyn tuy ngoai tit, kt
hp vi mt ch n ung t cht beo (50 g cht beo mi ngay), giup tng cn va
giam s ln i ngoai (Aliment Pharmacol Ther 2011;33:1152). Cac ch phm co
lp ao boc rut (Pancrease hoc Creon, 12 vin trong ba n) n nh pH axit.
Ri lon mt ty Bnh si mt l 821
B sung vitamin tan trong cht beo la cn thit.

iu tr bng insulin thng la cn thit cho bnh nhn suy ni tit nh ai thao
ng khng ap ng vi thuc ung.
iu tr cac bnh nn nu co (v.d., cng cn giap, ri loan lipid mau). Cn t
vn cai ru.
Bnh nhn b tc nghen ng tuy bi soi, hep, hoc hep nhu co th c ch nh
ERCP va ct c tht.
au khng ap ng vi iu tr co th cn tac ng c ch am ri thn kinh
thn tang (thng thc hin di hng dn cua siu m ni soi) hoc thm ch
phu thut, chng han phu thut Whipple (Aliment Pharmacol Ther 2009;29:
979).
Bnh si mt
I CNG
Soi mt khng triu chng (soi mt) c phat hin tnh c thng khng cn
iu tr c hiu (J Gastroenterol Hepatol 2010,25:719). Soi Cholesterol la loai
ph bin nht, nhng soi sc t co th gp trong trng hp tan mau hoc nhim
trung. Yu t nguy c bao gm beo ph, n gii va tin s gia nh.
Soi mt co triu chng, khi cac triu chng xut hin do soi mt, thng phai
iu tr bng phu thut ct bo tui mt.
Vim tui mt cp thng gp do tc nghen cua ng tui mt do soi mt nhng
vim tui mt hoai t co th xay ra nhng bnh nhn b bnh nng hoc bnh
nhn ang nm vin.
CHN ON
Biu hin lm sng
Co th xut hin cn au soi mt, au lin tuc keo dai trong nhiu gi, ha sn
phai, lan ra pha sau lng hoc ln vai phai va i khi kem theo bun nn hoc
nn.
Biu hin khac cua bnh soi mt bao gm vim tui mt cp, vim tuy cp, vim
ng mt. Bnh soi mt him khi lin quan vi ung th tui mt.
Bnh nhn b vim ng mt cp tnh co biu hin au ha sn phai, st ret run
va vang da (tam chng Charcot), thng nm trong bnh canh tc mt (soi ng
mt chu, u, vim x ng mt, tc stent ng mt). Bnh nhn cao tui co th
khng biu hin triu chng.
Test chn on
Siu m co chnh xac cao trong chn oan ( nhay va c hiu 95%) va
la xet nghim ban u.
Chup mt Hydroxy axit iminodiacetic (Hydroxy iminodiacetic acidHIDA)
co th cho thy hnh anh tui mt nhng bnh nhn vim tui mt cp.
IU TR
Thuc
Bin phap h tr bao gm truyn dch va cac khang sinh ph rng, c bit la
trong trng hp co bin chng nh vim tui mt cp tnh co nhim trung huyt,
thung, vim phuc mac, ap-xe, vim mu mang phi.
Axit ursodeoxycholic (810 mg/kg/ngay ung 23 ln trong thi gian dai) c
ch nh bnh nhn co soi cholesterol nho co chc nng tui mt bnh thng va
co nguy c cao b bin chng nu iu tr bng phu thut. Tac dung phu bao gm
tiu chay va tng transaminase huyt thanh.
Ct tui mt qua da co th c thc hin di man huynh quang nhng bnh
nhn nng vim tui mt cp khng th phu thut c.
X tr phu thut
Ct tui mt la iu tr c la chon cho bnh soi mt co triu chng va vim tui
mt cp. Ct bo tui mt ni soi so sanh vi phu thut bung m co ty l mc bnh
kem theo thp hn, chi ph thp hn, thi gian nm vin ngn hn, va kt qua thm
my tt hn (Lancet 2006;368:230).
BIN CHNG
Vim tuy cp. Xem phn Vim tuy cp.
Soi ng mt chu. Thng gp tc nghen ng dn mt, vang da, au do soi mt,
vim ng mt hoc vim tuy co th la do soi nm trong ng mt chu. Chn oan
c bng siu m, chup CT hoc cng hng t ng mt. ERCP vi ky thut
ct c tht va ly soi la phng phap iu tr trit .
Vim ng mt cp nng la trng hp cp cu vi ty l mc bnh va t vong
cao nu giai phong mt khng c thc hin khn trng. Tnh trang bnh nhn
phai c n nh bng truyn dch ng tnh mach va khang sinh ph rng. t
dn lu ng mt co th c thc hin thng qua ni soi (ERCP vi ky thut ct
c tht) hoc cach x ly qua da di hng dn man huynh quang.
Ri lon tiu ha khc Bnh Celiac l 823
RI LON TIU HA KHC
Ri lon hu mn trc trng
Huyt khi tr ngoai co biu hin au nhiu, cng, bui tr xanh bao phu bi da
vung hu mn. Cac trng hp huyt khi tr co th c phu thut ct bng gy
t tai ch lam giam au. Trong trng hp t nghim trong hn, thuc giam
au ng ung, tm ngi (ngi trong mt bn tm nc m), lam mm phn va
thuc m bi co th lam giam triu chng (BMJ 2008;336:380).
Tr ni thng biu hin mt trong hai biu hin chay mau hoc khi sa khi gng
sc. B sung cht x rt hu ch trong vic ngn nga gng sc khi ai tin. Tm
ngi va ming m Tucks (bng ngm trong hazel) co th lam giam triu chng.
Thuc m va thuc an co cha thuc giam au tai ch, cht lam mm da, cht
lam se da va hydrocortisone (v.d., Anusol-HC an, t trc trang mi ln 1 vin,
2 ln/ngay, t 7 n 10 ngay) co th lam giam phu n nhng khng lam giam chay
mau. Phu thut ct hoc tht vong cao su c ch nh bnh nhn tai phat hay
chay mau lin tuc (BMJ 2008;336:380).
Vt nt hu mn co biu hin khi phat cp tnh la au khi i v sinh va thng
gy ra bi phn cng. Soi trc trang cho thy vt nt hnh elip trong da cua hu
mn, thng ng gia sau. Vt nt cp tnh cha lanh trong 23 tun vi vic
s dung cac thuc lam mm phn, thuc giam au ng ung hoc thoa, va tm
ngi. Bi thuc m nitroglycerin 0,2% ba ln mt ngay co th co tac dung. Vt
nt man tnh thng oi hoi iu tr bng phu thut.
Ap-xe quanh trc trang thng biu hin bng mt am cng au khu vc quanh
hu mn. Bnh nhn b vim rut va suy giam min dch c bit nhay cam. Dn
lu nhanh chong la iu cn thit tranh nhng bin chng nghim trong lin
quan n iu tr mun. Khang sinh chng lai h vi sinh ng rut (metronidazole,
500 mg ung 3 ln/ngay va ciprofloxacin 500 mg ung 2 ln/ngay) nn c dung
bnh nhn vim nng, nhim c toan thn, suy giam min dch.
Bnh Celiac
I CNG
Bnh Celiac la tnh trang nhay cam vi gluten, mt loai protein c tm thy
trong lua m, lua mach, va lua mach en. Vim man tnh nim mac rut non gy
kem hp thu cac cht dinh dng.
Biu hin lm sang rt khac nhau t thiu mau thiu st khng co triu chng
n tiu chay nng va giam cn nhiu. Nhng biu hin khac co th bao gm
loang xng, vim da dang mun rp, men gan bt thng va au bung; tnh c
phat hin qua ni soi cung co th xay ra a c ghi nhn (N Engl J Med 2007;
357:1731).
Hn 7% bnh nhn IBS khng tao bon co khang th lin quan n bnh celiac,
cho thy tnh trang nhay cam vi gluten co th gy ra cac triu chng IBS
CHN ON
Cac xet nghim huyt thanh chn oan khng xm ln co nhay va c hiu
cao. Ca hai khang th IgA ni c va khang th chng m ni c transglutaminase
co chnh xac gn 100% (N Engl J Med 2007;357:1731). Nng nh lng
IgA phai c kim tra; Khang th IgG khang lai transglutaminase cua m c
xet nghim nu bnh nhn thiu IgA.
Ni soi sinh thit chn oan xac nh c khuyn cao. Kt qua sinh thit in
hnh thy nhung mao rut ngn hoc khng co nhung mao va s xm nhp t bao
lympho vao trong lp biu m.
Hu nh tt ca bnh nhn b celiac mang phn t HLA DQ2 va HLA DQ8, v vy
nhng trng hp ang nghi ng chn oan nu bnh nhn khng co cac alen nay,
gia tr d oan m tnh cao (Gastroenterology 2006;131:1981).
IU TR
Thuc
Bnh nhn cn b sung st, folate, canxi va cac vitamin.
Corticosteroid (prednisone, 10 n 20 mg/ngay) co th c ch nh trong
trng hp khang thuc; thuc c ch min dch va infliximab cung c ch
nh (N Engl J Med 2007;357:1731).
Mt ch n khng co gluten cai thin nhanh chong cac triu chng. Ch n
khng tun thu la nguyn nhn thng gp khin cac triu chng dai dng.
Nu triu chng khng giam mc du a thc hin nghim ngt ch n
khng co gluten, cn s dung cac phng tin chn oan hnh anh va ni soi
rut non loai tr vim ai trang collagen va u lympho rut. Tuy nhin, tin
lng bnh celiac ngi trng thanh khng c phat hin la tt mc du cac
khang th celiac dng tnh; do o, sang loc hang loat khng cn thit (Gut
2009;58: 643).
Ri lon tiu ha khc Ti tha v vim ti tha l 825
Ti tha v vim ti tha
I CNG
nh ngha
Tui tha bao gm cac tui nho, trong rut, ph bin nht la ai trang, nhng
cung co th gp ni khac trong rut nhng him.
Xut huyt tiu hoa do tui tha co th him khi xay ra t mt ng mach
ming cua rut tha. Xem chay mau ng tiu hoa bit thm chi tit.
Vim tui tha la kt qua cua vi thung tui tha gy vim bn ngoai rut hoc trong
thanh rut.
CHN ON
Biu hin lm sng
Tui tha thng khng co triu chng. Mc du tui tha co th c tm thy
nhng bnh nhn khi thc hin cac thm do chn oan v au bung hoc thay i
thoi quen i ai tin, rt kho khng nh mi lin quan.
Triu chng in hnh cua vim tui tha la au vung h chu trai, st, n lanh, va
thay i thoi quen i ai tin. au cuc b vung h chu trai co th c phat hin
khi kham lm sang.
Test chn on
Xt nghim
Vim tui tha co th lin quan n tng s lng bach cu tng (white blood cell
WBC) chu yu a nhn trung tnh.
Chn on hnh nh
Tui tha thng c phat hin khi ni soi ai trang.
Chn oan hnh anh, ph bin nht la chup CT, rt hu ch trong chn oan vim
tui tha.
Ni soi ai trang la chng ch nh cho n 46 tun sau vim tui tha cp tnh
nhng phai c thc hin sau khoang thi gian o loai tr v tn thng ac
tnh.
IU TR
Tng cht x trong ch n thng c khuyn cao nhng bnh nhn co tui
tha, mc du khng co d liu u manh chng to li ch cua no. Khng co d
liu tn tai chng to cn loai tr cac loai hat va bong ng t ch n ung
ngn nga vim tui tha cp tnh.
Mt ch n ung t cht ba c khuyn cao cho trng hp vim tui tha nhe.
Nhn n nu vim tui tha co bin chng va dinh dng ngoai ng tiu hoa co
th la cn thit nu bnh keo dai.
Thuc
Khang sinh ng ung (v.d., ciprofloxacin, ung 500 mg hai ln mt ngay, va
metronidazole, 500 mg ung 3 ln/ngay t 10 n 14 ngay) co th ch nh iu
tr cho vim tui tha nhe.
Nhp vin, nhn n, truyn dch va cac khang sinh ph rng ng tnh mach
thng c ch nh nhng trng hp trung bnh n nng.
X tr phu thut
Hi chn phu thut cn c thc hin sm trong vim tui tha t trung bnh n
nng v can thip phu thut cn thit tranh cac bin chng xay ra.
Phu thut co th cn thit trong vim tui tha thng xuyn, thng la t 3 ln
tr ln tai phat tai cung mt v tr.
Chm lm trng d dy
I CNG
nh ngha
Chm lam trng da day la tnh trang chm lam trng cac cht t da day xung rut
non mt cach bt thng trong trng hp khng co tc nghen c hoc, thng la hu
qua cua s tn thng cac dy thn kinh hoc c trn lin quan n vic lam rng
da day (Am J Gastroenterol 2006;127:287).
Nguyn nhn
Chm lam trng da day co th gp trong cac tnh trang ri loan man tnh (bnh
ai thao ng, x cng b, gia tc rut, tin s phu thut da day), hoc t thng
xuyn hn trong cac ri loan chuyn hoa cp (ha kali mau, tng canxi huyt, giam
canxi mau, tng ng huyt) hoc do thuc (thuc giam au co cht gy m,
thuc khang cholinergic, hoa tr liu). Bnh co th la t phat khi cac nguyn nhn
khng xac nh c (Gastroenterology 2004;127:1589).
Tc nghen c hoc lun cn c loai tr.
CHN ON
Biu hin lm sng
Cac triu chng bao gm bun nn, y hi, nn, thng gp nhiu gi sau ba n.
Ri lon tiu ha khc Chm lm trng d dy l 827
Test chn on
Chn on hnh nh
anh gia tnh trang da day trng da day bao gm quet hnh anh bng gn cht
phong xa vao thc n co th giup chn oan.
Bng chng ni soi thy manh vun thc n gi lai trong da day sau khi mt m
nhn oi co th la mt du hiu gian tip cua tnh trang chm lam trng da day.
IU TR
Ri loan chuyn hoa nn cn c iu tr. c bit, kim soat ng huyt bng
cach s dung cac ch phm insulin tac dung ngn co th cai thin giai oan u
cua tnh trang chm lam trng da day bnh nhn ai thao ng (Gastroenterol
Hepatol 2005,3:642).
T vn dinh dng co th giup giai quyt thiu hut dinh dng va at c ch
n ung co hiu qua (Gastroenterology 2011;141:486). Nn tranh cac cht beo
va cht x khng hoa tan trong cac ba n v chung se lam chm hin tng lam
trng da day. Ba n nhiu calo va dung dch ng trng co th co hiu qua trong
cac trng hp hay tai phat.
Thuc
Thuc nhom Prokinetic a c s dung vi mc ap ng khac nhau.
Metoclopramide (10 mg ung 4 ln/ngay na gi trc ba n) co hiu qua
rt khac nhau, va tac dung phu (bun ngu, ri loan vn ng mun, hi chng
Parkinson) co th la nhng han ch.
Domperidone (20 mg ung 4 ln/ngay trc khi n va trc khi i ngu) khng
qua hang rao mau nao, nhng co th dn n tng prolactin mau. Hin tng nay
khng thng gp.
Erythromycin (125250 mg ung 3 ln/ngay hoc 200 mg tnh mach) la mt chu
vn thu th motilin va kch thch nhu ng da day, nhng d nhn thuc, gy au
bung, bun nn khin han ch vic iu tr lu dai.
X tr phu thut
Cho n bng ng rut qua mt ng sonde hng trang co th c ch nh
b sung dinh dng va thng c dung hn dinh dng qua ng tnh
mach.
Kch thch in da day bng cach s dung phu thut cy ghep cac b phn kch
thch co th lam giam triu chng bun nn va nn mt na s bnh nhn khang
thuc nhng tnh trang chm rng da day thng khng cai thin bng phng
phap nay (Gastroenterology 2008;134:665; Gastrointest Endosc 2011;74:496).
Tn thng rut do thiu mu
I CNG
Kt qua thiu mau cuc b ng mach mac treo cp tnh (hoc tnh mach t gp)
do tn thng tun hoan mac treo trang trn.
Nghen mach va hnh thanh huyt khi la nhng nguyn nhn thng gp nht cua
thiu mau mac treo rut cp tnh, mc du thiu mau cuc b mac treo trang do
co mach cung co th lam nng cac ri loan.
Vim ai trang do thiu mau la hu qua cua thiu mau nim mac cuc b mac
treo trang di do lu thng tun hoan kem do tnh trang lu lng thp (ha huyt
ap, loan nhp tim, nhim trung huyt, phu thut ng mach chu) nhng bnh
nhn b bnh x va ng mach (Gastroenterology 2000;118:951).
Vim mach, bnh hng cu hnh lim, co mach va chay marathon co th dn n
cac vim ai trang thiu mau cuc b.
CHN ON
Biu hin lm sng
Bnh nhn b thiu mau mac treo cp tnh co th biu hin au bung, nhng thm
kham lm sang va chn oan hnh anh co th khng co biu hin ro rt cho n
khi hin tng nhi mau xay ra. Kt qua la chn oan thng mun va ty l t
vong cao.
Vim ai trang thiu mau cuc b co th biu hin nh xut huyt thoang qua hoc
tiu chay; hu qua nghim trong co th dn ti tnh trang hep, hoai t va thung.
Tnh a dang cua biu hin lm sang cua vim ai trang thiu mau giup giai thch
tai sao cac trng hp nghi ng trn lm sang thng la thp (Scand J Gastroen-
terol 2011, 46: 236).
Test chn on
Chup mach cp cu c ch nh nu nghi ng cao tnh trang thiu mau cuc b
mac treo cp tnh.
CT co tim thuc co gia tr chn oan vi nhay va c hiu cao trong trng
hp thiu mau mac treo cp tnh tin phat (Radiology, nm 2010; 256: 93), trong
khi siu m Doppler co th giup chn oan loai tr cac trng hp thiu mau mac
treo trang man tnh (Dig Liver Dis 2011,43:470).
bnh nhn vim ai trang thiu mau, biu hin in ngon tay cai (thumb-print-
ing) oan ai trang tn thng co th nhn thy trn X-quang bung.
Ni soi ai trang co th phat hin nim mac sung huyt, phu n, va loet; bng
chng hoai th hoc hoai t la ch nh cn can thip cua phu thut.
Ri lon tiu ha khc Tn thng rut do thiu mu l 829
IU TR
iu tr thiu mau mac treo rut cp tnh cn phai phu thut, trong khi ca hai
phng phap tao ng mach bang h va nong mach qua da la la chon trong iu
tr thiu mau mac treo rut man tnh (Ann VASC Surg 2010;24:935).
bnh nhn vim ai trang do thiu mau, khi khng co biu hin hoc bng
chng hoai th hoc thung, iu tr bao tn vi bi phu u dch va in giai,
khang sinh ph rng va duy tr huyt ng n nh la phac iu tr hiu qua.
Bng chng hoai th hoc hoai t xut hin cac trng hp cua vim ai trang
thiu mau la ch nh phu thut (Gastroenterology 2000;118:951).
27
Cp cu ni khoa
Jason Wagner, Christopher Sampson,
Rebecca Bavolek
CP CU NGNG TH
Tc nghn ng th trn cp tnh
I CNG
Tc nghen ng th cn phai c chn oan va x tr nhanh chong nu khng
co th dn n nhng hu qua nghim trong.
Vi nhng bnh nhn tnh tao khng cn h tr thng kh, tc nghen ng th
thng do d vt (thng la thc n), him gp hn la do phu mach.
Vi nhng bnh nhn hn m co vn v thng kh, tc nghen ng th co th
gy ra bi tc nghen do li, d vt, chn thng, nhim trung hoc phu mach.
CHN ON
Biu hin lm sng
Bnh s
Tin s bnh thng kho khai thac. nhng bnh nhn tnh tao vi thng kh y
u, cn hoi nhanh tin s tp trung vao cac nguyn nhn lit k phn sau.
Khm thc th
Cac triu chng bnh nhn tnh tao bao gm: th rt, thay i phat m, co rut
xng c hoc hom c, s xut hin cac du hiu nghen, du hiu suy h hp.
Cac triu chng bnh nhn hn m thay i t kho th n ngng th. Nghi
ng tc nghen ng th nu bop bong thy nng bnh nhn ngng th.
i vi tt ca i tng bnh nhn, cn tm kim du hiu may ay cp, phu
mach, st va bng chng cua chn thng.
Tc nghen mt phn bnh nhn tnh tao, thng kh y u.
Thc hin kham lm sang, phat hin phu n ng th, cng ham, tc nghen
thanh quan, co rut h hp, phu mach, th ngay, th rt, hach lympho ln va khi
u vung c.
Theo doi bnh nhn va chun b can thip bao v ng th.
1237
1238 l Ch. 27 Cp cu ni khoa
Tc nghen ng th bnh nhn hn m vi thng kh khng toan ven: Kham

quan sat ng th trn tm du hiu tc nghen la mt phn cua hi sc ng th.
Chn on phn bit
Chn thng mt c, d vt, nhim trung (bach hu thanh quan, vim thanh quan
cp, chng vim hong Ludwig, ap-xe thanh sau hong va bach hu), khi u, phu
mach, co tht thanh quan, phan ng phan v, tng tit m dai hoc tc nghen
ng th trn do tut li ( bnh nhn hn m).
Test chn on
Chn on hnh nh
Tc nghen mt phn bnh nhn tnh tao, thng kh thoa ang:
X-quang phn mm vung c thng nghing co nhay va c hiu thp hn
thm kham trc tip. Chup X-quang nn c thc hin tai n v cp cu hoc
hi sc tch cc bng may chup tai ging khi bnh nhn cn c theo doi cht
che.
Chup ct lp vi tnh xon c co tim thuc can quang vung c (di s theo doi
lin tuc) la phng phap hnh anh chn oan tc nghen ng th trn co nhay
va c hiu cao hn. Tr trng hp rt gn trung tm lm sang, vic chup
ct lp vi tnh la khng an toan nu may CT scanner khng gn khoa cp cu.
Nu ch nh chup ct lp vi tnh cn phai mang theo cac dung cu cp cu ng
th, gm ca ng ni kh quan c 6,0 t qua ng mui va b m kh quan.
K nng chn on
Tc nghen mt phn bnh nhn tnh va thng kh thoa ang: Nu tnh trang cua
bnh nhn n nh, thc hin ni soi thanh quan hoc ni soi mui hong thanh
quan ng mm. Thc hin ky thut cn thn se khng gy ra tc nghen ng th
cp tnh ngi ln.
IU TR
Nhanh chong loai bo tc nghen ngn nga ngng tun hoan va tn thng nao
do thiu oxy.
Tc nghen ng th bnh nhn tnh khng co thng kh:
Thc hin nghim phap Heimlich (thuc manh vung bung di c hoanh) lp lai
nhiu ln cho ti khi d vt c tng ra khoi ng th hoc khi bnh nhn bt
tnh. Co ti mt na s bnh nhn oi hoi thc hin nghim phap th hai (v.d.,
v lng, thuc manh vung ngc) tng thanh cng d vt ra ngoai (Circulation
2005;112(suppl 24):IV19).
Tc nghen ng th bnh nhn bt tnh khng co thng kh:
Cp cu ngng th H tr ng th cp cu l 1239
Nu khng co nghi ng chn thng tuy c, thc hin nghim phap nga u
nng cm. Ch thc hin thu thut y ham khi nghi ng chn thng tuy c.
Nu cac nghim phap trn co hiu qua, t ni kh quan qua mui hoc ming.
Nu khng co hiu qua, n lc thng kh cho bnh nhn qua bop bong ambu.
Nu cac phng phap trn u tht bai, khn trng thm kham vung hong
ming va hong hu. Khng nn dung ngon tay ly d vt trong trng hp
co th quan sat trc tip ng th bng ng soi hu hong va dung kep McGill
(nu cn thit) loai bo d vt.
Nu ni soi hu hong khng th thc hin ngay lp tc va nghi ng co d vt,
thc hin nghim phap Heimlich t th nm nga ( bnh nhn nm nga
va thc hin thuc vung bung di c hoanh lp i lp lai nhiu ln). Thuc vung
ngc co th tao ra ap lc ng th cao hn va co th hiu qua khi thuc vung
bung tht bai.
Thay th bng thuc vung ngc nu bnh nhn qua beo hoc mang thai nhng
thang cui.
X tr phu thut
Tc nghen ng th bnh nhn hn m khng co thng kh:
Nu nghim phap Heimlich t th nm nga tht bai cn ni soi hu hong trc
tip va t ng ni kh quan.
Thc hin m kh quan nu khng th t ni kh quan.
Nu khng co phu thut vin, thc hin m kh quan qua mang nhn giap s
dung catheter vi u kim c 12 n 14 gauge va mt dong oxy lu lng cao
(15 L/phut t ngun oxy ap sut 50 psi). Co mt thit b ring c thit k dung
thng kh dong phut nhng ta co th thay th bng cach gn ng ni kh quan
c 7,5 a ct u vao mt xilanh 3 mL a bo pitng sau o gn bong ambu vao
u cui ng ni kh quan va bop bong h tr. Ghi nh rng phng phap nay ch
cung cp oxy ch khng giup thng kh. iu o co ngha la, thng kh phut giup
ta tranh thu thi gian ch x tr khi nghi ng co tc nghen ng th.
M kh quan la la chon c u tin.
H tr ng th cp cu
Gy dn ng Eishman (Gum elastic bougieGEB [Eschman Introducer])

la que bng cao su mm vi u gy cong. Que co th c s dung mu nhng tt
hn ht nn dung en ni soi thanh quan trc tip khi khng quan sat c dy
thanh. Muc tiu la at c tm quan sat tt nht hng dn u soi cua gy dn
ng i vao su va hng ra trc. Khi u gy trong kh quan, chung ta co th
cam nhn c ting cham vao vong sun nhn khi di chuyn gy qua lai. Ngoai
ra, chung ta co th y gy xung hong hu cang su cang tt ma khng s mt

kim soat. Nu trong thc quan, gy se trt xung da day vi lc can rt nho.
Nu trong kh quan, gy se cham cac ph quan va gp can tr. Khi gy trong
kh quan chung ta co th d dang lun ng ni kh quan qua ng dn bi gy
dn ng vao ung v tr.
Mt na thanh quan (Laryngeal mask airwayLMA) la dung cu cp cu d s
dung cho hu ht cac trng hp cp cu ng th. o la ng ni kh quan vi
bong u di c bm cng phu ly kh quan va chen thc quan. Lu y dung
cu nay khng nn s dung cac bnh nhn tc nghen ng th ma d vt khng
th loai bo hoc trn bnh nhn co ap lc ng th cao nh COPD (Chronic
obstructive pulmonary disease), hen ph quan hay phu n co thai. Hin co cac
mask thanh quan th h mi (c la chon nhiu hn) chung cho phep ng ni
kh quan lun qua khi mun tip cn ng th. Bop bong thn trong do co th
gy nn.
Dung cu thng kh trn thanh mn c t mu vao hong ming va bm phng.
Bong pha trn lam chen hong ming trong khi bong thp hn lam chen thc
quan, cho phep thng kh din ra d dang tng t nh mt na thanh quan vi
cung nhng han ch nh trn.
Dung cu soi quang hoc hoc ky thut s ang ngay cang ph bin. Dung cu nay
cho phep quan sat dy thanh qua camera hoc ni soi quang hoc ma khng phai
quan sat qua ming, giup t ni kh quan d dang hn. Cht tit hoc mau co th
can tr camera quan sat.
Trn kh mng phi

I CNG
Tran kh mang phi co th do t phat hoc do chn thng.
Tran kh mang phi t phat xay ra khng do cac bnh ly phi.
Tran kh mang phi th phat xay ra do cac bnh ly nhu m phi bao gm COPD,
kh ph thung, bnh phi ke, vim phi hoai t, vim phi do Pneumocysitis
jiroveci, lao phi va x phi.
Tran kh mang phi do chn thng co th xay ra do chn thng ngc kn
hoc h.
Tran kh mang phi do thy thuc gy ra xut hin sau choc do mang phi, t
catheter tnh mach trung tm, sinh thit kh ph quan, sinh thit xuyn thanh ngc
va chn thng ap lc do th may va hi sc.
Tran kh mang phi ap lc gy ra bi s tch luy lin tuc kh trong lng ngc
nhiu ti mc e y trung tht va can tr mau tnh mach v tim. Tran kh mang
phi ap lc gy tut ap, ri loan trao i kh truy tim mach.
Cp cu ngng th Trn kh mng phi l 1241
Tran kh mang phi ap lc co th do chn thng ap lc do th may, vt thng

ngc mt chiu vao, bt thng mang phi la tang (hiu ng bong-van).
Nghi ng tran kh mang phi ap lc khi tut huyt ap va suy h hp bnh nhn
th may hoc sau bt ky thu thut xm ln vao thanh ngc.
CHN ON
Biu hin lm sng
Bnh s
Bnh nhn thng au ngc hoc vai cung pha tn thng, khi phat cp tnh.
Tin s chn thng ngc hoc can thip y t co th gi y chn oan.
Kho th la triu chng thng gp.
Khm thc th
Mc du triu chng lm sang cua bnh nhn tran kh mang phi s lng t co
th khng ro rang, cac triu chng kinh in bao gm r rao ph nang giam, rung
thanh giam, go vang cn c chu y phat hin bn cung pha tn thng.
bnh nhn tran kh mang phi s lng nhiu hoc co bnh phi kem theo, co
th co th nhanh va suy h hp. Bn phi tn thng co th thy cng phng (do
s giam co gian cua phi) va do s giam di ng trong qua trnh h hp.
Nu tran kh mang phi rt nhiu va c bit nu la tran kh mang phi ap lc,
bnh nhn co th biu hin suy h hp nng, va m hi, tm va tut ap. Ngoai ra,
kh quan cua bnh nhn co th b y sang bn i din.
Nu tran kh mang phi do vt thng thu ngc hoc tran kh trung tht co th
thy tran kh di da.
Triu chng lm sang khng cho phep tin lng mc tran kh mang phi va
bnh nhn n nh, cac phng phap chn oan tip theo cn c thc hin
a ra chin lc iu tr. Tuy nhin, tran kh mang phi ap lc chu yu vn chn
oan da trn triu chng lm sang va nu nghi ng tran kh mang phi ap lc can
thip ngay lp tc cn thc hin trc cac thm do chn oan.
Test chn on
in tm
in tm biu hin giam bin phc b QRS cac chuyn ao trc tim va
s thay i truc cua tim. Trong trng hp nng tran kh mang phi ap lc co th
gy phn ly in c.
Chn on hnh nh
X-quang phi biu hin s tach cua la mang phi khoi thanh ngc. Nu phim
X-quang phi thng bnh thng nhng vn nghi ng co tran kh mang phi, phim
chup phi nghing va nm cn ch nh thm chn oan xac nh (Thorax
2003;58(suppl II):ii39). Kh di chuyn ti im cao nht; do o, tran kh mang

phi bnh nhn nm co th phat hin nh hnh anh ranh sn hoanh su bt
thng va qua sang vung bung trn do kh xut hin pha trc ngc. Nhng
du hiu nay c bit quan trong tai n v hi sc tch cc, ni X-quang phi
bnh nhn th may thng c thc hin t th nm nga.
Mc du chn oan tran kh mang phi ap lc la da trn lm sang, X-quang bao
gm hnh anh trung tht va kh quan b keo sang bn i din va vom hoanh cung
bn tn thng b y xung thp.
Siu m la cng cu hu ch chn oan tran kh mang phi tai ging, c bit
nhng bnh nhn nm t th nm nga hoc tnh trang khng u n nh
chup ct lp vi tnh ngc. t u do khoang lin sn cung cp hnh anh v
mang phi va nhu m phi pha di. Trong th ht vao bnh thng, mang phi
la tang va la thanh trt ln nhau va tao du hiu trt mang phi. Hnh anh kh
lp y nhu m phi di mang phi tao du hiu ui sao chi. S xut hin
cua du hiu mang phi trt va du hiu ui sao chi trn siu m trong th ht
vao cho phep loai tr tran kh mang phi tai im t u do vi tin cy cao.
Ngc lai, mt cac du hiu trn la yu t tin lng co tin cy cao cho s hin
din cua tran kh mang phi. Mt vai v tr trong lng ngc cn c anh gia,
bao gm nhng v tr ma kh thng tch tu nh lng ngc pha trc va pha bn
(Chest 2012;141:1099).
Ct lp vi tnh ngc la tiu chun vang chn oan va xac nh mc tran
kh mang phi. Mc du khng phai thng xuyn cn thit nhng ct lp vi tnh
ngc c xem la c bit hu ch cho chn oan phn bit tran kh mang phi
vi bong ken kh phi (Thorax 2003;58(suppl II):ii42).
IU TR
Phng phap iu tr phu thuc vao nguyn nhn, kch thc va mc anh hng
sinh ly.
Tran kh mang phi tin phat
Tran kh mang phi tin phat t phat s lng t khng tip tuc tng thm co
th t hi phuc. Kh c hp thu bi mang phi xp x 1,5% mi ngay. Do o,
tran kh mang phi mc t (15%) co th hi phuc sau khoang 10 ngay ma
khng cn can thip.
Khng nh tran kh mang phi khng tng thm (chup X-quang phi sau 6
gi nu khng co thay i v triu chng lm sang) va cho bnh nhn ra vin
nu bnh nhn khng con triu chng (ngoai tr vim mang phi mc nhe).
Thc hin theo doi X-quang phi xac nh ht tran kh mang phi sau 7 n
10 ngay. Khng nn cho bnh nhn i may bay trong qua trnh theo doi, v giam
kh ap se lam tran kh mang phi tng ln.
Cp cu ngng th Trn kh mng phi l 1243
Nu tran kh mang phi t nhng bnh nhn co triu chng lm sang mc

trung bnh, xa nha, hoc khng hp tac theo doi, ch nh nhp vin va th oxy
lu lng cao; chnh ap nit se lam y nhanh qua trnh hp thu kh.
Nu bnh nhn co triu chng mc trung bnh hoc tran kh mang phi
kch thc ln hn, choc hut kh la chin lc iu tr ban u phu hp. Tuy
nhin, choc hut kh co th khng thanh cng vi tran kh mang phi mc
nng. Vi nhng bnh nhn choc hut tht bai, thc hin t ng dn lu mang
phi (Thorax 2003;58(suppl II):ii39).
Gy dnh mang phi d phong tai phat c khuyn cao bi cac chuyn gia,
tuy nhin, hu ht cac trng hp, khng ch nh ln tran kh mang phi
u tin tr trng hp tran kh mang phi tn tai dai dng.
Tran kh mang phi th phat
Bnh nhn tran kh mang phi t phat th phat thng co triu chng va cn tin
hanh thu thut hut kh giai quyt tnh trang xep phi.
Ch nh t ng dn lu mang phi ln hn va hut lin tuc trong trng hp ro
ph quan mang phi.
Xin y kin chuyn gia h hp v gy dnh mang phi vi ro kh dai dng va
d phong tai phat.
Phu thut co th ch nh cho ro kh dai dng va cho nhng bnh nhn nguy
c cao d phong tai phat.
Tran kh mang phi do thy thuc
Tran kh mang phi do thy thuc thng do kh b a vao khoang mang phi
qua la thanh mang phi (v.d., choc do mang phi, t catheter tnh mach trung
tm) hoc t nhu m phi qua l thung cua mang phi la tang (v.d., sinh thit
xuyn thanh ph quan). Thng thng khng ro kh tng thm sau bin c ban
u.
Nu tran kh mang phi s lng t va t triu chng, bnh nhn c ch nh
iu tr bao tn. Nu thu thut gy tran kh mang phi oi hoi phai gy m, ch
nh nhp vin, th oxy va chup lai X-quang phi sau 6 gi am bao tnh
trang n nh cua bnh nhn. Nu bnh nhn cai thin triu chng hoan toan va
X-quang phi khng thay i, bnh nhn co th xut vin.
Nu bnh nhn co triu chng hoc tran kh mang phi qua nhiu, hut kh qua
catheter hoc van mt chiu thng la u va co th rut catheter 1 ngay sau o.
Tran kh mang phi gy ra do chn thng ap lc do th may thng ro kh dai
dng, cn c ch nh t ng dn lu va hut.
Tran kh mang phi ap lc
Khi tnh trang lm sang va kham lm sang gi y chn oan tran kh mang phi
ap lc giai ep bn phi tn thng ngay lp tc bng kim 14 gauge. Choc kim
v tr khoang lin sn hai, ng gia on, b trn xng sn di. Hut ra kh
va tnh trang lm sang cai thin giup chn oan xac nh. Cn nhn thc ro rng
nhng bnh nhn beo ph hoc bnh nhn co m ngc ln cn kim choc hut dai
hn catheter tiu chun co th thm do ti khoang mang phi. Bng kn nhng
vt thng trn thanh ngc bng bng mt chiu (ch co kh ra).
ui nc
I CNG
nh ngha
ui nc c nh ngha la qua trnh h h hp b suy giam chc nng do chm
trong nc (Final Recommendations of the World Congress on Drowning, 2002).
Yu t nguy c gm tre tui, khng bit bi, ung ru, chn thng ap lc (do
ln cung bnh nen kh), chn thng u c, va mt y thc lin quan ti ng kinh,
ai thao ng, ngt hoc ri loan nhp.
Co nhiu khac bit v sinh bnh hoc gia ui nc ngot va ui nc mn. Tuy
nhin, cac tn thng chnh (v.d., giam oxy mau va giam oxy m lin quan ti
ri loan thng kh ti mau, toan hoa va tn thng nao do giam oxy gy phu nao)
thng cung xut hin.
Ha thn nhit, vim phi, him gp hn la ng mau ni mach rai rac, suy thn
cp, huyt tan cung co th xay ra.
CHN ON
Test chn on
Xt nghim
Xet nghim in giai, cng thc mau, kh mau ng mach. Theo doi nhp tim lin
tuc. Kim tra mc cn trong mau va xet nghim cht kch thch nu tnh trang
tinh thn bt thng.
in tm
Theo doi in tm .
IU TR
Hi sc
C nh ct sng c, do co th co chn thng.
Bt u tin hanh hi sc, tp trung kim soat ng th va thng kh vi oxy
100%. Co th bnh nhn cn c ch nh t ni kh quan.
Thit lp ng truyn tnh mach va truyn NaCl 0,9% hoc dung dch Ringer lactat.
iu tr ha thn nhit tch cc (xem phn Bnh ly do lanh gy ra).
Cp cu ngng th ui nc l 1245
Thuc
Ch nh khang sinh cho nhng bnh nhn ui nc trong mi trng nc
rt bn hoc nc thai.
Phn cp iu tr
Ch nh nhp vin khoa hi sc tch cc cho nhng bnh nhn sng sot sau giai
oan ui nc. Phu phi khng do tim vn co th xay ra nhng bnh nhn co
thi gian ui nc ngn.
Ch nh nhp vin cho tt ca nhng bnh nhn co nhng du hiu hoc triu
chng phi bao gm ho, co tht ph quan, kh mau bin i hoc bao hoa
oxy (SpO2) giam, X-quang phi bt thng.
Theo doi t 68 gi nhng bnh nhn khng co triu chng h hp hoc nhng
bnh nhn b ui nc trong thi gian ngn hoc nghi ng b ui nc, ch nh
xut vin nu phim X-quang phi va kh mau cua bnh nhn bnh thng (Ann
Emerg Med 1986;15:1048). Tuy nhin, nu bnh nhn b chm trong nc lu,
sau o bt tnh, tm hoc co cn ngng th, thm ch ch cn hi sc ban u rt
t, bnh nhn vn cn c nhp vin theo doi t nht 24 gi.
BIN CHNG
Phu nao
Phu nao co th xut hin t ngt trong vong 24 gi va la nguyn nhn chnh
gy t vong. iu tr phu nao khng lam tng kha nng sng sot va theo doi ap
lc ni so khng co nhiu tac dung (Crit Care Med 1986;14:529). Tuy nhin,
nu phu nao xay ra, cn tng thng kh giam mc PCO2 xung nhng khng
di 25 mm Hg ( tranh co tht mach qua mc) va truyn manitol (1 n 2 g/
kg mi 34 gi) hoc li tiu furosemide (1 mg/kg tim tnh mach mi 46 gi).
iu tr co git tch cc bng phenytoin.
Corticoid mt cach thng quy khng c khuyn cao.
An thn giam tiu thu oxy va kim soat ap lc ni so la cn thit.
Bin chng phi
Cung cp oxy 100% ngay t u, sau o iu chnh lai da vao kt qua kh mau
ng mach.
t ng ni kh quan va th may vi ap lc dng cui th th ra (Positive
end-expiratory pressure [PEEP]) nu bnh nhn ngng th, suy h hp nng
hoc giam oxy mau khang vi cac liu phap oxy thng thng.
Ch nh thuc gian ph quan nu co co tht ph quan (Acad Emerg Med
1995;2:204; Pediatr Emerg Care 1995;11:153).
Ch nh Surfactan nhn tao cho thy khng em lai li ch.
Bin chng chuyn hoa: Kim soat toan chuyn hoa bng thng kh nhn tao,
Natri bicarbonate (nu pH <7,2 dai dng), h tr thuc nng huyt ap.
TN THNG DO NHIT
Kit sc do nng
I CNG
Kit sc do nong xay ra do s mt nc hoc mui nhng thng la phi hp ca 2
nguyn nhn. Kit sc do mt nc thng xay ra ngi gia hoc ngi lam vic
mi trng nong bc va thiu cung cp nc. Mt mui xay ra ngi c bu
nc bng lng ln dch nhc trng.
CHN ON
Bnh nhn co biu hin au u, bun nn, nn, chong mt, mt moi, kch thch
va hoc chut rut.
Bnh nhn co th ha huyt ap t th, va m hi vi thn nhit trung tm bnh
thng hoc tng nhe.
IU TR
iu tr bao gm bnh nhn ngh ngi ni thoang mat, giam nong bng quat,
cung cp y u nc va in giai.
Nu bnh nhn khng nn va huyt ap n nh, cung cp nc va in giai qua
ng ming.
Nu bnh nhn nn hoc huyt ng khng n nh, theo doi in giai va truyn
tnh mach 1 n 2 lt dung dch NaCl 0,9%.
Thay i li sng
Bnh nhn cn tranh lam vic mi trng nng nong trong 2 n 3 ngay.
Ngt do nng
I CNG
Ngt do nong la s thay i do ha huyt ap t th.
Lam vic mi trng nong gy gian mach ngoai vi, mau b tnh mach va hu
qua gy mt y thc. Bnh nhn co thn nhit bnh thng va tnh lai sau khi nm.
y la im phn bit hi chng nay vi t quy do nong.
Tn thng do nhit t qu do nng l 1247
IU TR
iu tr bao gm ngh ngi ni thoang mat va bu nc.
t qu do nng
I CNG
t quy do nong xay ra hai dang kinh in va do gng sc. Ca hai dang u biu
hin vi thn nhit cao gy tn thng m do nhit. Cac bin i th phat bao
gm suy thn do tiu c vn. Ngay ca khi c iu tr nhanh chong, ty l t vong
co th vn rt cao nhng bnh nhn co thn nhit trn 41,1C (106F). Phn
bit gia dang t quy do nong kinh in va do gng sc la khng quan trong bi
muc tiu iu tr la tng t trong ca hai trng hp va tr hoan iu tr ha nhit
lam tng ty l t vong.
Triu chng chu yu cua t quy do nong la tng thn nhit (>40C, 104F) va
thay i y thc. Mc du nhng bnh nhn t quy do nhit dang kinh in co
th co giam tit m hi nhng khng phai la tiu chun chn oan, bi 50% vn
co toat m hi.
H thng thn kinh trung ng rt d b tn thng do shock nhit va tiu nao la
c quan nhay cam nht. Mt kha nng iu hoa co th la du hiu sm. Co git la
triu chng thng gp. Mc tn thng thn kinh la phu thuc vao nhit
cua c th thi im cao nht va thi gian tip xuc vi nhit cao (N Engl J
Med 2002;346:1978).
CHN ON
Chn oan da trn tin s tip xuc hoc lam vic mi trng nong, nhit trung
tm thng t 40,6C (105F) hoc cao hn, va thay i v y thc t lu ln, m sang
n hn m.
Chn on phn bit
Tng thn nhit ac tnh sau s dung thuc an thn, gy m
Hi chng an thn kinh ac tnh lin quan ti s dung thuc chng loan thn. Cn
lu y rng hi chng an thn kinh ac tnh va tng thn nhit ac tnh u kem theo
co cng c mc nghim trong.
Ng c cac thuc khang cholinergic
Ng c cac thuc cng giao cam (bao gm cocain)
Cn bao giap
Bnh ly nhim khun huyt (sepsis)
Vim mang nao
St ret th nao
Vim nao
Ri loan chc nng vung di i do t quy va xut huyt
Ap-xe nao
Test chn on
Xt nghim
Cac xet nghim bao gm cng thc mau, thi gian Thromboplastin tng phn,
(Partial thromboplastin timePTT), thi gian prothrombin (Prothrombin time
PT), san phm thoai hoa fibrin, in giai, blood urea nitrogen (BUN), creatinin,
glucose, canxi, creatin kinase, chc nng gan, kh mau, xet nghim nc tiu va
in tm .
Nu gi y nguyn nhn nhim trung, ch nh nui cy cac dch c th.
Chn on hnh nh
Nu nguyn nhn do h thng thn kinh trung ng, chup ct lp vi tnh va tip theo
la choc dch nao tuy.
IU TR
Lam mat ngay lp tc la cn thit.
Cach tt nht lam mat con tranh cai. Khng co nghin cu so sanh trc tip
vic dung nc a vi phun mat. Tuy nhin nc a ha nhit c th nhanh gp
2 ln va la phng thc c la chon khi d oan sc nhit do gng sc xay
ra (ua ng dai, ao tao qun s) (Int J Sports Med 1998;19(suppl 2):S150);
Ann Intern Med 2000;132:678).
Qun ngi bnh trong khn c lam m lin tuc vi nc a.
Nu ap ng khng u nhanh, cho ngi bnh ngm trong nc a, chp nhn
vic nay co th lam anh hng n nhng can thip hi sc khac (Am J Emerg
Med 1996;14:355).
Hu ht cac c s cp cu khng thng xuyn iu tr cac bnh ly lin quan
n nhit nn khng c trang b y u x tr tnh trang nay. Trong trng
hp nay, phun mat ngi bnh lin tuc vi nc mat (20C n 25C [68F n
77F]). Lam mat ngi bnh bng quat in ln vi vung da bc l cang rng
cang tt.
Nn t nhng goi a nhng im truyn nhit ln nh ben, nach va ngc
lam mat nhanh hn.
Khng co ch nh dung thuc ha st.
Dantrolene sodium khng co hiu qua cho iu tr sc nhit (Crit Care Med
1991;19:176).
Bnh l do lnh gy ra Cc (Chilblain) l 1249
Theo doi nhit trung tm lin tuc bng nhit k trc trang v nhit mang tai
gia va ming co th khng chnh xac.
Ngng lam mat khi nhit trung tm at mc 39C (102,2F), ly tng la at c
trong 30 phut. Nhit co th tng tr lai trong 3 n 6 gi, nn cn lp lai iu tr.
Vi trng hp huyt ap ha dung dung dch tinh th: Nu khng hi phuc, dung
thuc vn mach va theo doi huyt ng. Tranh cac thuc kch thch -adrenergic
tinh khit v chung gy co mach va lam chm qua trnh ha nhit. Thn trong khi
truyn dch ngi bnh co huyt ap bnh thng.
BIN CHNG
iu tr tiu c vn hoc tnh trang thiu niu lng nc tiu <30 mL/gi
bng cach bu th tch thch hp, mannitol (12,5 n 25 g ng tnh mach) va
bicarbonate (44 n 100 mEq/L trong dung dch nc mui 0,45%) thuc y
bai niu thm thu va kim hoa nc tiu. Du a ap dung nhng bin phap nay,
sc nhit vn co th gy bin chng suy thn cp (Chng 13, Bnh ly thn).
Giam oxy mau va hi chng suy h hp cp tin trin (acute respiratory
distress syndromeARDS) co th xay ra. iu tr c m ta trong Chng 8,
Chm soc cp cu.
iu tr co git vi diazepam va phenytoin.
GIM ST/THEO DI
Nn t ngi bnh trong phong theo doi.
BNH L DO LNH GY RA
Tip xuc vi lanh co th gy ra mt s dang tn thng khac nhau. Yu t nguy c

la mt nhit nhanh chong lam nng thm do tip xuc vi gio manh hoc ngm di
nc. Tip xuc vi lanh keo dai co th do nghin ru, lam dung thuc, chn thng
hoc b bt ng va ri loan tm thn.
Cc (Chilblain)
I CNG
Cc la dang nhe nht trong s cac tn thng do lanh va do tip xuc cua da kh
vi mi trng lanh, gio (0,6C n 15,6C [33F n 60F]).
Tai, ngon tay, u mui thng b tn thng dang nga, o, au khi c lam m
tr lai.
IU TR
iu tr bao gm si m lai nhanh (xem phn T cong b mt), kem dng m,
giam au va hng dn ngi bnh tranh b lanh tr lai.
Tn thng ngm nc (nt chn)
I CNG
Tn thng ngm nc la do b ngm nc keo dai (trn 10 n 12 gi) nhit
<10C (<50F).
IU TR
iu tr bng cach si m sau o lau kh. iu tr nhim trung th phat bng
khang sinh.
T cng b mt
I CNG
T cong b mt gy tn thng da va m di da.
CHN ON
Nhng vung tn thng u tin co mau trng, nht va t; thi gian phan hi mao
mach chm; au khi c lam m ln. Tn thng 2 biu hin bng cac bong
nc trong hoc mau sa.
IU TR
La chon iu tr la si m nhanh. Ngm phn c th b tn thng t 15 n 30
phut; co th thm hexachlorophene hoc povidoneiodine vao nc tm. Co th cn
cho thuc giam au an thn. Thng thng, khng co tn thng su sau o va lin
seo din ra trong 3 n 4 tun.
T cng su (deep frostbite)
I CNG
T cong su lam cht da, m di da va c ( ba) hoc gn su va xng ( bn).
ai thao ng, bnh mach mau ngoai vi (Peripheral vascular diseasePVD)
hoc sng ngoai tri va vung nui cao la nhng yu t nguy c cua bnh.
Bnh l do lnh gy ra H thn nhit l 1251
CHN ON
M b lanh va cng.
Khi si m lai khng thy co mao mach n.
Xut huyt, sau o la hoai t kh. Vic lanh rt chm va ranh gii cua m vi
phn t ct cut co th xut hin.
Phn ln t cong su xay ra nhit <6,7C (44F) vi thi gian tip xuc keo
dai hn 7 n 10 gi.
IU TR
iu tr la si m nhanh nh m ta trn. Ch nn bt u si m khi khng
con nguy c b lanh cong lai.
Dung thuc giam au khi cn thit (opioid tnh mach).
Can thip phu thut sm khng c ch nh.
K phn chi b tn thng, tranh eo vt nng, tach cac ngon tay, ngon chn b
tn thng bng bng gon, tranh tnh trang bt da bng cach dung gia k chn,
va cm hut thuc.
Tim phong un van.
Cac thuc gian ng mach, heparin, dextran, c ch prostaglandin, tiu huyt
khi va ct thn kinh giao cam khng c chng minh la co hiu qua.
Vai tro cua khang sinh la khng ro. (Tintinallis Emergency Medicine Manual. 7th
ed. New York: McGraw-Hill, 2010: Chapter 202: Frostbite and Other Localized
Cold Injuries).
Ct cut ch thc hin sau khi tn thng co ng ranh gii ro.
H thn nhit
I CNG
nh ngha
Ha thn nhit la khi nhit trung tm <35C (95F).
Phn loi
Phn loai mc nng theo nhit khng ph bin. Phn loai giam thn nhit;
nhe: nhit t 34C n 35C (93,2F n 95F), trung bnh: 30C n 34C
(86F n 93,2F) va nng: <30C (86F).
Nguyn nhn
Nguyn nhn thng gp nht cua ha thn nhit My la tip xuc vi lanh do ng
c ru.
Nguyn nhn thng gp khac la ngm nc lanh.
CHN ON
Biu hin lm sng
Triu chng thay i theo nhit cua ngi bnh khi n. Tt ca cac c quan co
th b tn thng.
Anh hng h thn kinh
Khi nhit <32C (89,6F), y thc chm chap va mt cam xuc.
nhit 32,2C (90F) kha nng run b mt va phan xa gn su giam.
nhit 28C (82,4F), thng b hn m.
Di 18C (64,4F) hoat ng in nao la ng thng. Khi si m bnh nhn
giam thn nhit nng, tiu huy myelin cu nao co th din ra.
Nhng anh hng tim mach
Sau khi tng giai phong catecholamine ban u, cung lng tim va nhp tim
giam vi ap lc ng mach trung bnh c gi mc tng i. in tim thay
i, biu hin u tin la nhp chm xoang vi song T ao ngc va khoang QT
keo dai va co th biu hin rung nh khi nhit <32C (<89,6F).
Co th thy song Osborne (im J tng), c bit trong chuyn ao II va V6.
Tng nhay cam gy loan nhp tht xay ra nhit di 32C (89,6F).
nhit 30C (86F), tnh nhay cam gy rung tht tng ang k va nn tranh
ng cham khng cn thit n ngi bnh.
Co th xut hin giam huyt ap trung bnh va nhit 28C (82,4F), nhp
tim chm t ngt.
Anh hng ln h hp
Sau khi tng thng kh phut ban u, nhp th va th tch kh lu thng giam
dn khi nhit giam.
Xet nghim kh mau vi may cai t 37C (98,6F) la thng s c ban cho
iu tr ma khng cn gia tr pH va ap lc PCO2 hiu chnh (Ann Emerg Med
1989;18:72; ArchIntern Med 1998;148:1643).
Triu chng v thn: Co th gp tng bai niu do lanh va suy giam chc nng
c c cua ng thn.
Chn on phn bit

Tai bin mach mau nao
Qua liu thuc
Nhim toan ceton ai thao ng
Ha ng mau
Tng ure mau
Suy thng thn
Phu nim
Test chn on
Xt nghim
Cac xet nghim cn lm sang c ban bao gm cng thc mau, xet nghim ng
mau, chc nng gan, BUN, in giai, creatinin, glucose, CK, Ca, Mg, amylase,
phn tch nc tiu, kh mau va in tim.
Sang loc tm c cht nu tnh trang thay i y thc nng hn so vi d oan.
Kali mau thng tng.
Tng amylase huyt thanh co th phan anh vim tuy tim tang.
Tng ng mau cn c chu y nhng khng nn iu tr v ha ng mau phan
ng co th xay ra khi si m.
DIC cung co th gp.
Chn on hnh nh
Chup phim X-quang ngc, bung, ct sng c anh gia tt ca nhng ngi bnh
co nguy c chn thng hoc ui nc.
IU TR
Thuc
B sung oxy.
Dung vitamin B1 cho hu ht ngi bnh tip xuc vi lanh v nhim lanh thng
gp do ng c ru.
S dung khang sinh la vn con tranh cai; nhiu tac gia khuyn cao dung khang
sinh trong 72 gi, trong khi ch kt qua cy vi khun. Noi chung ngi bnh giam
thn nhit do tip xuc va ng c ru thng t co nhim trung nng tim n hn
ngi gia hoc ngi co mt bnh ly tim tang.
Si m: Nn si m ngi bnh vi muc tiu tng nhit t 0,5C n 2C/
gi (32,9F n 35,6F)/gi) mc du tc si m khng cho thy co lin quan
vi tin lng bnh.
Si m thu ng bn ngoai
Phng phap nay phu thuc vao kha nng run c cua ngi bnh.
Ch co hiu qua vi nhit trung tm ln hn hoc bng 32C (89,6F).
Ci bo qun ao t, p chn ln ngi va t ngi bnh trong iu kin m
va theo doi.
Si m bn ngoai chu ng
Dung chn si nhit (40C n 45C [104F n 113F]) hoc ngm trong bn
tm m co th gy tac dung nhim toan, tng kali mau va giam nhit trung
tm nghch thng v mau lanh ong tr v mach mau trung tm (J Royal
Naval Med Serv 1991;77:139), mc du nghin cu cua hai qun an Mach ung
h vic si m lai chn va tay la hiu qua va an toan (Aviat Space Environ
Med1999;70:1081).
Trong khi ch cac nghin cu su hn, si m tch cc la cach tt nht cho
ngi tre, ngi trc o khoe manh b giam thn nhit cp tnh va ri loan sinh
ly bnh ti thiu.
u tin si m trung tm tch cc cho iu tr giam thn nhit nng, mc du
co t d liu v hiu qua (Resuscitation 1998;36:101).
Th oxy m la la chon iu tr u tin cho ngi bnh co tnh trang tim mach
n nh. Cach nay co th lam tng nhit trung tm 0,5C n 1,2C/gi
(32,9F n 34,2F) (Ann Emerg Med 1980;9:456). Bnh nhn c th oxy
m qua ni kh quan se si m nhanh hn th qua mt na. Th oxy m qua may
lam m nhit bng hoc thp hn 45C (113F).
Lam m dch truyn tnh mach bng lo vi song hoc truyn qua h thng si
m mau; ch truyn dch qua tnh mach ngoai vi.
Ra da day hoc bang quang vi nc m co hiu qua han ch v din tch b
mt tip xuc t va ch dung cho ngi bnh co tnh trang tim mach khng n nh.
Ra mang bung vi dch c si m 40C n 45C (104F n 113F) hiu
qua hn kh dung hi nc m nhng ch dung cho ngi bnh co tnh trang tim
mach khng n nh. Ch nhng bac s co kinh nghim mi thc hin ra mang
bung vi nc m va kt hp vi cac bin phap si m khac.
Ra lng ngc kn vi dch si m qua ng ni soi lng ngc c khuyn cao
nhng kho kim chng hiu qua (Ann Emerg Med 1990;19:204).
Co th s dung thn nhn tao cho giam thn nhit nng, c bit khi co dung
thuc qua liu co th iu tr bng loc mau.
Tun hoan ngoai c th (khng qua tim) ch c s dung nhng ngi giam
thn nhit gy ngng tim; trong nhng trng hp nay co th co hiu qua ang
k (N Engl J Med 1997;337:1500). Tun hoan ngoai c th co th tng nhit
nhanh ti 10C n 25C/gi (50F n 77F/gi) nhng phai thc hin ICU
hoc phong m.
Hi sc
Duy tr ng th va b sung oxy.
Nu cn t ni kh quan, ngi co kinh nghim nht se thc hin (xem phn
Kim soat ng th va t ni kh quan trong Chng 8, Chm soc cp cu).
Tin hanh hi sc tim phi (Cardiopulmonary resuscitationCPR) theo quy
trnh chun. Tin hanh ng thi vi si m trung tm tht nhanh; ngay ca khi
nhit trung tm giam nghim trong, khng nn cho rng ngi bnh khng th
hi sinh. Kh rung ch co hiu qua khi nhit trung tm bng hoc cao hn 32C
(89,6F); co th cn n lc lu hn (ti nhit trung tm 35C, 95F) v tac ng

bao v thn kinh cua giam thn nhit. Khng tin hanh hi sinh tim phi nu
vn thy co nhp trn in tim v co th khng bt c mach ngoai bin do co
tht mach va thu thut nay co th kch thch rung tht.
Khng t catheter Swan-Ganz v co th kch thch rung tht.
Nu xay ra rung tht, bt u hi sinh tim phi theo hng dn hi sc tim
phi nng cao (Advanced cardiac life supportACLS) (Phu luc C). Co th dung
Amiodarone theo quy trnh mc du khng co bng chng ung h vic s dung
hoc hng dn v liu lng; mt s chuyn gia gi y giam liu tch luy ti a
con mt na. Tranh procainamid v co th thuc y rung tht va cn tng nhit
kh rung ngi bnh. Si m lai la then cht.
Theo doi nhp tim trn monitor, lng nc tiu, va nu co th theo doi ap lc tnh
mach trung tm tt ca nhng ngi bnh khng co suy tun hoan.
Phn cp iu tr
Nhp vin nhng ngi bnh co bnh ly nn, ri loan sinh ly hoc nhit trung
tm <32C (89,6F), u tin ICU.
Xut vin nhng ngi ha nhit nhe (32C n 35C [89,6F n 95F]),
khng co bnh ly nn hoc bin chng khac khi nhit a tr lai bnh thng,
cn am bao mi trng nha thch hp.
GIM ST/THEO DI
Theo doi nhit trung tm.
Nhit k chun ng ming ch o c nhit >35C (95F). Theo doi bnh
nhn lin tuc vi u do trc trang co pham vi o rng t 20C n 40C (68F
n 104F).
Ch mc (Index)
S trang co b hoc h i kem ngha la ni dung nm trong Bang hoc Hnh.
A chuyn angiotensin, 104,...

Acebutolol, tng huyt ap, 100b
A1AT, -1 antitrypsin, 379 ACE-I, angiotensin-converting enzyme
A1C, hemoglobin A1c, 48 inhibitor, thuc c ch men chuyn
AACE, american association of clinical angiotensin, 294
endocrinologists, hi ni tit hoc lm ACEIs, ACE inhibitors, thuc c ch men
sang Hoa Ky, 1066 chuyn angiotensin, 154,...
AAPCC, american association of poison Acetaminophen, 10~11, 177, 856, 906, 994,
control centers, hi cac trung tm 1057, 1058, 1164, 1213, 1259
chng c Hoa Ky, 1257 trong ng c, 1263~1268
AASLD, american association for the study trong suy gan cp, 887, 889
of liver diseases, hip hi gan mt Hoa Acetazolamide, 537, 547, 551, 593, 976b
Ky, 873 Acetylcholine trong ng c, 1308
A-AVRT, antidromic AVRT, nhp nhanh Acetylcystein trong tn thng thn, 564
vao lai nh tht ngc chiu, 288 Ach, Acetylcholine, 1258
Abacavir (ABC), 729b Ache, Acetylcholinesterase, 1258
Abatacept trong vim khp dang thp, Achr, acetylcholine receptor, thu th
1160~1161 acetylcholine sau synap, 1228
Abciximab, 168b, 193h, 774, 906 Acinetobacter, 681, 688, 693, 692, 704
ABCs, assess airway, breathing, and ACIP, advisory committee on immunization
circulation, anh gia ng th, h hp practices, uy ban c vn thc hanh tim
va tun hoan, 1265 chung, 728
ABE, acute bacterial endocarditis, vim ni ACLS, advanced cardiac life support, phac
tm mac nhim khun cp tnh, 612 hi sc tim phi nng cao, 283,...
ABG, arterial blood gas, kh mau ng ACQ, asthma control quenstionnaire, cu
mach, 40,... hoi kim soat hen ph quan, 387
ABI, ankle-to-brachial index, ch s c ACS, acute coronary syndrome, hi chng
chn-canh tay, 1102 mach vanh cp, 125,...
Abiraterone trong ung th tin lit tuyn, 1025 ACT, asthma control test, th nghim kim
ABPA, allergic bronchopulmonary soat hen ph quan, 387
aspergillosis, bnh nhim nm ACTH, adrenocorticotropic hormone,
aspergillus ph quan phi, 663 hormone kch thch thng thn, 1123
AC, activated charcoal, than hoat, 1262 ACTH trong suy thng thn, 1123
Acarbose, 1088, 1084b, 1107 Actinobacillus, 616, 619b
ACC, american college of cardiology, hip Actinomyces, 629, 660b, 687
hi trng tim mach Hoa Ky, 24,... ACV, assist-control ventilation, th may
ACD, anemia of chronic disease, thiu mau kim soath tr, 347
trong cac bnh man tnh, 954 Acyclovir, 647b, 675, 714, 736b, 750,
ACE, angiotensin-converting enzyme, men 752b, 762, 1144~1145
1373
1374 l Ch mc (Index)
trong vim nao, 610 ke cp tnh, 556

trong vim thc quan do HSV, 793 AIP, acute interstitial pneumonia, vim
ADA, Adenosine deaminase, 448 phi ke cp tnh, 427
Adalimumab, 809, 1159 AIP, autoimmune pancreatitis, vim tuy t
Adamantanes trong cum, 626 min, 819
Adefovir (ADV) trong vim gan B, 846 Ais, aromatase inhibitors, 1011
vi vim gan B man tnh trong HIV- AKA, alcoholic ketoacidosis, toan ceton do
AIDS, 753b ru, 1335
Adenoma, 1132, 1116, 1116b, 1129, 1134 AKI, acute kidney injury, tn thng thn
Adenosine trong nhp nhanh tht, 292b, 312 cp tnh, 557
Adenovirus vi nhim trung khp v AL, bnh amyloidosis, 989
khun, 1148 Albendazole, 611, 748
ADH, Alcohol dehydrogenase, 1328 Albumin, 533, 635, 832, 894, 1096
ADH, Antidiuretic hormone, hormon chng trong anh gia gan, 832
bai niu, 503 Albuterol, 376, 382b, 394, 396, 466, 483
ADPKD, autosomal dominant polycystic vi thuc co tac dung giao cam, 1320
kidney disease, bnh thn a nang gen Aldosterone, 521, 546b, 1123, 1125
tri, 578 Alemtuzumab trong ghep tang, 492,
ADR, adverse drug reaction, Phan ng co 761~762, 1041
hai cua thuc, 473 Alendronate trong bnh Paget, 1137
Adrenalin trong shock phan v, 957 ALF, acute liver failure, suy gan cp tnh,
Adriamycin, 1011, 1043 835,...
ADV, adefovir, 846 Aliskiren trong bnh thn, 575
Advair trong phi tc nghen, 376 Alitretinoin vi Kaposi sarcoma, 748
AF, atrial fibrillation, rung nh, 33,... ALK1 vi tng ap ng mach phi, 406b
AFB, acid-fast bacili, trc vi khun khang Alkyl hoa trong bnh bach cu, 1041
axit, 1367 ALL, acute lymphoblastic leukemia, bnh
AFB, acid-fast bacteria, vi khun khang bach cu cp dong lympho, 1036
axit, 630 Allopurinol, 564, 565, 593, 736b, 1153, 808
Afl, atrial flutter, cung nh, 281 trong hi chng tiu u, 1051
AFP trong anh gia gan, 833~834 trong vim gan do thuc, 856
AFP, alpha-fetoprotein, 833,... Alosetron trong ri loan tiu hoa, 813
AG, Anion gap, khoang trng anion, 543 ALP, alkaline phosphatase, nng
Aggrastat trong xut huyt tiu hoa, 774 phosphatase, 832
AHA, american heart association, hip hi Alphanate trong bnh von Willebrand, 925
tim mach Hoa Ky, 24,... ALS, amyotrophic lateral sclerosis, x cng
AHI, apnea hypopnea index, Ch s ngng ct bn teo c, 1229
thgiam th, 420 ALT, alanine transaminase, 307,...
AIDS, acquired immunodeficiency Alteplase, tiu si huyt, 197, 198b, 943
syndrome, hi chng suy giam min Aluminium hydroxide trong tiu u, 1051
dch mc phai, 723 Alvimopan trong lit rut, 816
AIH, autoimmune hepatitis, vim gan t Alzheimer (bnh), 1192~1194
min, 850 Amantadine, 626, 713, 1223
AIHA, autoimmune hemolytic anemia, Ambrisentan trong tng ap mach phi, 416b
thiu mau tan mau t min, 978 Amebiasis tiu chay bnh nhn HIV, 788
AIN, acute interstitial nephritis, vim thn AMethyldopa gy ri loan hng cu, 976b
Ch mc (Index) l 1375
Amiante vi ung th phi, 1007 ANA, antinuclear antibodies, khang th

Amidan d phong vim ni tm mac, 619b khang nhn, 107,...
Amikacin, 696 Anagrelide trong tng tiu cu, 917
Amiloride, 103b, 547, 551, 892 Anakira trong vim khp dang thp, 1160
Aminoglycoside, 564, 597, 581, 608 640, Anaphylactic trong vim ni tm mac, 618b
643b, 678, 694~696, 805, 807, 1229 Anaplasmosis trong nhim khun, 668
trong vim ni tm mach, 615 Anastrozole trong ung th vu, 1010
trong x nang phi, 467 ANC, absolute neutrophil count, lng bach
5Aminosalicylates trong vim rut, 805 cu trung tnh tuyt i, 660...
Amiodarone, 132, 318, 878, 1322, 735b, 937 ANCA, antineutrophil cytoplasmic
trong rung nh, 297b, 298b, 305b, 306~307 antibodies, khang th khang bao tng
trong tuyn giap, 1111, 1111b, 1114, 1115 bach cu a nhn trung tnh, 219...
Amip trong tiu chay, 786, 1214 Androgen, 1111b, 1132
Amitriptyline, 813, 1098, 1288, 1309 Angiomax trong huyt khi tnh mach, 942
AML, acute myelogenous leukemia, bnh Anidulafungin, 656b, 636b, 720
bach cu cp dong tuy, 982, 1034 Antazoline gy ri loan hng cu, 976b
Amlodipine, 100b, 416b, 1304 Anthracycline trong bnh bach cu, 1036
Ammoniac trong ng c, 1284 Anthraquinones trong tao bon, 789
Amoxapine trong ng c, 1288 AntiD immunoglobulin vi tiu cu, 907
Amoxicillin, 602, 619b, 666, 674, 682, 688 Anti-GAD, antibodies to glutamic acid
trong bnh Lyme, 667, 1150 decarboxylase, khang th khang
trong st giam bach cu, 1050 glutamic acid decarboxylase, 1073
trong vim khp nhim khun, 1148 Anti-Hbe, khang th khang hbeag, 842
trong vim phi, 628 Anti-HCV, khang th khang HCV, 849
vi H. Pylori trong loet da day, 801, 802 Antineoplastic gy ri loan hng cu, 976b
Amoxicillin-clavulanate, 625, 630, 688 Anti-SLA/LP, antibodies to soluble liver
trong loet, 603, 1104 antigen/liver pancreas, khang nguyn
trong vt cn, 675, 676 hoa tan c cua gan/gan tuy, 861
Ampc vi Carbapenem, 693 Antithrombin c c trong huyt khi, 944
Ampc -lactamase vi ceftaroline, 692 Antithymocyte globulin vi sinh tuy, 1033
Amphetamine, 1258, 1260, 1320~1322 AntiTNF vi lupus do thuc, 1174
vi ng kinh, 1197b Antivert trong nn, bun nn, 785
vi hi chng serotonin, 1292 Antizol vi methanol trong ng c, 1330
Amphotericin, 643b, 656b, 660b Anusol-HC trong tr ni, 823
Amphotericin B, 547, 680, 688, 717, 976b APA, antiphospholipid antibody, hi chng
trong HIV-AIDS, 744, 745, 754b, 755b khang phospholipid, 906
trong nhim nm, 657b~659b, 662, 663, 792 APAP, N-acetyl-para-aminophenol,
trong nhim trung catheter, 678 acetaminophen, 1259...
trong vim mang nao, 607, 608 APCC, activated prothrombin complex
trong vim ni tm mac, 617b~619b concentrate, phc hp prothrombin c
Ampicillin-sulbactam, 638b, 643b, 688, c hoat hoa, 922
619b, 630, 636b, 649b, 1104 Apixaban, , 938, 947, 1209
trong vt cn t ngi, 676 APP, amyloid precursor protein, t
trong vim phi, 629 bin gen quy nh protein tin cht
Amyl nitrit vi cyanua, 1337 amyloid,1192
Amyloidosis, 900, 989 Aprepitant trong bun nn, 785, 1054
APRI, aminotransferase to platelet ratio Argatroban trong giam tiu cu do heparin,

index, ch s aspartate aminotransferase 913, 941~942, 774
vi tiu cu, 835 Aromatase trong ung th vu, 1010, 1011
Apriso trong bnh vim rut, 806 Arsenic trioxide trong bnh bach cu, 1036
APRV, airway pressure release ventilation, Artesunate trong st ret, 672
thng kh xa ap lc th, 349 ARVD, arrhythmogenic right ventricular
Aptt, activated partial thromboplastin time, dysplasia, loan san tht phai gy loan
thi gian hoat hoa thromboplastin tng nhp, 336
phn, 198... AS, ankylosing spondylitis, vim ct sng
Aptt trong ri loan ng mau, 903~904 dnh khp lm sang, 1166
Ap lanh (cryoablation), 1020, 1056 AS, aortic stenosis, hep van ng mach chu,
Ap lc dng cui th th ra trong th may, 24...
350, 353 ASA, acetylsalicylic acid, aspirin, 35...
Ap lc thm thu vi natri mau, 509, 517 5ASA, 5Aminosalicylates, 805
Ap lc xuyn thanh trong huyt ng, 366~367 Asacol trong bnh vim rut, 806
Ap-xe amidal, 622, 700 ASO, antistreptolysin O, khang th lin cu
Ap-xe gan do amip, 884~886 O, 556...
Ap-xe hu vi Clindamycin, 700 Asopressin trong ho mau, 461
Ap-xe ln, 602 Aspart insulin trong ai thao ng, 1074b
Ap-xe mun nhot va nhot c, 601 Aspergilloma trong nhim nm, 659b
Ap-xe nao, 610, 702, 707, 1211, 1248 Aspergillosis trong ghep tang, 770
Ap-xe ngoai mang tuy vi tuy sng, 1218b Aspergillus, 471, 659b, 662, 718, 719, 720,
Ap-xe ni tang trong bnh cu thn, 576 1048
Ap-xe bung vi anidulafungin, 720 Aspirin, 10, 30, 35, 455, 793, 918, 985,
Ap-xe phi, 456b, 629~630, 700 1066, 1177, 1206, 1209, 1150, 1153
Ap-xe quanh trc trang, 823 trong au, 11, 1213
Ap-xe rng vi metronidazole, 707 trong bnh mach vanh, 142, 165, 167,
Ap-xe thn cp, 566 168b, 1100
Ap-xe trong ly nhim cach ly, 1363b trong hen ph quan, 389, 391b, 399, 401
Ap-xe trong soi mt, 822 trong loet da day ta trang, 799, 801
Ap-xe trong vim tuy cp, 819 trong ng c, 1260, 1274~1277
Ap-xe vung hu hong, 622, 1238 trong nhi mau c tim ST chnh ln, 188,
Aqueous penicillin G, 687 189b, 193h, 201, 206
AR, aortic regurgitation, h van ng mach trong rung nh, 295, 299b, 300b
chu, 270 trong xut huyt ng tiu hoa, 774, 781
ARB, angiotensin receptor blockers, chen A.S.P.E.N, american society for parenteral
thu th angiotensin, 109... and enteral nutrition, hip hi dinh
Arbaclofen placarbil trong trao ngc da dng ng tnh mach va ng tiu
day thc quan, 794 hoa Hoa Ky, 84
Arcapta trong phi tc nghen, 376 AST, aspartate transaminase, 307,...
ARDS, acute respiratory distress syndrome, AT, antithrombin, 928, 1202
hi chng suy h hp cp tin trin Atazanavir (ATV), 732b, 735b
nhanh, 339... Atenolol, 100b
Arenaviruses trong nhim virus, 685 trong cng giap, 1117, 1118, 1121
ARF, acute renal failure, suy thn cp, 56 ATG, antithymocyte globulin, 1033
Arformoterol trong phi tc nghen, 376 ATGAM, horse antithymocyte globulin,
khang th khang thymocyte t huyt 1331
thanh nga, 761 Axit gamma-aminobutyric vi da day, 794
ATLS, advanced trauma life support, hi Axit hyaluronic vi xng khp, 1146,
sc chn thng nng cao, 1215 1165
ATN, acute tubular necrosis, hoai t ng Axit-kim trong ha kali mau, 523
thn cp, 556 Axit mt trong anh gia gan, 833
Atorvastatin, 133b, 735b Axit mycophenolic trong ghep tang, 759
Atovaquone, 670, 672, 743, 762 Axit tranexamic trong m ay, 497
ATP III, adult Treatment Program III, 126 Axit uric, 559b, 1051, 1150
ATP, adenosine triphosphatase, 521,... Axit ursodeoxycholic trong soi mt, 822
Atracurium trong ni kh quan, 359b Axit valproic, 906, 1283~1284
Atropin, 327, 787, 1055, 1306, 1307, 1316 Axitinib trong ung th thn, 1022
vi cht i khang -Adrenergic, 1303 Azathioprine, 575, 576, 591, 758~759, 882,
vi phospho hu c, 1313~1314 910, 1172, 1178, 1232
vi thuc khang cholinergic, 1258, 1309, trong bnh vim rut, 808, 1167
1310~1311 trong vim a c va vim da c, 1184
Atrovent trong phi tc nghen, 376 trong vim gan t min, 862, 863
ATZ/r, atazanavir/ritonavir, 733 Azilsartan, tng huyt ap, 101b
Augmentin vi amoxicillin, 688 Azithromycin, 468, 623, 627, 640, 648b,
Aura, 1195, 1211 670, 673, 700, 1099
Auto-PEEP trong th may, 353 trong vim phi, 628, 629
AV, arteriovenous, ng tnh mach, 584 vi H. Pylori trong loet da day, 801
AV, atriventricular, nh tht Azole, 656b, 662, 679, 718~719
AVA, anthrax vaccine absorbed, vc-xin Aztreonam, 474, 692
phong bnh than, 1354 u trung san dy ln nao, 611
AVM, arteriovenous malformation, d dang
thng ng tnh mach, 1202 B
AVN, avascular necrosis, hoai t v mach, Babesia (nhim), 670
972 Bacillus anthracis, 681, 682
AVNRT, atrioventricular nodal reentrant Baclofen trong trao ngc, 794
tachycardia, nhp nhanh vao lai tai nut Bacteroides fragilis vi Cefuroxime, 690
nh tht, 281 Bacteroides spp., trong vt cn, 676
AVR, aortic valve replacement, van ng Bach cu ri loan, 981~983
mach chu, 258 Bach hu, 728, 1238, 1350b
AVRT, atrioventricular reentrant Bach qua trong ri loan tiu cu, 918
tachycardia, nhp nhanh vao lai nh Bai niu cng bc vi ng c, 1262, 1300
tht, 281,... BAL, bronchoalveolar lavage, ra ph quan
AWS, acute withdrawal syndrome, hi ph nang, 431,...
chng ngng thuc cp tnh, 108 Balsalazide trong bnh vim rut, 806
Axit all-trans retinoic vi bnh bach cu, 1036 Ban, 435, 476, 480, 667, 1036, 1149, 1183
Axit amin trong dinh dng, 84~85 trong Lupus ban o h thng, 1170
Axit aminocaproic trong ho mau, 461 Ban xut huyt, 906, 908~911, 565, 559b
Axit ascorbic trong lam sach rut, 790 HenochSchnlein, 572~573
Axit beo thit yu, 58, 135~136, 136, 918 sau truyn mau, 905b, 914~915, 995
Axit fibric trong triglyceride mau tng, 135 s thy vi hi chng Cryoglobulin, 1182
Axit folic, 961~962, 974, 1157, 1191~1192, Bang quang, 1022~1023, 1220
Bang im Beo ph, 389~390, 426, 570, 878, 1203

4T trong giam tiu cu heparin, 912, 912b tng huyt ap, 116~117
CHADS2, trong rung nh, 295 Beo trong hi chng Cushing, 1126
Glassgow trong chn thng u, 1215 Betalipoproteine mau trong gan, 878
lm sang vi phat hin DIC, 929b Betaxolol, tng huyt ap, 100b
MELD trong ghep gan, 900 Bethanechol trong ai thao ng, 1099
Barbiturates, 888, 962, 1197b, 1235 Bevacizumab, 998b, 1008, 1017, 1022
trong ng c, 1290, 1297, 1316~1318, Bexarotene trong suy giap, 1112
1322, 1324 Bnh ac tnh, 630, 454, 562, 928, 932, 1229
Bari sulfat trong tao bon, 788 trong tc mach phi, 936
Barrett thc quan trong trao ngc, 796 trong tng canxi mau, 528~529
Bartonella henselae, 616, 673, 675, 753b trong vim thc quan, 792, 793
Basedow, 962, 1115 vi huyt khi tnh mach ca, 883
Basiliximab trong ghep tang, 761 Bnh Addison, 489b, 962
BAV, block atrioventricular, block nh tht, Bnh Alzheimer, 1192~1194, 1222b
530 Bnh amyloidosis, 989
Bt ng d phong chng ng, 932, 944 Bnh apatit vi mang hoat dch, 1150, 1151
Bt san hng cu trong HIV-AIDS, 752b Bnh bach cu, 488b, 489b, 1041~1042
Bm tm, 901, 923, 1032 cp, 487, 1034~1036, 1036~1038
BBL, -Adrenergic blockers, thuc chen man, 978, 1038~1039, 1039~1041
giao cam, 174 Bnh Basedow, 1116b, 1118
BE, Barretts esophagus, Barrett thc quan, Bnh Behcet trong ri loan tuy sng, 1218b
796 Bnh Brucella vi vim gan dang u hat, 886
Beclomethasone vi hen ph quan, 397b Bnh cu thn, 567~569, 570, 575~576, 577
Belatacept trong ghep tang, 761 nguyn phat, 568~574
Belimumab trong Lupus ban o, 1173 th phat, 574~580
Belladonna, 787, 1309 Bnh Celiac, 823~824, 861, 864, 954
Benadryl trong nn, bun nn, 785 trong hi chng rut kch thch, 813
Benazepril, tng huyt ap, 101b Bnh coi xng vi ha phosphate mau, 537
Bendamustine trong bnh bach cu, 1041 Bnh Crohn, 804, 805
Bendroflumethiazide, tng huyt ap, 102b vi vim khp, 1167~1168
Benzathine PCN, 688 Bnh c, 1145, 1183, 1232
Benzathine penicillin G, 623, 647b, 751 Bnh c tim, 233~243, 247, 263, 264, 280,
Benzene trong ung th bang quang, 1022 294, 316, 874
Benzodiazepin, 19, 19b, 21, 384, 737, 814, trong loan nhp chm, 322
1192, 1197b, 1259, 1260, 1318~1319 trong nhp nhanh tht, 310
trong hi chng serotonin, 1234, 1294 Bnh Cushing, 1126, 1130
trong un van, 599, 1235 Bnh da vi tng bach cu ai toan, 486, 1032
trong ng c, 1272, 1276, 1278, 1281, Bnh dai, 676, 1350b, 1355b, 1356b~1360b
1283, 1287, 1290, 1292, 1297, 1298, Bnh do cao vi tng ap mach phi, 406b
1300, 1308, 1311, 1314, 1316, 1322, Bnh d ng vi tng bach cu ai toan, 488b
1324, 1326 Bnh dch hach, 683~684
vi flumazenil trong ri loan y thc, 1190 Bnh a dy thn kinh mt myelin t min
Benzthiazide, tng huyt ap, 102b cp, 1223~1227, 1225b
Benztropine, 1309, 1299 Bnh au o chi trong tng tiu cu, 916
Benzylpenicillin, trong phan ng thuc, 474 Bnh u mua, 620, 682~683
Bnh ng kinh, 1195 giam th tch, 506~507
Bnh n dy thn kinh a , 1225b tng th tch, 507~509
Bnh gan, 45~48, 831~900, 927 Bnh nhim trung mi ni, 681~686
trong thiu mau tng tao hng cu, 670 Bnh nhc c, 1227~1232
trong xut huyt ng tiu hoa, 774 Bnh nhuyn xng, 1135~1136
Bnh gan tim cung la gan sung huyt, 246 Bnh Paget, 1136~1137
Bnh Gaucherbnh tch lipid, 406b Bnh Parkinson, 1221~1223
Bnh GAVE trong x cng b toan th, 1175 Bnh phi, 38~42, 405~472, 546b, 654
Bnh gia gut, 1141b, 1150, 1151, tc nghen man tnh, 369~384, 391b, 406b
1154~1155 vi tran kh mang phi, 1240
Bnh giam thng kh ph nang, 406b Bnh r thn kinh tuy, 1225b
Bnh giang mai, 570, 646~650, 687~688 Bnh rng ming vi au u, 1212
vi vim gan dang u hat, 886 Bnh san mang, 406b, 890
Bnh glanzmann trong ri loan tiu cu, 918 Bnh sarcoid, 240, 241, 427~437, 890 cung
Bnh glaucoma trong ai thao ng, 1094 la bnh c tim han ch
Bnh Grave, 1115 cung la Basedow Bnh Schilder trong suy thng thn, 1124
vi vim gan t min, 861 Bnh st m vung nui a, 667~668
Bnh ha cam, 648b, 650 Bnh Sturge-Weber vi ng kinh, 1197b
Bnh Hashimoto, 1112, 1122 Bnh Takayasu trong vim mach, 1179
Bnh herpes sinh duc, 645~646, 647b Bnh tc ng mach tng bach cu, 487
Bnh ho ga, 627 Bnh tc mach, 488b
Bnh ht xoai, 648b, 650 Bnh tng t bao mast trong sc phan v, 482
Bnh hng cu hnh lim, 931, 962, 971~975 Bnh than, 681~682, 1354b
trong ung th thn, 1021 Bnh thm nhim bach cu lympho, 663, 664
Bnh Huntington vi Parkinson, 1222b Bnh thn, 54~55, 539, 555~592, 799, 930
Bnh Kawasaki trong vim mach, 1179 cp do phosphate, 790
Bnh ke thn, 565~566 do thuc can quang, 150
Bnh khi u lin quan HIV-AIDS, 748~749 ai thao ng, 574~575, 1096~1098
Bnh lu, 648b IgA/ ban xut huyt HenochSchnlein,
Bnh ly t thu sang ngi, 672~674 572~573
Bnh Lyme, 666~667, 1149~1150, 1225b Bnh thn kinh c, 1223~1233
vi Tetracyclin, 702 Bnh thiu G6PD, 670, 975~977
Bnh mach mau, 406b, 932, 1101~1102 Bnh thoai hoa tinh bt cung la bnh c tim
Bnh mach nao, 1194b, 1201~1210 han ch, 240
Bnh mach ngoai vi, Lupus ban o, 1171 Bnh t bao mast, 486
Bnh mach vanh, 125, 131b, 145b, 1114 Bnh to u chi, 1130, 1064
va au tht ngc n nh, 139~158 Bnh toxoplasma, 700, 702
Bnh macroglobulin huyt, 1182 Bnh trao ngc, 783
Bnh meo cao (Bartonellosis), 673 Bnh truyn nhim, 322, 595~597
Bnh m lin kt, 427, 406b Bnh tui tha vi vim khp, 1167~1168
Bnh nao, 634, 881, 1190 Bnh Tularemia, 669~670
Bnh nao gan, 889, 893, 896~898, 1019 Bnh tuy thn dang bot bin, 579
Bnh nang tuy thn trong bnh thn, 579 Bnh u hat va vim nhiu mach, 1179
Bnh nhn beo ph tng huyt ap, 116~117 Bnh a chay mau, 922
Bnh nhn (th tch) Bnh da vi tng bach cu ai toan, 488b
ng th tch, 504~506 Bnh van tim, 251~277, 619b, 930
Bnh vim rut, 804~812 nghim chuyn hoa c ban, 1204,...

Bnh vong mac DM, 1095~1096 BMPR-II, bone morphogenetic protein
Bnh von Willebrand (vWD), 774, 922~925 receptor II, thu th protein tao hnh thai
Bnh Waldenstrm, 988~989 xng II, 407
Bnh Weil vi leptospira, 673 BMS, bare metal stents, stent kim loai
Bnh Whipple trong vim ni tm mac, 616 thng, 178
Bnh Wilson, 547, 870~873, 887, 1222b B-NHL, B-cell non-Hodgkins lymphoma,
Bnh Woolsorter trong bnh than, 681 u lympho non Hodgkin t bao B, 1043
Bnh x hoa cu thn khu tru, 569~570 BNP, brain natriuretic peptide, peptide natri
Bnh x hoa phi t phat, 427~437 li niu nao, 934
Bnh xng, 580, 583 BNP, Btype natriuretic peptide, peptide li
chuyn hoa, 1135~1137 niu (chng bai niu) loai B, 218,...
trong dinh dng tnh mach, 88 B ba Samter trong phan ng thuc, 475
B ai trong khang cholinergic, 1258 Bo His trong loan nhp chm, 321
B tiu trong ai thao ng, 1099 Boc mang phi trong tran dch mang phi,
B tiu vi thuc chng trm cam, 1289 451, 453
Bicalutamide vi tin lit tuyn, 1025 Boc tach ni mac ng mach canh trong
Bicarbonate, 566, 1079, 1093, 1249, 1281 bnh mach nao, 1209
trong bnh thn, 584, 593 Bong i xung ng mach chu, 210, 228,
Bifidobacteria trong ri loan tiu hoa, 813 235, 1304, 1306
Biguanide trong ai thao ng, 1084b Bong, 599, 880, 928
Bit hoa cua khi u, 1002 Boceprevir, 851, 851h, 852~853, 853b
Bin th MillerFisher, 1224 Bordetella pertussis vi ph quan, 626
Bilirubin trong anh gia gan, 833 Borrelia burgdorferi, 666, 1149, 1043
BiPAP, bilevel positive airway pressure, Bortezomib trong a u tuy xng, 1047
th may ap lc dng hai th, 343,... Bosentan, 416b, 1177
Biphosphonate trong tng canxi mau, 1052 Botulinum, 1354b, 1233
Bisacodyl trong tao bon, 789, 790 trong kho nut nut au, 783
Bismuth subsalicylate trong tiu chay, 787 trong ri loan vn ng thc quan, 798
Bismuth vi H. pylori trong loet da day, 801 Bm cho n qua ng tiu hoa, 80, 82
Bisoprolol tng huyt ap, 100b BP, blood pressur, huyt ap, 7,...
Bisphosphonate, 531, 532, 793, 869, 1058, Bpm, beats per minute, nhp (s ln p)
1059, 1137, 1145, 1166 trn phut, 1371
Bivalirudin, 172~174, 173b, 190b, 192, Brentuximab vedotin trong u lympho, 1043
193h, 774, 942 Bromocriptine, 1085b, 1234
Blastomyces, 658b, 661, 718 Brovana trong phi tc nghen, 376
Bleomycin, 1004b, 1005b, 1026, 1043, 1056 BRTO, balloon-occluded retrograde
Block ng ra nut xoang, 325, 325h transvenous obliteration, bong chen
Block nh tht, 208, 288, 291b, 667 tnh mach ngc dong, 780
trong loan nhp chm, 325~327, 326h Brucella, 616, 674
-blockers vi bnh nhc c, 1229 Bu dch, 787, 1077~1078, 1294, 1300, 1303
BLS, basic life support, hi sc c ban, 1371 trong tng ap lc thm thu, 1092, 1093
BMs, Bone marrows, hng cu cua tuy Budesonide, 376, 396, 397b, 792, 807, 863
xng, 952 Bui Jamaica, 882
BMI, body mass index, ch s khi c th, 3... Bui phi silic vi lao phi, 630
BMP, basic metabolic panel, bilan xet Bung trng au, 883, 893, 891
Bumetanide, 102b, 892 cAMP, cyclic adenosine monophosphate,

BUN, blood urea nitrogen, nit ur mau, 47,... adenosine monophosphate vong, 1326
Bunyavirus vi virus st xut huyt, 685 Campylobacter, 753b, 786, 1168, 1224
Bun ngu ban ngay, 421, 1112 CA-MRSA, community-associated
Bun nn va nn, 784~785, 989, 1054, methicillin-resistant staphylococcus
1055, 1326 aureus, ty l tu cu khang methicillin
Bung trng ung th, 1029~1030 lin quan ti cng ng, 601
Bupropion trong ng c, 1296~1297 Can thip mach vanh qua da, 194~196, 942
Burkholderia vi carbapenem, 693 c-ANCA, cytoplasmic antineutrophil
Butalbital trong au u, 1213 cytoplasmic antibodies, 1180
Bu a nhn tuyn giap, 1122 Candesartan, tng huyt ap, 101b
c, 1115, 1116b, 1118 Candical, 655, 636b, 643b, 656b, 718,
Bu n nhn c tuyn giap, 1118 719~720, 762, 770, 792, 1048
Bu giap, 1121~1123, 1116, 1122 Cannabinoid, 1260
Canxi clorua, 534, 1306
C Canxi docusate trong tao bon, 789
C, cephalosporin, 691 Canxi hoa m mm, 536
C1 INH, C1 esterase inhibitor, 482 Canxi mau, 528~535, 1051~1052
C1 INHRP, C1-inhibitor replacement, cht Canxi niu, 530
c ch thay th C1, 496 Canxi pyrophotphat, 1150
Cabazitaxel, 1025 CaO2, arterial oxygen content, ham lng
Cabergolin, 1133 oxy ng mach, 368
CABG, coronary artery bypass graft, bc CAPD, continuous ambulatory peritoneal
cu ni ng mach vanh, 148,... dialysis, thm phn phuc mac lin tuc
Cach ly, 5~6, 1363b~1368b ngoai tru, 588
CAD, coronary artery disease, bnh ly ng Capecitabine, 1004b, 1005b, 1011, 1055
mach vanh, 23,... Capnocytophaga canimorsus vi cho cn, 675
Caffeine vi thuc tac dung giao cam, 1320 Capsaicin, 1098, 1164
Cam lua m trong tao bon, 789 Captopril, tng huyt ap, 101b
Cai ru, 821, 1191~1192 Carapenem, 638b
Cai th may, 354~356, 358b Carbamat ng c, 1258, 1315~1316
Cai thuc la, 371b, 812 Carbamazepin ng c, 1280~1281
Cai t lai trung tm iu hoa thm thu, 511 Carbamazepine, 736b, 737, 906, 976b,
Calci, 92, 869, 1114, 1145 1098, 1114
Calcineurin, 910 Carbapenem, 474, 603, 604, 630, 636b,
Calcitonin, 531, 1052, 1145 643b, 678, 681, 693, 818
Calcitriol, 528, 535, 584, 1136 Carbohydrate, 59, 789, 1106, 1232
Calcium Carbon monoxide, 1212, 338~1340
acetate, 535, 583 Carbon tetrachloride, 856
carbonate, 535, 583 Carbonyl iron, 956b
chloride, 1303 Carboplatin, 1004b, 1005b, 1030
gluconat, 527, 534, 540, 566, 1303, 1306 Cardiobacterium, 616, 619b
phosphate, 1056 Carmustine, 1056
CALLA, common actute lymphoblastic Carnitine vi acid valproic, 1284
leukemia, 1037 Carteolol, tng huyt ap, 100b
cAMP, cyclic adenosine monophosphate, 919 Carvedilol, tng huyt ap, 100b
Cascara trong tao bon, 789 Cefepime, 467, 602, 608, 629, 643b, 678,
Caspofungin, 679, 719, 744 691, 1104, 1148
Catecholamin, 1304, 1306 Cefotaxime, 608, 609, 623, 628, 629, 643b,
Catheter Swan-Ganz, 232 667, 691, 894, 1104
Ct hach thn kinh vi au do ung th, 1058 Cefotetan, 649b, 690~691
Ct lach, 780, 883, 907, 910, 960, 980, 982 Cefoxitin, 648b, 649b, 676, 690~691
Cn bng dch, 353, 503~520 Cefpodoxime proxetil, 691
Cn bng nc va in giai, 503~554 Cefprozil, 690
Cn nng ly tng, 58, 59b, 78~79 Ceftaroline, 602, 680, 692
Cn sa trong nc tiu trong ng c, 1260 Ceftazidim, 474, 589, 602, 643b, 691, 1104
Cp cu, 248, 339~368, 607, 1049~1054, trong vim mang nao, 608
1115, 1121, 1125, 1237~1256 Ceftibuten, 691
Cy co ban, 735b, 736b Ceftobiprole, 692
Cy may kh rung tim, 228, 235, 316~317 Ceftriaxone, 623, 628, 629, 636b, 638b,
CBC, complete blood cell, tng phn tch 641, 643b, 648b, 667, 691, 754b, 779,
t bao mau (cng thc mau toan phn), 894, 1104
9,... trong vim khp nhim khun, 1147, 1148
CCB, calcium channel blocker, thuc chen trong vim mang nao, 607~ 609
knh canxi, 324,... trong vim ni tm mac, 615, 617b, 619b
CCHF, Congo-Crimean hemorrhagic fever, Cefuroxime, 642b, 667, 690
685 Celecoxib, 12, 1143
CCP, cyclic citrullinated peptide, peptit Cephalexin, 602, 642b, 690, 754b
citrulline mach vong, 1142,... Cephalosporin, 467, 474, 589, 597, 603,
CCPD, called continuous cycling peritoneal 606, 610, 619b, 638b, 640, 643b, 674,
dialysis, thm phn phuc mac lun 678, 690~692, 976b, 1099, 1104
chuyn theo vong, 588 trong vim mang nao, 607, 609
CCS, Canadian cardiovascular society, hi trong vim phuc mac, 636b , 894
tim mach Canada, 144 Cephalothin trong loc mang bung, 589
CCU, coronary care unit, n v chm soc Certolizumab pegol vi vim khp, 809, 1159
mach vanh, 201,... Cetirizine trong m ay va phu mach, 496
CD, Crohns disease, bnh Crohn, 804 Ceton trong ai thao ng, 1067
CDC, centers for disease control and Cetuximab, 998b, 1013, 1017, 1055
prevention, trung tm kim soat va Cevimeline trong hi chng Sjgren, 1163
phong chng dch bnh Hoa Ky, 611,... CF, complement fixation, phan ng ngng
CDI, central diabetes insipidus, ai thao kt b th, 661
nhat trung ng, 518 CF, cystic fibrosis, x nang, 1367
CDR, clinical dementia rating scale, thang CFTR, xystic fibrosis transmembrane
im lm sang suy giam tr nh, 1193 conductance regulator gene, gen iu
CEA, carotid endarterectomy, ni mac ng hoa dn cht xuyn mang x hoa nang,
mach canh, 1205 462
Cefaclor, 690 CGD, chronic granulomatous disease, bnh
Cefadroxil, 690 u hat man tnh, 498
Cefazolin, 589, 605, 615, 618b, 619b, 643b, CGM, continuous glucose monitoring, theo
678, 690 doi ng mau lin tuc, 1067
Cefdinir, 691 Chan n, 1061, 1326
Cefditoren pivoxil, 691 Chay mau, 451, 599, 902, 920, 923, 929,
936, 991, 1027, 1028, 1032, 1056 Chen giao cam, 100b, 151, 153b, 174,
da day, 781, 1142 175b, 192~193, 201, 220, 222b, 234,
do thuc, 689, 946~948 295, 301, 312, 318, 327, 547, 918
ng tiu hoa, 634, 773, 800, 923, 954, 1017 tng huyt ap, 105~106
nao, 1202, 1210, 1211 Chen H2 trong sc phan v, 480
nim mac, 901, 906, 923, 968 Chen knh canxi, 100~101b, 107~108, 238,
trong bnh bach cu, 1036, 1037, 1041 255, 416b, 788, 918, 1097, 1177
Chay thn ngt quang trong vim thn, 565 loan nhp, 301, 312, 319, 327
Chm dn truyn trong tht, 208 vi au tht ngc, 151, 153, 154b, 174,
Chm lam trng da day, 826~827 176b
Chn thng, 353, 816, 883, 928, 944, Chen thn kinh c trong un van, 599
1218b, 1125, 1126, 1240 Chen thu th
u, 608, 1186b, 1187, 1197b, 1214~1217 angiotensin I, tng huyt ap, 109
Cht can quang, 479, 482, 581 -adrenergic trong suy tim, 224
Cht chu vn -adrenergic trong sc, 483 Ch n, 81b, 515, 581, 898
Cht dinh dng vi lng, 59 Ch tao nhp, may tao nhp, 329~331
Cht c dang ht vi ri loan y thc, 1186b Ch phm st, 956, 956b, 957b
Cht i khang -Adrenergic ng c, Cht nao trong ri loan y thc, 1191
1301~1304 CHF, congestive heart failure, suy tim sung
Cht ng vn trong ng c, 1258, 1320 huyt, 7,...
Cht gn phong xa trong au ung th, 1058 Chi di trong huyt khi, 932~933
Cht hoat hoa plasminogen, 943 Ch ng c, 961
Cht khoang chnh, 59, 60~73b Ch du vim gan virus B, 844b
Cht nhum vi suy thn cp, 559b Ch s BODE trong phi, 384, 384b
Cht tng t nucleoside, 843 Ch s c chn-canh tay trong bnh mach
Cht c ch mau ngoai bin 1101
C1 esterase trong m ay phu mach, 494 Ch s Duke trong bnh mach vanh, 148b
chon loc COX2 thoai hoa khp, 1164 Ch s hiu chnh trng thanh vi hng
cholinesterase trong ng c, 1311 cu li, 953b
h thng renin-angiotensin, 108~109 Ch s khi c th, 58b, 75, 76, 78~79, 141
interleukin trong vim khp, 1160 Chnh hnh ph quan bng nhit, 400
min dch, 908, 1182 Chlamydia, 626, 640, 641, 648b, 650, 652,
mc phai cac yu t ng mau, 928~929 699, 700, 702, 703, 704, 788, 1043,
neuraminidase trong cum, 625 1148, 1168
phosphodiesterase5, 414 Chlamydophila, trong vim phi, 627
thay th C1, 496~497 Chlorambucil trong bnh cu thn, 568,
thrombin, 938 569, 571, 1041
yu t VIII hoc IX, 921~922, 929 Chloramphenicol, 608, 668, 684, 703~704,
-lactam, 638, 638b 961, 976b
Chy rn trong ly nhim cach ly, 1364b Chlordiazepoxide, 1190, 1192
CHD, coronary heart disease, bnh mach Chloroquine trong st ret, 672
vanh, 97,... Chlorothiazide, 102b, 906
Chen chon loc giao cam, 106~107 Chlorpromazine ng c, 1174, 1297, 1309
Chen ep tuy, 1052~1053, 1217 Chlorpropamide ri loan hng cu, 976b
Chen , 238, 239, 243, 255, 384, 389, 884, Chlorthalidone, tng huyt ap, 102b
1097 Cho cn, 675
Choc do, 891 trong HIV-AIDS, 743, 753b, 753b, 754b

tuy sng, 646, 1189, 1219 Cisplatin, 1004b, 1005b, 1008, 1009, 1023,
trong mang phi, 449~450, 629, 1240 1026, 1013
Choc dch nao tuy trong au u, 1213 Citalopram trong ng c, 1291
Choc hut Citrate, 533, 584, 586, 593
dch khp, 1146, 1148, 1149, 1155 CK, creatine kinase, 564,..
iu tr c trng, 891~892, 894 CKD, chronic kidney disease, bnh thn
kh trong tran kh mang phi, 1243, 1244 man tnh, 556
Chol, cholesterol, 122 CK-MB, creatine kinase - myocardial band,
Cholecalciferol trong bnh thn, 583 men tim, 158
Cholesterol, 132~135, 833 CK-MB, 161~162, 162b, 182
Cholestyramine, 133, 787, 869~670, 1114 Cladribine, 1041, 1042
Chong mt, 951, 952, 1105, 1338 Clarithromycin, 132, 700, 735b, 737, 743
Chng dnh mang phi, 450 trong vim ph quan phi, 627, 628
Chng ng, 172~174, 173b, 191, 295, vi H. Pylori, 801, 802
300b, 882, 913~914, 918, 943~944 Clavulanic acid vi bach cu, 1050
quanh phu thut, 31~35 Clindamycin, 600b, 601, 602, 603, 604, 605,
thuc, 884, 936~944 619b, 629, 636b, 638b, 640, 649b, 660b,
trong may tao nhp, 329 666, 670, 675, 682, 700, 743, 1104
Chng huyt khi, 31~35, 277 trong vim hong, 623
Chng loan nhp, thuc, 303~305b trong vim xoang, 625
Chng nn trong ri loan tiu hoa, 813 CLL, chronic lymphocytic leukemia, bnh
Chng tng nhu ng vi bnh ac tnh, 1056 bach cu lympho man tnh, 978
Chuyn nhp trong rung nh, 301~302, CLO, campylobacter-like organism, vi sinh
308~309 vt ging campylobacter, 800
Chc nng thng kh, o trong phi, 373 Clomipramine ng c, 1288
Chng ong canxi trong x cng b, 1174 Clonidine, 103b, 1308, 1306~1308
CI, cardiac index, ch s tim, 247 Clopidogrel, 35, 171~172, 774, 1101, 1209
Ciclesonide vi hen ph quan, 397b khang tiu cu, 167, 169, 168b
Cidofovir, 716, 736, 736b, 741, 750, 768, 793 trong nhi mau c tim, 188, 189b, 193h, 201
Cilostazol trong bnh mach mau, 1101~1102 Clorgiline trong ng c, 1285
Cimetidine, 795b, 801, 906 Clostridium, 684, 707, 1233
CIN, contrast-induced nephropathy, thuc Clostridium difficile, 597~598, 697b, 707,
can quang, 150 786, 788, 1168, 1363b
Cinacalcet trong bnh thn man tnh, 584 Clostridium tetani trong un van, 598, 1234
CINV, chemotherapy-induced nausea and Clotrimazole, 744, 762
vomiting, t l bun nn va nn do hoa Cloxacillin, 689
tr, 1054 Clozapine, 1222, 1309
Ciproflacin trong gan mt, 638b Clozapine ng c, 1299~1300
Ciprofloxacin, 579, 602, 603, 608, 619b, CMAP, compound muscle action potential,
629, 640, 641, 642b, 648b, 670, 675, bin in th hoat ng cua c, 1230
680, 682, 684, 698, 779, 787, 1104 CML, chronic myelogenous leukemia, bnh
trong ap-xe quanh trc trang, 823 bach cu dong hat man tnh, 917
trong bnh vim rut, 807 CML, chronic myeloid leukemia, bnh bach
trong vim tui tha, 638, 826 cu dong tuy man tnh, 982,...
trong vim tuyn tin lit cp, 644 CMML, chronic myelomonocytic leukemia,
bnh bach cu dong hat n man tnh, COPD vi tran kh mang phi, 1240
1032 Coronavirus, 626, 686
CMV, cytomegalovirus, 724,... Corticoid, 663, 799, 805, 1054, 1231
CMV, 762, 768, 805, 905b, 991~992, 1048 trong suy h hp cp nng (SARS), 686
CNNA, culture-negative neutrophilic Corticosteroid, 41, 51~54, 497, 498, 792,
ascites, c trng kt qua m tnh, 635 807, 810, 824, 860, 886, 1052, 1057,
CNS, central nervous system, h thng thn 1058, 1154~1155
kinh trung ng, 15,... dang ht, 375, 396, 397b, 402
CO, carbon monoxide, 1338 ng toan thn, 496, 378~379, 381,
CO, cardiac output, cung lng tim, 247,... 398~399
Co Jimson vi khang cholinergic, 1309 Corticotropin (ACTH) vi tuyn yn, 1129
Co cng, 598, 1235, 1293, 1295 Cortisol, 1123, 522, 1126~1127
Co ng t vi opiate, 1258, 1272 Cortisone trong bnh xng khp, 1144
Co git, 598, 611, 693, 973, 1092, 1186b, Cortrosyn trong suy thng thn, 1124
1195, 1196, 1247, 1258 Corynebacterium diphtheria vi xoang, 624
trong ng c, 1274, 1281, 1286, 1289, Coumadin trong t quy, 1209
1291, 1296, 1302, 1312, 1320, 1323, COX, cyclooxygenase, 11
1325, 1329, 1332, 1336, 1338 COX-1, cyclooxygenase-1, 919
Co tht COX-2, cyclooxygenase-2, 12,...
mang ngoai tim, 246~247 Coxiella burnetii vi vim ni tm mac, 616
ph quan, 1258, 1315 C trng, 881, 890, 891~892, 893, 1019
tm v, 783, 792, 797, 798, 799 trong ung th bung trng, 1029
Cocain, 205, 455, 1197b, 1247, 1258, 1260, trong x gan, 889
1292, 1320, 1323~1325 C t cung ung th, 749, 1026~1028
Coccidioides immitis, 658b, 662, 755b Cn thuc phin trong tiu chay, 787
Coccidioidomycosis, 718 Cng thc Cockcrofl-Gault vi thn, 555
Coccidiomycosis, 488b Cng thc Harris-Benedict, 57, 78
Codeine, 14, 1058 Cng thc MDRD vi thn, 555~556
Colazal trong bnh vim rut, 806 Ct sng, 605, 608, 1166~1167
Colchicin ng c, 1152~1153, 1155, 1268~1369 Cn au hng cu hnh lim cp, 972, 973
Colchicin trong tiu chay, 786 Cn ng kinh, 5, 611, 1195
Colesevelam hydrochloride, 133, 1085b, Cn bao giap vi t quy do nong, 1247
1089~1090 Cn bt san trong bnh hng cu, 973
Colestipol, 133, 670 Cn Porphyria cp vi y thc, 1186b
Colistin, 681, 704 Cn tan mau t bao hnh lim, 880
Colistinethate sodium, 704 Cn tetany vi ha magie mau, 541
Combivent trong phi tc nghen, 376 Cn tng huyt ap, 95~96, 114~115 CP,
Compazine trong nn, bun nn, 784 chest pain, au ngc, 324
COMT, catecholOmethyl transferase, 1223 CPAP, continuous positive airway pressure,
Conivaptan trong ha natri mau, 515 th may ap lc dng lin tuc, 42
Coombs m tnh trong bnh Wilson, 871 CPE, cardiogenic pulmonary edema, phu
COP, cryptogenic organizing pneumonia, phi do tim, 230
vim ph quan tc nghen t chc hoa, CPEO, chronic progressive external
427,... ophthalmoplegia, lit vn nhan ngoai
COPD, chronic obstructive pulmonary disease, tin trin man tnh, 1230
bnh phi tc nghen man tnh, 14,... CPK, creatine phosphokinase, 599,...
CPM, central pontine myelinolysis, trung Cung nh, 208, 284, 286, 289
tm cu nao, 513 Cuc sn lao tim n, 633
CPN, central parenteral nutrition, nui Cum, 389, 470, 625~626, 627, 661, 673,
dng qua h tnh mach trung tm, 84 762, 908, 1363b
CPPD, calcium pyrophosphate dehydrate, trong suy h hp cp nng (SARS), 686
1142 trong HIV, 727~728
CPR, cardiopulmonary resuscitation, hi C ng mt, ri loan y thc, 1188~1189
sc tim phi, 1254,... Cng b ngon tay trong x cng b, 1174
CPVT, catecholaminergic polymorphic VT, Cng khp, 1139, 1155
VT a dang lin quan h giao cam, 311 Cc (Chilblain), 1249~1250
Cr, creatinin, 555,... Cng , 376, 381, 394, 396, 402
CrCl, creatinine clearance, thanh thai Cng -adrenergic, 375, 396, 398, 466
creatinine, 305 Cng aldosterone trong ha kali mau, 522
Creatinin, 555, 694 Cng cn giap, 528, 529, 531~532, 583,
Creon trong vim tuy man, 820 965, 1096
CRI, chronic renal insufficiency, suy thn Cng cholinergic trong ng c, 1258
man tnh, 54 Cng giao cam, 99, 226~227, 1257~1258,
Crizotinib, 999, 1009 1285, 128
Crm (Cr3+) dinh dng, 60b Cng giap, 1115~1121, 1116b, 1122,
CRP, C-reactive protein, 1142 1186b, 1197b
CRRT, continuous renal replacement Cng lach trong x gan, 889
therapy, liu phap thay th thn lin Cng muscarinic trong ng c, 1258
tuc, 586 Cng ph v, 291b
CRT, cardiac resynchronization therapy, tai CVA, cerebrovascular accident, tai bin
ng b c tim mach mau nao, 23,...
Cryoglobulin, 841, 849, 572 CVCs, central venous catheters, catheter
Cryptococcus, 655, 657b, 718, 720, 721, tnh mach di on, 677
739, 770 CVD, cardiovascular disease, bnh tim
Cryptosporidium, 747, 788 mach, 139
CS, corticosteroid, 395 CVD, cerebrovascular disease, bnh mach
CSA, central sleep apnea, ngng th khi mau nao, 324
ngu do thn kinh trung ng, 420 CVID, common variable
CsA, cyclosporine, 758 immunodeficiency, suy giam min dch
CSF, cerebral spinal fluid, cerebrospinal chung khng hng nh, 498
fluid, dch nao tuy, 607,... CVP, central venous pressure, ap lc tnh
CSFTPC, Surfactant protein, protein C b mach trung ng, 364
mt phi, 428 CVS, cyclic vomiting syndrom, hi chng
CSS, churgStrauss syndrome, hi chng nn chu ky, 814
Churg-Strauss, 486 CVVDHF, continuous veno-venous
CT, computed tomography, chup ct lp vi hemodiafiltration, loc mau lin tuc, 586
tnh, 7,... Cx, culture, nui cy, 660
CTA, computerized tomographic angiography, CXR, chest X-ray, Chup X-quang, 449
chup mach ct lp vi tnh, 261 Cyanoacrylate (keo) trong xut huyt, 780
CTD, connective tissue disease, bnh m Cyanocobalamin trong thiu mau, 963
lin kt, 1140 Cyanua ng c, 1336~1338
Cung lng tim theo doi huyt ng, 367 Cyclobenzaprine vi khang cholinergic, 1309
Cyclopentolate vi khang cholinergic, 1309 Du hiu ha canxi mau, Chvostek,
Cyclophosphamide, 910, 929, 1004b, Trousseau, tetany, 533
1005b, 1011, 1041, 1045, 1046, 1172, Du hiu Kussmal, 202, 246
1176, 1178, 1232 Du trong tao bon, 789
trong bnh thn, 568, 569, 571, 570, 575 DBP, diastolic blood pressure, huyt ap tm
trong hi chng phi-thn, 573, 574 trng, 24,...
Cycloserine, 961, 976b DBS, deep brain stimulation, kch thch nao
Cyclospora trong HIV-AIDS, 747 su, 1223
Cyclosporine, 132, 497, 525, 547, 565, 569, DCCV, DC cardioversion, sc in chuyn
570, 591, 760, 810, 863, 910, 969 nhp, 308
trong bnh nhc c, 1232 DCIS, ductal carcinoma in situ, ung th
trong hi chng ri loan sinh tuy, 1033 biu m ng tuyn vu tai ch, 1009
Cyproheptadine, 1234, 1287, 1294 DCM, dilated cardiomyopathy, bnh c tim
Cytarabine, 1004b, 1036 gian, 223,...
Cytokine, 533 DCP, des-gamma-carboxyprothrombin, 898
Cytomegalovirus, 715~716, 740~741, 788, DDAVP, diamino-8-D-arginine vasopressin,
835, 968, 1123, 1224 desmopressin acetate, 919,...
DDAVP, 517, 920, 925
D DDD, disease makes a dual chamber
Da, 771 874, 952, 1101, 1134, 1146, 1174, device, may tao nhp hai bung, 331
1175, 1250, 1258 D-dimer, 904, 933
nhim khun, 692, 690, 698, 700, 701, DEA, drug enforcement administration, c
703, 709, 710 quan phong chng ma tuy Hoa Ky, 21
tn thng, 654, 655, 755b, 804, 1250 Deferasirox, 875, 960
Da day, 74~75, 781, 962, 1015~1016 Deferoxamine, 875, 960
Dabigatran, 774, 938, 947~948, 1209 Defibrotide trong hi chng tc nghen
Dacarbazine, 1004b, 1043 xoang gan, 883
Daclizumab trong ghep tang, 761 Delta genus trong vim gan D, 853
Dalfopristin, 615, 618b Demeclocycline trong ha natri mau, 515
Dalteparin, 940b, 1060 Dengue virus, 609, 685
Danazol, 908 DES, drug eluting stents, stent boc thuc, 178
Dantrolene, 1234, 1248 Desipramine, 1288, 1309
Dapsone, 660b, 743, 762, 976b Desloratadine, trong m ay va phu mach,
Daptomycin, 602, 605, 678, 680, 705 496
trong vim ni tm mac, 616, 618b, 619b Desmopressin acetate, 519, 520, 567, 919
Darbepoetin, 582, 964, 965b, 1055 Detemir insulin vi ai thao ng, 1074b
Darunavir (DRV) ), 732b DEXA, dual energy x-ray absorptiometry,
Dasatinib, 998b, 1039 hp thu nng lng i quang tuyn, 869
DASH, dietary approaches to stop Dexamethasone, 632, 1052, 1053, 1054,
hypertension, ch n ngn chn tng 1061, 1125, 1126, 1144, 1191, 1220
huyt ap, 143 trong vim mang nao, 608
DAT, direct antiglobulin test, xet nghim Dexferrum trong thiu mau, 956, 957b
trc tip phat hin khang th, 1351 Dexlansoprazole c ch axit, 795b
Day tht trai, tng huyt ap, 117 Dexmedetomidine, 360b
Dn lu, 251, 822, 886, 1059, 1191, 1243 Dextran st trong bnh thn man tnh, 582
Du n sinh hoc cua tim, 162b Dextromethorphan vim ph quan, 627
Dextrose, 85, 589, 1107, 1125, 1190, 1276, ng tiu hoa, 77~84, 1071
1302, 1335 tnh mach, 84~90, 878, 1071
DF, discriminant function, cng thc anh nhu cu, 57~75
gia chc nng, 859 DIP, desquamative interstitial pneumonia,
DGI, disseminated gonococcal infection, vim phi ke bong biu m, 427,...
nhim trung lu cu lan toa, 652 Dipentum trong bnh vim rut, 806
DHE, dihydroergotamine, 1213 Diphenhydramine, 496, 670, 785, 994,
DHP, dihydropyridin, 104 1299, 1309
D nguyn vi hen ph quan, 391b trong sc phan v, 480, 483, 957
D tt xng trong Thalassemia, 959 Diphenoxylate trong tiu chay, 787, 1055
D thc trong thiu mau hng cu nho, 954 Diphenylhydantoin vi axit folic, 962
D ng, 473~502, 624, 792, 1212 DJD, degenerative joint disease, thoai hoa
trong truyn mau, 994 khp, 1164
vi thuc, 692, 693, 689, 912 DIPSS Plus, DIPSS cng thm, 987
D vt trong tc nghen ng th trn, 1237 DIPSS, Dynamic IPSS, IPSS Nng ng, 987
Diazepam, 1249, 1276 Dipyridamole trong t quy, 1209
Diazoxide, 111b, 113 Disaccharides khng hp thu, 897
DIC, disseminated intravascular coagulation, Disopyramide trong rung nh, 303b
ng mau ni mach rai rac, 904,... DKA, diabetic ketoacidosis, nhim toan
DIC, 327, 905b, 908, 915, 932 ceton ai thao ng, 1068,...
Dch ng trng, 507, 520 DLCO, diffusing capacity for carbon
Dch c trng nhim khun, 893 monoxide, kha nng khuch tan carbon
Dch hach, 1354b, 1368b monoxide, 373,...
Dch khp trong bnh xng khp, 1139 DM, dermatomyositis, vim da c, 1183
Dch nao tuy, 551, 552, 607, 611, 1205, 1226 DM, diabetes mellitus, ai thao ng, 498,...
Dch truyn m trong ha thn nhit, 1254 DMARDs, disease-modifying antirheumatic
Diclofenac, 856, 906, 976b drugs, thuc chng thp khp lam thay
Dicloxacillin, 602, 689, 1104 i din bin bnh, 1146
Dicyclomin trong ri loan tiu hoa, 813 DMARD trong vim khp dang thp,
Didanosine, 729b, 736b 1156~1158, 1161
Dientamoeba fragilis, 488b DN, diabetic nephropathy, bnh thn do ai
Diethylstilbestrol, 976b thao ng, 574
Digitalis, 225, 786 DNase, trong x nang phi, 466
Digoxin, 132, 225, 239, 243, 287, 301, 312, DNS, delayed neurologic sequelae, di
327, 418, 541 chng thn kinh mun, 1338
trong rung nh, 297b, 295, 301 Dobutamine, 418, 1320, 210, 361, 363
Dihydroergotamine trong au u, 1213 trong suy tim, 227, 227b
Dihydropyridin, 1177, 1304 Docetaxel, 1004b, 1005b, 1025, 1011
Dilaudid trong vim tuy cp, 818 DOE, dyspnea on exertion, kho th khi
DILI, drug-induced liver injury, tn thng gng sc, 324
gan do thuc, 855 Dofetilide trong rung nh, 302, 304b, 306
Diltiazem, tng huyt ap, 100b, 101b, 238, Dolasetron trong bun nn, 1054
239, 416b, 1174, 1304 Domperidone, 785, 827
trong rung nh, 296b, 301 Donepezil trong bnh Alzheimer, 1194
Dimenhydrinate trong nn, bun nn, 785 Dopamin, 17, 1111b, 1133~1134, 1223, 1300
Dinh dng, 57~94, 75~76, 1067~1968 trong sc, 210, 361, 363, 364
trong suy tim, 227, 227b Dung dch
Doripenem, 603, 693, 638b, 636b dinh dng tnh mach, 84~85
Dornase-, trong x nang phi, 466 glucose 5% trong tng natri mau, 519
DOT, directly observed therapy, liu phap HCl ng trng kim chuyn hoa, 551
kim soat trc tip, 631 huyt thanh mn trong tng magie, 540
Doxazosin, tng huyt ap, 103b mui, 467, 520, 551, 1125, 1262, 1296
Doxepin, 497, 670, 813, 976b, 1288 nhc trng trong chn thng u, 1216
Doxercalciferol trong bnh thn, 584 tinh th trong t quy do nong, 1249
Doxorubicin, 976b, 1004b, 1005b, 1020, DuoNeb trong phi tc nghen, 376
1023, 1045, 1046 Duy tr hiu qua loc mau thp trong thn
Doxycycline, 602, 605, 625, 640, 641, 647b, nhn tao, 586
648b, 649b, 666, 667, 668, 670, 672, D phong ly nhim, 2~6, 762, 1341, 1361~1362
674, 682, 684, 703, 751, 753b, 793, 1150 DVT, deep vein thrombosis, huyt khi tnh
trong nhim nm, 660b, 666 mach su, 33
trong vim ni tm mac, 618b Dx, diagnosis, chn oan, 523
trong vim phi cng ng, 628 Dz, disease, dch bnh, 660
vi H. pylori, 801
Doxylamine vi khang cholinergic, 1309
DPenicillamine trong soi thn, 593 a hng cu, 984, 985, 985b
DPI, Dry powder inhaler, ng ht bt kh, 396 a niu, 529, 562
Dramamine trong nn, bun nn, 785 a u tuy xng, 547, 988, 988b,
DRE, digital rectal exam, thm trc trang, 1046~1047, 1051, 1058
1024 ai dch cum gia cm va cum ln, 686
DRESS, drug reaction with eosinophilia ai huyt sc t kch phat ban m, 881,
and systemic symptoms, phan ng 931, 955
thuc vi bach cu ai toan va gy triu ai mau, 973
chng toan thn, 476 trong bnh thn, 567, 579, 581, 592
DRI, direct renin inhibitor, thuc c ch trong ung th, 1021, 1023, 1024
trc tip renin, 110 ai mu, 639, 644
Dronabinol trong chan n va suy kit trong ai thao ng, 117, 421, 469, 536, 546b,
ung th, 1061 547, 574~575, 606, 788, 792, 826, 849,
Dronedarone trong rung nh, 306 874, 879, 917, 1018, 1063~1108, 1145
Droperidol vi amphetamine trong ng c, quanh phu thut, 48~51, 1071~1072
1322 ri loan cng dng, 1102~1103
DRV/r, daranavir/ritonavir, 733 type 1, 1063~1064, 1072~1075
DS, double strength, manh gp i, 602,... type 2, 878, 1064, 1081~1091, 1203
DtaP, diphtheria and tetanus toxoids and vi lao phi, 630
acellular pertussis, c t un van va vi suy giam min dch, 498
ho ga khng co mang t bao, 1343 ai thao nhat, 516, 517, 520
DTI, direct thrombin inhibitor, cht c ch ai trang, 775, 780, 781, 1016~1018
thrombin trc tip, 913 ap ng vn ng trong y thc, 1189
DTP, diphtheria and tetanus toxoids and au bung, 597, 636, 638, 639, 653, 818,
pertussis, vc-xin c t bach hu, c 820, 828, 883, 1067, 1076, 1329, 1332
t un van va ho ga, 1343 trong ung th, 1016, 1017, 1018, 1019,
Duke, ch s, 148b, 613b, 614b 1029, 1056
Duloxetine, 813, 1165 au cach hi trong bnh mach mau, 1101
au, chm soc bnh nhn, 10~16 kh rung tim t ng bn ngoai, 1371
au chi d di trong tng tiu cu, 916 im Glasgow vim gan do ru, 859, 859b
au cng dng vt trong bnh hng cu im lm sang phat hin DIC, 929b
hnh lim, 971, 972, 974 im MELD trong ghep gan, 900
au dy thn kinh sinh ba vi au u, 1211 im tin lng quc t (IPSS) trong hi
au do thn kinh, 16, 1057 chng ri loan sinh tuy, 1033, 1033b
au do ung th, 1057~1058 im tnh trang hoat ng cua bnh nhn
au a c do thp, 1181~1184 ung th (ECOG), 1002, 1002b
au a khp trong nhim trung lu cu, 652 im v tiu chun bnh gan giai oan
au u, 1105, 1203, 1054, 1187, cui, 900
1211~1214, 1246, 1336, 1338 in c trong bnh nhc c, 1230~1131
trong thiu mau, 952 in tm
au ha sn phai, 821, 881 loan nhp chm, 323
au hong, 724, 1120 nhp nhanh, 282, 286, 287, 288, 313, 315
au h chu trai trong vim tui tha, 825 trong van tim, 254, 260, 267, 273
au h tht lng trong bnh thn, 581 trong nhi mau c tim, 160~161,
au keo dai, trong au, 13 182~186, 183b
au khi ngh trong bnh mach mau, 1101 ging nhi mau c tim, 186
au khu tru, gy t tai ch, 16 ic trong bnh Paget, 1137
au khp, 1139, 1149, 1170, 1182 iu tr ch trong ung th, 997~999, 998b
trong nt n c phi, 438 o a ky gic ngu trong ngng th khi ngu,
trong vim ni tm mac, 612, 613 423
au lng, 641, 1027, 1052, 1217 c cht trong nc tiu, 1260
au man sn, 592, 1021, 579 oi, ri loan kim toan, 546b
au ngc, 6~7, 144, 146b, 179, 206, 791, ng kinh, 1192, 1195~1201, 1326, 1051
797, 971~974, 1007, 1036, 1241, 1321, ngt, 335
1323, 1324, 1338 ng vt hoang da cn, 675
kho th trong thiu mau tan mau, 979 i khang dopamine trong bun nn, 785
kho th trong tc mach phi, 932 i khang thu th -opioid vi lit rut, 816
au qun mt, 635, 821 i khang thu th leukotrien, 399, 497
au tht ngc, 143, 144, 144b, 175~176b, 280 i khang thu th serotonin vi nn, 785
n nh, 139~158, 152h ng mau, 460, 568, 901~904, 925~929
khng n nh, 158~178 trong suy gan cp, 887
au thng v, 800, 817 ni mach rai rac (DIC), 685, 774, 928,
au trong hi chng GuillainBarre, 1225 981, 991, 1286
au b phn sinh duc va hu mn, 645 quanh phu thut, 31~35
au vung tht lng, 592, 1166 ng (Cu2+), dinh dng, 60b, 961
au xoang, 624 ng vn (thuc), 226~227, 227b
au xng, 1047, 1136, 1137 ng vn GLP trong ai thao ng, 1086b
t canuyn sun nhn giap ng th, 347 t bng song cao tn, 796, 899, 1020
t ni kh quan vi gy dn ng t in, 309, 460
Eishman, 1239~1240 t quy, 964, 971, 982, 1197b, 1201, 1202,
t sonde dn lu mang phi, 453 1210b, 1247~1249
u mua, 1354b, 1364b, 1368b do tim, 1099, 1201~1202
y hi trong chm lam trng da day, 826 nao, 1201~1210, 1207b, 1208b
AED, automated external defibrillator, may t t, 310, 316, 1051
n v ru, 858 soi thc quan da day ta trang, 775
uc thuy tinh th vi ai thao ng, 1094 EGFR, epidermal growth factor receptor,
ung dp nao trong chn thng u, 1214 thu th yu t tng trng biu b, 997
ui nc, 1244~1246 EGFR vi vim phi do bnh ac tnh, 1056
ng h hp nhim khun, 688, 690, 709 EGFR-TKIs, epidermal growth factor
ng huyt, 51, 82~83, 86~87, 590, 1066, receptor tyrosine kinase inhibitors, cht
1067, 1069, 1210, 1259, 1304 c ch thu th tyrosine kinase yu t
trong ai thao ng, 1065, 1066, 1095 tng trng biu b, 1008
ng niu nhim khun, 688, 690, 691, Ehrlichia, 668~669, 702, 905b
698, 707, 708, 762 EIA, enzyme immunoassay, min dch
ng thng ca-chu, 892, 896 enzym, 628,...
ng tiu hoa, 773~781, 1014~1020, Eikenella corrodens, 616, 619b, 676
1142, 1175, 1176 ELISA, enzyme-linked immunosorbent
assay, phan ng min dch gn enzym,
E 726,...
EASD, european association for the study ELISA trong giam tiu cu do heparin, 913
of diabetes, hi nghin cu ai thao Eltrombopag trong xut huyt giam tiu
ng u chu, 1066 cu, 908
EAT, ectopic atrial tachycardia, nhp nhanh EM, erythema multiforme, hng ban a
nh do ngoai vi, 286 dang, 476
Ebola, 685, 835, 1367b, 1368b EMB, ethambutol, 631
EBUS, endobronchial ultrasound, ni soi EMG, electromyography, in c, 1226
siu m, 443 Emtricitabine (FTC), 730b
EBV, Epstein-Barr virus, virus Epstein- ENA, extractable nuclear antigen, khang
Barr, 724,... nguyn nhn, 410
EBV, 770, 978 Enalapril, tng huyt ap, 101b
E. coli, 638b, 645, 705, 786, 905b Enalaprilat, tng huyt ap, 112b, 113, 224
ECF, extracellular fluid, dch ngoai bao, 503 Encainide vi thuc khang retrovirus, 737
ECG, electrocardiogram, in tm , 7,... Encephalitozoon intestinalis trong HIV-
Echinocandin, 656b, 679, 719~720 AIDS, 748
ECMO, extracorporeal membrane Enfuvirtide (T20), 733, 734b
oxygenation, trao i oxy qua mang Enoxaparin, 940b, 945
ngoai c th, tim phi nhn tao, 184,... Enoxaparin trong nhi mau c tim, 172,
ECOG, the eastern cooperative oncology 173b, 189b, 191, 192, 193h
group, nhom hp tac v ung th phng Entamoeba histolytica, 707, 786
ng, 1002 Entecavir (ETV) trong vim gan B, 845
Eculizumab, 572, 762, 911 Enterobacter, 705, 638b
Eczema trong vim thc quan, 792 Enterobacteriaceae, 688, 689
EDTA, ethylenediaminetetraacetic Enterococci, 689, 693, 696, 697, 704~706, 709
acid, cht chng ng axit Enterococcus, 615, 617b, 638b, 688, 692,
ethylenediaminetetraacetic, 903 696, 704, 705, 706, 708, 709
EEG, electroencephalogram, in nao , 17,... Enterocytozoon bieneusi trong AIDS, 748
EF, ejection fraction, phn sut tng mau, Enterovirus, 607, 609, 620, 1148
148,... Enzyme
Efavirenz (EFV), 731b, 736b huyt thanh trong anh gia gan, 832
EGD, esophagogastroduodenoscopy, ni tuyn tuy trong vim tuy man, 820
EoE, eosinophilic esophagitis, vim thc 795b

quan do bach cu a axit, 792 ESR, erythrocyte sedimentation rate, xet
EP, electrophysiology, thm do in sinh nghim nh mau lng, 1204
ly, 248 ESRD, end stage renal disease, bnh thn
Ephedrine, 1321 giai oan cui, 54,...
Epinephrin, 396, 460, 495, 496, 1304, 1306, Estrogen, 532, 878, 919, 932, 1025, 1111b,
1320 1114, 1132
trong sc, 361, 479, 483 Eszopiclone trong mt ngu, lo u, 21
Epirubicin hoa tr liu, 1004b, 1005b ET, essential thrombocytosis, tiu cu
Eplerenone, 103b, 225, 892 nguyn phat, 916,...
EPO, erythropoietin, 964 Etanercept, 630, 1159
Epoetin, 582 964, 965b Ethacrynic acid trong tng huyt ap, 102b
Epoprostenol trong tng ap mach phi, 417b Ethambutol, 631, 712, 743, 754b
Eprosartan, tng huyt ap, 101b Ethanol, 918, 961, 976b, 1232, 1260, 1330,
EPS, electrophysiology study, thm do in 1334~1336
sinh ly, 283 Ethylene glycol, 546b
EpsteinBarr, 748, 905b, 968, 1043, 1224 trong ng c, 1332~1334
Eptifibatide, 168b, 774, 906 Etidronate vi bnh nhuyn xng, 1136
ER, estrogen receptor, thu th estrogen, 1009 Etomidate, 360b, 1124
ER, extended release, giai phong m rng, 305 Etoposide, 1004b, 1005b, 1009, 1026
ERCP, endoscopic retrograde Etravirine, 731b
cholangiopancreatography, ni soi mt ETV, entecavir, 845
tuy ngc dong, 637,... Euflexxa trong thoai hoa khp, 1165
Ergocalciferol, 583, 1136 EUS, endoscopic ultrasound, siu m ni
Ergotamine trong au u, 1213 soi, 820,...
Erlotinib, 998b, 999, 1008, 1019, 1055 Everolimus, 759~760, 998b, 1022
ERS, erythrocyte sedimentation rate, tc Exemestane trong ung th vu, 1010
mau lng cao, 1181 Exenatide vi ai thao ng, 1086b, 1090
Ertapenem, 603, 636b, 638b, 693 Ezetimibe, 134~135, 584, 879
Erythromycin, 132, 648b, 699~700, 737,
753b, 775, 816, 827 F
trong bnh hng cu hnh lim, 975 FAB, the French-American-British, hi hp
trong do ai thao ng, 1098 tac PhapMyAnh, 1031
Erythropoietin, 919, 1033, 1060 Famciclovir, 647b, 715, 750, 752b, 793
trong thiu mau, 964, 965, 965b, 966, 967, Famotidine c ch axit, 795b
1055 fAPV/r, fasamprenavir, 733
ESA, erythropoiesis-stimulating agent, tac FDA, food and drug administration, c
nhn kch thch tao hng cu, 582,... quan quan ly thc phm va dc phm
ESBL, extended-spectrum -lactamase, Hoa Ky, 12,...
-lactamase ph rng, 692 FDGPET, Fluorodeoxyglucose positron
Escherichia coli, 638b, 690, 909 emission tomography, chup ct lp phat
Escitalopram trong ng c, 1291 xa positron fluorodeoxyglucose, 442,...
ESLD, end-stage liver disease, bnh gan Febuxostat trong gut, 1153
giai oan cui, 831 FENa, fractional excretion of sodium, phn
Esmolol, 112b, 113, 296b, 1327 sut bai tit Na, 560
Esomeprazole c ch axit trong trao ngc, Fenofibrate, 135, 1095
Fenoldopam, tng huyt ap, 111b, 113 Fluorouracil (5-FU), 1017, 1019
Fentanyl, 14, 359b, 737, 1058 Fluoxetine, 813, 1291
Ferric gluconate trong thiu mau, 957, 957b Fluphenazine trong ng c, 1297
Ferritin trong thiu mau, 955 Flutamide trong tin lit tuyn, 1025
Ferrlecit trong thiu mau, 957, 957b Fluticasone, 735b, 376, 396, 397b, 792
Ferrous trong thiu mau, 956b Fluvastatin, ri loan lipid, 133b
Ferumoxytol trong thiu mau, 957b Fluvoxamine ng c, 1291
-Fetoprotein trong anh gia gan, 833~834 FN, febrile neutropenia, st giam bach cu,
FEV1, forced ejection fraction volume in 1 1049
second, th tch th ra gng sc trong FNA, fine needle aspiration, choc hut bng
giy u tin, 758 kim nho, 1000
FEV1/FVC, forced expiratory volume in Folate trong giam tiu cu, 905b
the first second/forced vital capacity, Folfiri, 1017
ty l th tch th ra gng sc trong giy Folfox, 1017
u tin/dung tch sng th manh, 373 Fomepizole liu phap, ng c, 1330, 1334
Fexofenadine, trong m ay va phu mach, 496 Fomivirsen tim ni nhan, 741
FFP, fresh frozen plasma, huyt tng ti Fondaparinux, 172, 173b, 190b, 191, 192,
ng lanh, 910,... 913, 945, 940b, 941
FFR, fractional flow reserve, lu lng Foradil trong phi tc nghen, 376
mach vanh, 150 Formoterol, 376, 396, 397b, 466
Fibrate, ri loan lipid, 132 Fosamprenavir (fAPV), 732b
Fibrinogen trong ri loan ng mau, 904 Foscarnet, 533, 716, 741, 750, 793, 768
Fidaxomicin, 598, 787 Fosfomycin, 642b, 705~706
Filgrastim vi clozapine trong ng c, 1300 Fosinopril, tng huyt ap, 101b
Filoviruses trong st xut huyt, 685 Fosphenytoin, 1200, 1277~1279
FIO2 trong th may, 349 FQ, fluoroquinolone, 643
FISH, fluorescent in situ hybridization, ky Francisella tularensis, 669, 704
thut phat huynh quang tai ch, 867,... FSGS, focal segmental glomerulosclerosis,
Flavivirus, 848, 685 bnh x hoa cu thn khu tru tng , 569
Flecainide, 302, 304b, 735b, 737 FSH, follicle-stimulating hormone, 1129
Fleet, 790 FT4, free T4, T4 t do, 1111
Flouroquinolone 5-FU, fluorouracil, 1017
Fluconazole, 643b, 649b, 656b~659b, 679, 5-FU, 1004b, 1005b, 1055
718, 744, 745, 755b, 762, 792 Fulvestrant trong ung th vu, 1010
Flucytosine, 657b, 720 Furazolidine vi H. pylori, 801, 802
5-Flucytosine vi nhim nm, 745 Furosemide, 103b, 232, 563, 892, 1111b
Fludarabine, 1004b, 1041 Fusarium vi Voriconazole, 719
Fludrocortisone, 549, 1098, 1125, 1126 Fusobacterium, 629, 676
Flumazenil, 21, 1190, 1319 FVC, forced vital capacity, dung tch sng
Flunisolide vi hen ph quan, 397b gng sc, 765
Fluoride vi bnh nhuyn xng, 1136
Fluoroquinolone, 533, 590, 597, 604, 606, G
629, 638b, 643b, 644, 648b, 652, G6PD, glucose-6-phosphate dehydrogenase,
697~699, 754b, 779, 787, 818, 1050 727,...
vim phi cng ng, 628, 629 GABA, -Aminobutyric acid, 1258
trong vim xoang, 625 Gabapentin, 1058, 1098, 1165
GABHS, group A -hemolytic Glasgow, 1187

streptococcus, lin cu khun tan huyt G-CSF, granulocyte colony-stimulating
nhom A, 599 factor, yu t kch thch bit hoa bach
GABHS, 600b, 602 cu, 1048,...
Gadolinium trong bnh thn, 557 GCT, germ cell tumors, khi u t bao mm,
GAHS, glasgow alcoholic hepatitis Score, 1003
im Glasgow vim gan do ru, 859 GEB, gum elastic bougie, gy dn ng
Galantamine trong bnh Alzheimer, 1194 Eishman, 1239
Gallium nitrate trong tng canxi mau, 531 Gefitinib trong bnh ac tnh, 998b, 999
Gan, 87~88, 246, 307, 701, 765, 766, Gemcitabine, 1004b, 1005b, 1019, 1023
831~835, 857, 858, 878, 882~883, Gemfibrozil, 132, 135
884~886, 886, 887 Gemifloxacin, 698
huyt khi tnh mach, 881~884 Gentamicin, 467, 643b, 649b, 670, 674,
khng do ru, 877~879 678, 684, 695
sinh thit, 843, 850, 862, 864, 866 875, trong vim ni tm mac, 615~616, 617b~619b
876, 878, 879, 883, 886, 899 GERD, gastroesophageal reflux disease,
to, 881, 882, 884, 885, 898, 988, 1036, trao ngc da day thc quan, 146,...
1038, 1041 GFR, glomerular filtration rate, mc loc cu
trong ng c, 1264, 1265, 1268, 1284 thn, 169,...
ung th biu m t bao, 1019~1020 GGT, -glutamyl transpeptidase, 832
Gan GH, growth hormone, 1135
huyt tng, 989 Ghep gan, 846, 857, 860, 865, 867, 872,
bach cu trong tng giam bach cu, 983 873, 876, 877, 879, 882, 889, 896, 900
tiu cu trong tng tiu cu, 917 trong nhim sc t st di truyn, 875, 876
Ganciclovir, 715, 736, 736b, 741, 762, 793 trong ung th gan, 899, 1020
Gardasil trong ung th c t cung, 1027 Ghep phi, 380, 418~419, 434, 434b, 470
GAVE, gastric antrum vascular ectasia, Ghep tang, 757~772, 792, 908, 1049
gian mach vung hang v da day, 890 bin chng, 768~772
Gay cng vi vim mang nao, 1212 Ghep t bao gc, 908, 960, 969, 986, 1026,
Gay xng, 529, 1136 1033, 1036, 1038, 1039, 1045
Gng tay trong ly nhim, 1361 Ghep thn, 537, 590~591, 896, 1173
Gng sc, anh gia kha nng, 26 Ghep tim, 229
Gy dnh mang phi, 453, 1059, 1243 phi, 418~419
Gy d ng min dch hen ph quan, 401 GI, gastrointestinal, ng tiu hoa, 7,...
Gy m vi tng thn nhit ac tnh, 1234 Gia ephedrine vi amphetamine, 1321
Gy nn trong ng c, 1261~1262 Gia ha
Gy t, 16 canxi mau, 532
vi tng thn nhit ac tnh, 1234 kali mau, 521
Gy tc mach trong ho mau, 461 natri mau, 509
Gy dn ng Eishman trong h tr ng Gia ho mau, trong ho mau, 456
th, 1239~1240 Gia hi chng cum trong dch hach, 683
GBM, glomerular basement membrane, Gia phnh tht trong nhi mau c tim, 211
mang ay cu thn, 556 Gia tc ai trang, 814
GBS, GuillainBarre syndrome, hi chng Gia tc rut, 814~816, 826
GuillainBarre, 1223,... Gia tng kali mau, 525, 526
GCS, Glasgow coma scale, thang im Giai c c hiu trong ng c, 1262
Giai mn cam trong phan ng thuc, 477 Globulin min dch, 620, 838~839, 1184, 1233
Giai phu da trn in tm , 183b Glolimumab, vim khp dang thp, 1159
Giai phu h thng dn truyn, 320~321 GLP, glucagon-like peptid, 1086
Giam bach cu, 668, 982 Glucagon, 483, 783, 1107, 1303
Giam canxi mau vi chm lam trng da Glucocorticoid, 241, 468, 491, 531, 532,
day, 826 565, 574, 624, 625, 632, 758, 803, 969,
Giam cn, 800, 820, 824, 879 980, 1052, 1095, 1111b, 1118, 1126,
Giam mt xng va loang xng trong 1152, 1155, 1167, 1172, 1176, 1178
HIV-AIDS, 738 tim ni khp, 1146, 1164, 1168, 1169
Giam nhu ng rut, 1258 trong au a c, 1181
Giam nhu ng thc quan, 797 trong bnh vim rut, 807
Giam t bao mau do bnh ac tnh, 1055~1056 trong bnh xng khp, 1143~1145, 1146
Giam th tch, 530, 546b, 547, 550 trong giam tiu cu, 907, 910
Giam thng kh, 341 trong sc phan v, 483
Giam tiu cu, 327, 905, 914~915, trong suy thng thn, 1124, 1125, 1126
915~916, 930, 968, 1041, 1056 trong vim ct sng, 1166~1167
do heparin, 905b, 911~913, 932, 936 trong vim khp, 1161~1162, 1169
huyt khi, 905b, 908~911 Gluconate st trong bnh thn, 582
min dch, 905b, 906~908 Glucose, 85, 90, 505b, 566, 738, 1106,
Giam ti mau, 341, 982, 1202 1107, 1065, 1134
Gian ng t, 1258, 1281, 1286, 1288, Glulisine insulin vi ai thao ng, 1074b
1289, 1320, 1323 Gluten, vim nim mac rut non, 823
Gian mach, 109, 220~227, 234, 274, 414 Glyburide vi ai thao ng, 1082, 1083b
Gian mao mach, 456b, 1174 Glycopyrrolate vi khang cholinergic, 1309
Gian ph nang vi thiu 1-Antitrypsin, 876 GN, postinfectious glomerulonephropathy,
Gian ph quan, 391b, 456b, 462, 464 bnh thn sau nhim khun, 576
thuc dang ht, 374~375, 466 Gold salts gy ri loan hng cu, 976b
Gian tnh mach, 780, 819, 889, 890 GoLytely trong lam sach rut, 790
Giang mai, 646~650, 688, 788, 1218b Gonadotropin, 1129~1130
thn kinh, 646, 648b, 687~688, 751, 1193, Goserelin trong ung th vu, 1010, 1025
1194b GP, glycoprotein, 173
trong HIV-AIDS, 750~754 GPA, granulomatosis with polyangiitis,
Giardia, 707, 786 bnh u hat vi vim nhiu mach, 573
Git c trong cng cholinergic, 1258, GPC3, glypican-3, 898
1293, 1295, 1299 GPIIb/IIIa, glycoprotein IIb/IIIa inhibitor,
GISTs, gastrointestinal stromal tumors, thuc c ch thu th glycoprotein IIb/
khi u m m ng tiu hoa, 997 IIIa, 167
Giun, 488b, 489b GRACE, global registry of acute coronary
Glargine insulin vi ai thao ng, 1074b events, bin c mach vanh cp tnh, 163
Glaucoma vi au u, 1212 Granisetron trong bun nn, 785, 1054
Gleevec trong tng bach cu ai toan, 491 GRS, global risk score, im nguy c toan
Glibenclamide vi ai thao ng, 1082, 1083b b, 141
Gliclazide, ai thao ng type 2, 1082 GU, genitourinary, tit niu, 643
Glimepiride, 1082, 1083b Guanabenz, tng huyt ap, 103b
Glipizide, 1082, 1083b Guanadrel, tng huyt ap, 107
Globulin, 969, 1181 Guanethidine, tng huyt ap, 107
Guanfacine, tng huyt ap, 103b truyn, 494

Guanosine trong vim gan virus B, 845 Haemophilus, 616, 619b, 623, 650, 699,
Gut, 1141b, 1150, 1151, 1152~1154, 1268 700, 709, 754b
Gng trong ri loan cht lng tiu cu, 918 Haloperidol, 17, 1297, 1322
GVHD, graft-versus-host disease, bnh Halothane vi tng thn nhit ac tnh, 1234
manh ghep chng vt chu, 1048 Hanh kinh sm trong ung th, 1028, 1029
Hanh ty trong ri loan tiu cu, 918
H Hantaviruses trong st xut huyt, 685
H&N, head and neck, vung u va c, 1012 Harris-Benedict, trong dinh dng, 57, 78
H, hepatic, gan, 305 Hat bng Colace trong tao bon, 790
H. influenza, 624, 973 Hat Osler, vim ni tm mac, 612, 613
H2RA, histamine-2 receptor antagonist, Hat sulfur, nhim nm Actinomyces, 665
thuc i khang thu th histamine2, 779 Hat thp di da trong vim khp, 1155
H2RA, 801, 802 HAV, hepatitis A virus, virus vim gan A, 835
Ha ng huyt, 1105~1108, 1069, 1186b, Hu hong, 718, 1012
1302, 1335 Hb A1c trong ai thao ng, 1065, 1067
vi ng kinh, 1197b HB, heart block, block tim, 305
vi ha thn nhit, 1252 Hb, hemoglobin, 951,...
Ha cam, 650 Hb F, fetal Hb, Hb bao thai, 972
Ha canxi mau, 532~535, 536, 552, 992, 1197b Hb SC, heterozygous conditions, th d hp
Ha huyt ap, 111~112b, 113~114, 352~353, khac, 971
506, 588, 1098, 1246 Hb SS, homozygous sickle cell anemia, thiu
ngt, 333, 335, 337 mau hng cu hnh lim th ng hp, 971
trong ng c, 1299, 1300, 1301, 1302, HbcAg, hepatitis B core antigen, khang
1305, 1289 nguyn loi vim gan B, 842
Ha kali mau, 521~524, 546b, 550, 552, 826 Hb-CO, nh lng carboxyhemoglobin, 1339
Ha magie mau, 534, 540~542, 1197b HbeAg, hepatitis B e antigen, virus vim
Ha natri mau, 509~516, 1186b, 1197b, 1226 gan B dng tnh, 841
Ha oxy mau vi ri loan y thc, 1186b HBIG (HBIg), hepatitis B immunoglobulin,
Ha phosphate mau, 537~539, 552 globulin min dch vim gan B, 847
Ha thn nhit, 888, 992, 1251~1255, 1317, HbMCH, mean cellular, lng huyt sc t
1335 trung bnh hng cu, 952
trong ui nc, 1244 HBO, hyperbaric oxygen, oxy cao ap, 1339
HAART, highly active antiretroviral therapy, HbsAg, hepatitis B surface antigen, khang
thuc khang retrovirus hoat lc cao, 724 nguyn b mt vim gan B, 842,...
HACA, human antichimeric antibodie, HBV, hepatitis B virus, virus vim gan B, 835
khang th khang kham ngi, 1161 HC, homocysteine, 963
HACEK, haemophilus-actinobacillus- HCC, Hepatocellular carcinoma, ung th
cardiobacterium-eikenella-kingella, 613 biu m t bao gan, 833,...
HACEK trong vim ni tm mac, 616, 619b HCDD, heavy chaindeposition disease,
Hach c, 438, 622, 630, 1030, 1042 bnh lng ong chui nng, 577
Hach giao cam vi hi chng Raynaud, 1177 -hCG, human chorionic gonadoropin, 1026
Hach nach trong ung th, 1030 HCM, hypertrophic cardiomyopathy, bnh
Hach to bung trong bnh bach cu, 1036, c tim ph ai, 146,...
1038, 1040 Hct, hematocrit, 951,...
HAE, hereditary angioedema, phu mach di HCT, hematopoietic stem cell transplantation,
ghep t bao gc tao mau ng loai, 986 H thng im tin lng quc t (IPSS)
HCV, hepatitis C virus, virus vim gan C, trong hi chng ri loan sinh tuy, 1033,
835,... 1033b
HDCV, human diploid cell vaccine, vc-xin H thng P450 vi thuc, 735b, 736b, 737
t bao lng bi ngi, 1357 HF, heart failure, suy tim, 23,...
HDL, high-density lipoprotein, lipoprotein HFA, hydrofluoroalkane, 396
ty trong cao, 107,... HFE, homozygous for hemochromatosis,
HDL thp, 122b, 130~131, 136 nhim sc t st, 873
HDV, hepatitis D virus, virus vim gan D, HfpEF, heart failure with preserved ejection
835 fraction, suy tim vi phn sut tng
Helicobacter pylori, 700, 702, 799, 800, mau c bao tn, 235
801, 905b, 906, 954, 1016, 1043, 1142 HGA, human granulocytic anaplasmosis,
phac , 802 giam bach cu a nhn, 668
Heliox, 349, 400 HH, hereditary hemochromatosis, nhim
Hemophilia A, 919~921 sc t st di truyn, 873
Hemophilia B, 921~922 HHT, hereditary hemorrhagic
Hen ph quan, 384~404, 395h, 475, 488b, telangiectasia, gian mao mach xut
489b, 573, 791, 792, 1142, 1325 huyt di truyn, 438
Hep ng mach canh vi t quy, 1203, HHV-6, human herpesvirus 6, virus herpes
Hep mn v cp tnh, 784 6 ngi, 905
Hep tm v trong ung th thc quan, 1014 HHV-6 trong giam tiu cu, 905b
Hep van ng mach chu, 257~263 HIC, hepatic iron concentration, tp
nng vi suy tim mt bu, 261~262 trung st gan, 874
Hep van hai la, 251~257 HIDA, hydroxy iminodiacetic acid,
Hep van hai la trong ho mau, 454 hydroxy axit iminodiacetic, 820
Hepadnavirus trong vim gan virus B, 840 Hin tng Gallavardin trong hep van ng
Heparin, 55, 243, 525, 568, 586, 590, 774, mach chu, 260
1111b, 1206, 1220 Hin tng Raynaud vi gan x, 864
khng phn oan, 34, 189b, 191, 193h, Hiu ng muscarinic vi phospho, 1312
938~939, 939b Hiu ng nicotinic vi phospho, 1312
trong lng phn t thp, 34, 939~941, Hnh anh rui bay, ai thao ng, 1094
940b, 945, 948, 1209, 1060 HIPA, Heparin-induced platelet activation,
trong ng mau, 172, 173b, 928 hoat hoa tiu cu do heparin, 913
trong giam tiu cu, 911~913 Histoplasma capsulatum, 657b, 661, 745~746
Hepeviridae trong vim gan E, 854 Histoplasmosis, 718, 1123
Herceptin trong ung th, 1011, 1016 HIT, heparin induced thrombocytopenia,
Heroin opioid trong ng c, 1273 giam tiu cu do heparin, 172,...
Herpes, 607, 645, 788, 1042, 1048 HITT, heparin induced thrombocytopenia
Herpes sinh duc, 645~646, 675, 714, 749~750 and thrombosis, giam tiu cu do
Herpes zoster, 715 heparin va huyt khi, 911
HES, hypereosinophilic syndrome, hi HIV, human immunodeficiency virus, virus
chng tng bach cu ai toan t phat, 486 gy suy giam min dch ngi, 723
Hetastarch 5% trong xut huyt ng tiu HIV, 406b, 485, 486, 488b, 489b, 498,
hoa, 778 570, 622, 630, 646, 788, 905b, 906,
HEV, hepatitis E virus, virus vim gan E, 835 908, 967~968, 982, 1043, 1027, 1218b,
Hexachlorophene trong t cong, 1250 1225b, 1232, 1352b
khang thuc, 737, 739 1371h, 1372h

type 1, 723~739 Hi chng an thn kinh ac tnh, 18, 1223,
type 2, 724 1233, 1247, 1299
HIVAN, HIV-associated nephropathy, bnh vi hi chng serotonin, 1234, 1293
thn lin quan HIV, 578 Hi chng antiphospholipid antibody i, 930
HL, Hodgkins lymphoma, u lympho Hi chng Bartter_Gitelman, 522, 541
Hodgkin, 1042 Hi chng Bernard-Soulier, 918
HLA, human leukocyte antigen, khang Hi chng bnh nao h sau co hi phuc, 1211
nguyn bach cu ngi, 757,... Hi chng bong da do tu cu, 1365b
HME, human monocytic ehrlichiosis, bach Hi chng Brown-Sequard, 1219
cu n nhn, 668 Hi chng Brugada, 313, 314h, 315h, 316
HMG-CoA, hydroxymethylglutaryl- Hi chng Budd-Chiari, 881~882, 890, 1019
coenzyme A, cht c ch Hi chng cai caffeine vi au u, 1212
hydroxymethylglutaryl-coenzym A, 125 Hi chng cai ru, 1191~1192
HMWK, high-molecular-weight kininogne, Hi chng cn ung th, 1007, 1218b
kininogen trong lng phn t cao, 904 Hi chng chen ep tuy sng, 1217
HNPCC, hereditary nonpolyposis colorectal Hi chng chn b kch thch vn ng, 954
cancer, ung th ai trc trang khng Hi chng Churg-Strauss, 391b, 486, 488b,
polyp di truyn, 1016 489b, 573, 1180
Ho, 626, 791 Hi chng chuyn hoa, 128~129, 129b, 878
Ho ga, 627, 728, 1364b Hi chng CREST, 864, 1174
Ho ra mau, 438, 454~462, 470, 630, 932 Hi chng Cryoglobulin, 1181~1182
Hoa tr liu, 498, 785, 882, 1003, 1004b, Hi chng Cushing, 1064, 1126~1127, 1145
1005b, 1010, 1225b Hi chng Digeorge, ha canxi mau, 532
Hoa xa tr trong bnh ung th, 1003 Hi chng Down vi bnh bach cu, 1034
Hoai th, 600, 819, 971, 972, 974, 1101 Hi chng Dressler, nhi mau c tim, 206
sinh hi, 604 Hi chng au c tng bach cu, 488b, 489b
chi, hi chng Cryoglobulin, 1182 Hi chng eo gng tm vi phenytoin, 1278
da, 476, 948 Hi chng o bng trong sc phan v, 482
Fournier, 604, 693 Hi chng o da trong sc phan v, 482
ng thn, 563, 559b, 1332 Hi chng o ngi vi vancomycin, 697
tn thng rut do thiu mau, 828, 829 Hi chng ui nga, 1219
Hoai t xng trong HIV-AIDS, 738 Hi chng ng hm c tay, 1162
HOCM, hypertrophic obstructive Hi chng Fanconi vi phosphate mau, 537
cardiomyopathy, bnh c tim ph ai Hi chng Felty, 905b, 1163
tc nghen, 280 Hi chng Fitz-Hugh-Curtis, 634, 636b, 653
Homatropine vi khang cholinergic, 1309 Hi chng gan phi trong ghep gan, 900
Homocystinuria vi huyt khi, 931 Hi chng gan thn, 561, 889, 894~896
Hormon chng bai niu, cn bng dch, 503 Hi chng Gardner trong sarcoma, 1013
Hormon liu phap vi tin lit tuyn, 1025 Hi chng giam T3/T4, 1110~1111
Hormon tuyn cn giap, 528, 530, 533, 535, Hi chng Goodpasture nang vi hi chng
537 phi-thn, 573
Hormon tng trng, 1128~1129, 1130, 1134 Hi chng GuillainBarre, 1223~1227
H tr ng th cp cu, 1239~1240 bin chng, 1227
H tr tm tht trong suy tim, 228~229 Hi chng HELLP, 908, 915
Hi sc tim phi nng cao, 1369, 1370h, Hi chng hoang hn, 16
Hi chng Horner trong t quy, 1204 1292~1294, 1295, 1322
Hi chng Job vi min dch, 499~500 Hi chng Sheehan, 1129
Hi chng khang cholinergic, 1258, 1309 Hi chng Shulman vi tng bach cu, 486
Hi chng khang enzyme tng hp, 1232 Hi chng Shwachman-Diamond, 464
Hi chng khang phospholipid, 906 Hi chng Sjgren, 547, 1163, 1218b
Hi chng khoang bung, 562 Hi chng SLUDGE, 1312, 1315
Hi chng khoang vi phenytoin, 1278 Hi chng sc c t, 599~601
Hi chng khp thai dng ham, 1212 tu cu, 599~600
Hi chng Klinefelter vi tinh hoan, 1025 lin cu khun, 600~601
Hi chng Liddle trong ha kali mau, 522 Hi chng suy h hp cp nng (SARS), 686
Hi chng Li-Fraumeni vi sarcoma, 1013 Hi chng sa-kim vi canxi mau, 529
Hi chng loan dng m, AIDS, 737~738 Hi chng Sweet, ri loan sinh tuy, 1032
Hi chng Loffler, 485, 488b, 490 Hi chng tai nui dng, 90~91, 537
Hi chng Lfgren trong bnh sarcoid, 435 Hi chng tan mau do ure huyt, 565, 787,
Hi chng ly giai khi u, 539, 564 905b, 981
Hi chng Lynch, 1028, 1029 Hi chng tc nghen xoang gan, 882~883
Hi chng mach vanh cp, 125, 781 Hi chng tng ap lc bung, 559b
Hi chng mt cn bng trong loc mau, 588 Hi chng tng bach cu ai toan, 486~487,
Hi chng ng c, 1257 488b, 489b, 491
Hi chng ngc cp vi bnh hng cu, 972 Hi chng tng chylomicron mau, 124b
Hi chng ngng thuc, trong huyt ap, 119 Hi chng tng IgE vi min dch, 499~500
Hi chng ngng th - giam th do tc Hi chng tng sinh tuy vi tiu cu, 918
nghen khi ngu, 389, 419~427 Hi chng tng tnh thm mao mach, 482
Hi chng nhim retrovirus cp, 724, 726 Hi chng thn h, 498, 567, 569, 571, 891,
Hi chng nhp nhanhchm, 325, 325h 932
Hi chng nhc c LambertEaton, 1229 Hi chng tiu u, 1050~1051
Hi chng nn chu ky, 813 Hi chng tnh mach chu trn, 1007, 1054
Hi chng Ogilvie, 814 Hi chng Trousseau, bnh ac tnh, 1060
Hi chng ng c tay trong to u chi, 1134 Hi chng trung gian vi phospho, 1314
Hi chng Pancoast, ung th phi, 1007 Hi chng tuy, 1219
Hi chng phi man tnh vi nitrofurantoin, Hi chng Turner va Klinefelter, 1034
708 Hi chng ure mau tan huyt, 908~911
Hi chng phi-thn, 573~574 Hi chng vanh cp, 158~178
Hi chng phuc hi min dch, 739 Hi chng VIDAL vi phan ng thuc, 475
Hi chng Plummer-Vinson, 954 Hi chng vim mach chay mau, 456b
Hi chng porphyrin biu hin da, 874 Hi chng vim niu ao cp tnh, 640
Hi chng QT keo dai, 313, 316, 319 Hi chng vim thn, 567, 571
Hi chng Raynaud, 1174, 1175, 1176~1177 Hi chng vim tnh mach sau huyt khi, 936
Hi chng Reiter vi vim khp, 1168 Hi chng Von Hippel-Lindau, 1021
Hi chng Reye trong suy gan cp, 887 Hi chng Waldenstrm, thiu mau, 978
Hi chng Richter, bnh bach cu, 1040 Hi chng Wallenberg trong t quy, 1204
Hi chng ri loan sinh tuy, 961, 965b, Hi chng Wells vi tng bach cu, 486
1031~1033 Hi chng X, bnh mach vanh, 140, 146
Hi chng rut kch thch, 812 Hi chng xng oi vi phosphate, 537
Hi chng sa van hai la, 263 Hi chng Young trong x nang phi, 464
Hi chng serotonin, 1223, 1234, 1286, Hi chng Zollinger-Ellison, 801, 803
Hn m, 1189~1190, 1238, 1247, 1252, Hut thuc la, 370, 917, 1006~1007, 1203
1258, 1293 Huyt ap, 8~9, 35~36, 95~121, 142
trong ri loan y thc, 1185 Huyt ng, 366~368, 979
trong toan, 552, 1077 Huyt khi, 86, 174, 203~204, 243, 277,
trong ng c, 1258, 1259, 1274, 1281, 406b, 916, 917, 930, 931, 1060, 1218b
1289, 1295, 1298, 1299, 1307, 1317, ng mach, 917, 1080
1318, 1320, 1323, , 1329 1332, 1336, quanh phu thut, 31~35
1338 tnh mach, 2~3, 568, 581, 812, 819,
Hng cu, 670, 952~953, 1157 881~884, 890, 913, 930~949, 964, 1226
truyn mau cha tr, 989~990, 992, 1055 tr ngoai, 789, 823
H van ng mach chu, 270~275 trong thn nhn tao, 587
H van hai la, 204~205, 263~270 tc mach, 295~301, 299b, 912, 1093
biu hin lm sang, 265~267 vi mach, 565, 908, 928
HPA, hypothalamic-pituitary-adrenal, truc xoang tnh mach nao, 1202
ha ituyn ynthng thn, 53,... Huyt niu, 556 cung la nc tiu co mau
HPF, high-power field, hat m trong mt vi Huyt tng, 573, 574, 577
trng, 786 Huyt tng ti ng lanh, 327, 497, 910,
HPS, heart protection study, 128 920~921, 926~927, 928, 947, 990
HPV, human papillomavirus, 1345 hVISA, heteroresistant vancomycin-
HPV, 1012, 1027 intermediate S. aureus, tu cu khang
HR, heart rate, nhp tim, 253 trung gian vi vancomycine, 709
HRCT, high-resolution CT, CT phn HVT, hepatic vein thrombosis, huyt khi
giai cao, 431 tnh mach gan, 880
HRM, high resolution manometry, may o Hyalgan trong thoai hoa khp, 1165
ap lc thc quan vi phn giai cao, Hydantoins gy ri loan hng cu, 976b
783,... Hydralazine, 103b, 113, 223, 112b, 1174
HRS, hepatorenal syndrome, hi chng gan Hydrochlorothiazide, 102b, 976b
thn, 561,... Hydrocodone trong au, 14, 1058
HSCT, hematopoietic stem cell transplant, Hydrocortisone, 483, 1115, 1144, 1125,
cy ghep t bao gc h tao mau, 1047 1126
HSPCs, hematopoietic stem and progenitor Hydroflumethiazide, tng huyt ap, 102b
cells, t bao gc h tao mau, 1048 Hydromorphone, 14, 973, 1058
HSV, herpes simplex virus, virus herpes Hydroxocobalamin vi cyanua, 1337
simplex, 607,... Hydroxychloroquine, 1158, 1171
HSV, 716, 750 Hydroxyurea, 491~492, 917, 960, 974, 985,
HSV1, Herpes simplex virus 1, 749 986
HSV-1 trong vim nao, 609 Hydroxyzine, 496, 670
HSV2, Herpes simplex virus 2, 749 Hyoscyamine trong ri loan tiu hoa, 813
HTN, hypertension, tng huyt ap, 180,... Hypaque trong tao bon, 790
Human herpes virus 8 vi sarcoma, 748 I&D, cision and drainage, rach va dn lu
Humate-P trong bnh von Willebrand, 925 ap-xe, 601
HUS, hemolyticuremic syndrome, hi
chng xut huyt (tan mau) do tng ur I
huyt, 565,... IA, internal dearrangement, au ni tang, 1140
Hut dch da day trong ha magie mau, 540 IA, invasive aspergillosis, bnh nm
Hut mau tu, 1191, 1217 aspergillus xm nhp, 662
IABP, intra-aortic balloon pump, bong bm dch H, 1044
trong long ng mach chu, 184,... IGRA, interferon gamma release assay, xet
IAP, intra-abdominal pressure, ap lc trong nghim giai phong interferon gamma,
bung, 562 633
IBD, inflammatory bowel disease, bnh IGT, impaired glucose tolerance, ri loan
vim rut, 74,... dung nap glucose, 1065
IBMs, inclusion body myopathies, bnh ly IgVH, immunoglobulin variable heavy,
vim c th vui, 1232 chui nng Ig, 1040
IBS, irritable bowel syndrome, hi chng IHC, immunohistochemistry, hoa m min
rut kch thch, 812 dch, 1009
Ibuprofen, 468, 976b, 1271~1272 IHD, intermittent hemodialysis, chay thn
Ibutilide trong rung nh, 301, 305b nhn tao lin tuc, 586
IBW, ideal body weight, trong lng c th IL, interleukin, 484
ly tng, 694 IL-11 trong giam tiu cu, 1056
ICD, implantable cardioverter defibrillator, ILD, interstitial lung disease, bnh phi ke,
may kh rung tim cy trong c th, 37,... 410,...
ICF, intracellular fluid, dch ni bao, 503 Iloprost trong tng ap ng mach phi,
Icodextrin trong loc mang bung, 589 417b
ICP, intracranial pressure, ap lc so nao, 1371 ILR, insertable loop recorder, may ghi in
ICSs, inhaled corticosteroids, corticosteroid tm dnh vao c th, 283
dang ht, 375 IM, intramuscular, tim bp, 12,...
ICU, intensive care unit, n v hi sc tch Imatinib, 491, 998b, 999, 1014, 1039
cc, 84,... Imipenem, 629, 638b, 643b, 660b, 665, 693
Idarubicin hoa tr liu trong bnh ung th, trong ap-xe phi, 630
1004b trong vim phuc mac, 636b
IDLs, intermediate-density lipoproteins, Imipramine, 813, 1288, 1309
lipoprotein ty trong trung gian, 121 Imiquimod vi herpes sinh duc, 750
IDV/r, indinavir/ritonavir, 733 Immunoglobulin, 501, 600b, 676, 752b,
IE, infective endocarditis, vim ni tm 968, 1226~1227, 1231, 1235
mac nhim khun, 612 trong giam tiu cu min dch, 907
IFG, impaired fasting glucose, ri loan IMS, intermediate syndrome, hi chng
ng mau luc oi, 1065 trung gian, 1314
IFN, interferon, 843,... IMV, intermittent mandatory ventilation,
IFN trong vim gan virus B, 843, 846 thng kh nhn tao ngt quang, 347
IFN, 1182, 846, 850, 854 Indacaterol trong phi tc nghen, 376
Ifosfamide hoa tr liu trong bnh ung th, Indapamide, tng huyt ap, 102b
547, 1004b, 1005b Indinavir (IDV), 732b
IG, immune globulins, globulin min dch, Indinavir, 578, 737
1341,... Indomethacin, 1166, 1169
Ig, immunoglobulin, globulin min dch, INFeD trong thiu mau, 956, 957b
476,... Infliximab, 809, 824, 1159
IgE, immunoglobulin E, 473 vi lao phi, 630
IGF-1 mau trong to u chi, 1134 INH, isoniazid, 631,...
IGF-1, insulin-like growth factor 1, yu t Inotropes trong sc, 361, 363
tng trng ging insulin 1, 1130 INR, international normalized ratio, ch s
IgH, immunoglobulin H, globulin min chun hoa quc t, 33,...
Insulin, 527, 535~537, 566, 590, 821, 827, Itraconazole, 132, 636b, 718, 737, 744, 746,
1063, 1064, 1076, 1078, 1092, 1093 755b
liu cao trong ng c, 1303, 1306 Itraconazole trong nhim nm, 661, 663,
trong ai thao ng type 1, 1073~1075 664, 657b, 658b, 659b, 792
trong ai thao ng type 2, 1090~1091 IV, intravenous, (tim/truyn) vao tnh
Integrilin, xut huyt ng tiu hoa, 774 mach, 2,...
Interferon, 686, 736, 846, 1022 Ivacaftor trong x nang phi, 468
Interferon-, 492, 748, 917, 976b, 1174 IVC, inferior vena cava, tnh mach chu
Interferon- trong suy giap, 1112 di, 247,...
Interleukin-2, IVCD, intraventricular conduction delay,
Intravaginal azoles, 649b dn truyn chm trong tht, 147,...
IO, intraosseous, tim vao xng, 1371 IVIG, intravenous immunoglobulin, 499,...
Iod, 1111, 1115~1116, 1111b, 1121, 1112 IVIg, 908, 915
dinh dng, 61b IVP, intravenous pyelogram, niu tnh
phong xa, 1117, 1118, 1122 mach, 645,...
Iodoquinol trong tiu chay, 788 IVUS, intravascular ultrasound, siu m ni
IPF, idiopathic pulmonary fibrosis, bnh x mach, 149
hoa phi t phat, 427,...
Ipratropium, 376, 382b, 394, 1309 J
IPSS, international prognostic scoring system, JC, John Cunningham, 754
h thng im tin lng quc t, 1033 JC virus trong HIV-AIDS, 752b
IR, immediate release, giai phong ngay lp JVP, jugular venous pressure, ap lc tnh
tc, 305 mach c, 246
IRA, infarct-related artery, ng mach gy
ra nhi mau, 196 K
Irbesartan, tng huyt ap, 102b Kali, 92, 538, 582, 590, 793, 963,
Irinotecan, 1004b, 1005b, 1009, 1017, 1078~1079, 1093
1019, 1055 chloride vi salicylat, 1275~1276
Iron sucrose trong thiu mau, 957, 957b citrate, 549, 593
IRV, inverse ratio ventilation, thng kh ty iod, 659b, 664, 1120
l I:E ao ngc, 348 mau, 313, 520~527, 1051, 1096
ISA, intrinsic sympathomimetic activity, Kaolin trong tiu chay, 787
hoat ng giao cam ni tai, 106 Kaposi sarcoma trong HIV-AIDS, 748
Isocarboxide trong ng c, 1285 Kayexalate trong tng kali mau, 527
Isoniazide, 631, 961, 976b, 711, 1174 KCH, the Kings college hospital, 1265
Isoproterenol vi ng c, 1298, 1304, 1320 KCl pha nc mui sinh ly, trong ha kali
Isospora Belli, 488b, 747 mau, 524
ISR, in-stent restenosis, tai hep trong stent, Ke thn (bnh), 559b, 565~566
159 Kem, 63b, 961, 868, 872
Isradipine, tng huyt ap, 101b Ketoconazol, 132, 525, 737, 762, 1025, 1124
ISTH, international society for thrombosis Ketoprofen trong ng c, 1271~1272
and hemostasis, Hip hi huyt khi va Ketorolac trong au, 12
ng mau th gii, 928 Khang aldosteron, 176, 225
ITP, immune thrombocytopenia, xut huyt Khang axit trong trao ngc da day, 794
giam tiu cu min dch, 906 Khang cholinergic, 375, 376, 783, 787, 788,
ITP trong giam tiu cu khi co thai, 915 813
trong ng c, 1258, 1281, 1289, 1300, terbinafine, 721
1308~1311 Khat, 506, 1052, 1065
Khang histamin, 496, 670, 737, 785, 918, 994 Kh cu trong ngng th khi ngu, 425
Khang IgE, liu phap trong hen ph quan, Kh mau trong ng c, 1259
399~400 Kh ph thung, 369, 1240, 1325
Khang insulin, 738, 879 Kh thai xe, carbon monoxide, 1338
Khang muscarinic, 1288, 1309, 1310 Kh cn, trong ng vt hoang da cn, 675
Khang retrovirus, 728~737, 752b, 753b Kho noi trong bnh nhc c, 1228
Khang sinh trong bnh truyn nhim, 595 Kho nut, 782~784, 783, 796, 797, 792
Khang vi khun, 687~703 Kho th, 7~8, 160, 408, 508, 952, 968, 982,
aminoglycoside, 694~696 1036, 1076, 1237
carbapenem, 693 trong phi, 249, 429, 446, 463, 481, 627,
cephalosporin, 690~692 629, 630, 1007, 1241
fluroquinolone, 697~699 trong suy tim, 218, 280, 252
marcrolide va lincosamide, 699~701 Kho tiu trong loet da day ta trang, 800
monobactam, 692 Khoang cht chnh, dinh dng, 92~93b
penicilin, 687~689 Khoang trng anion, 544~545, 547~548
sulfonamide va trimethoprim, 701~702 Khoang trng delta, cn bng kim toan, 545
tetracyclin, 702~703 Khoi cac am chay, ng c, 1336, 1338
vancomycin, 696~697 Kh mt va ming, hi chng Sjgren, 1163
Khang vi sinh vt, hn hp, 703~710 Khp, 1139, 1147~1149, 1149, 1162
chloramphenicol, 703~704 thoai hoa, 1164~1166
colistin va polymyxin B, 704 Khung b hoa hoc vi phospho, 1311
fosfomycin, 705~706 Kh cc tht sm (VPD) trong tht, 209
linezolid, 706~707 Kch ng, 17~18, 1258
methenamine, 707 trong ng c, 1286, 1298, 1309, 1312,
metronidazole, 707~708 1321, 1323
nitrofurantoin, 708 Kch thch in da day trong chm lam
quinupristin/dalfopristin, 708~709 trng da day, 827
televancin, 709~710 Kim chuyn hoa, 543, 544b, 546b, 550~551
tigecycline, 710 Kim h hp, 543, 544b, 552~553
Khang vi khun ni bao, 710~713 Kim hoa mau, 543, 550
isoniazid, 711 Kim hoa nc tiu, 564, 1262, 1275, 1276,
rifamycin, 711~712 1318 , 1330
pyrazinamide, 712 Kim soat ng th, 343~344, 346~347
ethambutol, 712 ni kh quan, 344~346, 345b
streptomycin, 713 Kit sc do nong, 1246
Khang virus, 713~716 Kiu th, 1187~1188, 1329, 1332
chng cum, 713~714 Kingella vi vim ni tm mac, 616, 619b
chng herpes, 714~715 Klebsiella, 591, 638b, 681, 690, 692
chng cytomegalovirus, 715~716 KPC, klebsiella pneumoniae carbapenemas,
Khang nm(thuc), 717~721 692
amphotericin B, 717 KSHV, Kaposi sarcomaassociated
azole, 718~719 herpesvirus, virut herpes lin quan vi
echinocandin, 719~720 Kaposi sarcoma, 748
flucytosine, 720~721 Ky sinh trung, 488b, 700 , 770
Ky thut th T-tube, cai th may, 355 b phi ghep, 418,...

Kytril trong nn, bun nn, 785 LAV, live attenuate vaccine, vc-xin sng
giam c lc, 1342
L Lu, 648b, 652, 691
LA, left atrium, tm nh trai, 251 Lu trong vim khp nhim khun, 1147
LA, lupus anticoagulant, cht chng ng Ly nhim, kim soat va cach ly,
lupus, 904 1361~1368, 1363b~1368b
LABAs, long-acting -adrenergic agonists, Ly huyt khi ngoai khoa trong huyt khi
thuc cng -adrenergic tac dung keo tnh mach, 944~945
dai, 375 LBBB, left bundle branch block, block
Labetalol, 110~113, 100b, 111b, 115 nhanh trai, 147,...
Lach, 972, 985b LC1, liver cytosol type 1, khang th vi bao
to, 890, 917, 954, 959, 986b, 988, 1163 tng t bao gan type 1, 861
trong bnh bach cu, 983, 1036, 1038~1041 LCDD, light chain deposition disease, bnh
-lactam, 473~474, 565, 603~605, 615, lng ong chui nhe, 577
618b, 629, 638, 638b, 678, 681, 692 LCH, langerhans histiocytosis, bnh phi
trong vim phuc mac, 636b m bao, 427
trong ap-xe phi, 629 LCIS, lobular carcinoma in situ, ung th
Lactulose, 789, 897 biu m tiu thuy tai ch, 1009
LAD, left anterior descending, ng mach LCX, left circumflex artery, ng mach mu
lin tht trc, 156,... trai, 183
LADA, latent autoimmune diabetes in LDH, lactate dehydrogenase, 445,...
adults, ai thao ng t min tim n LDL, low-density lipoprotein, lipoprotein ty
ngi ln, 1064 trong thp, 29,...
LAE, left atrial enlargement, nh trai gian LDL, 132~135
rng, 254 LDopa, 976b, 1233
LAM, lamivudine, 845 LdT, telbivudine, 846
LAM, lymphangioleiomyomatosis, 427 Leflunimide, 1158, 1170
Lamivudine, 730b, 845, 846 Legionella, 627, 699
Lamotrigine ng c, 1282~1283 LEMS, LambertEaton myasthenic
Lam cng t sng trong vim khp, 1162 syndrome, hi chng nhc c
Lam sach rut (thuc), 790~791 LambertEaton, 1229
Lam try xc mang phi, 453 Lenalidomide, 986, 1033, 1047
Lam dung thuc, 1186b, 1211 Lente insulin, ai thao ng type 1, 1074b
Lansoprazole c ch axit, 795b Lepirudin trong giam tiu cu, 913
Lanthanum carbonate trong bnh thn, 583 Leptospira interrogans, 673~674
Lao, 456b, 630~634, 711, 713, 740b, LES, lower esophageal sphincter, nong chu
741~742, 886, 891, 1123, 1129, 1218b, ng c tht thc quan di, 783
1240 Lesogaberan trong trao ngc da day, 794
k, lao ngoai phi, 630 Letrozole trong ung th vu, 1010
mang bung, 636b Leucovorin, 746, 1017, 1019, 1331
mang nao, 713 Leukotriene bin th trong hen, 399, 402
tim n, 632~634, 809 Leuprolide, 1010, 1025
LAP, left atrial pressure, ap lc nh trai, 253 Levalbuterol, 376, 396
Lapatinib, 998b, 1011, 1055 Levamisole vi cocain trong ng c, 1325
LAS, lung allocation score, im s phn Levetiracetam, 814, 1283
Levocetirizine, m ay va phu mach, 496 706~707, 906
Levodopa trong Parkinson, 1223 Linezolid trong vim ni tm mac, 615,
Levofloxacin, 625, 629, 638b, 643b, 698 616, 618b, 619b
vi H. Pylori, 801, 802 Linezolid trong vim phi cng ng, 629
L thuc thuc, 15, 19 LIP, lymphocytic interstitial pneumonia,
LFT, liver function test, test chc nng gan, vim phi ke thm nhim lympho bao,
218,... 427
LGV, lymphogranuloma venereum, bnh Lipid, 85, 1066, 1232, 1203, 1303~1304, 1306
ht xoai, 650 ri loan, 121~138, 738, 819, 879, 1210
LH, luteinizing hormone, 1129 Lipoprotein, 120, 121b, 124b
LHC, left heart catheterization, thng tim Liposomal, 659b, 748
trai, 268 Liposomal amphotericin, 660b, 664, 746
LHRH, luteinizing hormone- release Liraglutide vi ai thao ng, 1086b, 1090
hormone, 1010 Lisinopril, tng huyt ap, 101b
Li b trong ng c, 1264, 1274, 1282, 1283, Lispro insulin trong ai thao ng, 1074b
1299, 1310, 1312, 1329, 1336, 1338 Listeria monocytogenes, 607, 608, 687
Lialda trong bnh vim rut, 806 Lithium, 516, 982, 1111b, 1112, 1229
Lidocain, 783, 793, 1056, 1146, 1164 trong ng c, 1294~1296
Lidocain trong ng c, 1290, 1292, 1298, LKM1, liver/kidney microsome type 1,
1322, 1324 khang th vi ty lap th cua gan/thn
Lidocaine trong tim mach, 303b, 319 type 1, 861
Lin cu khun, 565, 576, 600~602, 600b, LMA, laryngeal mask airway, mt na ng
615, 675, 687~688, 690, 700, 1104, 1147 th thanh quan, 343,...
Lit, 684, 1196, 1203, 1204, 1219, 1224, LMWH, low-molecular-weight heparin,
1225b, 1230, 1258, 1314, 1094 heparin trong lng phn t thp, 3,...
rut, 814~816 LMWHs trong huyt khi tnh mach, 939~941
Tick, 1225b LN, lupus nephritis, bnh thn do lupus, 575
Todd, 1196 Lo u, 18~22, 546b, 1116
Liu phap bc cu trong chng ng, 33, 34 Loan dng m trong HIV-AIDS, 737~738
Liu phap don ng trong ghep tang, 758 Loan dng trng lc c trong tao bon, 788
Liu phap khang IgE trong hen, 399~400 Loan khun rut trong ai thao ng, 1099
Liu phap khang retrovirus, 728~737 Loan nhp, 90, 206~207, 208~209b, 233,
Liu phap khang tiu cu, 165~172 234, 239, 279~338, 303b~305b, 1252
Liu phap lipid, 1303 loan nhp chm, 320~333
Liu phap min dch, 1341 loan nhp nhanh, 279~320
Liu phap oxy, 342~343, 379, 381, 468 Loan san tht phai, 310, 313
Liu phap thay th thn, 584~590 Loang xng, 469, 583, 808, 824, 868~869,
Liu phap c ch min dch trong Lupus 871, 948, 1132, 1145, 1167
ban o, 1172~1173 Loc huyt tng, 915, 1226~1227
Liken phng trong vim gan C, 849 Loc mang bung, 585, 588~590
LIMA, left internal mammary artery, ng Loc mau, 527, 531, 534, 537, 540, 563,
mach vu trong trai, 157 566, 567, 576, 910, 1254, 1262, 1300
Linaclotide, 790, 813 sut i trong lupus ban o h thng, 1173
Linagliptin vi ai thao ng, 1085b, 1089 trong ri loan cht lng tiu cu, 919
Lincosamide, 699~701 trong ng c, 1262, 1270, 1276, 1296, 1300,
Linezolid, 602, 603, 605, 630, 678, 680, 1318, 1322, 1324, 1327, 1331, 1334, 1335
LOAD, levofloxacin, omeprazole, Lu ln, 1196, 1215, 1247

nitazoxanide, doxycycline, 801 trong ng c, 1278, 1295, 1309, 1312,
LOAD vi H. pylori, 801 1335
Loet Lubiprostone, 790, 813
ban chn ai thao ng, 603, 1103~1105 Lupus, 547, 1174, 1228
chn trong bnh hng cu hnh lim, 971, ban o h thng, 498, 906, 932, 1119,
972, 974 1170~1174, 1182 , 1218b,
da day ta trang, 779, 799~804, 951, 955 Luteinizing hormone, 1010, 1129
decubitus xng cut, 605 Li to chng vi amyloidosis, 989
do nhim trung va bong, 602 Li trong tc nghen ng th, 1237, 1238
do ty e, 3~5, 1365b LV, left ventricular, tm tht trai, 217,...
do t th nm, 603 LVAD, lefft ventricular assist device, thit
gn mn v gy tc nghen da day, 803 b h tr tm tht trai, 184,...
hai khoe ming trong thiu mau, 952 LVE, left ventricular enlargement, gian tht
ming, 1056, 1171 trai, 267
sinh duc, 647b, 650 LVEDP, left ventricular end-diastolic, ap
Lomotil trong tiu chay, 787, 1055 lc tht trai cui ky tm trng, 246,...
Loperamide, 787, 813, 1055, 1099 LVEF, LV ejection fraction, suy giam chc
Lopinavir (LPV), 732b nng tht trai, 316
/ritonavir (LPV/r), tng tac thuc, 735b LVH, left ventricular hypertrophy, ph ai
Loratadine, 496, 737 tm tht trai, 99,...
Lorazepam, 18, 359b, 814, 1190, 1200, LVOT, left ventricular outflow tract, tc
1055 nghen ng ra tht trai, 260
Lorazepam trong hi chng cai ru, 1192 LVOT-VT, left ventricular outflow tract-
Losartan, tng huyt ap, 102b ventricular tachycardia, nhp nhanh tht
Lotronex trong ri loan tiu hoa, 813 tc nghen ng ra tht trai, 311
Lovastatin, 133b, 735b Lymphoma, 788, 886
Li mt trong cng giap, 1115, 1116
L m, 1259, 1284 M
Li tiu, 104~105, 226, 238, 243, 255, 261, Maalox trong tng magie mau, 540
418, 522, 884, 892, 1097 Mac treo rut thiu mau cp tnh, 828
gi kali, 226, 509, 551 MAC, mycobacterium avium complex,
quai, 226, 508, 515, 531, 541 mycobacterium avium phc hp, 699,...
thm thu, 537, 541 Macroadenoma, 1129, 1130, 1132,
thiazide, 226, 508, 520, 593 1133~1134
Lxmi cp, 918, 928 Macrolid, 376~378, 602, 625, 628, 736b,
Lp(a), lipoprotein(a), 121 737, 743, 753b, 755b
LP, lumbar puncture, choc do tht lng (tuy MADIT, multicenter automatic defibrillator
sng), 646,... implantation trial, th nghim cy may
LPV/r, lobinavir/ritonavir, 733 pha rung t ng a trung tm, 316
LTBI, latent TB infection, nhim lao tim Magie, 93
n, 632 citrate, 540, 789, 790
LTMs, leukotriene modifiers, leukotriene mau, 534, 539~542, 1079~1080, 1292, 1298
bin th, 398 sulfate, 400, 534, 1229
LTRAs, leukotriene-receptor antagonists, Mag-OX 400 trong ha magie mau, 541
thuc i khang thu th leukotrien, 399 MAHA, microangiopathic hemolytic anemia,
thiu mau tan mau vi mach, 908,... o lng c, 544

MALT, mucosa-associated lymphoid tissue, MCV, mean cellular volume, th tch trung
m dang lympho lin quan vi nim bnh hng cu, 952
mac, 1044 MCV4, meningococcal conjugate vaccine,
Mang phi, dch, 445~446, 447, 448b vc-xin lin hp nao m cu, 1348
Mannitol, 888, 1191, 1249 MDAC, multidose activated charcoal, than
MAOIs, monoamine oxidase inhibitors, hoat a liu, 1279
cht c ch oxy hoa monoamine, 119,... MDI, metered-dose inhaler, dang ht co
MAOI, 1284~1288, 1292 nh liu, 374
MAP, mean arterial BP, huyt ap trung bnh MDMA, 3,4 -methylene dioxy methamphet
ng mach, 363 amin, 1320
Maraviroc (MVC), 733, 734b MDMA vi amphetamine, ng c, 1320
Marburg, 685, 1367b MDP, myeloproliferative disorder, ri loan
Marcrolid va lincosamide, 699~701 tng sinh tuy, 1034
Mas, measured anions, lng anion co th MDRD, modification of diet in renal
o lng c, 544 disease, iu chnh ch n ung
MAT, multifocal atrial tachycardi, nhp trong bnh thn, 555
nhanh nh a , 286 MDR-TB, multidrug-resistant forms, a
Mau tu, 1031~1048, 1215 khang thuc, 630
trong ri loan ng mau, 902 MDS, myelodysplastic syndrome, hi
t phat vi chay mau Hemophilia A, 920 chng ri loan sinh tuy, 961,...
May kh rung tim cy trong c th, 37~38, Meclizine trong nn, bun nn, 785
241, 316~317 MEDICINE, Metabolic, Excessive
May tao nhp, 37~38, 327~332 exercise/exertion, Drugs, Ischemic,
May ay cung la M ay, 476b, 492~497 Compression/crush, Infection/
Mng-gan (Mn2+), dinh dng, 61b Inflammatory, Noxious, Electrolyte
Mt bnh ly trong hng cu hnh lim, 972 abnormalities, 1233
Mt trong ri loan y thc, 1188~1189 Mefenamic acid vi hng cu, 976b
Mt tn thng trong bnh vim rut, 804 Mefloquine trong st ret, 672
Mt o, sng va mau vi hi chng tnh Megestrol acetate trong ung th, 1061
mach chu trn, 1054 Meglitinide trong ai thao ng, 1087
Mt na thanh quan, 343, 1240 MELD, model for end-stage liver disease,
Mt dch ng tiu hoa, 546b, 550 tiu chun bnh gan giai oan cui, 900
Mt dch t chc trong th may, 352~353 Melphalan trong bnh cu thn, 577
Mt kali vi thn, 521~522 Memantine trong bnh Alzheimer, 1194
Mt mau, 670, 880, 951~952, 954, 955 Men tim trong nhi mau c tim, 162, 182
Mt ngu, 18~22 Meo cn, 675
Mt nc, 516~517, 974, 1092, 1246 Meperidine trong vim tuy cp, 818
Mt th tch kh lu thng, th may, 352 Meperidine, 14, 737, 1292
Mt thnh lc trong hng cu hnh lim, 973 Mepolizumab, 492, 792
Mt th lc vi methanol, 1329 Mercaptopropionylglycine vi soi thn, 593
MCD, minimal change disease, bnh ly cu 6-Mercaptopurine trong vim rut, 808
thn co tn thng ti thiu, 568 Meropenem, 603, 608, 629, 630, 636b,
MCL, mantle cell lymphoma, u lympho t 638b, 643b, 693
bao vo, 1045 Mesalamine trong bnh vim rut, 806, 807
MCs, measured cations, lng cation co th Mesoridazine trong ng c, 1297
MET, metabolic equivalents, ng lng bnh ly, 987

chuyn hoa, 26 MI, myocardial infarction, nhi mau c tim,
Metaproterenol trong sc phan v, 483 3,...
Metformin, 1065, 1082, 1084b, 1087~1088 Micafungin sodium, 720
trong gan nhim m khng do ru, 879 Microadenoma, 1126, 1129, 1130, 1132, 1133
Methadone, 735b, 736b, 737, 1272, 1273 Microsporidia trong HIV-AIDS, 747~748
trong au, 14, 1058 Microsporidium, tiu chay trong HIV, 788
Methamphetamin vi amphetamine, 1320 Midazolam, 359b, 737, 1200
Methanol, 546b, 1328~1332 Midodrine trong hi chng gan thn, 896
Methemoglobin trong suy tim, 224 Min dch, 1022, 1144~1145
Methenamine, 707 chu ng, 599, 1341
Methicillin trong vim ni tm mac, 615 thu ng, 599, 1341, 1350b~1351b
Methimazole trong cng giap, 1119 Miglitol trong ai thao ng, 1084b, 1107
Methohexital trong ni kh quan, 360b Milrinone, 210, 227, 227b, 361, 363, 418
Methotrexate, 808, 1172, 1004b, 1005b, Mineralocorticoid, 517, 527, 549, 550
1023, 1159, 1178, 1184 Minocycline, 602, 660b, 703, 1174
trong vim khp, 1156~1157, 1167, 1169, Minoxidil, tng huyt ap, 103b
1170 MIPI, mantle cell lymphoma international
Methyclothiazide, 102b prognostic index, bang tin lng u
Methyldopa, 103b, 112b, 1174 lympho t bao vo quc t, 1045
Methylene blue gy ri loan hng cu, 976b MiraLax trong tao bon, 790
Methylnaltrexone trong tao bon, 790 Misoprostol trong bnh xng khp, 1142
Methylparaben trong m ay, 495 Mitiglinide trong ai thao ng, 1083b
Methylphenidate trong ung th, 1060 Mitomycin-C, 565, 1023
Methylprednisolone, 398, 565, 574, 575, 810, Mitoxantrone hoa tr liu, 1004b, 1005b
910, 957, 1144, 1146, 1172, 1178, 1220 MLD, multilineage dysplasia, a dong, 1032
4-Methylpyrazole vi methanol, 1330 MM, multiple myeloma, a u tuy xng, 1046
Methylxanthine, 381, 400, 402, 1320 MMA, maxillomandibular advancement,
Metoclopramide, 785, 827, 1098, 1132, keo ham trn ham di ra trc, 426
1176, 1222, 1233, 1326 MMA, methylmalonic acid, axit
Metolazone, tng huyt ap, 102b methylmalonic, 963
Metoprolol, 100b, 190b, 296b 6-MMP, 6-methyl mercaptopurine, 808
Metronidazole, 598, 599, 603, 636b, 638b, MMR, measles, mumps, rubella, Si, quai
648b, 649b, 707~708, 787, 788, 807, b, rubella, 728, 1346, 1351
818, 897, 1099, 1104, 1176, 1235 MMSE, mini-mental state examination,
trong ap-xe, 610, 823, 885 thang anh gia tm thn ti thiu, 1193
trong vim tui tha, 638, 826 MN, membranous nephropathy, bnh cu
vi H. pylori, 802 thn mang, 568
Mexiletine, 304b, 319 MNT, medical nutrition therapy, liu phap
M sang, 1185, 1190, 1298 dinh dng, 1067
M ay, 480, 481, 492~497 Mong tay hnh tha trong thiu mau, 952, 954
Mt moi, 954, 1060~1061, 1112, 1116 MOCA, montreal cognitive assessment, 1193
MG, myasthenia gravis, bnh nhc c, 1227 Moclobemide, 1285, 1288
MGUS, monoclonal gammopathy of Modafinil, 424, 1060
undefermined significance, bnh ly Moexipril, tng huyt ap, 101b
gamma n dong khng co y ngha Mometasone trong hen ph quan, 397b
Monobactam, 474, 692 methicillin, 619
Montelukast trong hen ph quan, 399 MS, mitral stenosis, hep van hai la, 231,...
Moraxella, 624, 709 MSCC, malignant spinal cord compression,
Morphine, 14, 176b, 192, 232, 359b, 973, 1058 chen ep tuy ac tnh, 1052
Mosapride citrate trong lit rut, 816 MSM, men who have sex with men, ngi
Moxifloxacin, 625, 628, 629, 638b, 698 nam quan h tnh duc ng gii, 1345
M hoc trong bnh ung th, 1000 MSMDs, mendelian susceptibility to
M mm nhim khun, 688~691, 710 mycobacterial diseases, nhay cam dang
M hi vi bnh phi, 438, 629, 630, 464~465 mendel vi cac bnh mycobacteria, 498
Mi ung th, 771, 1012 MSSA, methicillin-sensitive staphylococcus
M-lip-en (Molybdenum), dinh dng, 64b aureus, tu cu vang nhay vi
M kh quan, 346, 425, 1239 methicillin, 688
M sun nhn giap, kim soat ng th, 346 MSSA vi cephalosporin th h 3, 691
MPA, mycophenolic acid, axt MSSE, methicillin-sensitive staphylococcus
mycophenolic, 759 epidermidis, tu cu da nhay cam
mPAP, mean pulmonary artery pressure, ap methicillin, 619
lc ng mach phi trung bnh, 405 mTOR, Mammalian target of rapamycin,
MPD, myeloproliferative disorders, ri loan tac ng ch cua rapamycin, 758,...
tng sinh tuy, 984 Mu mang phi, lc x tr, 451h
MPGN, membranoproliferative Mucomycosis, 659b, 718
glomerulonephropathy, vim cu thn Mucor, 770, 664
mang tng sinh, 571 Mun coc sinh duc/sui mao ga, HIV-AIDS, 750
MPNST, malignant peripheral nerve sheath Mun trng ca nng vi tetracyclin, 702
tumor, khi u vo thn kinh ngoai vi ac Mui, 467, 581~852, 1098, 1191
tnh, 1014 kem trong bnh wilson, 872
MPSV4, meningococcal polysaccharide magi trong tao bon, 789
vaccine, vc-xin polychaccaride nao Mupirocin trong nhim tu cu, 680
m cu, 1348 MuSK, muscle-specific tyrosine kinase,
MR, magnetic resonance, cng hng t, 934 tyrosin kinase c hiu c, 1228
MR, mitral regurgitation, h van hai la, 145,... MUSTT, multicenter un-sustained
MRA, magnetic resonance angiography, tachycardia trial, th nghim nhp
chup cng hng t mach mau, 557,... nhanh khng bn b a trung tm, 316
MRCP, magnetic resonance MVP, mitral valve prolapse, sa van hai la, 280
cholangiopancreatography, chup cng MVR, nitral valve replacement, thay van
hng t dng hnh mt tuy, 834 hai la, 277
MRI, magnetic resonance imaging, chup 6-MWT, six-minute walk test, test 6 phut i
cng hng t, 219,... b, 410
MRI trong nhim nm, 664, 665 Mycobacteria, 471, 627, 630, 634, 666,
MRS, modified Rankin scale, thang im 711, 754b, 755b, 886, 1148
Rankin cai tin, 1208 Mycobacterium avium, 699, 700, 711, 740b,
MRSA, methicillin resistant staphylococcus 742~743, 788, 967~968
aureus, tu cu vang khang methicillin, Mycobacterium tuberculosis, 636b, 788
601,... Mycophenolate mofetil, 591, 863, 1172,
MRSA vi thuc, 692, 693, 700, 701, 706 1184, 1232
MRSE, methicillin-resistant staphylococcus Mycophenolate mofetil trong bnh thn,
epidermidis, tu cu da khang 570, 575, 576
Mycophenolate mofetil vi vim mach, 1178 aspergillus, 391b, 662~663

Mycoplasma, 626, 652, 699, 702~704, 973, blastomyces, 661~ 662
978, 1224, 1364b candida, 654~655, 677, 679, 718, 719, 774
Myoglobin, 162, 162b, 564, 1232, 1234 cy en trong ri loan tiu cu, 918
Myxedema vi c trng, 891 coccidioides, 662 , 739
cryptococcus, 655~660, 744~745
N a phng vi Itraconazole, 718
NA, not applicable, khng ap dung, 13,... ng niu vi Fluconazole, 718
NAC, N-acetylcysteine, 1266 histoplasma, 661, 739
NAC vi acetaminophen, 1266~1267 mucor, 664
NaCl, 505b, 527, 1246 nocardia, 665
Nadolol, tng huyt ap, 100b sporotrum, 663~664
Nafcillin, 609, 689 trong ghep tang, 762, 770
NaHCO3, 527, 549, 552, 564, 584 Nng chn cao trong huyt khi, 944
NALFD, nonalcoholic fatty liver disease, Nng u ging trong trao ngc, 796
bnh gan nhim m khng do ru, 877 NCEPs, national cholesterol education
Nalidixic acid gy ri loan hng cu, 976b programs, chng trnh hng dn
Naloxone, 15, 1190, 1273, 1308 quc gia v cholesterol, 125
Naltrexone trong nga do mt, 670 nCPAP, nasal CPAP, CPAP mui, 424
Nang gia tuy, 819 NDI, nephrogenic diabetes insipidus, ai
Nao, 609, 1197b thao nhat do thn, 518
m cu, 608, 1364b Nebivolol, tng huyt ap, 100b
-tim, ngt, 333, 334, 337 Nefazodone va Statin, ri loan lipid, 132
NAPQI, N-acetyl-p-benzoquinone imine, 1264 Neisseria gonorrhoeae, 634, 640, 641, 652
Naproxen trong ng c, 906, 1271~1272 Neisseria meningitides, 608, 711, 911
Narcotics, 812, 814, 818 Nelfinavir (NFV), 732b, 735b
NARES, nonallergic rhinitis with Neomycin trong bnh nao gan, 897
eosinophilia syndrome, hi chng tng Neostigmine, 815~816, 1315
bach cu ai toan, 484 Nesiritide, 224, 232
NASH, nonalcoholic steatohepatitis, vim Neumega trong giam tiu cu, 1056
gan nhim m khng do ru, 877 Nevirapine (NVP), 731b, 736b
Natalizumab vi bnh vim rut, 809~810 Nga, chm soc bnh nhn, 5
Nateglinide vi ai thao ng, 1083b, 1087 Ngay to trong ngng th khi ngu, 421
Natri, 92 , 504, 506, 507, 538, 790, 1337 Ngt, 322, 333~337, 336h, 816, 1246~1247
bicarbonate, 1246, 1262, 1275, 1283, Nghim phap
1290, 1318, 1330, 1324, 1334 ap ng vi desmopressin acetate, 519
cromolyn trong hen ph quan, 399 m, 1226, 1229
docusate trong tao bon, 789 dung nap glucose, 1065
mau, 353, 509~520, 1124 Heimlich, 1238, 1239
niu vi th tch, 506, 508 nc a, 1231
Nng lng nhu cu dinh dng, 57~58, c ch bng dexamethasone, 1126~1127
58b, 78~79 Valsalva, 414
Nm, 456b, 717~719 721, 886, 1123, 1148 Nghin ru, 537, 540, 546b, 819, 961, 1203
actinomyces, 665~666 Ngoai tm thu nh nhanh, iu tr, 289
actinomycete vung mt-c, 703 Ngon tay (chi) dui trng, 372, 464, 1007
amanita, 1309 Ng c, 585, 1197b, 1257~1340
arsen, 1225b gy ra bi c t, 597~599
botulinum, 684~685, 1225b, 1233 h sinh duc bnh nhn HIV, 788
ch, 954, 1225b h thn kinh trung ng, 606~611, 745,
oxy trong th may, 354 788, 1186b, 1197b
ru, 547 huyt, 559b, 563, 615, 616, 683, 693,
NGSP, national glycohemoglobin 697b, 742, 754b, 880, 884, 887, 889,
standardization program, chng 1186b, 1247
trnh chun hoa quc gia v khp, 1141b, 1144, 1148
glycohemoglobin, 1065 lin quan ti chm soc y t, 676~681
Ngu ga vi ethanol trong ng c, 1335 lin quan ti ng thng, 640, 644
Ngu gt trong ngng th khi ngu, 421, 422b man tnh, 462, 571
Nguyn hng cu khng l trong thiu mau, men nm m ao, 652
961~963 nao tht va nao tht shunt bung, 609
Nguyn tc cua cy ghep t bao gc, 1047~1048 nhu m thn, 566
Nga, 480, 869~870 phc tap da va m mm, 602~603
Ngc anh trng trong loan nhp nhanh, 280 qua ng tnh duc, 645~654
Ngc au, 6~7, 280 sau ghep tang, 768~770, 769b
Ngng th - giam th do tc nghen khi ngu, su m mm, 602
419~427 sinh mu tai phat, 499~500
Ngng th, 1188, 1237~1246 tiu chay cp, 786
khi ngu, 420, 421, 422b, 322, 1210, 1237 tim mach, 611~621
vi hen ph quan, 391b toan thn, 742, 894
Ngng tim trong tng magie mau, 540 trong huyt khi tnh mach, 931
1047~1048 trong thn nhn tao, 587
Nhan cu vn ng trong y thc, 1188~1189 vt thng, 602, 605
Nhn sm trong ri loan tiu cu, 918 vi truyn mau, 991, 992~993
Nhn tuyn giap, 1121~1123 vi ng mau ni mach rai rac (DIC), 928
Nhim n bao trong HIV-AIDS, 746~748 Nhim virus nng trong hen ph quan, 386
Nhim ky sinh trung, 962, 485, 488b Nhim virus West Nile, 1225b
Nhim sc t st, 240, 241, 898 NHL, non-Hodgkins lymphoma, u lympho
di truyn, 873~876 khng Hodgkins, 1043
Nhim tap khun, loet, 603 Nhp chm
Nhim toan trong ai thao ng, 539, 585, x tr hi sc tim phi, 1371h
1068, 1072 xoang, 208, 323, 325h
Nhim trung, 87, 690~691, 670, 975, 978 Nhp cua may tao nhp tim, 329, 330h
catheter, 589, 677~679 Nhp nhanh
c hi trong HIV-AIDS, 739~740 tht, 209, 239, 309~320
da, m mm va xng, 601~606, 689 trn tht, 280~281, 283~290, 291~292b,
do dn lu nao tht, 576 312~315, 314~315h
do mui truyn, 670~672 xoang, 208, 286, 289
ng h hp di, 626~634 x tr hi sc tim phi, 1372h
ng h hp trn, 622~626, 1238 Nhp th trong ri loan y thc, 1187~1188
ng sinh duc, 639~645 Nhp tim, 322, 325h, 353, 889, 1051, 1225,
ng tit niu, 581, 639~644 1281, 1305, 1312, 1336
ng tiu hoa va da day, 634~637 chm, 540, 816, 1112, 1252, 1258, 1302,
gan mt, 635~637, 638 1307, 1315
nhanh, 506, 945, 952, 1258, 1293 5-Nitroimidazole trong ap-xe gan, 885
trong ng c, 1274, 1286, 1288, 1289, Nitroprusside, 232, 1287, 1322, 1324
1291, 1296, 1298~1300, 1301, 1309, Nizatidine c ch axit trong trao ngc, 795b
1310, 1320, 1323, 1325, 1326, 1332 NK1, neurokinin 1, 785
Nhp xoang trong rung nh, 301, 302~307 Nl, normal, bnh thng, 924
Nhi mau NLPHD, nodular lymphocyte predominant,
nao, 1186b, 1197b, 1211 t bao lympho dang nt, 1042
phi, nhim khun, 613 NMDA, N-methyl-D-aspartate, 1194
thn, 971~973, 1123 NMS, neuroleptic malignant syndrome, Hi
tuyn yn sau e, 1129 chng an thn kinh ac tnh, 1223
Nhi mau c tim, 186, 322, 362~363, 982, NNRTIs, nonnucleoside reverse
1099, 1100, 1338 transcriptase inhibitors, thuc c ch
khng ST chnh, 158~178 men sao chep ngc nonnucleoside, 724
quanh phu thut, 22~23 NO, nitric oxide, 348
sau phu thut va theo doi, 31 NOACs, novel oral anticoagulants, thuc
ST chnh ln, 178~213, chng ng mau mi ng ung, 947
Nhm hydroxide trong suy giap, 1114 Nocardia, 660b, 665, 701~703, 762
Nhu ng rut trong tiu chay, 788 Nofloxacin trong nhim trung ng tit
Nhu ng thc quan giam, 792, 797 niu, 642b
Nhu cu dinh dng, 57~75 Nonalbicans vi Voriconazole, 719
Nhuyn sun kh quan vi hen ph quan, 391b Nonbenzodiazepine, trong mt ngu, 21~22
Nhuyn xng, 1135~1136 Nondihydropyridine trong ng c, 1304
Nhc c, 1227~1232 Nong c tht thc quan, 783, 792, 796
Niacin, 134, 135 cung la Nicotinic acid Non-HDL cholesterol, 130
Nicardipine, 101b, 112b, 113, 1304 Norcardia vi amikacin, 696
NICM, nonischemic cardiomyopathy, bnh Norepinephrine, 361, 364, 896
c tim khng do thiu mau, 220 Norepinephrin trong ng c, 1287, 1290,
Nicotinic acid, 134 cung la Niacin 1300, 1301, 1306, 1318, 1320, 1327
NIF, negative inspiratory force, lc ht vao Norfloxacin, 643b, 698, 779, 787, 894
m tnh, 1226 Nortriptyline, 813, 1058, 1214, 1288, 1309
Niedipine, 101b, 416b, 878, 1304 Ni kh quan, 381, 400~401, 778, 1231,
Niferex trong thiu mau hng cu nho, 956b 1239, 1244, 1245, 1254
NIHSS, national institute of health stroke t, 344~346, 345b
scale, thang im anh gia t quy cua gy dn ng Eishman, 1239~1240
vin sc khoe quc gia Hoa Ky, 1208 rut ng, 356
Nilotinib, 998b, 1039 thuc s dung, 356~357, 359~360b
Nimodipine, 1209, 1304 trong ng c, 1270, 1276, 1283, 1290,
Nisoldipine, 101b 1305, 1317, 1319, 1326
Nitazoxanide, 747, 801 Ni mac t cung ung th, 1028
Nitrate, 223, 918, 153, 154, 155b Ni soi ai trang, 597, 775, 811~812
Nitrites vi au u, 1212 Ni tit t androgen trong xut huyt giam
Nitrofurantoin, 642b, 680, 708, 976b tiu cu min dch khang thuc, 908
Nitroglycerin, 110, 111b, 190b, 192, 232, Ni m ay, 475, 489b, 1142
779, 783, 823, 1177, 1287, 1322, 1324 Nn, 550, 599, 773, 800, 810, 989, 1019,
chng thiu mau, 174, 175b 1052, 1054~1055, 1125~1126
trong suy tim, 223 trong ai thao ng, 1067, 1098~1099
trong ng c, 1269, 1274, 1295, 1325, khun lao khng in hnh, 630,...
1329, 1332, 1338 NT-proBNP, N-terminus ProBNP, 261
Nn, bun nn, 784~785, 807, 817, 1124, Nut au, 782~784, 1056
1187, 1211, 1246, 1291 Nut kho, 623, 1015
trong chm lam trng da day, 826 Nut mach trong ung th gan, 899, 1020
Nng oxy, 339, 341~342 Nut nh tht, 320, 325~327, 326h
Nt n c phi, 437~444 Nut xoang, 320, 323, 325h
NPH, neutral protamine hagedorn, insulin Nucleoside trong tng tac thuc, 736b
tac dung trung bnh, 51 NuLYTELY trong lam sach rut, 790
NPH insulin trong ai thao ng, 1074b Nc b sung trong tao bon, 789
Nplate trong xut huyt giam tiu cu min Nc mui lanh, trong ho mau, 460
dch khang thuc, 908 Nc mui sinh ly, 519, 530, 1052, 1298,
NPO, nothing by mouth, nhn n qua ng 1318
ming, 2,... Nc mui u trng trong phu nao, 888
NPPV, noninvasive positive pressure Nc nho ep vi khang retrovirus, 737
ventilation, th ap lc dng khng Nc tiu trong bnh thn, 556
xm nhp, 42 Nc trong ng th tch, 504~505
NPV, negative predictive value, gia tr d Nc trong c th, tng lng, 503
bao m tnh thp, 907 Nt chn do ngm nc, 1250
NRTIs, nucleotide and nucleoside reverse Nt hu mn trong tao bon, 789
transcriptase inhibitors, thuc c NYHA, New York heart association, hip
ch sao chep ngc nucleotide and hi tim mach New York, 23,...
nucleoside, 729 Nystatin, 744, 762, 792
NS, normal saline, nc mui sinh ly, 1298
NSAID, nonsteroidal anti-inflammatory O
drug, thuc chng vim khng steroid, OA, osteoarthritis, thoai hoa khp, 1146,...
7,... O-AVRT, orthodromic AVRT, nhp nhanh
NSAID, 11~12, 176~177, 193, 793, 796, vao lai nh tht xui chiu, 287
799, 801, 1059, 1152, 1154, 1171, OCS, oral corticosteroids, corticosteroid
1181, 1213 ng ung, 386
trong ng c, 1271~1272 Octreotide, 580, 779, 787, 896, 1099, 1135
trong xng khp, 1142~1143, 1148, OD, optical density, n v mt quang, 913
1161, 1164, 1166, 1167, 1169 Ofatumumab trong bnh bach cu, 1041
NSCLC, non-small cell lung cancer, bnh Ofloxacin, 643b, 698, 801
nhn ung th phi khng t bao nho, 997 OGTT, oral glucose tolerance test, nghim
NSF, nephrogenic systemic fibrosis, tnh phap dung nap glucose, 1065
trang x hoa thn h thng, 557 25[OH]D, 25-hydroxy vitamin D, 1135
NSIP, nonspecific interstitial pneumonia, Olanzapine, 1055, 1300, 1309
vim phi ke khng c hiu, 427,.. Olmesartan, tng huyt ap, 102b
NSTEMI, nonST-segment MI, nhi mau Olsalazine trong bnh vim rut, 806
c tim khng ST chnh ln, 140 Omalizumab, 399~400, 402
NSVT, nonsustained ventricular Omeprazole, 779, 795b, 801, 1142
tachycardia, nhp nhanh tht khng bn Ondansetron, 785, 814, 1054, 1326
b, 234 OP, organophosphates, phospho hu c,
NTG, nitroglycerin, 146 1311
NTM, nontuberculous mycobacteria, vi Opiate, 737, 787, 1258
OPIDN, OP-induced delayed neurotoxicity, thuc c ch hoat hoa plasminogen-1, 198

c tnh thn kinh mun gy ra bi OP, Palifermin trong vim nim mac, 1056
1314 Palonosetron trong bun nn, 1054
Opioid, 12~16, 13b, 973, 1058, 1059, 1250, 2-PAM, Pralidoxime, 1314
1260, 1272~1274 Pamidronate trong au do ung th, 531,
Opium trong tiu chay, 787 1052, 1058, 1137, 1166
Oprelvekin trong giam tiu cu, 1056 pAminosalicylic acid gy ri loan hng
OS, opening snap, m van hai la, 252 cu, 977b
OSA, obstructive sleep apnea, ngng th p-ANCA, perinuclear antineutrophil
khi ngu do tc nghen, 324,... cytoplasmic antibodies, khang th t bao
OSAHS, obstructive sleep apneahypopnea cht chng bach cu trung tnh, 805,...
syndrome, hi chng ngng thgiam Pancrease trong vim tuy man, 820
th khi ngu do tc nghen, 419 Pancuronium, trong ni kh quan va th
OSAS, obstructive sleep apnea syndrome, may, 359b
hi chng ngng th khi ngu do tc Panitumumab trong ch bnh ac tnh, 998b
nghen, 408 Pantoprazole c ch axit trong trao ngc,
Oseltamivir, 625, 714 795b
OsmoPrep trong lam sach rut, 790 PaO2, arterial oxygen tension, phn ap O2
Oxacillin, 600b, 605, 609, 615, 616, 618b, trong mau ng mach, 339
619b, 678, 689, 1104 PAOP, pulmonary artery occlusive pressure,
Oxaliplatin, 1004b, 1005b, 1017, 1019 ap lc ng mach phi bt, 363
Oxazepam trong hi chng cai ru, 1192 Paracetamol ng c, 1263~1268
Oxazolidinone, 706 Parainfluenza trong vim ph quan cp, 626
Oxcarbazepin trong ng c, 1280~1281 Paravirut B19 trong thiu mau, HIV, 968
Oxy, 400, 1249, 1253, 1254, 1339 Parenteral nutrition, dinh dng tnh mach, 84
liu phap, 379, 381, 468 Paricalcitol trong bnh thn man tnh, 584
Oxycodone, trong au, 14, 1058 Parkinson, 1221~1223
bung nhim khun, 710, 688, 689, 691, Paromomycin trong tiu chay, 788
693, 698, 707, 884 Paroxetine, 813, 1291
vi huyt khi tnh mach ca, 883 Paroxysmal AF, rung nh kch phat, 290
PARP, Poly-ADP-ribose phosphorylase, 1030
P Parvovirus, 752b, 1148, 1364b
PA, pernicious anemia, thiu mau ac tnh, 962 PASP, pulmonary artery systolic pressure,
PA, pulmonary angiography, chup mach huyt ap ng mach phi tm thu, 255,...
phi, 935 Pasteurella multocida, 675, 687, 702
PA, pulmonary artery, ng mach phi, 349 Pazopanib trong ung th thn, 1022
PAC, pulmonary artery catheters, ng thng PBC, primary biliary cirrhosis, x gan mt
ng mach phi, 361 nguyn phat, 832,...
Paclitaxel, 748, 1004b, 1005b, 1011, 1030 PBP, penicillin binding proteins, penicillin
PaCO2, arterial carbon dioxide tension, phn gn protein, 687
ap CO2 trong mau ng mach, 339 PBP2a, penicillin binding protein 2a, 692
PACs, premature atrial complexes, ngoai PCA, patient-controlled analgesia, iu chnh
tm thu nh, 286 thuc giam au tng bnh nhn, 818
PAH, pulmonary arterial hypertension, tng PCC, prothrombin complex concentrate,
huyt ap ng mach phi, 405 phc hp prothrombin c c, 922
PAI-1, plasminogen activator inhibitor-1, PCECV, purified check embryo cell
vaccine, vc-xin t bao phi ga tinh ch Pentasa trong bnh vim rut, 806
a c kim tra, 1357 Pentasaccharide bin chng chay mau, 947
PCI th u trong nhi mau c tim, 194~196 Pentobarbital trong ng kinh, 1200
PCI, percutaneous coronary intervention, can Pentostatin trong bnh bach cu, 1042
thip ng mach vanh qua da, 149,... Pentoxifylline, 860, 879
PCN, penicillin, 619,... PEP, postexposure prophylaxis, thuc d
PCP, Phencyclidine, 1260 phong sau phi nhim, 1352
PCP, pneumocystis jiroveci pneumonia, Peptide li niu, 218, 224, 232, 261, 945
vim phi do pneumocystis jiroveci, 743 Pepto-Bismol vi H. pylori, 802
PCR, polymerase chain reaction, phan ng Permanent AF, rung nh man tnh, 290
khuch ai chui, 595,... Perphenazine ng c, 1297
PCWP, pulmonary capillary wedge pressure, Persistent AF, rung nh dai dng, 290
ap lc ging mao mach moi, 268 PET, position emission tomography, chup
PD, peritoneal dialysis, thm phn phuc ct lp phat xa positron, 241,...
mac, 584,... Petrolatum trong nga do mt, 670
PDA, posterior descending artery, ng PEX, plasma exchange, trao i huyt
mach lin tht sau, 320 tng, 910
PDE4, phosphodiesterase 4, 375,... PF4, platelet factor 4, phc hp yu t 4
PDE-5 I, phosphodiesterase-5 inhibitor, tiu cu, 911
cht c ch phosphodiesterase5, 415 PFA-100 trong ri loan ng mau, 903
PE, pulmonary embolism, tc mach phi, 930 PFT, pulmonary function test, thm do chc
PEA, pulseless electrical activity, hoat ng nng phi, 40,...
in v mach, 1371 PH, pulmonary hypertension, tng ap ng
Pectin trong tiu chay, 787 mach phi, 266,...
PEEP trong th may, 350 Phan hi sinh hoc trong tao bon, 791
PEEP, positive end-expiratory pressure, ap Phan ng
lc dng cui ky th ra, 348,... cheo trong truyn mau cha tr, 991
PEF, peak expiratory flow, lu lng nh co hai cua thuc, 473~478
th, 386 huyt thanh trong vim gan virus B, 841
PEG, polyethylene glycol, 790 tan mau mun trong truyn mau, 993
Peg-IFN/RBV, peginterferon/ribavirin, 851 Phan v, 476b, 994, 1238
Pegloticase trong gut, 1154 Phan xa gn xng, 1112, 1224
Pegvisomant trong to u chi, 1135 Phat ban, 492
Pegylated interferon- vi vim gan, 752b, Phn, 773
753b long ra mau trong vim loet ai trang, 804
Pemetrexed, 1004b, 1005b, 1008 m, 786, 820, 867, 868
Penbutolol, tng huyt ap, 100b Phn loai
Penicillamine, 570, 872, 976b, 1174 Coomb trong phan ng thuc, 475, 476b
Penicillin, 467, 474, 597, 600b, 604, 615, Killip trong nhi mau c tim cp, 180h, 196
617b, 619b, 640, 648b, 666, 682, Mallampati trong ngng th khi ngu, 422,
687~689, 918, 976b 422b
G, 615, 629, 648b, 660b, 667, 674, 751, Phenazopyridine vi hng cu, 976b
1233, 1235 Phencyclidine trong ng c, 1260~1261
V, 602, 623, 660b, 688 Phenelzine trong ng c, 1285,
VK trong bnh hng cu hnh lim, 974 Phenobarbital, 737, 1125, 1276, 1318, 1327
Pentamidine, 391b, 744, 762 Phenolphthalein trong tao bon, 789
Phenothia trong ng c, 1297~1299 trong suy gan cp, 887~889

Phenothiazine, 784, 1132 Phu nim, 1115, 1116, 1252
Phentolamine, 112b, 1287, 1322, 1324 Phu phi, 340b, 367~368, 453, 1245, 1332
Phenylbutazone vi hng cu, 976b do tim, 230~232
Phenylephrine trong ng c, 1327 Phu thai trong Thalassemia, 959
Phenylketon niu vi ng kinh, 1197b Phu khoa, 691
Phenytoin, 319, 736b, 737, 906, 1111b, ung th, 1026~1030
1114, 1125, 1249 Phc b min dch, 476b, 980
ng c, 1277~1279 Phc hp prothrombin c c, 327, 922,
Ph cu khun, 608, 621, 754b, 762 926~927
Phnh ng mach Phc hp st gn polysaccharide, 956, 956b
chu trong giam tiu cu, 905b Phng trnh Henderson-Hasselbalch trong
nao, 579, 1202 ri loan kim toan, 542
Phnh mach do nm, 613 Physostigmine, 1310, 1315
Phnh tach ng mach chu, huyt ap, 115 PICA, posterior inferior cerebellar artery,
Phnh thanh tim trong nhi mau c tim, 211 ng mach tiu nao sau di, 1204
Phong co ap sut m trong ly nhim, 1362 Picornavirus trong vim gan virus A, 838
Phosphate, 1079~1080, 790 PID, pelvic inflammatory disease, bnh
mau, 536~539, 1136 vim vung chu hng, 653
Phospho, 93, 535~539, 581~583, 856, 1051, PID, primary immunodeficiencies, suy
1135, 1258 giam min dch nguyn phat, 497
hu c, ng c, 1311~1313 PIE, pulmonary infiltrates with
mau vi canxi mau, 530, 533, 534 eosinophilia, hi chng thm nhim
Phosphodiesterase type 5 trong ri loan phi vi tng bach cu ai toan, 485
cng dng do ai thao ng, 1102 pIFN, pegylated interferon alpha, 845
Phi hp thuc trong ai thao ng, 1091 pIFN, 851, 852
Phi, 38~42, 405~472, 488b, 679, 683, 704 Pilocarpine trong hi chng Sjgren, 1163
bin chng, 819, 1245 PiM, protease inhibitor M, c ch men tiu
ke, 427~437 protein, 876
nt n c, 437~444 Pindolol, tng huyt ap, 100b
tc nghen, 369~384, 376~377b, 379, 380 Pioglitazone, 1084b, 1088~1089
tng ap ng mach phi, 405~419 Piperacillin, 643b, 689
thai ghep cp tnh, 764~765 Piperacillin/tazobactam, 629, 630, 636b,
thm do chc nng, 389, 410~411, 431 638b, 643b, 689, 1104
tn thng cp vi truyn mau, 994~995 Pi, protease inhibitor, c ch men tiu
tran dch, 445~454 protein, 731
trong nhim nm, 662, 663, 664~666, 703 Pitavastatin, ri loan lipid, 133b
ung th, 1006~1009 PiZZ, bin th thiu Pi, 876
x nang, 462~471 PJC, juxtacardiac pressure, ap lc canh tim,
Phu, 567, 881 363
gai th trong au u, 1212 PK, prekallikrein, 904
Phu mach, 476b, 475, 480, 486, 489b, Plasmapheresis trong nga do mt, 670
492~497, 488b, 1237 Plasmodium trong st ret, 671, 672
ma khng ni m ay, 494, 495 Platinum trong ung th, 1008, 1013
Phu mt va quanh mt trong suy giap, 1112 Plavix trong xut huyt ng tiu hoa, 774
Phu nao, 1080~1081, 1093, 1210, 1244 PLEDs, periodic lateralized epileptiform
discharges, 1189 PPI, proton pump inhibitor, c ch bm
PM, polymyositis, vim a c, 1183 proton, 170,...
PMBV, percutaneous mitral balloon PPI, 794, 798, 803
valvotomy, phng phap nong van hai PPI vi H. pylori, 801, 802
la bng bong qua da, 254 PPM, permanent pacemaker, may tao nhp
PMF, primary myelofibrosis, x tuy nguyn tim vnh vin, 324
phat, 984 PPSV, pneumococcal polysaccharide vaccine,
PMI, perioperative myocardial infarction, vc-xin phong ph cu khun, 1347
nhi mau c tim quanh phu thut 22 PR, progesterone receptor, thu th
PML, progressive multifocal progesterone, 1009
leukoencephalopathy, bnh ly cht Pralidoxime, 1313~1314, 1316
trng nao a tin trin, 810,... Pramipexole trong Parkinson, 1223
PMN, polymorphonuclear leukocytes, bach Pramlintide vi ai thao ng, 1086b, 1090
cu a nhn, 894 Prasugrel, khang tiu cu, 168b, 169~170,
PMN, polymorphonuclear neutrophils, t 188, 189b, 201
bao a nhn trung tnh, 635 Pravastatin, 133b, 735b, 737
PMR, polymyalgia rheumatica, au a c Praziquantel trong u trung san nao, 611
do thp, 1181 Prazosin, 103b, 1177
Pneumocystis, 574, 701, 1042, 1048, 1145 PRBC, packed red blood cells, khi hng
Pneumovax trong suy giam min dch, 501 cu, 362
PNH, paroxysmal nocturnal Prednisolone, 819, 860, 1057
hemoglobinuria, ai huyt sc t niu Prednisone, 382b, 398, 574, 590, 632, 743,
kch phat v m, 931 744, 807, 808, 824, 907, 908, 910, 929,
PNS, persistent neurologic sequelae, di 980, 1144, 1045, 1046, 1161, 1172,
chng thn kinh dai dng, 1338 1178, 1181, 1182, 1183, 1231
PO, per os, by mouth, oral, ng ung, 596 trong bnh thn, 565, 569~571, 573,
Polydeoxyribonucleotide trong hi chng 575~577, 591, 1125
tc nghen xoang gan, 883 trong sc phan v, 480
Polyethylene glycol, 790, 1262, 1275, 1296, trong vim gan t min, 862, 863
1305 Pregabalin, 820, 1098
Polymer glucose trong loc mang bung, 589 PRES, posterior reversible encephalopathy
Polyp mui, 401, 624 syndrome, hi chng bnh nao h sau
Polythiazide, tng huyt ap, 102b co hi phuc, 1211
Porphyria vi ng kinh, 1197b Prevotella spp. , 624, 629
Porphyrin cp tng cn vi hi chng Primaquine, 672, 976b, 700, 743
GuillainBarre phn bit, 1225b PRN, pro re nata, as needed, b sung khi
Posaconazole, 656b, 718, 744 cn thit, 2,...
post-TURP, posttransurethral resection of Probenecid gy ri loan hng cu, 688, 716,
the prostate syndrome, sau ct tin lit 977b, 1154
tuyn qua niu ao, 512 Probiotic trong ri loan tiu hoa, 813
Potassium chloride trong loc mang bung, 590 Procain penecillin G, 688
Povidoneiodine trong t cong b mt, 1250 Procainamide, 303b, 976b, 1174
PPCM, peripartum cardiomyopathy, bnh Procaine penicillin, 648b
c tim chu san, 216,... Prochlorperazine, 784, 814, 1055, 1222, 1297
PPE, personal protective equipment, thit b Proguanil trong st ret, 672
bao h ca nhn c bit, 1313 Prokinetic, 785, 827
Prolactin mau, 1128~1129, 1130, 1132~1134 trong gan qua da, 834
Promacta trong xut huyt giam tiu cu, 908 PTH, parathyroid hormone, hormon tuyn
Promethazine, 784, 1233, 1309 cn giap, 528
Promotility trong x cng b toan th, 1176 PTH-rP, parathyroid hormone-related
Propafenone trong rung nh, 302, 304b protein, protein lin quan hormone cn
Propanolol, tng huyt ap, 100b giap, 1051
Prophy-lactic trong hen ph quan, 401 PTHrPs, PTH related peptides, khi u tit
Propionibacterium vi nao tht, 609 peptide ging PTH, 529
Propofol, 360b, 1200, 1290, 1297, 1322, PTLD, posttransplant lymphoproliferative
1324, 1327 disorder, bnh tng sinh lympho bao
Propoxyphene opioid trong ng c, 1272 sau ghep tang, 767
Propranolol, 296b, 1121, 1214, 1302, 1303 PTP, posttransfusion purpura, ban xut
Propylthiouracil, 1118, 1119, 1121 huyt sau truyn mau, 914
PROSPER, prospective study of pravastatin PTT, partial prothrombin time, thi gian
in the elderly, nghin cu thun tp cua prothrombin tng phn, 181,...
pravastatin ngi cao tui, 132 PTU, propylthiouracil, 1118
Prostaglandin trong hi chng Raynaud, PUD, peptic ulcer disease, loet da day ta
1142, 1177 trang, 779,...
Prostanoids trong tng ap mach phi, 414 Pulmozyme trong x nang phi, 466
Protamine sulfate trong huyt khi, 938 Purine trong bnh vim rut, 808
Protein, 58, 59b, 78~79, 498, 576~577, 590 PV, polycythemia vera, a hng cu, 984
niu, 556, 559b, 577, 578 PVC, premature ventricular contractions,
Proteus, 591, 645, 690, 704, 708 ngoai tm thu tht, 1326
Providencia vi colistinethate sodium, 704 PVD, peripheral vascular disease, bnh ly
Prucalopride trong tao bon, 790 mach mau ngoai bin, 139,...
PSA, prostate-specific antigen, khang PVE, prosthetic valve endocarditis, vim
nguyn c hiu tin lit tuyn, 1024,... ni tm mac do van gia, 612
PsA, psoriatic arthritis, vim khp vay nn, PvO2, mixed venous oxygen tension, ap lc
1140 trao i oxy mau tnh mach, 341
PSC, primary sclerosing cholangitis, vim PVR, pulmonary vascular resistance, sc
x ng mt nguyn phat, 832,... can mach phi, 253,...
Pseudomonas, 589, 609, 629, 681, 689, PVT, portal vein thrombosis, huyt khi
691, 692, 693, 695, 698, 704, 705, 708, tnh mach ca, 883
1148 Pyradoxine trong lao phi, 631
PSG, polysomnography, o a ky gic ngu Pyrazinamide, 631, 712, 961, 976b
qua m, 423 Pyridostigmine, 1231, 1315
PSV, pressure support ventilation, thng Pyridoxine, 632, 872, 961, 1287, 1333, 1334
kh h tr ap lc, 348 Pyrimethamine, 700, 746, 962
Psyllium trong tao bon, 789 PZA, pyrazinamide, 631
PT, prothrombin time, thi gian PZI, protamine zinc insulin, 1074
prothrombin, 181,... PZI insulin trong ai thao ng, 1074b
PT, 833, 903
PT/INR, thi gian prothrombin/ty s chun Q
hoa quc t, 1208 Qua liu, 1257~1263
PTC, percutaneous transhepatic Qua tai tun hoan, 90, 566, 567, 585, 994
cholangiography, dng hnh ng mt Quai b, 728, 1148
Quanh phu thut, 22~56, 245, 249, 1071~1072 RBC, red blood cells, t bao hng cu, 556,...
Quetiapine, 1190, 1222, 1300~1301, 1309 RB-ILD, respiratory bronchiolitis
Quinacrine, 788, 976b interstitial lung disease, vim tiu ph
Quinapril, tng huyt ap, 101b quan phi ke, 427,...
Quinethazone, tng huyt ap, 102b RCA, right coronary artery, ng mach
Quinidine, 303b, 672, 735b, 737, 786, 793, vanh phai, 183,...
906, 977b, 1174 RCC, renal cell carcinoma, ung th biu m
Quinine, 670, 672, 700, 906, 977b, 1229 t bao thn t bao sang, 1021
Quinolone, 894, 1229 RCM, restrictive cardiomyopathy, bnh c
Quinupristin, 615, 618b tim han ch, 233
Quinupristin/Dalfopristin, 680, 708~709 RCRI, revised cardiac risk index, ch s
nguy c tim sa i, 26,...
R RDI, respiratory disturbance index, ch s
R, renal, qua thn, 305 ri loan h hp, 420
RA, refractory anemia, thiu mau dai dng, RDW, red cell distribution width, dai phn
1031 b kch thc hng cu, 952
RA, rheumatoid arthritis, vim khp dang Regular insulin trong ai thao ng, 1074b
thp, 446,... REM, rapid eye movement, pha chuyn
RAAS, renin-angiotensin-aldosterone ng mt nhanh, 423,...
system, h thng renin-angiotensin- ReoPro trong xut huyt ng tiu hoa, 774
aldosterone, 217 Repaglinide vi ai thao ng, 1087, 1083b
Radon vi ung th phi, 1007 RERAs, respiratory effort related arousals,
RADT, rapid antigen detection testing, test gng sc h hp lin quan khi thc, 420
phat hin khang nguyn nhanh, 622 Reserpine, tng huyt ap, 103b, 107
RAEB, refractory anemia with excess Reteplase, thuc tiu si huyt, 197, 198b
blasts, thiu mau dai dng tng t bao Reticularis livedo, 930
non (blasts), 1031 Retrovirus, 723
RAEB-t, refractory anemia with excess RF, rheumatoid factor, yu t dang thp,
blasts in transformation, thiu mau dai 1142,...
dng tng blast chuyn dang, 1031 RFA, radiofrequency ablation, t nhit
Raloxifene, 532, 1111b bng song cao tn, 797,...
Raltegravir, 733, 734b rFVIIa, recombinant factor VIIa, yu t
Ramelteon trong mt ngu, lo u, 21~22 VIIa tai t hp, 918
Ramipril, tng huyt ap, 101b RHC, right heart catheterization, thng tim
Ranitidine, 496, 795b phai, 250,...
Ranolazine trong bnh mach vanh, 155 Rhinovirus, 626, 1365b
RAP, right atrial pressure, ap lc nh phai, Rhizopus trong nhim nm mucor, 664
412 Rhodococcus equi trong HIV-AIDS, 753b
Rapamycin, 591, 1022 RI, reticulocyte index, ch s hng cu li,
RARS, refractory anemia with ringed 953
sideroblasts, thiu mau dai dng tng Ribavirin, 685, 736, 736b, 752b, 851, 852,
nguyn hng cu st vong, 1031 1182
Rasburicase, 564, 1051 Rickettsia, 620, 667, 702, 704, 886, 905b
Rm lng, 1126, 1145 RIF, rifampin, 631
RBBB, right bundle branch block, block Rifabutin, 711), 735, 735b, 736b, 737, 742,
nhanh phai, 186,... 743, 802
Rifampicin trong HIV-AIDS, 753~755b thng bng kim toan, 542~553

Rifampin cung la Rifampicin, 602, 606, tm thn, 871, 887
608, 609, 668, 674, 680, 711, 735b, thn kinh, 788, 909
736b, 737, 906, 937, 977b, 1114, 1125 thn kinh c, 1232~1233, 1233~1235
trong lao phi, 631 thn kinh trung ng, nn, bun nn, 784
trong nga do mt, 670 th lc trong ai thao ng, 1094
trong vim ni tm mac, 616, 619b tin nh vi vitamin B12, 962
Rifamycin, 711~712, 736b, 737 tiu hoa, 784, 812~814, 1271
Rifapentine vi thuc c ch protease, 735b tr nh trong bnh Alzheimer, 1192, 1193,
Rifaximin, 598, 897 1194b
RIG, rabies immune globulin, globulin vn ng thc quan, 797~799
min dch khang dai, 1359 vn ngn, 871, 1229
Rilpivirine, 731b, 736b y thc, 16~18, 896, 1092, 1185~1194
Rimantadine, 626 713 Romiplostim trong xut huyt, 908
Ringers lactated, 505b, 778, 1262 Rong kinh trong bnh von Willebrand, 923
RIS, immune reconstitution syndrome, hi Ropinirole trong Parkinson, 1223
chng phuc hi min dch, 739 Rosvastatin, ri loan lipid, 133b
Risedronate trong bnh Paget, 1137 r-PA, reteplase , 197
Risperidone trong ng c, 1132, 1300~1301 RPGN, rapidly progressive
Ritonavir (RTV), 732b glomerulonephritis, vim cu thn tin
Rituximab, 574, 762, 908, 910, 929, 980, trin nhanh, 564
1041, 1045, 1160, 1172, 1184, 1232 RPR, rapid plasma reagin, xet nghim
trong bnh cu thn, 568 nhanh chn oan giang mai, 607,...
trong vim mach hoai t, 1178 RR, relative risk, nguy c tng i, 943
Rivaroxaban, 937~938, 947, 1209 RSV, respiratory syncytial virus, virus hp
Rivastigmine trong bnh Alzheimer, 1194 bao h hp, 387
RLQ, right lower quadrant, goc phn t RTA, renal tubular acidosis, toan hoa ng
pha bn phai, 639 thn, 522, 546
RMSF, rocky moutain spotted fever, bnh RTA1, distal (type 1) RTA, Toan hoa ng
st m vung nui a, 667 thn do ng ln xa, 547
RNS, repetitive nerve stimulation, kch thch RTA2, proximal (type 2) RTA, Toan hoa
dy thn kinh lp lai nhiu ln, 1230 ng thn do ng ln gn, 547
ROD, renal osteodystrophy, loan dng RTA4, distal hyperkalemic (type 4) RTA,
xng do thn, 580 Toan hoa ng thn do tng kali mau
Ri loan ng ln xa, 547
cam giac, 684, 1224 rt-PA, recombinant tissue plasminogen
chay mau di truyn, 919~925 activator, hoat hoa plasminogen tai t
chc nng tang ghep man tnh, 767~768 hp, 197,...
in giai vi ng kinh, 1197b rt-PA ng tnh mach trong t quy, 1206,
hu mn trc trang, 823 1207b, 1208b
huyt hoc va iu tr truyn mau, 951~996 RTV(r), ritonavir, 733
kinh nguyt trong tng prolactin mau, 1132 Rubella, 728, 1148, 1365b
lng ong/ri loan protein mau, 576~577 Run, 871, 1221, 1222b, 1284
lu tr lysosomal vi giam tiu cu, 905b vi hi chng serotonin, 1234, 1292, 1293
mt tuy, 816~822 Rung git nhan cu trong ng c, 1278,
ng tiu hoa, 791~816 1281, 1282, 1295
Rung nh, 255~256, 290~309, 1116 Salicylate, 546b, 1111b, 1143, 1260
vi nhp nhanh trn tht, 284, 286 trong ng c, 1274~1277
Rung tht, 209, 310 Salmeterol trong hen, 466, 396, 376, 397b
Rung toc vi colchicin trong ng c, 1269 Salmonella, 754b, 786, 788, 973, 1168
Rut trong dinh dng, 59, 74~75, 83~84 SAM, systolic anterior motion, chuyn ng
RUQ, right upper quadrant, goc phn t v pha trc trong th tm thu, 237
pha trn bn phai, 635,... SANRT, sinoatrial nodal reentrant tachycardia,
Rut mau tnh mach trong a hng cu, 985 nhp nhanh vao lai nut xoang nh, 288
Ruxolitinib trong x tuy nguyn phat, 986 SaO2, arterial oxygen saturation, bao hoa
Ra oxy trong mau ng mach, 339
da day trong ng c, 1261~1262 Saquinavir (SQV), 732b, 737
ph quan trong bnh phi ke, 431 Sarcoidosis trong bnh phi ke, 427~437
rut toan b trong ng c, 1262 Sarcoidosis, 406b, 565, 886, 1218b, 1225b
Ru, 495, 816, 860, 962, 1014, 1019, Sarcoma, 771, 788, 931, 1013~1014
1197b, 1199, 1251, 1318 Sarin vi phospho hu c trong ng c, 1311
c, 1327~1328 SARS trong ly nhim cach ly, 1365b
RV, right ventricle, tm tht phai, 250,... SARS, severe acute respiratory syndrome,
RVEDP, right ventricular end-diastolic, ap hi chng suy h hp cp nng, 686,...
lc cui thi ky tm trng tht phai, 246
Saxagliptin vi ai thao ng, 1085b, 1089
RVF, Rift valley fever, st thung lung Rift, St, 61b, 788, 793, 956, 957b, 1055, 1114
685 Sy thai, 930, 931, 1174
RVMI, right ventricular myocardial SBE, subacute bacterial endocarditis, vim
infarction, nhi mau c tim tht phai, 181 ni tm mac ban cp do vi khun, 612
RVOT-VT, right ventricular outflow tract- SBP, spontaneous bacterial peritonitis, vim
VT, VT t phat bt ngun t ng ra phuc mac nguyn phat hoc t phat do
tht phai, 311 vi khun, 634,...
RVSP, right ventricular systolic pressure, SBP, systolic blood pressure, huyt ap tm
ap lc tm thu tht phai, 246 thu, 24,...
Rx, treatment, iu tr, 167 SC, subcutaneous, tim di da, 13,...
SCD, sickle cell diseases, bnh hng cu
S hnh lim,971
Sa sut tr tu, 1194b, 1221, 1222, 1222b SCD, sudden cardiac death, t t do tim,
trong bnh Alzheimer, 1192, 1193, 1194b 310,...
Sa van hai la trong loan nhp nhanh, 280 Scedosporium apiospermum vi
SA, sinoatrial, nut xoang, 288 voriconazole, 719
SAAG, serum-to-ascites albumin gradient, Scombroidosis trong sc phan v, 482
chnh lch nng albumin trong huyt Scopolamine, 783, 1258, 1309
thanh va trong dch c trng, 881 SCORE, systemic coronary risk evaluation,
San mang trong ung th bang quang, 1022 bnh mach vanh h thng, 141
San git, 112b, 118~119, 908, 915, 930, 981 SCT, stem cell transplantation, ghep t bao
vi ng kinh, 1197b gc, 960
SABA, short-acting -agonist, thuc cng ScvO2, central venous blood oxygen
tac dung ngn, 377 saturation, bao hoa oxy mau tnh
SAC, standardized assessment of mach trung tm, 364
concussion, bang anh gia chn ng Secnidazole trong ap-xe gan do amip, 885
chun hoa, 1215 Serevent trong phi tc nghen, 376
Serotonin, 1213, 1234 khang c trn, 861

Serratia, 704, 708 SMART, salmeterol multicenter asthma
Sertraline, 813, 1291 research trial, nghin cu th nghim
Sevelamer carbonate trong bnh thn, 583 a trung tm v Salmeterol bnh nhn
S-len (SeO42-), dinh dng, 62b hen, 402
SFU, sulfonylurea, 1069, 1086 SMBG, Self monitoring of blood glucose,
Shigella, 786, 788, 1168 t theo doi ng mau, 1066
Shunt, 340b, 341 SND, sinus node dysfunction, ri loan chc
SIADH, including syndrome of nng nut xoang, 324
inappropriate diuretic hormone, hi SNRIs, serotonin norepinephrine reuptake
chng tit hormone li niu khng phu inhibitors, thuc c ch tai hp thu
hp, 1226 serotonin norepinephrine, 1214
SIADH, syndrome of inappropriate SNRIs trong au u d phong, 1214
antidiuretic hormone, hi chng tit SNS, sympathetic nervous system, h thn
hormon khang niu khng thch hp, 440 kinh giao cam, 1311
Sildenafil, 416b), 735b, 737, 1102, 1177 SOB, shortness of breath, kho th, 324
SIMV, synchronized intermittent Sodium nitroprusside, 224, 110, 111b, 115
mandatory ventilation, thng kh nhn Sodium polystyrene sulfonate trong tng
tao ngt quang ng th, 347 kali mau, 527
Simvastatin, 133b, 735b, 1095 Soi, 591, 592
Sinemet trong Parkinson, 1223 mt, 821~822, 692, 816, 864, 971, 972 , 974
Sinh mau ngoai tuy, 905b, 959 ng mt chu, 821, 822
Sinh non trong hi chng antiphospholipid thn, 529, 562, 591~592
antibody, 930 Somatostatin, 896, 1135
Sinh tuy ri loan, 931, 918, 1031~1033 Song ai bac A trong loan nhp nhanh, 281
Sinh vt n bao vi metronidazole, 707 Sorafenib, 899, 998b, 1020, 1022
Sipuleucel-T trong ung th tin lit tuyn, SOS, sinusoidal obstruction syndrome, hi
1025 chng tc nghen xoang, 882
Sirolimus trong ghep tang, 759~760 Sotalol, 304b, 318, 1301, 1303
Sitagliptin vi ai thao ng, 1084b, 1089 Sc, 358~366, 362b, 546b, 880
Sitaxsentan trong tng ap mach phi, 417b in, 308~309, 316
SJS, Stevens-Johnson syndrome, hi chng giam th tch, 361~362
Stevens-Johnson, 475 nhim trung, 364~366, 365h
SLE, systemic Lupus erythematosus, Lupus phan v, 475, 476b, 478~483, 957, 1142
ban o h thng, 251,... phn b, 364~366
SLED, sustained low efficiency dialysis, tim, 207, 210, 184h, 362~363
duy tr hiu qua loc mau thp, 586 vi ng mau ni mach rai rac (DIC), 928
SLL, small lymphocytic lymphoma, u St, 9~10, 252, 565, 587, 606, 609, 612, 622,
lympho t bao lympho nho, 1045 625, 627, 644, 669, 670, 674, 685, 810,
Slow-Mag trong ha magie mau, 542 991, 993, 1192, 1197b, 1212, 1367b
SLUDGE, Salivation-Lacrimation- au u, au c, 668, 671, 685
Urination-Defecation-Gastrointestinal m vung nui a, 667~668
[GI] distress- Emesis, 1258 giam bach cu, 691, 703, 703, 715,
SM, Smith, 1171 1049~1050
SM, streptomycin, 631 Lassa trong nhim virus st xut huyt,
SMA, smooth muscle antibodies, khang th 685
phat ban Rocky Moutain, 703 Stavudine (d4T), 730b
Q trong vim ni tm mac, 616 STD, sexually transmitted disease, bnh ly
ret, 670, 671~672, 905b, 975, 1248 truyn qua ng tnh duc, 1349
Rickettsia, 667, 668 STEMI, ST-segment elevation MI, nhi
vet, 703 mau c tim co ST chnh ln, 140
xut huyt, 685, 1368b Stenotrophomonas, 689, 693, 701
S lanh trong suy giap, 1112 Steroid, 574, 575, 576, 982, 1216, 1232
S nong trong cng giap, 1116 Stimate trong chay mau Hemophilia A, 920
Si, 728, 835, 1350b, 1363b Streptococci, 691, 705, 706, 690, 699, 709
SPECT, single photon emission computed Streptococcus, 615, 623, 624, 627, 629,
tomography, chup ct lp vi tnh ti 676, 709, 973, 1364b
mau phat xa n photon, 1194 Streptokinase, thuc tiu si huyt, 197, 198b
Spectinomycin vi ly qua ng tnh duc, 648b Streptomycin, 617b, 631, 632, 669, 684, 713
SPEP, serum protein electrophoresis, in Stress, anh gia tnh trang, 28
di protein huyt thanh, 556,... Strongyloides stercoralis, trong tng bach
Spiriva trong phi tc nghen, 376 cu ai toan, 488b
Spirochetes vi chloramphenicol, 704 STS, society of thoracic surgeons, hi phu
Spironolactone, 103b, 225, 551, 892 thut lng ngc, 156
SPN, solitary pulmonary nodule, nt n Succinylcholine, 359b, 1234
c tai phi, 437 Sucralfate, 793, 801, 1114
Sporothrix schenckii trong nhim nm Sucrose st trong bnh thn man tnh, 582
sporotrum, 663 SUDEP, sudden death in epilepsy, t t
Sporotrichosis vi Itraconazole, 718 trong cn ng kinh, 1199
SPS, sodium polystyrene sulfonate, 55 Sulbactam, 617b, 618b
SQV/r, saquinavir/ritonavir, 733 Sulfacetamide gy ri loan hng cu, 976b
SR, sustained release, giai phong keo dai, 305 Sulfadiazine, 702, 701, 746
SRA, serotonin release assay, nh lng s Sulfamethoxazole, 574, 579, 701, 937, 976b
tit serotonin, 913 Sulfanilamide gy ri loan hng cu, 977b
SS, single strength, 643 Sulfapyridine gy ri loan hng cu, 977b
SSKI, supersaturated potassium iodide, kali Sulfasalazine, 806, 962, 1157~1158, 1167,
iodide qua bao hoa, 1120 1169, 1170
SSRI, selective serotonin reuptake inhibitor, Sulfinpyrazone trong gut, 1154
cht c ch tai hp thu chon loc Sulfite, 401, 482
serotonin, 337,... Sulfonamide, 474~475, 597, 665, 701~702,
SSRI, 820, 1214, 1291~1292 906, 977b
SSTIs, skin and soft tissue infections, Sulfonylurea vi ai thao ng, 1082, 1083b
nhim trung da va m mm, 601 Sumatriptan vi hi chng nn chu ky, 814
ST, sinus tachycardia, nhp nhanh xoang, 286 Sunitinib, 998b, 1022, 1055, 1112
Staphylococci, 587, 690, 696, 699, 705, 706 Supartz trong thoai hoa khp, 1165
Staphylococcus aureus, 623, 624, 629, 675, Sup mi mt trong bnh nhc c, 1228, 1229
677, 709, 1104 Sut cn, 438, 630, 1116 , 1124
Staphylococcus aureus, 616, 645, 677, 692, Suy dinh dng, 498, 630, 867
704, 705 Suy a phu tang, 599, 661, 928
Statin, 29, 176, 177~178, 261, 568, 584, Suy gan, 561, 896, 918, 960, 1186b, 1197b,
590, 796, 879 1264, 1265, 1268
trong ri loan lipid, 132~133, 133b cp, 839, 841, 849, 862, 871, 887~889, 900
Suy giam min dch, 487, 497~501, 498, bao hoa oxy mau tnh mach pha trn, 342
607, 624, 654, 661, 662, 663, 665, 693, SVR, systemic vascular resistance, sc can
792, 1043 mach mau h thng, 221,...
ngi, HIV-AIDS, 498, 723~754 SVT, superficial vein thrombophlebitis,
Suy giap, 788, 1112~1115, 1118, 1120, huyt khi tnh mach nng, 945
1123, 1132, 1186b, 1193, 1194b SVT, supraventricular tachycardia, nhp
Suy h hp, 339~342, 540, 668, 1077, nhanh trn tht, 1326
1220, 1224, 1229, 1237, 1241, 1244 SVTs, supraventricular tachyarrhythmias,
cp, 566, 686, 1093, 1249 nhp nhanh trn tht, 283
nng ln trong th may, 351~352 Symbicort trong phi tc nghen, 376
trong sc phan v, 480 Synvisc trong thoai hoa khp, 1165
trong ng c, 1233, 1270, 1283, 1301,
1314, 1315, 1317, 1332, 1335, 1336 T
vi opioid, 1272 T3, triiodothyronine, 1111
Suy kit trong ung th, 1061 T4, thyroxine, 1111
Suy nhau thai trong hi chng TA, temporal arteritis, bnh vim ng
antiphospholipid antibody, 930 mach thai dng, 1181
Suy sinh duc, 874, 960 Tai ng b c tim, 235, 338
Suy thn, 406b, 562, 573, 634, 668, 819, 894, Tai thng mach, 30
891~892, 909, 1047, 1247, 1182, 1186b vanh, 125, 155~157, 163, 177~178
cp, 56, 887, 1142, 1249, 1332 Tai ti mau mach vanh, 194~201, 195h, 228
man, 54~55, 117, 537, 630, 770, 1132 Tao bon, 788~791, 1052, 1055
thiu mau, 964~965 Tabun vi phospho hu c, 1311
trong bnh thn, 558, 559, 567, 575, 576, TACE, transarterial chemoembolization,
579, 580, 982, 989 nut ng mach gan bng hoa cht, 899
Suy thng thn, 51~54, 364~366, TACO, transfusion-associated circulatory
1123~1126, 1131, 1252 overload, qua tai tun hoan do truyn
Suy tim, 117~118, 215~232, 233, 235~236, mau, 994
246, 258, 456b, 533, 538, 559b, 616, Tacrolimus trong ghep tang, 591, 760~761,
880, 891, 952, 964, 1099, 1116, 1332 565, 863, 910
phai, 408~409, 436 Tacrolimus, 810, 1232
sung huyt, 90, 281, 338, 391b, 580, 960, 1302 Tadalafil, 416b, 1102
tm thu, 338, 406b Taenia solium trong u trung san, 611
tm trng, 235, 406b Tai bin mach mau nao cp, 973, 974, 1252
trai, 445, 454 Tam chng Beck, 249
Suy tuy trong ri loan sinh tuy, 1031, 1032 Tam chng Charcot, 635, 821
Suy tuy vi vitamin B12, 962 Tamoxifen, 1010, 1011, 1111b
Suy tuyn cn giap, 532, 536 Tan mau, 670, 907, 951, 954, 961, 962,
Suy tuyn tuy, 469, 820 971, 972, 975
Suy tuyn yn, 1129, 1130~1131 TARE, transarterial radioembolization, nut
Sa magi trong tao bon, 789 mach xa tr, 899
Sc khoe tim mach ly tng, 143b TAVR, Transcatheter aortic valve
SV, strocke volume, th tch tng mau, 265 replacement, Thay van ng mach chu
SVC, superior vena cava syndrome, hi qua da, 262
chng tnh mach chu trn, 1007 Taxane trong ung th vung u va c, 1013
SvO2, mixed venous oxygen saturation, Tc hep mn v, nn, bun nn, 784
Tc mach, 406b, 565, 971 Tng thn nhit, 1234, 1258, 1274, 1286,
kh, 364, 1218b 1293, 1298, 1310, 1320, 1322, 1323, 1324
i, 364, 931 ac tnh, 1234, 1233, 1247
phi, 86, 364, 456b, 930, 931, 934~936, 945 Tng thng kh, 391b, 888, 1188, 1276, 1290
vi tiu si huyt, 943 Tng tit hormone, 1127, 1130
Tc mt cp tnh, 635, 821 Tng tiu si huyt trong bnh gan, 327
Tc nghen ng th, 462, 1237~1239 Tng tiu cu, 916~917
Tc nghen ng tit niu, 547, 559b, 581 Tng triglyceride mau, 122b, 129~130,
Tc nghen ng tuy trong vim tuy man, 821 135~136, 816
Tc nghen da day, 803 Tng trng lc c, thn kinh c, 1233~1235
Tc rut, 469, 810, 1055, 1225 Tng ur huyt, 546b, 585, 1197b
Tc tnh mach gan, 882~883 Tn sut cho n, qua ng tiu hoa, 79
Tng ap caphi trong ghep gan, 900 Tp th duc, 869, 879, 1065, 1068
Tng ap ng mach phi, 405~419, 406b, 436 Tt ap lc, 944, 1098
trong bnh hng cu, 971, 972, 974 TB, tuberculosis, bnh lao, 438,...
Tng ap lc ni so, 655, 888, 1053, 1187, TBG, thyroxine-binding globulin, globulin
1211 gn thyroxine, 1109, ...
Tng ap lc thm thu, 509, 1068, 1091~1094 TBI, traumatic brain injury, chn thng so
Tng ap lc tnh mach ca, 778, 779, 780, nao, 1214
884, 886, 889, 890, 891, 905b TBIs, tick-borne infections, bnh do tit tuc
Tng bach cu, 484~492, 981, 982 truyn, 666
Tng canxi mau, 435, 528~532, 535, 816, TBW, total body water, tng lng nc
819, 826, 1051~1052, 1186b trong c th, 503
Tng carbonic, 1186b, 1212 TCA, tricyclic antidepressants, thuc chng
Tng cholesterol, lipid ri loan, 122b, 123b trm cam ba vong, 10,...
Tng ng mau, 883, 931, 932, 1060 TCA, 813, 814, 815, 820
Tng ng huyt, 509, 590, 738, 819, 826, vi hi chng serotonin, 1292
1070, 1145, 1186b, 1197b, 1326 TCC, transitional cell carcinoma, ung th
Tng hoat hoa vitamin D, 529 biu m t bao chuyn tip, 1021
Tng huyt ap, 8~9, 35~36, 95~121, 406b, TCT, thrombin clotting time, thi gian ng
908, 936, 981, 1258 mau thrombin, 948
trong bnh tim mach, 97, 117~118, 261 Td, Tetanus, diphtheria, un van, bach hu,
trong thn, 117, 579~582, 852, 1021, 1127 1343
trong ng c, 1286, 1312, 1320 Tdap, Tetanus diphtheria, pertussis, un
vi thuc, 100~103b, 104~108, 109~113, van, bach hu, ho ga, 1343
111~112b, 113~114 TDF, Tenofovir, 845
Tng kali mau, 524~527, 566, 567, 585, 892 TDF/FTC, tenofovir/emtricitabine, 754
trong truyn mau cp cu, 992 TdP, Torsades de pointes, xon nh, 305
Tng lipid mau, 122b, 122, 123b, 917 TdT, terminal deoxynucleotidyl transferase,
Tng magie mau, 539~540 1037
Tng marcroglobulin mau, 988~989 TEE, total daily energy expenditure, tng
Tng m mau, 584, 590 nng lng tiu hao hang ngay, 57
Tng natri mau, 516~520, 518h, 1186b TEE, transesophageal echocardiogram, siu
Tng phosphate mau, 536~537 m tim qua thc quan, 182,...
Tng prolactin mau, 1132~1134 Telaprevir, 851, 852h, 853, 853b
Tng sinh tuy, 984~987, 1034 Telavancin, 602, 680
Telbivudine (LdT), 846, 753b 1290, 1292, 1303, 1300, 1305, 1326
Televancin, 709~710 Than hoat a liu trong ng c, 1275,
Telmisartan, tng huyt ap, 102b 1278, 1281, 1296, 1318, 1326
Temozolomide hoa tr liu, 1004b, 1005b Thang im Child-Pughn, bnh gan, 46
Temsirolimus, 998b, 1022 Thang im Epworth trong th, 421, 422b
TEN, toxic epidermal necrolysis, hoai t da Thang im Glasgow, ri loan y thc, 1187
do c t, 475 Thang im MELD bnh gan,, 46
Tenecplase, thuc tiu si huyt, 197, 198b Thang im nguy c TIMI, 180h, 196
Teniposide gy ri loan hng cu, 976b Thang im Rockall, xut huyt, 776b
Tenofovir (TDF), 730b, 736b, 578, 845 Thang im tin lng quc t (IPSS), 987
Terazosin, tng huyt ap, 103b Thng bng kim toan ri loan, 542~553
Terbinafine, 721 Thm nhim phi, 484~485, 491, 488b, 489b
Terbutaline trong hen ph quan, 396 Thn, 555~594, 763~764, 764b, 770,
TERC, telomerase RNA component, t 972~973, 989, 1020~1022, 1175, 1176
bin trong oan kt thuc RNA, 428 giam chc nng man tnh, 580~584
Teriparatide vi glucocorticoids trong bnh nhn tao, 232, 565, 586~588, 896
xng khp, 1145 vi cac thuc, 696, 697, 704, 717, 989
Terlipressin, 779, 896 Thp tim, 251, 258, 264, 688
TERT, telomerase reverse transcriptase, sao THCA, tetrahydrocannabinolic acid, 1260
chep ngc oan kt thuc, 428 Them n khoang cht, cat, a, t set, 954
Test cosyntropin trong suy thng thn, 1124 Theophyllin, 378, 381, 737, 1320, 1325~1327
Test gng sc, 146~149, 148b, 202, 254, Thiamin, 1186b, 1191, 1190, 1333, 1335
260, 267~268, 283 Thiazide (li tiu), 226, 520, 582
Test ly da, 474, 477, 482 Thiazolidinediones, 879, 1084b, 1088
Testosterone, 1102, 1131 Thienopyridines, trong quanh phu thut, 35
Tetanospasmin c t trong un van, 1234 Thiu mau, 43~45, 264, 908, 982, 951~953,
Tetracycline, 597, 702~703, 647b, 668, 976b 965b, 967~968, 976~977b, 1034, 1039,
trong ai thao ng, 1099 1041, 1207b, 1208b
vi H. pylori, 802 ac tnh, 962, 1228
Tetrahydrocannabinolic acid trong nc bt san, 841, 905b, 968~969, 976~977b
tiu, 1260 cp, 951~952
T cong, 1250~1251 c tim, 7, 117, 139~214, 174~176, 192~193
T bao CD4, 723, 726 cuc b, 828, 928
T bao gc, 1033, 1047~1048 do thuc, 976~977b, 980~981
trong bnh bach cu, 1036, 1038, 1039 do tng huy t bao mau, 969~981
T bao hoc trong ung th, 1000, 1025~1026 hng cu, 954~969, 969~970
TF, tissue factor, yu t m, 902 nao, 1186b, 1201 , 1202, 1203, 1211
TG, triglyceride, 122 nguyn hng cu st, 960~961, 976~977b
6-TG, 6-Thioguanine, 808 tan mau, 406b, 476b, 861, 871, 874, 909,
Thac ng mau, 902 908, 978~980, 981, 1040
Thai ghep (tang), 488b, 763~772, 786 trong bnh thn, 567, 580, 582~583,
Thai st liu phap, 960, 974 964~965, 1021, 1096
Thalassemia, 874, 958~960 trong cac bnh, 83, 774, 800, 824,
Thalidomide, 748, 779, 1047, 1112 828~829, 874, 880, 887, 955b, 965b,
Than hoat trong ng c, 1262, 1266, 127, 966, 975~977, 977b, 986b, 1201~1202,
12720, 1275, 1282~1283, 1284, 1287, 1212, 1017, 1031, 1047, 1055
Thiu oxy, 546b, 974, 1197, 1212 Thuc chen knh canxi, 107~108, 151, 153,
Thiu st, 954, 964 154b, 174, 176b, 815
Thiu vitamin, 498, 532~533, 774, 867, 925~927 trong ng c, 1304~1306, 1322, 1324
Thionamides trong cng giap, 1117, 1118, Thuc chen thu th angiotensin, 101~102b,
1119 109, 494, 879, 1308
Thiopental, 359b, 977b trong bnh thn, 573, 575, 578, 579, 582
Thioridazine, 977b, 1297 Thuc chen , 28~29, 105~106, 151, 153b,
Thiothixen, 1297 174, 175b, 384
Thoai hoa khp, 1137, 1164~1166 trong hen ph quan, 389
Thoat v a m trong tuy sng, 1218b Thuc chng co git, 16, 735, 736b, 737
Thoat v nao, ri loan y thc, 1187, 1222b Thuc chng cum, 713~714
Thng ng tnh mach trong tuy sng, 1218b Thuc chng ng mau, 173b, 418, 455,
Thng kh, 341 565, 586, 799, 884, 936~944, 945~948
ap lc, ch may th, 355, 348~349 Thuc chng ng kinh, 814, 1058, 1197b,
khoang cht, 340 1216~1217
khng xm nhp, 381, 383b, 468 Thuc chng loan nhp, 737, 1301
nhn tao, 347~348, 349~351, 355, 358b, Thuc chng loan thn ng c, 1297, 1309
400~401 Thuc chng nm, 717~721, 737
phut trong th may, 340~341, 350 Thuc chng nn, 814, 1233, 1272
th ra ti a, 340~341 Thuc chng Parkinson, 1309
xm nhp trong phi tc nghen, 381, 383b Thuc chng trm cam ba vong, 798, 918
Thng s huyt ng, sc, 362b ng c, 1197b, 1260, 1288~1290, 1309
Thng tim, 232, 247~248, 250, 254~255, trong au, 16, 1058, 1214
260~261, 268, 274, 412, 413 Thuc chng vi khun ni bao, 710~713
Th kho, 7~8, 475, 1237 Thuc chng vim giam au khng steroid,
Th khng ng b trong th may, 352 389, 479, 495, 525, 547, 565, 580, 607,
Th kiu Kussmaul, 1076 774, 951, 1057, 1140~1143, 1213
Th may, 342, 343, 347~358, 424~425, ng c, 475, 1271~1272
1240, 1245, 1283, 1305, 1319, 1326 trong ri loan cht lng tiu cu, 918
thuc s dung, 359~360b Thuc cha nhm vi nhuyn xng, 1136
Th oxy, 342, 342~343, 778, 1243, 1244, Thuc co mach, 361, 483, 1258
1254 Thuc cng , 375, 466, 566
Th tng cum trong ri loan y thc, 1188 tac dung keo dai, , 376, 396, 398, 402
Thi im trong t quy, 1203 tac dung ngn, 376, 381, 394, 396
Thung Thuc dit cn trung ng c, 1311
rut trong loc mang bung, 589 Thuc iu hoa min dch, 498, 1145
trong loet da day ta trang, 803 Thuc iu hoa thn kinh, 798, 813, 820
tui mt trong soi mt, 822 Thuc i khang glycoprotein IIB/IIIA, 774
vach lin tht trong nhi mau c tim, 212 Thuc i khang leukotrien trong hen, 399, 497
Thuc an thn, 888, 918, 1222, 1233, Thuc ng vn, 232, 226~227, 227b
1258~1259 trong ai thao ng type 2, 1085b, 1090
Thuc can quang trong tuyn giap, 559b, Thuc gn axit mt, 787, 1085b
564, 1088, 1111, 1111b, 1115 Thuc gy bong trong vim thc quan, 793
Thuc cm mau tai ch trong ho mau, 460, Thuc gy nghin ng tnh mach, 570
461 Thuc gy thiu mau tan mau, 978, 980~981
Thuc chen chon loc , 106~107, 1308 Thuc gy tn thng thn cp, 562, 563
Thuc giam au, 559b, 815, 820, 906, 881, 1210

1235, 1250 Thuc tr su ng c, 1311, 1315
Thuc giam cholesterol mau, 155, 1232 Thuc c ch axit, 793, 795b, 800, 818
Thuc gian c, 798, 1309 Thuc c ch bm proton, 170, 565, 591,
Thuc gian ng t vi cholinergic, 1309 735b, 736b, 779
Thuc gian mach, 103b, 109, 414, 416~417b Thuc c ch catecholOmethyl
Thuc gian ph quan, 374~375, 393, 396, 466 transferase trong Parkinson, 1223
Thuc ha huyt ap, 100~103b, 113~114, 1308 Thuc c ch chon loc COX2, 1143, 1161,
ng tnh mach, 109~113, 111~112b 1166, 1169, 1171, 1271~1272
Thuc ha st, 10 Thuc c ch cholinesterase trong bnh
Thuc khang acid, 539, 786 Alzheimer, 1194
Thuc khang cholinergic, 375, 376, 815, 1223 Thuc c ch dipeptidyl peptidase-4 (DPP-
ng c, 1247, 1308~1311 IV), 1084b, 1089
Thuc khang cholinesterase, 1231 Thuc c ch dopamine trong Parkinson, 1222
Thuc khang cytokin, 1158 Thuc c ch Glycoprotein IIb/IIIa,
Thuc khang cytomegalovirus, 715~716 170~171, 188~191
Thuc khang histamin, 22, 483, 496, 815 Thuc c ch H2, 735b, 736b
vi khang cholinergic, 1258, 1309 Thuc c ch HIV hoa mang, 733, 734b
Thuc khang ngng tp tiu cu, 1209 Thuc c ch HMG-CoA, 132~133, 176,
Thuc khang retrovirus, 729~734, 735 202, 568, 590
Thuc khang thu th endothelin, 414 Thuc c ch men chuyn angiotensin,
Thuc khang tiu cu, 34~35, 165~172, 946 101b, 201, 221~223, 222b, 234, 243,
Thuc khang TNF, 1166, 1168, 1169, 1170 261, 318, 391b, 494, 525, 1308
Thuc khang vasopressin vi natri mau, 515 bnh mach vanh, 154, 155, 176
Thuc khang vi khun, 687~703 bnh thn, 568, 573, 575, 578, 579, 582
Thuc khang vi sinh vt, 687~722 trong ai thao ng, 1095, 1097
hn hp, 703~710 Thuc c ch men cyclooxygenase-2, 12
Thuc khang virus, 578, 713~716 Thuc c ch men sao chep ngc, 729,
Thuc khang vitamin K, 32~33 729b~730b, 731, 731b, 735b, 736b
Thuc khang yu t Xa, 937~938 Thuc c ch men tch hp, 733, 734b
Thuc kch thch thu th giao cam, 103b, 107 Thuc c ch min dch, 432, 433, 568,
Thuc la, 370, 800, 801, 1014 , 1021, 1022 591, 1178, 758, 808, 824, 910, 969
cai, 142~143, 371b, 374, 812 trong bnh xng khp, 1145~1146
vi ai thao ng, 1100, 1101 Thuc c ch phosphodiesterase, 378, 227,
Thuc lam sach rut, 790~791 414
Thuc li tiu, 102~103b, 104~105, 236, Thuc c ch protease, 132, 731~733,
508~509, 520, 525, 882, 1308 732b~733b, 735b
quai, 531, 892 Thuc c ch tai hp thu serotonin, 918,
Thuc nhun trang, 539, 786, 789~790, 1262 1214, 813
Thuc ni tuy trong bnh bach cu, 1038 Thuc c ch thn kinh c, 1232
Thuc phin, 495, 788, 1258, 1272~1274 Thuc c ch thrombin trc tip, 774, 913
Thuc phu nim mac trong thc quan, 793 Thuc c ch trao ngc, 794
Thuc tac dung giao cam, 1247, 1319~1320 Thuc c ch trc tip renin, huyt ap, 109
Thuc tng tit insulin khng phai SFU, 1083b Thuc c ch yu t hoai t u, 1158~1160
Thuc thng mui trong vim xoang, 624 Thuc c ch -glucosidase, 1084b, 1088
Thuc tranh thai vi cac thuc, 735b, 737, Thuc vn mach, 1212, 1320
Thuc vi ri loan y thc, 1186b bnh nhn HIV, 788
Thuc vi tng bach cu ai toan, 488b Tiu chun Duke vim ni tm mac, 613b~614b
Thut lactulose trong bnh nao gan, 897 Tiu c vn, 132, 1093, 1232~1233, 1249,
Thut trong tao bon, 790, 791 1293, 1294
Thuy u, 728, 752b, 762, 1350b, 1367b trong tn thng thn cp, 564
-zona, 714, 1145 Tiu si huyt, 882, 942~943, 1203
Thuy trc tuyn yn, 1128~1135 trong nhi mau c tim, 191, 196~200, 199b
Tha dch trong tng th tch, 508 Tiu u hi chng, 1050~1051
Tha st trong Thalassemia, 960 Tiu xng tn thng, 654
Thc n nhiu purin trong gut, 1153 Tiu cu, 902~903, 905~919, 928, 1056, 1142
Thc quan ung th, 1014~1015 truyn mau cha tr, 990, 991
Thyrotropin (TSH) trong tuyn yn, 1129 Tiu
Thyroxine (T4), 1109, 1110, 1113~1114, 1115 gp trong ai thao ng, 1099
TIA, transient ischemic attack, cn thiu kho, 639, 640, 1023
mau cuc b thoang qua, 23,... khng t chu vi ai thao ng, 1099
TIBC, total iron binding capacity, kha nng mau trong chay mau hemophilia A, 920
gn st toan th, 955 nhiu, 1052, 1065
Ticagrelor, 168b, 170, 188, 189b, 190, 201 TIG, tetanus immune globulin, globulin
Ticarcillim-clavulanate trong vim phuc min dch khang un van, 1351
mac, 636b Tigecycline, 638b, 681, 710
Ticarcillin/axit clavulanic, 638b, 676, 689, Tim du n sinh hoc, 162b
1104 Tim mach, 22~31, 25h, 143b, 367
Ticlopidine trong xut huyt giam tiu cu thai ghep cp tnh, 765
min dch, 906 Tim phi nhn tao, 1290, 1306
Ting Korotkoff trong tng huyt ap, 98 TIMI, thrombolysis in myocardial
Tin lit tuyn, 698 infarction, huyt khi trong nhi mau
ung th, 1023~1025, 1052, 1058 c tim, 164
Tin san git, 908, 915, 930, 981 Timolol vi tng huyt ap, 100b
tng huyt ap, 118~119 Tinh dch co mau trong tin lit tuyn, 1024
Tin tng huyt ap, 95 Tinh hoan ung th, 1025~1026
Tim chung, 380, 598, 599, 1173, 1342b~1349b Tnh mach c ni trong hep van hai la, 254
trong cum, 626 Tinidazole, 788, 649b, 885
Tim corticosteroid trong thoai hoa khp, Tinzaparin trong huyt khi tnh mach, 940b
1161~1162, 1164, 1165 Tiotropium trong phi tc nghen, 376
Tip xuc trong ly nhim, 1361~1362 Tipranavir (TPV) ), 733b, 735b
Tit ADH, 510~511 TIPS, transjugular intrahepatic
Tit niu, 701, 705, 1020~1026 portosystemic shunt, ng thng ca
Tiu ban mau ngoai vi, 546b, 670, 953, chu trong gan qua tnh mach canh (ni
978, 979 thng ca chu), 780,...
Tiu chay, 83, 565, 597, 599, 674, 785~788, Tirofiban, 168b, 774, 906
786, 804, 812, 824, 883, 1099 1293, TIV, trivalent inactivated vaccine, vc-xin
cp, 785, 786 cum bt hoat ba hoa tr, 1342
man tnh, 540, 747, 785, 786~787 TKI, tyrosine kinase inhibitor, thuc c ch
trong bnh ac tnh, 1055, 1056 thu th tyrosine kinase ng ung, 997
trong hi chng ure mau tan huyt, 909 TLC, therapeutic lifestyle change, thay i
trong ng c, 705, 989, 1269, 1295 li sng, 126
TLS, tumor lysis syndrome, hi chng tiu TRALI, transfusion-related acute lung
u, 1050 injury, tn thng phi cp tnh lin
TMA, Thrombotic microangiopathy, huyt quan n truyn mau, 43, ...
khi mao mach, 565, 908 Tramadol, 15~16, 1058, 1164
TMPSMX, trimethoprim Tran dch mang bung, 634, 891
sulfamethoxazole, 602,... Tran dch mang ngoai tim, 248~251
TNF, tumor necrosis factor, yu t hoai t Tran dch mang phi, 445~454, 590, 1059~1060
khi u, 630,... Tran dch mang tinh hoan, 1025
TNK-tPA, tenecplase, 197 Tran dch nao, 1186b, 1194b, 1211
TNM, Tumor, lymph Node, and Metastasis, Tran kh mang phi, 470, 1240~1244
khi u, hach, va di cn xa, 1001 Tran kh trong th may, 353
To u chi, 1134~1135 Trandolapril, tng huyt ap, 101b
Toan ceton, 546b, 548, 1076~1081, 1252 Trang thai ng kinh, 1195, 1196, 1200h
Toan chuyn hoa, 354, 536, 543, 544b, Tranylcypromine trong ng c, 1285
547~550, 566, 567, 584, 1096, 1244, 1246 Trao ngc da day thc quan, 389, 391b,
Toan co khoang trng anion, 546~547 791~797, 799, 1014, 1176
Toan hoa mau, 543 TRAP, tartrate-resistant acid phosphatase,
Toan hoa ng thn, 547, 549, 864, 871, 1135 acid phosphatase khang tartrase, 1041
Toan h hp, 551~552, 543, 544b Trastuzumab trong bnh ac tnh, 998b, 999,
Toan khng co khoang trng anion, 547 1011
Toan lactic, 546b, 548, 738, 1080, 1087 Trazodone trong mt ngu, lo u, 21
Tobramycin, 467, 643b, 695 Trm cam, 962, 1060
Tocilizumab trong vim khp, 1160 TRBC, tagged red blood cell, ky thut anh
Toi trong ri loan tiu cu, 918 du hng cu, 777
Tolbutamide gy ri loan hng cu, 976b Treponema trong bnh giang mai, 646
Tolmetin gy ri loan hng cu, 977b Treprostinil trong tng ap ng mach phi,
Tolvaptan, 515, 580 417b
Topical, 656b Tr, 823, 955
Topiramate trong au u d phong, 1214, Triamcinolone, 397b, 1146
Topotecan trong bnh ung th, 1004b, 1005b Triamterene, 103b, 547, 892
Torcemide, tng huyt ap, 103b Triazolam vi thuc khang retrovirus, 737
Toxocara canis trong tng bach cu, 488b Trichinella trong tng bach cu ai toan,
Toxoplasma, 701, 740b, 746~747 488b
Tc dong ht vao trong th may, 350 Trichlormethiazide tng huyt ap, 102b
Ti u hoa chc nng tim, 367 Trichomonas, 649b, 707, 652
Tn thng do nhit, 1246~1249 Trientine trong bnh Wilson, 872
Tn thng ngm nc (nt chn), 1250 Trifluoperazine trong ng c, 1297
Tn thng rut do thiu mau, 828~829 Trifluridine trong HIV-AIDS, 750
tPA, tissue plasminogen activator, yu t Triglyceride mau tng, iu tr, 135~136
hoat hoa plasminogen m, 1207 Trihexyphenidyl vi khang cholinergic, 1309
TPMT, thiopurine methyltransferase, 808 Trit t bng song cao tn, 288, 317
TPN, total parenteral nutrition, dinh dng Trimethaphan camsylate tng huyt ap, 115
hoan toan qua ng tnh mach, 1071 Trimethobenzamide trong nn, bun nn, 784
TPO-R, thrombopoietin receptor, thu th Trimethoprim, 701, 743, 962
thrombopoietin, 908 Trimethoprim-sulfamethoxazole, 603, 605,
TPV/r, tipranavir/ritonavir, 733 625, 638, 641, 642b, 644, 680, 701, 743,
747, 754b, 762, 787, 1144~1145, 1050 potassium gradient, 523
trong vim mach hoai t, 1178 TTNA, transthoracic needle aspiration,
trong vim mang nao, 607, 608 choc hut bng kim qua thanh ngc, 443
trong vim m t bao, 601, 602 TTP, thrombotic thrombocytopenic
Trimipramine trong ng c, 1288 purpura, ban xut huyt giam tiu cu
Triptans trong au u, 1213 huyt khi, 565,...
Troches clotrimazole, 792~793 TTP trong giam tiu cu khi co thai, 915
Tropheryma whippelii, 616, 701 TTP/HUS, thrombotic thrombocytopenic
Tropicamide vi khang cholinergic, 1309 purpura/hemolytic uremic syndrome,
Troponin, 162b ban xut huyt giam tiu cu huyt
Truy tim mach, 887, 1312, 1320, 1323, 1336 khi /hi chng tan huyt tng ure mau,
Truy tun hoan trong choc hut c trng, 892 1005
Truyn dch tch cc, 483, 1051, 1052, TTS, transdermal therapeutic system, h
1308, 1313, 1324 thng iu tr thm thu qua da, 104
Truyn hng cu, 979, 1055 Tu cu, 599~600, 600b, 605, 606, 609, 615,
Truyn mau, 177, 507, 919, 974, 966, 969, 616, 618~619b, 621, 675, 676, 690,
986, 992~993, 1033 697b, 709
cha tr, 991, 992, 989~995 Tu cu trng, 677, 678
Truyn tiu cu, 908, 910, 915, 918, 919 Tu cu vang, 609, 677, 678, 679, 973, 1170,
trong bnh ac tnh, 1056 1147, 1149
trong bnh gan, 327 Tu cu vi methicillin, 601, 627, 630, 629,
Trc khn mu xanh, 754b, 609, 679 679, 680, 688, 689, 690, 697b, 709
Trc khun rut gram m vi ap-xe phi, 629 Tu mau, 1215, 1218b
Trc khun than, 681~682 Tua lanh (Cryoprecipitate), 327, 920~921,
Truc renin-angiotensin-aldosterone, 526 925, 928, 991
Trc trang, 775, 823 Tui tha, 825~826, 779, 780
ung th, 1016~1018 Tularemia (bnh), 669~670, 1354b, 1368b
-tryptase trong sc phan v, 482 TUR, transurethral resection, ct qua niu
TSCI, traumatic spinal cord injury, tn ao, 1023
thng tuy sng do chn thng, 1217 Tut huyt ap, 945, 952, 1218b, 1124, 1125
TSH, thyroid-stimulating hormone, trong ng c, 1298, 1307, 1320, 1325,
hormone kch thch tuyn giap, 324,... 1332
TSH vi tuyn giap, 1112, 1113, 1117 vi suy thn cp, 559b
TSI, thyroid-stimulating immunoglobulin, Tuy sng ri loan chc nng cp tnh, 1217~1221
1121 Tuy xng ri loan, 984~987, 982
TSS, toxic shock syndrome, hi chng Tuy thai ghep cp tnh, 766~767
shock c t, 599 Tuy ung th, 1018~1019
TSST-1, toxic shock syndrome toxin-1, hi Tuyn cn giap, 528, 529, 532
chng shock c t toxin-1, 599 Tuyn giap, 307, 1109~1111, 1121, 1295
TST, tuberculin skin testing, test da nhn n c ung th, 1122~1123
tuberculin, 632,... suy chc nng, 1112~1115
TT, thrombin time, thi gian thrombin, 904 Tuyn thng thn, 1144, 1123~1128
TT trong ri loan ng mau, 903~904 Tuyn c trong nhc c, 1228, 1229, 1232
TTE, transthoracic echocardiogram, siu Tylenol acetaminophen trong ng c, 1263
m tim qua thanh ngc, 182,... TZD, thiazolidinedione, 1082
TTKG, trao i qua ng thn, Transtubular
U UDCA trong gan nhim m khng do ru,

879
U ac tnh trong bnh cu thn, 569, 570 UF, ultrafiltration, siu loc, 585
U bt thng trong ghep gan, 900 UFH, unfractionated heparin, heparin
U a u tuy xng, 1046~1047 khng phn oan, 3,...
U c vi bach cu ai toan, 489b UFH, LMWH bin chng chay mau, 947
U hat, 573, 661, 905b UFH trong huyt khi tnh mach, 938~939
hat Wegener, 573, 1178 UIP, usual interstitial pneumonia, vim
U hc t, 1052, 1053 phi ke thng thng, 427
U lympho, 748~749, 799, 824, 849, 978, UIV, intravenous urography, chup X-quang
1051, 1052, 1059, 1123, 1182 h tit niu co can quang ng tnh
Hodgkin, 1042~1043 mach, 557
non Hodgkins, 1043~1046, 771 UKPDS, united kingdom prospective
U mach, 406b, 489b, 753b diabetes study, nghin cu trin vong
U nao, 1186b, 1197b ai thao ng Anh Quc, 1095
U nm do aspergilloma phi, 662, 663 Ultralente insulin vi ai thao ng, 1074b
U phi nguyn phat vi hi chng tnh Ung th, 770, 905b, 1001, 1002, 1030
mach chu trn, 1054 bang quang, 1022~1023, 1058
U, tc mt, 821 biu m, 528, 981, 1030
U tit t bao gan, 900, 898~899, 1019~1020
ACTH vi hi chng Cushing, 1126 bung trng, 1029~1030
gastrin trong loet da day ta trang, 799, 803 c t cung, 749, 1026~1028
U trung biu m vi tran dch phi, 1059 ai trc trang, 955, 1016~1018, 1184
U trung tht trc trong bnh bach cu,1038 au, 1057~1058
U tuy thng thn trong tng huyt ap, 36 ng mt trong vim ng mt, 866
U tuy trong hi chng Cryoglobulin, 1182 ng tiu hoa, 1014~1020
U tuyn da day, 799, 1015~1016
trong tng canxi mau, 528 gan, 771, 876, 877, 878, 889
thng thn, 1126, 1127~1128 hach tng bach cu ai toan, 487
U vi au u, 1211 mau, 1031~1048
U x cu thn kinh vi ng kinh, 1197b ni mac t cung, 1028
U xng trong tng canxi mau, 529 phi, 1006~1009, 1051, 1052, 1053, 1058,
UA, unstable angina, au tht ngc khng 1059
n nh, 140 phu khoa, 1026~1030
UA, urinalysis, nc tiu, 639 phuc mac vi c trng, 891
UA, urine alkalinization, xet nghim nc sinh duc tit niu, 1020~1026
tiu, 1333 t bao mm, 1025~1026, 1030
UAG, urine anion gap, khoang trng anion thn, 1020~1022, 1058
nc tiu, 548 thc quan, 796, 1014~1015
Uas, unmeasured anions, lng anion tin lit tuyn, 1023~1025, 1184
khng th o lng c, 544 tinh hoan, 1025~1026
UC, ulcerative colitis, vim loet ai trang trong ghep tang, 771
chay mau, 804 tuy, 1018~1019
Ucs, unmeasured cations, lng cation vo thng thn, 1127, 1128
khng th o lng c, 544 vu, 1009~1012, 1051~1053, 1058, 1059,
UDCA, ursodeoxycholic acid, 865 1184
vung u va c, 1012~1013 Valproate trong ng kinh, 1200

UNOS, united network for organ sharing, Valproic acid trong au u d phong, 1214
mang li ni tang Hoa Ky, 899 Valsartan, tng huyt ap, 102b
Un van, 598~599, 728, 1234, 1350b, 1351b Van tim, 275~277, 276, 616, 620, 981
UPEP, urine protein electrophoresis, in di Vancomycin, 495, 589, 598, 600b, 602,
protein nc tiu, 557,... 603, 604, 605, 629, 643b, 678, 682,
UPPP, uvulopalatopharyngoplasty, tao hnh 696~697, 753b, 787, 906, 1104, 1147
vom ming-li ga, 425 trong nao, 607, 608, 609, 610
Ure mau cao, 55, 918~919, 1252 trong sc phan v, 479, 480
Ureaplasma urealyticum, 640, 652 trong vim ni tm mac, 615, 616, 617b,
Uricase trong gut, 1153~1154 618b, 619b
Uricosuric trong gut, 1153, 1154 vi tu cu khang methicillin, 630, 680
URL, upper rate limit, gii han trn cua tn Vang da, 570, 839, 857, 862, 864, 866, 881,
s, 312 884, 979, 1018, 1019, 1120
UroMag trong ha magie mau, 542 VAP, ventilator-associated pneumonia,
URR, urea reduction ratio, t sut giam ure, vim phi lin quan n may th, 353
587 Vardenafil trong ri loan cng dng do
Ursodeoxycholic acid trong gan mt, 865, 867 ai thao ng, 1102
US, ultrasound, siu m, 913,... Varicella zoster trong ly nhim cach ly,
UTI, urinary tract infection, nhim trung 1367b
ng tit niu, 556,... Vasopressin, 361, 460, 503, 515, 516
UV, ultraviolet, tia cc tm, 870 trong hi chng gan thn, 896
mt, 839, 856, 857, 863, 864, 865, trong xut huyt ng tiu hoa, 779
867~870, 876 VATS, video-assisted thoracoscopic surgery,
c ch calcineurin trong ghep tang, 760 phu thut ni soi lng ngc, 431
c ch h hp, 546b, 1258 Vay nn vi vim khp, 1169~1170
c ch men alcohol dehydrogenase, 1328 Vc xin
c ch men MAO trong thai nghen, 118~119 HPV, 728, 1345b
c ch P2Y12 trong nhi mau c tim, 170, 188 bnh dai, 1355b
c ch receptor 5HT3 trong bun nn, 1054 cum, 975, 1342b
c ch thay th C1 trong m ay, 496~497 HAV, 838, 1348b
c ch tuy xng vi methotrexate, 1157 HBV, 854, 975, 846~847, 1349b
c ch tyrosine kinase, 491, 1039 nao m cu, 1348b
c ch giao cam trong cng giap, 1117 ph cu khun, 908, 975, 1347b
bnh Zona, 1345b
V si, quai b, rubella, 1346b
Va m hi, 1105, 1258, 1293 thuy u, 1344b
trong ng c, 1286, 1312, 1323 un van, bach hu, 1343b
VAD, ventricular assist devices, thit b h un van, bach hu, ho ga, 1343b
tr tm tht, 228 VBGs, kh mau tnh mach, venous blood
VAERS, vaccine adverse events reporting gases, 1259
system, h thng bao cao tac dung phu VC, vital capacity, dung tch sng, 1126
cua vc-xin, 1341 VCD, vocal cord dysfunction, ri loan chc
Valacyclovir, 647b, 715, 736b, 750, 752b, 793 nng dy thanh, 389
Valganciclovir, 715, 736, 736b, 741, 762, VDRL, venereal disease research laboratory,
768, 793 nghin cu bnh hoa liu, 646
Vecuronium trong ni kh quan va th may, Vim a ng mach nut vi vim mach, 1179
359b Vim a c, 1182, 1185~1184, 1228, 1232
VEGF, vascular endothelial growth factor, Vim a khp i xng, 1155
yu t tng trng ni mac, 1096 Vim a mach, 841, 1180
Veillonella spp. vi vim xoang, 624 Vim a r thn kinh trong nao, 671
Venofer trong thiu mau, 957, 957b Vim ai trang, 707, 805, 810, 824, 828, 697b
Venom trong thiu mau, tao hng cu, 670 gia mac, 597, 701, 785, 786
Verapamil, 101b, 201, 238, 239, 297b, Vim ai-b thn vi suy thn cp, 559b
1117, 1132, 1214, 1304 Vim ng mach thai dng, 1179, 1181, 1211
Vt cn, 675~676 Vim t sng bnh vim rut, 1167
Vt nt hu mn, 823 Vim n khp, 667, 1032
Vt thng phu thut vi nhim tu cu, 599 Vim ng h hp, 369, 663
VF, ventricular fibrillation, rung tm tht, Vim ng mt, 819, 821, 822, 884
1371 thp, 635~637, 638b
VF/VT, ventricular tachycardia/fibrillation, Vim ng rut vi ng mt, 866
rung tht/nhp nhanh tht, 207 Vim gan, 674, 689, 835, 849, 876, 877,
Vi khun gram m, 587, 679, 689, 690~693, 880, 886, 968, 1119
697b, 699, 703~705, 707, 709, 710, 754b do ru, 857, 858
Vi khun gram m va dng, 589, 693, 694, do thuc, 855~857
711 nhim m khng do ru, 877~878, 889
Vi khun gram dng, 681, 691, 696, 698, t min, 861~863, 887, 1019
700, 705, 706, 709 virus, 570, 766, 835~855, 837b
Vi khun hiu kh gram m, 677, 691, 692, Vim gan A, 727, 762, 836b, 837~839,
698 837b, 1350b
Vi khun hiu kh, 691, 700, 704, 707 Vim gan B, 727, 768, 770, 836b, 837b,
Vi khun ky kh, 629, 690, 694, 688, 689, 840~848, 844b, 898, 1019, 1148,
691, 693, 698, 700, 710 1350b, 1353b
Vi khun ni bao, 696, 710~713, 711, 712 vi hi chng Cryoglobulin, 1182
Vi khun sinh ur trong soi thn, 591 Vim gan C, 571, 752b, 768, 770, 836b,
Viconazole trong nhim nm toan th, 659b 837b, 848~853, 898, 905b, 1019, 1353b
Vim m ao, 599, 649b, 651~654, 707 vi hi chng Cryoglobulin, 1182
Vim bang quang, 640, 641, 642b Vim gan D, 836b, 837b, 853~854
Vim bao hoat dch nhim khun, 1149 Vim gan E, 836b, 837b, 854~855
Vim cac khp nho trong bnh Lyme, 667 Vim giac mac trong hi chng Guillain
Vim cu thn, 565, 571~572, 577, 841, Barre, 1226
849, 876, 1182 Vim hong, 622~623, 688, 690, 698, 699
Vim cn mac hoai t, 604, 700 Ludwig trong tc nghen ng th, 1238
Vim chu hng, 648b Vim kt mac, 1168, 1169, 1363b
Vim ct sng dnh khp, 1166~1167 Vim kh ph quan herpetic vi hen, 391b
Vim c t cung, 648b, 652~653 Vim kh kt giac mac vi gan, 864
Vim c, 600, 1145, 1232 Vim khp, 573, 674, 691, 871, 874, 1134,
Vim c tim, 620, 667 1139~1184, 1147~1149, 1150, 1168
Vim da, 476b, 486, 488b, 599, 600, 604, dang thp, 498, 547, 861, 1155~1163,
667, 824 1180, 1182, 1228
c, 1183, 1185~1184, 1232 nhim khun, 652, 1163, 1146, 1147~1149
Vim da day, 488b, 909, 951, 1055 phan ng, 1168~1169
trong lupus ban o h thng, 1170 Vim ph quan, 391b, 454, 456b, 626~627,
trong nt n c phi, 438 690, 691, 699, 701
bnh vim rut, 804, 1167~1168 phi d ng, 488b, 662, 663
vay nn, 1169~1170 Vim phi, 391b, 445, 454, 485, 488b, 626,
vim kt mac va vim niu ao, 1168 683, 669, 674, 690, 691, 700, 701, 703,
Vim loet ai trang, 804, 805, 861, 866 762, 805, 1218b, 1240, 1244, 1364b
vi vim khp, 1167~1168 bnh vin, 679 , 689
Vim li, nut kho vi hi chng cp, 456b, 662
Plummer-Vinson, 955 cng ng, 627~629, 688, 691, 692, 698,
Vim mach, 406b, 476b, 486, 488b, 489b, 699, 703, 710
568, 573, 908, 930, 981, 1119, 1211 do iu tr bnh ac tnh, 1056~1057
da, 1032, 1180 do ht sc, 700, 797, 799, 819
hoai t, 849, 1177~1181 trong HIV-AIDS, 739, 740b, 743~744,
Vim mang b ao, 435, 1167 753b, 754b
Vim mang hoat dch, 861, 1146, trong bnh phi ke, 427~428
1147~1149, 1150~1155 trong hi chng suy h hp cp nng
Vim mang nao, 606~609, 654, 655, 657b, (SARS), 686
659b, 674, 691, 704, 718, 721, 908, trong nhim nm, 655, 661, 665
1186b, 1211, 1225b, 1247, 1363b, 1364b trong th may, 353~354
lao ngoai phi, 630, 632 Vim phuc mac, 634~635, 636, 718, 720, 822
trong HIV-AIDS, 745, 755b do vi khun nguyn phat, 562, 889,
do herpes simplex, 714 893~894
mu, 608, 697b, 911 lao ngoai phi, 630
Vim mang ngoai tim, 206, 585, 620~621 trong loc mang bung, 589, 590
co tht, 245~248 Vim qung, 602
lao ngoai phi, 630, 632 Vim rut tha, 639, 691
Vim mao tinh hoan, 641 Vim rut vi vim khp, 1167~1168
Vim ming do herpes, 714 Vim tai gia, 688, 690, 691, 699, 701
Vim m, 486, 488b, 601~602, 1104 Vim tc tnh mach nng, 931, 1060
hoai t, 603~604 Vim thanh quan, 622, 623, 791, 1238
m di da, 876 Vim thanh mach d ng, 572~573, 1180
quanh tuyn tuy, 816 cung xem Bnh thn IgA
Vim mu mang phi, 447, 454, 629, 822 Vim thn, 568, 572, 576, 691, 698, 805
Vim mui, 464, 488b, 489b, 624~625, 792 trong hi chng phi-thn, 573
xoang trong hen ph quan, 389 trong vim ni tm mac, 612, 613
Vim nang lng, 486, 488b ke, 488b, 559b, 563, 565~566
Vim nao, 609~610, 1186b, 1211, 1248 -b thn, 566, 644~645
mang nao, 667, 670~671 Vim thn kinh th vi au u, 1212
trong HIV-AIDS, 752b Vim thc quan, 792~793
Vim np thanh quan vi hen, 391b Vim trung tht x hoa, 406b, 931
Vim nim mac, 783, 1049, 1056 Vim trc trangai trang trong ht xoai, 650
Vim niu ao, 698, 648b, 1168 Vim tui mt cp tnh, 635~637, 638b, 821,
Vim ni tm mac, 610, 612, 617~619b, 822
621b, 674, 697b, 698, 705, 711 Vim tui tha, 637~638, 825~826
vi hi chng cryoglobulin, 1182 Vim tuy xng, 603, 605~606, 1217
nhim khun, 252, 264, 576, 611~620 lao ngoai phi, 630
Vim tuy, 464, 803, 805, 808, 816~821, 926, 926b, 946
883, 1329 VKA, vitamin K antagonists, thuc khang
Vim tuyn giap, 962, 1112, 1116, 1116b vitamin K, 32
t min, 861, 1228 VLDLs, very lowdensity lipoproteins,
Vim tuyn thng thn t min, 1123 lipoprotein ty trong rt thp, 121
Vim tuyn tin lit, 640~641, 644, 701 VOC, vaso-occlusive complications, bin
Vim vong mac do CMV trong HIV-AIDS, chng tc mach, 971
715, 716, 739 , 741 Voglibose vi ai thao ng, 1084b, 1088
Vim vung chu hng, 653~654, 691 Vong mac tng sinh vi bnh hng cu, 975
Vim xoang, 391b, 470, 624~625, 688, 691, Voriconazole, 636b, 658b, 719, 736b, 744
699, 701, 1212 V sinh, 653, 1132
Vim x ng mt, 804, 821, 865~867 VPA, Valproic acid, 1283
Vim xng x nang hoa, 529, 583 V/Q, ventilation/perfusion, thng kh/ti
Vildagliptin vi ai thao ng, 1085b, 1089 mau, 7,...
Vinblastine trong u lympho Hodgkin, 748, VRE, vancomycine-resistant enterococcus,
1023, 1043 enterococcus khang vancomycine, 696,...
Vincristine hoa tr liu trong bnh ung th, VRSA, vancomycine-resistant
910, 1004b, 1005b, 1045, 1046 staphylococcus aureus, tu cu vang
Vinorelbine hoa tr liu, 1004b, 1005b khang vancomycine, 692,...
Viridans streptococci, 615, 617b VSD, ventricular septal defect, thng lin
Virus cum, 713, 714 tht, 178,...
Virus Epstein-Barr, 835 VT, ventricular tachycardia, nhp nhanh
Virus Hepatitis, 835, 906, 1348, 1349 tht, 279,...
Virus herpes, 714, 835 VTE, venous thromboembolism, huyt khi
Virus JC trong vim khp dang thp, 1160 tnh mach, 2,...
VISA, vancomycine-intermediate Vu to nam gii, 892, 1025
staphylococcus aureus, tu cu vang Vu ung th, 1009~1012
trung tnh vi vancomycin, 692,... Vung di i ri loan, 1129, 1132, 1248
Visicol trong lam sach rut, 790 VVC, vulvovaginal candidiasis, nhim
Vitamin, 60~73 trung nm candida m ao, 652
Vitamin A (Retinol), 65b, 868 vWD, von Willebrand disorder, bnh von
Vitamin B1 (Thiamine), 67b, 1253, 1333 Willebrand, 903
Vitamin B12 (Cobalamin), 70, 905b, 961, vWF, von Willebrand factor, yu t von
962, 1193, 1194b Willebrand, 901,...
Vitamin B2 (Riboflavin), 68b vWF:Ag, von Willebrand factor antigen,
Vitamin B3 (Niacin), 68b khang nguyn yu t von Willebrand,
Vitamin B5 (Pantothenic acid), 68 903
Vitamin B6 (Pyridoxine), 69, 631, 1333, 1334 vWF:Rco, von Willebrand factor Ristocetin
Vitamin B7 (Biotin), 69 cofactor, ng yu t Ristocetin, 903
Vitamin B9 (Acid folic), 69 VZV, 714, 716
Vitamin C (Acid ascorbic), 70 VZV, varicella-zoster virus, thuy u-zona,
Vitamin D (Ergocalciferol), 534, 535, 66b, 536, 714,...
583, 868, 869, 1096, 1135, 1136, 1145
Vitamin E (, )- (Tocopherol), dinh dng, W
67b, 879, 868 Warfarin, 132, 133, 295, 299b, 418, 568,
Vitamin K (Phylloquinone), 327, 67b, 868, 737, 774, 914, 936~937, 946, 948, 1060,
1206, 1209 nao, 1186b, 1197b
bin chng chay mau, 946~947 ni so, trong vim ni tm mac, 612, 613
WBC, white blood cell, bach cu, 556,... tiu hoa, 562, 781, 801, 819, 825, 881,
WCT, wide-complex tachycardia, nhp 889, 894, 948, 1019
nhanh phc b QRS gian rng, 284 Xut vin, bnh nhn ni tru, 2
WD, Wilsons disease, bnh Wilson, 862 Xung trong loan nhp tim nhanh, 279, 280
WEANS NOW trong cai th may, 356, 357b Xng, 1136, 1137, 1145
West Nile virus trong vim nao, 609, 671 nhim khun vi Rifampin, 711
WHO, world hearth organization, t chc y vi Trimethoprim/sulfamethoxazole, 701
t th gii, 75,...
Wilate trong bnh von Willebrand, 925 Y
WinRho trong giam tiu cu min dch, 907 Y lnh cua bnh vin, 1~2
WMA, wall motion abnormality, vn ng Y thc, 16~18, 1185~1194, 1252, 1293
thanh tim bt thng, 167 Yersina, 683, 704, 786, 1168
WNV, West Nile virus, virus West Nile, 609 Yu c, 1136, 1224, 1232, 1233, 1314
WPW, Wolff-Parkinson-White, 285,... trong bnh nhc c, 1227, 1228, 1229
X Z
Xam da, 1124, 1126 Zafirlukast trong hen ph quan, 399
Xanthine trong hi chng tiu u, 1051 Zaleplon trong mt ngu, lo u, 21
XDR-TB, extensively drug resistant TB, Zanamivir, 626, 714
bnh lao khang thuc, 630 Zidovudine, 730b, 736b
Xep t sng vi glucocorticoids, 1145 Zileuton trong hen ph quan, 399
Xoa xoang canh, 291b Ziprasidone, 1300~1301
Xon nh, 541, 1292 Zofran trong nn, bun nn, 785
Xon khun, 673~674, 703 Zoledronate trong tng canxi mau, 531
Xopenex trong phi tc nghen, 376 Zoledronic, 1058, 1052, 1137
X cng b, 792, 826, 864, 1174~1176 Zolpidem, 21, 384
X cng ct bn teo c vi bnh c, 1229 Zona, 714, 1363b
X cng rai rac trong ri loan tuy sng, 1218b Zonisamide vi hi chng nn chu ky, 814
X cng toan thn vi tao bon, 788 Zygomycose trong nhim nm, 663
X gan, 246, 498, 559b, 580, 634, 874, 876,
877, 878, 883, 889, 890, 898, 900, 1019
do ru, 857, 858, 898
mt tin phat, 863~865, 866
X hoa van ng mach chu, 258
X nang phi, 462~471
X phi vi tran kh mang phi, 1240
X tuy, 905b, 985, 986, 986b
X tuyn tuy vi 1-Antitrypsin, 876
X va mach, 120~121, 1201
Xut huyt, 55, 563, 567, 573, 828, 884,
916, 917, 928, 1202
ng tiu hoa, 354, 773~781, 803, 890
di da, 901, 917
giam tiu cu, 905b, 906, 907~908, 981
NHA XUT BAN AI HOC HU
07 Ha Ni, Hu
in thoai: 054 383 4486; Fax: 054 381 9886
Chu trach nhim xut ban

Giam c: NGUYN THANH HA
Chu trach nhim ni dung
Tng bin tp: HOANG C KHOA
Bin tp vin
NGUYN THANH PHNG THAO
Bin tp ky thut
TN N QUYNH CHI
Trnh bay, minh hoa, ba
OAN TH HNG
Sa ban in
CAO HUY AI
Soan ch muc
CAO HUY AI
i tac lin kt xut ban

Cao Huy Ai, Cng ty C phn Cao Trn
S 10, ngo 27 ph Vnh Tuy, Qun Hai Ba Trng, Ha Ni
CM NANG IU TR NI KHOA
In 3.000 ban, kh 16x24 cm, tai Cng ty C phn in Sao Vit, 40/9 ph Nguy Nh
Kon Tum, Nhn Chnh, Thanh Xun, Ha Ni. S ng ky xut ban: 4125 2015/
CXBIPH/02 48/HH. Quyt nh xut ban s: 114/Q/HHNXB, cp ngay 23
thang 12 nm 2015. In xong va np lu chiu quy II/2016.

Cẩm nang điều trị nội khoa Washington PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Cẩm nang điều trị nội khoa Washington PDF

Uploaded by

Copyright:

Available Formats

Cm nang

BAN BIN DCH V HIU NH xxxiii

LI CH BIN BN TING VIT xxxix

1 Chm sc bnh nhn ni khoa 1

Tng quan chm sc bnh nhn ni tr 1

Bin php d phng 2

Chm sc bnh nhn ni tr c triu chng cp tnh 6

Ni khoa quanh phu thut (Perioperative) 17

X tr mt s bnh c th quanh phu thut 35

Nhu cu dinh dng 57

3 D phng bnh l tim mch 95

4 Bnh tim thiu mu cc b 139

Bnh mch vnh v au tht ngc n nh 139

5 Suy tim v bnh l c tim 215

Suy tim 215

Bnh c tim 233

6 Bnh l mng ngoi tim v bnh van tim 245

Bnh l mng ngoi tim 245

Bnh van tim 251

7 Lon nhp tim 279

Lon nhp nhanh 279

Nhp nhanh trn tht 283

Lon nhp chm 320

9 Bnh l phi tc nghn 369

Bnh phi tc nghn mn tnh 369

10 Bnh l phi 405

Tng p ng mch phi 405

11 D ng v min dch hc 473

Phn ng c hi ca thuc 473

12 Cn bng nc v in gii 503

Cn bng dch v ri lon th tch 503

Ri lon kali mu 520

Ri lon canxi mu 528

Ri lon phospho mu 535

Ri lon magie mu 539

Ri lon thng bng kim toan 542

13 Bnh l thn 555

nh gi bnh nhn mc bnh thn 555

Bnh cu thn nguyn pht 569

Bnh cu thn th pht 574

Gim chc nng thn mn tnh 580

Liu php thay th thn 584

14 iu tr bnh truyn nhim 595

Nhim trng gy ra bi c t 597

Nhim trng da, m mm v xng 601

Nhim trng h thn kinh trung ng 606

Nhim trng no tht v no tht shunt bng 609

Nhim trng tim mch 611

Nhim trng ng h hp trn 622

Nhim trng ng h hp di 626

Nhim trng ng tiu ha v d dy 634

Nhim trng khc 637

Nhim trng ng sinh dc 639

Nhim trng qua ng tnh dc, lot sinh dc 645

Nhim trng qua ng tnh dc, 651

Nhim nm ton th v vi khun khng in hnh 654

Bnh do tit tc truyn 666

Nhim trng do mui truyn 670

Bnh ly t th sang ngi 672

Bnh ly qua vt cn 675

Nhim trng lin quan ti chm sc y t 676

Bnh nhim trng mi ni v khng b sinh hc 544

15 Thuc khng vi sinh vt 687