Gio trnh Bnh nhim

447

BNH ST XUT HUYT DENGUE

BS. Nguyn vn K

Mc tiu

1. Bit c tc nhn gy bnh, dch t hc ca bnh xut huyt Dengue

(SXHD)

2. Hiu c c ch bnh sinh ca bnh SXHD

3. M t c biu hin lm sng, cc giai on ca bnh v bin php chn

on

4. Trnh by c cch theo di v iu tr SXHD

5. Nu c cc bin php phng bnh SXHD

I. NH NGHA

St Dengue v SXHD l bnh truyn nhim cp tnh gy dch do virus Dengue

gy nn. Virus c truyn t ngi bnh sang ngi lnh do mui t, ch

yu l mui Aedes aegypti.

SXHD ch yu l bnh vng nhit i v cn nhit i. Bnh xy ra quanh

nm, thng gia tng vo mua ma. Bnh gp c tr em v ngi ln.

Nhim virus Dengue gy nn triu chng lm sng khc nhau ty tng c th.

Bnh c th ch biu hin nh mt hi chng nhim virus khng c hiu hoc

bnh l nng, c im l st, xut huyt v thot huyt tng, c th dn ti

sc gim th tch tun hon, ri lon ng mu v suy tng, nu khng c

chn on sm v x tr ng, kp thi s dn n t vong.

II. TC NHN GY BNH

St xut huyt Dengue gy nn bi mt trong bn loi huyt thanh virus gn

gi nhng li khc nhau v mt khng nguyn l DEN-1, DEN-2, DEN-3 v

DEN-4. y l loi Flavivirus, thuc h Flaviviridae, virus RNA, hnh cu c

v lipid bao quanh, kch thc nh khong 4060nm.

nc ta, phn lp c c 4 type virus Dengue gy bnh. Vo nhng nm

19911995, type gy bnh ch yu l DEN1 v DEN2; nm 19971998 l

DEN3. T 1999 n nay, type DEN4 gia tng v c l s l type gy bnh

chnh trong nhng nm ti.

Hnh 1. Dengue virus

Gio trnh Bnh nhim

448

Khi b bnh, c th s xut hin khng th IgM khng Dengue tm thi ko di

8 tun v khi pht hin khng th ny trong huyt thanh chng t bnh nhn

ang b nhim virus Dengue cp tnh hoc va mi khi bnh.

Khng th lgG khng Dengue xut hin tr hn v tn ti nhiu nm hoc sut

i v c min dch vi type Dengue gy bnh. Khi b bnh do mt type huyt

thanh no ca virus Dengue th s c min dch sut i vi type Dengue

, nhng khng c min dch cho vi cc type khc.

Chnh v vy m nhng ngi sng trong vng lu hnh dch SXH Dengue c

th mc bnh nhiu hn mt ln trong i.

Hnh 2. Phn b st xut huyt Dengue trn th gii

III. DCH T HC

C th ni Dengue l mt bnh do virus ly truyn do mui thng gp nht

ngi. Trong nhng nm gn y bnh tr thnh mi quan ngi ln i vi

sc khe cng ng trn bnh din quc t. Trn ton th gii c khong 2,5 t

ngi hin ang sng trong vng c lu hnh bnh. S lan trn v mt a l

ca c vector truyn bnh l mui v virus a n s tng cao t l bnh

trong vng 25 nm qua cng nh kh nng xut hin dch do nhiu type huyt

thanh khc nhau cc th trong vng nhit i.

Nhng v dch u tin c ghi nhn xy ra vo nhng nm t 17781780

chu , chu Phi v Bc M. S xut hin gn nh ng thi ca cc v dch

trn ba lc a khc nhau chng t rng virus gy bnh cng nh vector truyn

bnh phn b rng ri trn ton th gii t hn 200 nm trc. Trong

thi gian ny Dengue ch c xem l bnh nh. Mt v i dch Dengue xut

hin ng Nam sau Chin tranh th gii th II v t lan rng trn ton

cu. Cng khu vc ng Nam , Dengue ln u tin c pht hin

Gio trnh Bnh nhim

449

Philippines vo nm 1950 nhng n nm 1970 bnh tr thnh nguyn nhn

nhp vin v t vong thng gp tr em trong vng ny.

T l mc bnh trn ton th gii gia tng mnh m trong nhng nm gn

y. Bnh ny hin tr thnh dch ti trn 100 quc gia chu Phi, chu

M, khu vc pha ng a Trung Hi, ng Nam v Ty Thi Bnh

Dng. ng Nam v Ty Thi Bnh Dng l khu vc chu nh hng

nng n nht. Trc nm 1970, ch c 9 quc gia c dch lu hnh. Con s ny

tng ln gp hn 4 ln vo nm 1995. T chc Y t Th gii (WHO) c tnh

mi nm c khong 50 n 100 triu ngi mc bnh. Khng ch c s trng

hp mc bnh gia tng m kh nng nhim nhiu type virus khc nhau cng

ngy cng ng bo ng. Sau y l mt vi con s thng k khc:

Trong v dch, t l mc bnh nhng i tng nhy cm thng l

4050% nhng cng c th cao n 8090%.

Mi nm c khong 500.000 trng hp SXHD cn nhp vin, phn

ln trong s l tr em. T l t vong chung vo khong 2,5%.

Nu khng c iu tr, t l t vong ca SXHD c th vt qu 20%.

Vi phng thc iu tr tch cc hin i, t l t vong c th thp hn

1%.

SXHD du nhp vo Vit Nam t nhng nm 1960, cho n nay tr

thnh mt bnh dch lu hnh. Bnh khng ch xut hin th m c vng

nng thn. Dch ln SXHD bng n theo chu k khong 35 nm. Nm 1998,

trn ton quc bng n v dch ln, s mc bnh v t vong cao (234.920

ngi mc, t vong 377).

Bnh SXHD Vit Nam pht trin theo ma v cng c s khc bit gia cc

min: min Bc, bnh thng xy ra nhiu t thng 7 n thng 9. Min Nam

v min Trung, bnh xut hin quanh nm v tn s mc bnh nhiu nht t

thng 6 n thng 10, nhng dch thng xy ra vo ma ma. Ti thnh ph

H Ch Minh v cc tnh pha nam, bnh tng nhiu vo ma ma (thng 511).

1. Ngun bnh

Ngi bnh SXHD l cha virus chnh.

Ngi bnh nhim virus Dengue b mui Aedes t mang virus ri truyn cho

ngi lnh. Mc du s ly truyn ng vt gia loi kh rng chu v

chu Phi c m t, s ly truyn virus ngi duy tr mm bnh,

v s nhim trng ng vt ny c th xem nh hin tng ph hoc c kh

nng l mt chu k d th cn li.

2. ng ly truyn

* Mui Aedes l trung gian truyn bnh chnh.

Mui Aedes mnh nh, en, c khoang trng

thng gi l mui vn

Ngi nhim virus Dengue do mui ci thuc

Gio trnh Bnh nhim

450

ging Aedes t. Mui Aedes aegypti l vector truyn bnh ch yu hu ht

cc khu vc bnh lu hnh. Mui Aedes aegypti hot ng vo ban ngy v ch

c mui ci mi t ngi v truyn bnh.

Mui b nhim virus Dengue khi t ngi bnh giai on nhim virus huyt

c st (1 ngy trc khi st, ko di cho n 67 ngy sau). Sau thi k bnh

812 ngy mui, n c th truyn bnh qua ngi khc. Trong khong thi

gian sng cn li sau , mui c nguy c truyn bnh cho ngi.

Virus Dengue khng gy hi cho mui. Mui b nhim virus Dengue c th

truyn bnh sut vng i ca n khong 174 ngy (56 thng), thay i ty

theo nhit v lng ma trong vng. Sau khi mui nhim virus Dengue t

ngi, virus sinh sn hch bch huyt ln cn, 23 ngy sau virus vo mu

n cc c quan khc nhau. Virus hin din trong mu khong 45 ngy, ch

yu trong thc bo, t bo B v t bo T, tng ng vi thi gian c st trn

lm sng v s bin mt trong vng 1 ngy sau khi h st.

Ngi l cha virus chnh ngoi ra ngi ta mi pht hin Malaixia c loi

kh sng cc khu rng nhit i cng mang virus Dengue. Aedes aegypti c

ngun gc t chu Phi. Loi mui ny dn dn lan trn ra hu ht cc khu vc

c kh hu nhit i u tin l nh tu thuyn v sau c th c my bay

na. Trong qu kh, mui Aedes aegypti phi nh vo cc vng nc ma

trng.

Aedes albopictus trc y l vector truyn bnh chnh ca Dengue v hin nay

vn cn l vector quan trng chu . Loi mui ny gn y lan trn n

khu vc Trung M, Hoa K v ti y mui ny l vector truyn bnh quan

trng th hai. Mui Aedes aegypti khng truyn virus cho trng trong khi mui

Aedes albopictus th c kh nng ny.

Nc ta c 2 loi gy bnh ch yu l Aedes aegypti v Aedes albopictus. Mui

Aedes ht mu ban ngy, thng nhiu nht vo sng sm v chiu ti, u

ni ti trong nh, thng sng cc th. Mui Aedes albopictus thch sng

lm cy, ngn c, phn ln sng vng nng thn.

* Ngoi mui, SXHD c th truyn bi kim chch. Tn xut nhim cao nhng

vng lu hnh ngh ti nhng ca kt hp vi truyn mu c th xy ra, nhng

trong dn s tng ng ny min dch ngi nhn cng cao, v kh phn

bit mt trng hp ly truyn theo truyn mu vi mt ca nhim t nhin.

3. C th cm th

Trc y bnh ch yu xy ra tr em < 15 tui. Bnh SXHD ngi ln

bt u t nm 1981 vi v dch xy ra Cuba. T nm 19901995, tui trung

bnh ca bnh nhn c khuynh hng tng dn ti cc nc ng nam v

Nam M. Nm 1998 v 1999, nhng v dch u tin ngi ln xy ra Vit

Nam y t l bnh nhn ngi ln tng ln, a s ngi tr t 1520 tui.

Gio trnh Bnh nhim

451

Gn nh ton b bnh nhn trn 1 tui b SXHD c sc u c tng th pht

khng th chng virus Dengue, chng t tng b nhim Dengue. SXHD

cng c th xy ra trong ln nhim Dengue u tin cc tr s sinh c m

c min dch vi virus Dengue.

Tr nh nhi l nhm bnh nhn SXHD rt ng quan tm. Nm 1997, trong

bo co ca bnh vin Nhi ng I c 47 tr nh nhi b SXHD c xc nhn

bng phn ng ngn ngng kt hng cu (HI test). Tt c cc bnh nhi ny u

c xc nhn l SXHD s nhim.

IV. BNH SINH

Trn th gii, ngi ta a ra rt nhiu gi thit gii thch c ch sinh bnh

SXH. Gi thit ca Halstead, l gi thit c nhiu ngi cng nhn.

SXH Dengue thng xy ra nhng ngi c khng th Dengue t trc.

Khi virus Dengue xm nhp ln sau s kt hp vi khng th trc to

thnh phc hp khng nguyn khng th, c gi l phc hp min dch.

Phc hp ny s hot ha b th (mt trong nhng h thng bo v ca c th)

dn n hu qu l lm tng tnh thm thnh mch, ph hy h thng cm mu

(do gii phng cc yu t ng mu) v gim tiu cu gy ra xut huyt, v

sc.

Gio trnh Bnh nhim

452

Nhim virus Dengue thng khng c biu hin r rng ch yu xut hin

ngi ln u mc bnh, cha c min dch. SXHD thng xy ra trong ln

nhim trng sau, khi bnh nhn c sn min dch ch ng (do b bnh)

hoc th ng (do m truyn sang) i vi mt loi huyt thanh khc. Bnh

thng biu hin nng t ngt sau 2 n 5 ngy (giai on h st). Cc phc

hp khng nguynkhng th (virusantibody complex) lu hnh trong mu, s

hot ha h thng b th

(complement activation) v

gii phng cc cht hot

mch (cytokine production)

c th gy nn tng tnh

thm mao mch i vi

huyt tng (plasma

leakage), xut huyt v c

th l ng mu ni mch

lan ta (DIC). Trong qu

trnh o thi min dch ca

cc t bo nhim virus, cc protease v lymphokine c phng thch gy hot

ha h thng b th cng nh cc yu t tng tnh thm thnh mch.

Min dch tng cng bnh: Mt s nh nghin cu a ra gi thuyt rng

"SXHD/Hi chng sc Dengue xy ra khi mt ngi nhim bnh trong qu

kh bi mt loi huyt thanh virus, nay li nhim mt loi huyt thanh virus

khc".

Gi

thuyt

ny c

cng c

bi cc

ghi nhn

lm sng

rng

SXHD

gp ch

yu

nhng

ngi

t nht

mt ln

mc bnh trc v xy ra thng xuyn hn cc c dn trong vng dch

lu hnh hn l cc du khch mc bnh ti ni ny trong cng thi im. Nu

Gio trnh Bnh nhim

453

gi thuyt ny l ng hon ton th vic lu chuyn cc loi huyt thanh virus

khc nhau t vng ny n vng khc trn th gii s ngy cng gy nn tnh

trng bnh nng n hn trong tng lai.

V. BIU HIN LM SNG

Nhim virus Dengue thng nht khng triu chng. Bnh SXHD c biu

hin lm sng a dng, din bin nhanh chng t nh n nng. Bnh thng

khi pht t ngt v din bin qua 3 giai on: giai on st, giai on nguy

him v giai on hi phc. Pht hin sm bnh v hiu r nhng vn lm

sng trong tng giai on gip chn on sm, iu tr ng v kp thi, nhm

cu sng ngi bnh.

1. Thi k bnh

T 315 ngy, trung bnh t 46 ngy.

2. Thi k khi pht

2.1. Giai on st

St cao t ngt, lin tc.

Nhc u, au c, au khp, nhc hai h mt.

Chn n, bun nn.

Da nim sung huyt. Nghim php

dy tht (lacet) dng tnh.

Biu hin xut huyt thng c

chm xut huyt di da, chy mu

chn rng, chy mu cam.

2.2. Giai on nguy him:

Thng vo ngy th 37 ca bnh. C

th cn st hoc gim st.

Biu hin thot huyt tng do tng tnh thm thnh mch (thng t 24

48 gi) :

1. Trn dch mng phi, mng k, mng bng, ph n mi mt, gan to, c th

au.

2. Nng s dn n sc vi cc biu hin vt v, bt rt hoc li b, lnh u

chi, da lnh m, mch nhanh nh, huyt p kt (hiu s huyt p ti a v ti

thiu 20 mmHg), huyt p tt hoc khng o c, tiu t.

Xut huyt:

1. Xut huyt di da: Nt xut huyt ri rc hoc chm xut huyt thng

mt trc hai cng chn v mt trong hai cnh tay, bng, i, mng sn

hoc mng bm tm.

2. Xut huyt nim mc: chy mu cam, chn rng, tiu ra mu. Kinh nguyt

ko di hoc xut hin sm hn k hn.

3. Xut huyt ni tng: tiu ha, phi, no ... l biu hin nng.

Gio trnh Bnh nhim

454

Biu hin suy tng: trng hp nng c th c vim gan nng, vim no,

vim c tim. C th xy ra mt s ngi bnh khng c du hiu thot huyt

tng r hoc khng sc.

2.3. Giai on hi phc

Sau 2448 gi nguy him, c hin

tng ti hp thu dn dch t m k

vo trong lng mch. Giai on ny

ko di 4872 gi.

Ht st, ton trng tt ln, thm

n, huyt ng n nh v tiu nhiu.

Pht ban dng hi phc, nhiu

nht hai chn.

C th c nhp tim chm v thay i v in tm . Nu truyn dch qu

mc c th gy ph phi v suy tim.

VI. XT NGHIM

1. Xt nghim mu

Dung tch hng cu (Hct): c th cn bnh thng trong giai on st.

Trong giai on nguy him, Hct tng so vi gi tr ban u ca ngi bnh

hoc so vi gi tr trung bnh ca dn s cng la tui.

Trong giai on hi phc, Hct tr v bnh thng hoc thp hn (do hin tng

dch c ti hp thu).

Tiu cu: gim dn, nhng cn > 100.000/mm3 trong giai on st.

Trong giai on nguy him, gim 100.000/mm3 t ngy th 3 ca bnh.

Giai on hi phc, tr v bnh thng dn, chm hn.

Bch cu: trong thi k u thng gim, bch cu a nhn trung tnh

chim u th.

Vo cui giai on st, bch cu a nhn trung tnh gim nhanh, bch cu

lympho tng tng i, tng lympho khng in hnh trn 15%.

Tng tr li sm sau khi h st.

Men gan AST, ALT: thng tng trong giai on nguy him.

Gio trnh Bnh nhim

455

Nng AST cao hn ALT v tng vi mc nh v trung bnh trong hu

ht trng hp (< 5 ln gii hn trn ca khong tr bnh thng), chng t tn

thng gan trong SXH ch nh n trung bnh.

Ri lon ng mu: trong trng hp nng. Thi gian mu chy ko di;

lng prothrombin gim, i khi di 40% so vi chun; Fibrinogen thp.

2. Xt nghim virus

Dengue NS1 antigen test:

L test nhanh tm khng nguyn NS1 trong mu, dng chn on sm nhim

Dengue nguyn pht v th pht, c bit trong vng 4 ngy u ca bnh.

Phn lp virus: trong mu trong 6 ngy u ca bnh.

- Huyt thanh chn on:

Xt nghim ngn ngng kt hng cu (HI: Haemaggglutination Inhibition

Test) chn on huyt thanh hc nhim virus Dengue. Khng th HI tn ti

lu (> 50 nm), dng nghin cu dch t hc.

Tm khng th IgM (MACELISA: IgM Antibody Capture Enzyme

Linked ImmunoSorbent Assay) t ngy th 5 ca bnh, c th ko di 23

thng.

Tm khng th IgG (tng ng xt nghim HI) xut hin ng thi

hoc ngay sau IgM nhng ko di hn.

PCR tm RNA ca Dengue.

3. Xt nghim khc

- Xquang lng ngc thng: trn dch mng phi (> 80%).

- Siu m: trn dch mng bng, mng phi (mc tng ng vi mc

trm trng ca bnh), ph ti mt (> 95% trng hp nng), trn dch quanh

thn hay cn thn (77%), trn dch di bao gan hay lch.

VII. CHN ON

Chn on thng da vo cc yu t dch t, biu hin lm sng cng nh cc

xt nghim n gin. Chn on lm sng da vo cc tiu chun ca T chc

Y t Th gii.

1. Chn on lm sng

Theo T chc Y t Th gii nm 2009, bnh SXHDengue c chia lm 3

mc :

St xut huyt Dengue (A91a).

St xut huyt Dengue c du hiu cnh bo (A91b).

St xut huyt Dengue nng (A91c).

1.1. St xut huyt Dengue (A91a)

a) Lm sng

St cao t ngt, lin tc t 27 ngy, v c t nht 2 trong cc du hiu sau:

Biu hin xut huyt: lacet dng tnh, chm xut huyt di da, chy

mu cam hoc chn rng (t/nh).

Gio trnh Bnh nhim

456

Da sung huyt, pht ban.

Nhc u chn n, bun nn.

au c, khp, nhc hai h mt.

b) Xt nghim mu:

Hematocrite bnh thng hoc tng.

S lng tiu cu bnh thng hoc hi gim.

S lng bch cu thng gim.

1.2. St xut huyt Dengue c du hiu cnh bo (A91b)

a) Lm sng

Bao gm cc triu chng ca SXHDengue, km theo cc du hiu cnh bo

sau:

Vt v, l , li b.

au bng hoc n au vng gan.

Gan to > 2 cm di b sn.

n i nhiu.

Xut huyt nim mc (nhiu/nng).

Tiu t.

b) Xt nghim mu

Hematocrite tng cao.

S lng tiu cu gim nhanh chng.

1.3. St xut huyt Dengue nng (A91c)

Khi ngi bnh c mt trong cc biu hin sau:

Sc SXHDengue: do thot huyt tng nng dn n sc gim th tch,

dch khoang mng phi v bng nhiu.

Xut huyt nng.

Suy tng.

a) Sc st xut huyt Dengue (A91c1)

Suy tun hon cp, thng xy ra vo ngy th 37 ca bnh, biu hin bi cc

triu chng vt v, bt rt hoc li b, lnh u chi, da lnh m, mch nhanh

nh,huyt kt hoc tt, hoc khng o c huyt p, tiu t.

Sc SXHDengue: c du hiu suy tun hon, mch nhanh nh,huyt kt

hoc tt km theo cc triu chng lnh u chi, da lnh m, vt v, bt rt hoc

li b.

Sc SXHDengue nng: sc nng, mch nh kh bt, huyt p khng o

b) Xut huyt nng (A91c2)

Chy mu cam nng, rong kinh nng, xut huyt trong c v phn mm,

xut huyt ng tiu ha, v ni tng, thng km theo tnh trng sc nng,

gim tiu cu, thiu oxy m v toan chuyn ha c th dn n suy a ph tng

v ng mu ni mch nng.

Gio trnh Bnh nhim

457

Xut huyt nng cng c th xy ra ngi bnh dng cc thuc khng

vim nh cetylsalicylic acid (Aspirin), Ibuprofen hoc dng Corticoid, tin s

d dyt trng, vim gan mn.

c) Suy tng nng (A91c3)

Suy gan cp, men gan AST, ALT > 1.000 U/L.

Suy thn cp.

Ri lon tri gic (SXH th no).

Vim c tim, suy tim, hoc suy chc nng cc c quan khc.

2. Chn on cn nguyn virus Dengue

Chn on nguyn nhn l cn thit nu xt trn phng din sc khe cng

ng, nhng li t ra khng cn thit cho vic thit lp mt ch iu tr h

tr sm cho bnh nhn.

Chn on xc nh bng cc xt nghim:

2.1. Huyt thanh chn on

Khi nhim virus Dengue cp tnh c hai kiu p ng huyt thanh: p ng tin

pht v th pht. Theo TCYTTG (1986), p ng huyt thanh th pht xy ra

nhng ngi b nhim virus Dengue cp m trc b nhim flavivirus.

Trong nhim trng tin pht th p ng khng th tng chm vi mc

tng i thp v c tnh cht c hiu cho tng type. i vi nhim trng th

pht, hiu gi khng th tng nhanh chng vi mc cao v c phn ng vi

nhiu loi khng nguyn ca nhm Flavivirus.

Khng th IgM khng Dengue to ra trong giai on cp. Nu c IgM l ang

b nhim virus Dengue cp tnh hoc va mi xy ra.

Khng th IgG khng Dengue xut hin trong nhim trng tin pht v th

pht, nhng trong nhim trng th pht hiu gi rt cao so vi nhim trng tin

pht.

Xc nh IgM, IgG khng virus Dengue c li ch pht hin bnh nhng

trng hp tn pht hoc bnh nng c nguy c t vong cao.

a) Xt nghim nhanh

Tm khng nguyn NS1: trong 4 ngy u ca bnh.

Tm khng th IgM: t ngy th 5 tr i.

b) Xt nghim ELISA

Tm khng th IgM: t ngy th 5 tr i.

Tm khng th IgG: ly mu 2 ln cch nhau 1 tun, so snh hiu gi

khng th (tng gp 4 ln).

2.2. Xt nghin PCR, phn lp virus

Virus Dengue c th phn lp c t cc bnh phm: huyt thanh, mu

ca ngi bnh. Thi gian c nng cao ca virus trong mu t ngy 1 6

ca bnh.

Gio trnh Bnh nhim

458

Khi ngi bnh t vong ly cc bnh phm gan, lch, hch, tuyn c

phn lp virus.

3. Chn on phn bit

3.1. Giai on cp ca bnh c st: cn phn bit vi st pht ban do virus, st

m, st rt, st xut huyt do siu vi khc,

Cc xt nghim nh AST > 60U /ml, BC < 5000, N < 3000 c gi tr hn c du

lacet trong chn on phn bit.

3.2. Trong trng hp bnh c sc: cn phn bit vi nhim trng huyt do

no m cu, nhim trng huyt vi khun gram m, do Streptococcus suis, vim

rut hoi t tr ln,

VIII. IU TR

A. Nguyn tc chung

Hin nay cha c thuc iu tr c hiu. iu tr ch yu l triu chng v

bin chng bnh. Cc bin php iu tr chung gm:

Thuc h st. Ch khng dng cc thuc salycilate v c a d gy xut

huyt, cng nh nguy c xut hin hi chng Reye.

Bi ph nc bng ng ung hoc bng ng tnh mch trong trng

hp cn thit nhm phng v iu chnh mt nc. Tuy nhin, cn cn trng

trnh bi ph dch qu mc cn thit khi sc n nh, phng bin chng

ph phi cp.

Nu c xut huyt nng v ri lon ng mu trm trng, cn phi truyn

mu ti hoc khi tiu cu.

Oxy liu php trong trng hp h oxy mu, sc.

Theo di bnh nhn cht ch nht l trong giai on bt u h st.

B. Phn cp iu tr (xem Ph lc 2)

Sau y l nhng gi v phn cp bnh nhn theo tuyn iu tr trong trng

hp c dch vi lng bnh nhn tng cao trong cng thi im.

1. Tiu chun iu tr ngoi tr v theo di ti y t c s

Tt c nhng bnh nhn SXHDengue khng c nhu cu phi truyn dch tnh

mch.

2. Tiu chun nhp vin

SXHDengue c du hiu cnh bo (A91b)

Tt c nhng trng hp bnh cn b dch qua ng tnh mch.

SXHDengue (A91a) trn c a c bit nh ph n mang thai, tr nh

nhi, ngi bo ph, ngi cao tui; c bnh l km theo nh tiu ng, vim

phi, hen ph qun, bnh tim, gan, thn, ; ngi sng mt mnh hoc nh

xa c s y t nn xem xt cho nhp vin theo di iu tr.

3. Tiu chun nhp vin vo khoa hi sc tng cng

Tt c bnh nhn SXHDengue nng (A91c).

Gio trnh Bnh nhim

459

C. Bin php c th

1. iu tr SXH-Dengue

1.1. iu tr triu chng

Nu st cao 39oC:

Cho thuc h nhit: Paracetamol n cht, 1015mg /kg /46gi, tng liu

khng qu 60mg /kg /24gi (khng dng Acetyl salicylic acid nh Aspirin,

hoc Analgin, Ibuprofen v c th gy xut huyt, toan mu)

Ni lng qun o, lau mt bng nc m.

1.2. B dch sm bng ng ung

Khuyn khch ngi bnh ung nhiu nc Oresol, hoc nc chin, nc tri

cy, nc cho long vi mui.

2. iu tr SXH-Dengue c du hiu cnh bo

2.1. iu tr triu chng

Tng t nh SXHDengue.

2.2. Truyn dch

Ch nh: nn xem xt truyn dch nu ngi bnh khng ung c, nn

nhiu, c du hiu mt nc, l , hematocrit tng cao mc d huyt p vn

n nh).

Dch truyn bao gm: Ringers lactate, NaCl 0,9%.

3. iu tr SXH-Dengue nng

3.1. iu tr sc SXH-Dengue

a) Sc SXH-Dengue

+ i vi ngi ln:

Chun b dch truyn: Ringers lactate, NaCl 0,9%, dung dch cao phn t nh

Dextran 40 hoc 70, HES (hydroxyethyl starch).

Cch thc truyn:

Phi thay th nhanh chng lng huyt tng mt i bng dung dch

Ringers lactate hoc NaCl 0,9%, truyn tnh mch nhanh vi tc 1520 ml/

kg/ gi.

nh gi li tnh trng ngi bnh sau 1 gi, truyn sau 2, 4, 6 gi phi

kim tra li hematocrite:

Nu ngi bnh ra khi sc, th gim dn tc truyn ty theo p ng

lm sng v hematocrite.

Nu tnh trng sc khng ci thin, th thay th dch truyn bng dung

dch cao phn t. Truyn 1520 ml/ kg/ gi trong 1 gi. Sau nh gi li:

* Nu sc ci thin, hematocrite gim, th gim dn tc truyn cao phn t.

Nu tnh trng n nh, th chuyn dung dch in gii.

* Nu sc vn cha ci thin, th o p lc tnh mch trung ng (CVP)

quyt nh cch x tr.

Gio trnh Bnh nhim

460

Nu sc vn cha ci thin m hematocrite gim xung nhanh (mc d cn >

35%) th cn pht hin xut huyt ni tng v xem xt ch nh truyn mu.

+ i vi tr em:

St xut huyt Dengue cnh bo c ch nh truyn dch

Truyn tnh mch ban u

(Ringer lactat hoc NaCl 0,9% 67 ml/kg cn nng/gi, truyn trong 13

gi)

b) Sc SXH-Dengue nng

Ngi bnh vo vin trong tnh trng sc nng (mch quay khng bt c,

huyt p khng o c), th phi x tr rt khn trng:

ngi bnh nm u thp.

Cho th Oxy.

Truyn dch:

+ i vi ngi bnh < 15 tui:

Bm trc tip vo tnh mch dung dch Lactate Ringer hoc mn ng trng

20 ml/ kg trong vng 15 pht. Sau nh gi li ngi bnh, c 3 kh nng:

Nu mch r huyt p ht kt, cho dung dch cao phn t 10 ml/ kg/ gi

v x tr tip nh st xut huyt cn b.

Nu mch nhanh, huyt p cn kt hoc h, th truyn dung dch cao phn

t 1520 ml/ kg/ gi, ri x tr nh sc SXH trn.

Gio trnh Bnh nhim

461

Nu mch v huyt p vn khng o c th bm trc tip dung dch cao

phn t 20 ml/ kg/ 15 pht. o CVP c phng hng x tr. Nu mch r

v o c huyt p, th truyn dung dch cao phn t 1520 ml/ kg/ gi, ri x

tr nh sc SXH trn.

Gio trnh Bnh nhim

462

+ i vi ngi bnh 15 tui:

3.2. iu tr xut huyt nng

a) Truyn mu v cc ch phm mu

Truyn khi hng cu hoc mu ton phn:

Sau khi b dch nhng sc khng ci thin, hematocrit gim xung

nhanh (mc d cn trn 35%).

Xut huyt nng

b) Truyn tiu cu

Khi s lng tiu cu xung nhanh < 50.000/mm3 km theo xut huyt

nng.

Nu s lng tiu cu < 5.000/mm3 mc d cha c xut huyt c th

truyn tiu cu ty tng trng hp c th.

c) Truyn plasma ti, ta lnh

Xem xt truyn khi ngi bnh c ri lon ng mu dn n xut huyt nng.

3.3. iu tr suy tng nng

a) Tn thng gan, suy gan cp

H tr h hp

H tr tun hon

Kim sot h ng huyt: gi ng huyt 80120mg%.

iu chnh in gii

Gio trnh Bnh nhim

463

iu chnh ri lon thng bng kim toan

iu chnh ri lon ng mu:

Vitamin K1: 1mg/kg/ngy (ti a 10mg) TMC x 3 ngy.

iu tr/phng nga XHTH: Ranitidine hoc Omeprazole.

Ri lon tri gic/co git:

Chng ph no: mannitol 20%

Chng co git: diazepam hoc midazolam. Chng ch nh: phenobarbital.

Gim amoniac mu: Tht tho bng nc mui sinh l m, lactulose,

metronidazol, neomycin (gavage).

Khng sinh ton thn ph rng:

Trnh dng cc khng sinh chuyn ha qua gan nh pefloxacine,

ceftraxone.

Khng dng paracetamol liu cao v gy c tnh cho gan.

b) Suy thn cp

iu tr bo tn v chy thn nhn to khi c ch nh v huyt ng n nh.

Lc mu lin tc nu c biu hin suy a tng i km hoc suy thn cp huyt

ng khng n nh. Ch nh chy thn nhn to trong st xut huyt suy thn

cp:

Ri lon in gii kim toan m khng p ng iu tr ni khoa:

Tng kali mu nng > 7mEq/L.

Na > 160 hay < 115 mmol/L.

Toan ha mu nng khng ci thin vi b Bicarbonate (pH < 7,1).

Hi chng ur huyt cao:

Ri lon tri gic, nn, xut huyt tiu ha.

Ur mu > 200 mg% hoc creatinine tr nh > 1,5 mg% v tr ln > 2mg%.

3.4. Qu ti dch khng p ng iu tr ni khoa

Suy tim huyt, cao huyt p.

Ph phi cp.

Ch nh lc mu lin tc trong st xut huyt: Khi c hi chng suy a

tng km suy thn cp hoc suy thn cp huyt ng khng n nh.

3.5. St xut huyt Dengue th no, ri lon tri gic, co git

H tr h hp

Bo m tun hon

Chng co git

Chng ph no

H st

H tr gan nu c tn thng

iu chnh ri lon nc in gii, kim toan

Bo m chm sc v dinh dng

Phc hi chc nng sm

Gio trnh Bnh nhim

464

3.6. Vim c tim, suy tim:

S dng thuc vn mch dopamine, dobutamine, o CVP.

4. Th oxy: Tt c cc ngi bnh c sc cn th oxy gng knh.

5. S dng cc thuc vn mch:

Khi st ko di, cn phi o CVP quyt nh thi x tr.

Nu truyn dch y m huyt p vn cha ln v CVP trn 10

cm nc th truyn tnh mch Dopamine/Dobutamine.

6. Cc bin php iu tr khc

Khi c trn dch mng bng, mng phi gy kh th, SpO2 gim xung

di 92%, nn cho ngi bnh th NCPAP trc. Nu khng ci thin mi

xem xt ch nh chc ht gim bt dch mng bng, mng phi.

Nui dng ngi bnh st xut huyt Dengue.

7. Chm sc v theo di ngi bnh sc

Gi m.

Khi ang c sc cn theo di mch, huyt p, nhp th t 1530 pht 1

ln.

o hematocrit c 12 gi 1 ln, trong 6 gi u ca sc. Sau 4 gi 1

ln cho n khi sc n nh.

Ghi lng nc xut v nhp trong 24 gi.

o lng nc tiu.

Theo di tnh trng thot dch vo mng bng, mng phi, mng tim.

8. Tiu chun cho ngi bnh xut vin

Ht st 2 ngy, tnh to: t nht 24 gi sau khi h st m khng phi dng

thuc h st, thm n, tng trng kh hn, tiu nhiu.

Mch, huyt p bnh thng: Hct n nh mc bnh thng, t nht 2

ngy sau khi sc xy ra, khng suy h hp do trn dch mng phi / c trng.

S lng tiu cu > 50.000/mm3: khng bin chng xy ra.

Gio trnh Bnh nhim

465

TI LIU THAM KHO

1. St xut huyt DengueWikipedia ting Vit

(http://vi.wikipedia.org/wiki/St_xut_huyt_Dengue)

2. Nguyn Th Xuyn, Th trng B Y t "Hng dn chn on, iu tr

st Dengue v st xut huyt Dengue"(Ban hnh km theo Quyt nh s

458/QBYT ngy 16 thng 02 nm 2011 ca B trng B Y t).

3. Nguyn Thanh Hng, Nguyn Trng Ln v cs. Mi nm kinh nghim

iu tr st xut huyt Dengue ti bnh vin Nhi ng 1 (1991 2000).

(http://www.ykhoanet.com/tapchiyhoc/B0106_IN/4_HUNG_SXH4TR149_152

.htm)

4. Theodore F. Tsai, David W. Vaughn, and Tom Solomon. Flaviviruses

(Yellow Fever, Dengue, Dengue Hemorrhagic Fever, Japanese Encephalitis,

West Nile Encephalitis, St. Louis Encephalitis, TickBorne Encephalitis). In

Mandell, Douglas, and Bennetts Principles and Practice of Infectious Diseases,

6th edition, 2005. Chapter 149 (Pages 19261950).

5. S Datta, C Wattal. Dengue NS1 antigen detection: A useful tool in early

diagnosis of dengue virus infection (Department of Clinical Microbiology, Sir

Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India). In Original

Article, Volume : 28, Issue : 2, 2010 (Page : 107110).

6. Carlos H. RamirezRonda, Carlos D. Garcia, Dengue in the western

hemisphere, Infectious Disease clinics of north america, volume 8, number 1,

March 1994, p.107125.

7. CDC, Dengue Fever, slide set, 2004.

8. Duane J. Guble, Dengue and Dengue Hemorrhagic Fever, Tropical

Infectious Disease: Principle, pathogen and practice 1999 p.12651279.

9. Ingrid Kautner, Max J. Robinson, Ursula Kuhnle, Dengue virus infection:

Epidemiology, pathogenesis, clinical presentation, diagnosis, and prevention, J

Pediatr 1997; 131:51624.

10. Scott B. Halstead, Dengue and Dengue Hemorrhagic Fever. In Textbook

of Pediatric Infectious Disease 1998 p.19841993.

Gio trnh Bnh nhim

466

CU HI TRC NGHIM

1. Trong bnh st xut huyt, thay i sinh l bnh chnh l:

a. Tng cp tnh thm thnh mch lm tht thot huyt tng

b. Tn thng trm trng t bo gan

c. Bt thng ng mu

d. Suy thn nng

2. St xut huyt Dengue:

a. Bnh ch yu xy ra tr em di 1 tui

b. Khng gp ngi ln.

c. Ch yu l tr di 15 tui

d. Ch yu l ngi gi

3. St trong st xut huyt:

a. St t ngt km cc mt mi, nn i, nhc u, chn n v ho.

b. St ko di 2 tun

c. St va tng cn

d. St tng t t

4. Giai on chnh ca bnh l:

a. Vo khong 2 gi trc n 2 gi sau khi h st

b. Vo khong 4 gi trc n 4 gi sau khi h st

c. Vo khong 24 gi trc n 24 gi sau khi h st

d. Vo khong 2 ngy trc n 2 ngy sau khi h st

5. Sc:

a. Khng xy ra vo thi im h st.

b. Thng t ngy 46

c. Thng ngy 12

d. Thng sau 7 ngy

6. Theo TCYTTG, chn on st xut huyt c sc da vo cc tiu chun

nh:

a. Li b

b. Mch quay r va

c. Huyt p kp hoc khng o c

d. Chn lnh

7. Trong SXHD, h st bng:

a. Acetaminophen

b. Salicylate

c. Seduxen

d. Khng sinh

P N:

1. a 2. c 3. a 4. c 5. b 6. d 7. a