chuan bi tien phau & chan soc hau phau

8/14/2019 Chuan Bi Tien Phau & Chan Soc Hau Phau

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NGOI KHOA LM SNG-2007

CHUN B TIN PHU V CHM SC HU PHU

cuc phu thut thnh cng, khng ththiu vai tr ca cng vic chun b tr c m v chm sc sau m.Cng vic chun b tr c m c thc hin b i -kpiu tr (phu thut vin, bc s gy m, chuyn vin vtm l, chuyn vin vvt l tr liu).Mc ch ca cng vic chun b tr c ml:

o nh gi ton tr ng v cc bnh l ni khoa m BN mc phi.o Xcnh cc yu tnguy c c th nh h ngn k t quphu thut.o Gio dc BN (cho BN bit vcc ph ng phpiu tr , u v khuyt im ca

tng ph ng php, v ph ng php ti u i v i BN). BN cng cn c bitmc tr m tr ng ca cn bnh ca mnh v nguy c xy ra bin chng ca cuc

phu thut, cng nhcc vn khc c thxy ra trong v sau m, c bit ccvn c lin quann thm m, vn ng v sho nh p v i cngng.o Ti u ho tnh tr ng ton thn cng nh tr ng thi tm l, nhm hn ch n

mc th p nht nguy c xy ra cc tai bin v bin chng sau m, lm cho cuc phu thut thnh cng tt p.

1-Chun b chung tr c m:1.1-Thm khm tin phu:Cng vic thm khm tin phu c tin hnh b i phu thut vin v bao gm cc b csau:

o Khai thc tin cn vnh gi ton tr ngo Thm khm ton thno Thm khm cc hc quano Xcnh cc yu tnguy c ca cuc phu thut

Khi khai thc tin cn, cn ch n:o Cc bnh l vthn kinh (tai bin mch mu no, co git, tm thn)o Cc r i lon ng mu:

Xut huyt d i da Chy mu ko di vt th ng Rong kinh

o Cc bnh l ni khoa: Bnh tim mch (tng huyt p, thiu mu c tim, bnh van tim) Bnh h h p (hen, bnh phi tc nghn) Bnh gan (vim gan, suy gan) Bnh thn (suy thn)

Tiu ng

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Suy gip hay c ng gip Bnh vkh p (vim kh p c p hay mn tnh)

o Cc bnh l nhim trng: Vim ng h h p trn Nhim trng ngoi da (Herpes simplex virus) Nhim trng tiu

o Sn phkhoa (thai k , kinh nguyt)o Vn dinh d ng (chnn, st cn)o Hin t ng ngy hay ngng th trong lc ng.o Tin cn phu thut (chn on v ph ng php phu thut, cc bin chng xy

ra trong v sau m).o

Cc thit b nhn to: trong c thc mnh ghp (mch mu), ct my tonh p tim hay van tim nhn to.o D ng thuc (khng sinh, thuc gim au, thuc gy t, latex).o T ng tc thuc:

L i tiu (c thgy hK +, Mg2+ huyt t ng, lm tng nguy c lon nh pkhi c tcng ca epinephrine).

MAO, phenothiazine, thuc chng tr m cm ba vng (lm tng tcngln htim mch ca epinephrine)

Propranolol: lm tng huyt p k ch pht v chm nh p tim khi k t h pv i epinephrine.

Cc loi thuc c tcng bt l i n cuc phu thut: Aspirin, NSAID (lm tng nguy c chy mu) Corticoid (c thgy suy tuyn th ng thn) Hormone tuyn gip (vic ngng s dng cc ch phm ca

hormone tuyn gip do bnh l hay phu thut sdn n cc binchng ca suy gip)

Vic nh gi ton tr ng (bng 1) nhm xcnh khnng thch nghi v mc chung ca BNi v i cuc phu thut, ng th i gp phn vo vic nh gi cc yu t nguy c ca cc hc quan,c bit nguy c trn hh h p v tim mch.

Xu t s c Trung bnh KmCh y b(1,5 km/ pht) Lau chi sn nh nh tennis

p xe p i b trong khong th i giantrn 4 pht Leo mt t ng l u

Sinh hot h ng ngy ( n, t m,m c qun o) i b trong khong th i giand i 2 pht Vi t lch

Bng 1- nh gi ton tr ng BN 1.2-Y lnh tin phu:1-Thuc l: BN cn ngng ht thuc l ti thiu 8 tun tr c phu thut. Thuc l lmtng tnh kch thch ca phqun, tng nguy c co tht phqun v tng tit m trongv sau phu thut. Tnh tr ng tng tit m c thdn n x p phi, vim phi. Nghin

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cu cho thy r ng, vic ngng ht thuc l trong th i gian ngn h n 8 tun tr c m khng lm thayi nguy c xy ra cc bin chng vh h p sau m.2-Cc xt nghim tin phu: nu BN khomnh, cc xt nghim tin phu th ng quisauy c ch nh:

o Cng thc muo Nhm muo ng huyto Creatinine huyt t ngo AST, ALTo ECG (nu BN trn 40 tui)o X-quang phi thngo Tng phn tch n c tiuo Test thai nhanh (QS): cho tt cphntrongtui sanh n .

3-n ung:o Ngy tr c m: ch n khng c cht bo Khngn thc c (bao gm cn c cam, soda v sa) ti thiu 6 gi tr c

phu thuto Khng ung dch trong (bao gm n c v n c to) ti thiu 2 gi tr c phu

thut4-Vn ng:C ba mc : ngh ng i trn gi ng, vn ng c gi i hn, vn ng bnh th ng. Tu thuc vo bnh l v yu cu ca cuc phu thut m BN c yu cu mt trong ba ph ng php vn ng ni trn.Tr tr ng h p c ch nh c bit, hu ht BN c yu cu vn ng bnh th ng.Vic duy tr vn ng bnh th ng tr c mslm tng hiu quhot ng ca htimmch v h h p, tng c ng chc nng chuyn ho, ni tit v min dch, gim nguy c huyt khi t nh mch v teo c b p.5-Cc loi thuc:Trong giaion tr c trong v mt khong th i gian nht nh sau m, cc loi thuc

sauy khng c ti p tc sdng:o Thuc lm tng nguy c chy mu:

Thuc khngng Thuc c ch s k t t p tiu cu (aspirin,clopidogrel, dipyridamole,

ticlopidine). Cc loi thuc ny c yu cu ngng sdng 5 ngy tr c phu thut.

Thuc khng vim non-steroid (NSAID). Cc loi thuc ny c yucu ngng sdng vo ngy phu thut.

o Thuc lm tng nguy c huyt khi (tamoxifen)

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i v i thucc chCOX-2 (Celebrex, Vioxx), khng cn thit phi ngng sdng vongy phu thut.Vo sng ngy phu thut, mt sloi thuc c th c ti p tc sdng (bng 2).

c s d ng Khng c s d ng

T t c cc loi thu c tim mch (tr thu c l iti u)Thu c ch ng tro ng c d dy (omeprazol,ranitidin)Thu c dn ph qunThu c ng a thai u ng Corticoid hay cc tc nhn c ch mi n d ch Levothyroxine Acetaminophene v thu c gim au gy nghin

Thu c khng vim non-steroid (NSAID)Thu c tr ti u ng Thu c l i ti u v cc loi thu c lm gim cnVitamine v cc ch ph n ca kali

Bng 2- Vic s d ng cc loi thu c vo sng ngy ph u thut 6-Chun bmu (xem bi huyt hc trong ngoi khoa)

7-Nga nhim trng (xem bi bin chng ngoi khoa)8-Nga huyt khi t nh mch su (xem phn sau)9-Chun b ng tiu ho:

o Chun b i trng: dnh cho cc phu thut trni trng.o Chun b tr c trng: dnh cho phu thut vng hu mn, tng sinh mn.

10-Vsinh vng m: thng th ng BN s c yu cu tm r a vo ngy tr c phuthut v vsinh vng m vo sng ngy phu thut. Tuy nhin, nguy c nhim trngvng msth p nht khi vsinh vng mbng cch ct lng v cng vic ny c tin

hnh ngay tr c cuc m.11-Cc cng vic chun b khc (tho ttrang, ty s n mng tay).12-Bui sng ngy m:

o Thay, tho ttrango t thng ddy c ch nh trong cc tr ng h p sau: phu thut thc qun,

phu thut ddy, BN c bnh l tro ng c.o t mt ng truyn t nh mch ngoi bin. Dung dch c chn la l Ringer-

Glucose 5%.13-Ch nn chuyn BN vo phng tin m 1 gi tr c khi bt u phu thut.1.3-Chun b tm l:Cc sang chn vtm l (lo lng, xcng, s hi) c tcng bt l i n k t quphuthut.Cn thng bo cho BN bit:

o Ph ng phpiu tr , h ng xtr cng nhk t qu iu tr .o Nu c nhiu ph ng phpiu tr , nu r mt tch cc v mt gi i hn ca tng

ph ng php v cho BN bit ph ng php no thch h p nht cho BN.o Mt phn c thhay mt c quan ni tng sb ct b, c bit cc phn c lin

quann vn ng (chi) v thm m(v).

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o Vn bi tit skhng theo cch thc t nhin (hu mn nhn to, m niuqun ra da).

o Tin l ng ca cuc phu thut (scho k t qutt, trung bnh hay km). Nu BNkhngn nh vtm l, thng boiu ny cho thn nhn ca BN.

Khng nn thng bo cho BN bit:o Cc bin chng (c bit cc bin chng c nguy him n tnh mng) c thxy

ra.o Nguy c tvong

m tr c phu thut, cho BN mt loi thuc an thn nh(diazepam 10 mg ung).1.4-Mu v dch truyn:L t ng nht l duy tr Hct t30% tr ln, nng Hb t10 g/dL tr ln, c bit khiBN s p tri qua phu thut l n, BN c bnh l tim mch, h h p.

Tuy nhin, nu BN c sinh hiu n nh v khng thiu n c, nng Hb t7 g/dL tr ln khng lm tng t lbin chng v tvong hu phu.1.5-Dinh d ng:BN c nng albumin d i 2 g/dL hay st cn h n 10% tr ng l ng c thcn cnui d ng htr qua ng t nh mch 7-9 ngy.BN bo ph, sgim cn sc tcng tch cc n htim mch v h h p trong vsau mcng nhslnh vt th ng.2-Chm sc chung sau m: 2.1-Chm sc BN ngay sau m:Cch thc chm sc BN ngay sau m c trnh byy trong y lnh hu phu. Ylnh hu phu c chnh phu thut vin vit, nhm cung c p cho -kpiu d ng ph trch chm sc BN cc thng tin v: 1-chn on, 2-ph ng php phu thut, 3-tnhtr ng BN (bnh l ni khoa, tin cn d ng, thuc khngng ang sdng), 4-ccthng scn theo di (th ddu hiu sinh tn, ECG, SpO2, p lc t nh mch trung tm,kh mung mch), 5-cc bin phpiu tr (gim au, khng sinh, dch truyn), 6-cc chm scc bit khc (tthBN, catheter v ccng dn lu).Tu thuc vo tnh tr ng v tnh cht ca cuc phu thut, BN ngay sau mc th cchuyn vphng sn scc bit hay phng hi tnh.

Tiu chun ti p nhn BN vo phng sn scc bit:o BN cnang c thng kh quno Huyt p tm thu d i 90 mmHgo Sau cc phu thut l n (phu thut tim, ct phi, phnhng mch ch...)

Ni dung ca vic chm sc BN trong phng sn scc bit:o o kh mung mch haybo ho oxy mung mch (SpO2)o Cai my th : gim dn tn sca ch thng kh c ng bc (IMV) xung cn

4 nh p/pht. Nu BN khng c biu hin kh th v SpO2 trn 95%, chuyn sangch thng kh htr .

o Gim dn nngoxy trong kh th xung cn 0,4

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Ty thuc vo bnh l, ph ng php gy m v ph ng php phu thut m cc BN s c chm sc vmt vn ng khc nhau. Nu phu thut vng bng c gy m tonthn, sau khi chuyn BN vphng hu phu, cho BN nm ngh d ng t thFowler.TthFowler cng thch h p cho BN sau phu thut lng ngc.Tr mt s tr ng h p c bit, BN s c yu cu ngi dy vo bui ti ca ngy phu thut vi li vo ngy hm sau. Sau 3-5 ngy sau m, BN s i li bnh th ng.ngn nga bin chng h h p c thxy ra sau m, cn thc hin cc bin php sau:

o Hn chvic nm bt ng ko di,c bit nm nga thng trn gi ng. Cnthayi tthth ng xuyn

o T p th sutng c ng hot ng c honho T p ho khco Phdung khuyn khch (hnh 1)o Trnh truyn qu nhiu dch.

Hnh 1- Ph dung khuy n khch: bnh nhn c khuy n khch ht su, sao cho qu bng c nng ln t i mt cao cho tr c

Nu khng c ch nh khc, thng tiu c rt khi BN bt u ngi dy.Vn n ung:

o Chon khi BN tnh to hon ton v ng tiu ho bt u hot ng.o C nhung rut, BNi bng: cho ung dch long. Trnh cc cht sinh h i

hay cn nhiu nng l ngtiu ho (m ).o Khi c trung tin, cho BNn c dn v i sl ng tng dn.

2.3-Gim au sau m:Gim au tt sau mshn ch c nguy c xy ra cc bin chng sau m:

o Thiu mu c tim, nhi mu c timo Nh p tim nhanh v r i lon nh p timo Chm lnh vt th ngo X p phi, vim phio Huyt khi t nh mcho Co tht mch mu ngoi bino Nhim toan chuyn ho

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o Cht chuyn ho ca meperidine (normeperidine) lm tng tnh khch thch h thn kinh trung ng, c thdn n ng kinh.

o Khng s dng meperidine cho BN s dng cc thuc c chmonoaminoxydase (IMAO) tr c 2 tun, BN c tin cn ng kinh, BN b suy thn, suygan.

Pethidine (Dolargan):o Liu: 25 mg ung x 2-3 ln/ngy, 50-100 mg TB x 2-3 ln/ngy. Nu cn thit,

c thsdng pethidine qua ng t nh mch.Hydromorphone:

o L mt dn xut mnh ca morphine.o Liu: 2-4 mg ung mi 4-6 gi , 1-2 mg TB hay TM mi 4-6 gi , 3 mg cho mi

ln dng qua ng tod c.Methadone:

o Hiu qutt khi sdng qua ng ung.o Do c th i gian bn hu di, c thdng methadone c chtriu chng ca

hi chng ngng cc loi thuc gim au gy nghin khc.Oxycodone, propoxyphene v codein:

o C tc dng gim au yu.o c sdng qua ng ung.o Th ng c sdng k t h p v i aspirin hay acetaminophene.

2.3.2-Tramadol:o C tc dng gim au mnh t ng ng pethidine.o C tc dng gy nghin yu.o Khng gyc chh h p v tim mch.o t tc dng ph.o Cn thn khi ch nh Tramadol trn BN sdng IMAOs.

2.3.3-Thuc khng vim non-steroid (NSAID):Thu c Li u s d ng (mg) cho ng i l n/ngy Li u t i a (mg) cho ng i

l n/ngy Diclofenac (Voltarene) 50-75 (u ng/TB) x 2 l n 150 Ibuprofen 200-400 (u ng) x 4-6 l n 1200 Indomethacin 25 (u ng) x 3 200 Ketoprofen 50-75 TB x 2-3 l n 300 Ketorolac 10 (u ng) x 4, 15-60 (TB/TM) x 4 40 (u ng, 120 (TB) Naproxen 375 (u ng) x 2, 750 (u ng) x 1 1500 Piroxicam (Feldene) 10-20 (u ng /TB) x 1 l n

Bng 3- M t s NSAID c s d ng ph bi nCc loi thuc NSAID (bng 3) c tc dng gim au nh n trung bnh.So v i thuc gim au gy nghin, NSAID cu im l khngnh h ng n huytng, khngc chh h p, khng lmc chs tiu thot ddy v khng lm gimnhung rut.

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Tuy nhin, do c tcngc chsk t t p tiu cu, NSAID lm tng nguy c chy mutcc vt th ng (phu thut) hay vt lot (ddy-t trng).Khng sdng NSAID cho BN l n tui hay cho tr em. Cn thn khi sdng NSAIDi v i BN b suy gan hay suy thn

2.3.4-Acetaminophene:Mt svn cn ch khi ch nh acetaminophenegim au hu phu:

o Acetaminophene c tc dng gim au, hst nhng khng c tc dng khngvim.

o Acetaminophene khngnh h ng n sk t t p tiu cu, khng lm tng nguyc chy mu.

o Acetaminophene cc tnh trn gan. Liu 10-15g acetaminophene c thdnn hoi tgan.

o Liu sdng: 325-1000 mg mi 4-6 gi . Liu ti a: 4000 mg/ngy.3-Chun b v chm sc BN trong cc hon cnh c bit:3.1-BN mc bnh tim mch:Tim mch l mt trong nhng c quan chu nhiu sang chn nht khi tin hnh gy mv phu thut. Thng k cho thy r ng bin chng tim mch xy ra v i t l1-10% BNngoi khoa. Nguy c nhi mu c tim sau m BN c bnh mch vnh stng 10-50 lnso v i ng i khng mc bnh mch vnh.Cc thuc m thkh c tnhc ch i v i tbo c tim. Khi bt u tin hnh gy mton thn, cung l ng tim sgim 20-30%.

ng tct ni kh qun slm tng huyt p ton thn 10-15 mmHg.Cc thuc sdng qua ng t nh mch nh fentanyl, sufentanil, alfentanil tc cht bo c tim h n cc thuc m thkh. Tuy nhin, chng li c tcng gy dn t nhmch, lm gim tin ti v gim cung l ng tim. Nhng bin i ny sr h n BN b suy timhuyt.H n na, cc thuc m thkh, v cc thuc m qua ng t nh mch cng nhcc loithuc dn c lm tng tnh nhy cm ca tbo c timi v i catecholamine, mt chtng hnh v i cc sang chn ni chung v sang chn do phu thut gy ra ni ring.Gy t tusng v ngoi mng cng gy dnng v t nh mch (do xungng giao cm b c ch), dn n gim cung l ng tim. S y t nh mch tr c m (truyn nhiudch v i tc nhanh) shn chb t mc ca sbin i bt l i ny, tuy nhin saumnguy c suy timhuyt stng 10-15%.Khng c skhc bit vbin chng tim mch gia gy t vng (tu sng, ngoi mngcng) v i gy m ton thn. Sk t h p gia gy m ton thn v t ngoi mng cng,k t h p v i thuc gim au s dng trong lc phu thut, shn chb t mc tnghot ca h thng giao cm, lm gim nhu cu cn gim au v ci thin tnh tr ngthng kh sau m, rt ngn th i gian BN phi nm trong phng chm scc bit.3.1.1-nh gi nguy c :Cc yu tnguy c tim mch c chia lm hai nhm: nhm cc yu tc lin quann

BN (bng 4) v nhm cc yu tc lin quann cuc phu thut.Cc yu tnguy c lin quann cuc phu thut:

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o Phu thut c nguy c cao (t ltvong phu thut hay nhi mu c tim > 5%): phu thut l n c thc hin trong c p cu, phu thut trnng mch chhaymch mu ngoi bin, phu thut ko di v mt nhiu mu.

o Phu thut c nguy c trung bnh (t ltvong phu thut hay nhi mu c tim 1-5%): cc phu thut ngc, bng, chnh hnh khng bin chng.

o Phu thut c nguy c th p (t ltvong phu thut hay nhi mu c tim 110mmHg)

Bng 4- Cc y u t nguy c tim mch c lin quan n BN (theo ACC/AHA-American College of Cardiology/American Heart Association)3.1.2-nh gi ch c nng tim mch tr c phu thut: Nhm l ng gi chc nng ca h tim mch tr c phu thut, nhm c bin php cithin chc nng tim mch v chn la ph ng php v cm cng nhph ng php phuthut thch h p, mt sxt nghim nh gi chc nng tim mch c th c ch nh(bng 5).

Ch nh ca cc xt nghim nh gi chc nng tim mch::o Nguy c tim mch th p trn BN c ton tr ng km v nguy c phu thut caoo Nguy c tim mch trung bnh trn BN c ton tr ng km hay nguy c phu thut

caoo Nguy c tim mch cao

Siu m tim gng sc v i dobutamine: dobutamine, cht ng vn receptor beta, lmtng nh p tim v tng co bp t bo c tim. Khi k t h p siu m tim v i s dngdobutamine, cc bt th ng khu tr trn thnh tim, th dvng b thiu mu, c th c pht hin.

C hiu qu t c hiu qu Siu m tim g ng s c v i dobutamine X hnh tim v i dipyridamole-thallium X-quang ng mch vnh

Th nghim b ng vn ng trn my ch y b (Exercise treadmill testing) ECG g ng s c

Bng 5- Cc ph ng php nh gi ch c n ng tim mchX hnh tim v i dipyridamole-thallium: dipyridamole, khi c tim truyn vo t nhmch, lm tng lu l ng mung mch vnh 2-3 ln. Cc tbo c tim khomnh bt gi thallium 201, mt cht nh du nucleotide phng x. V th, schm tr trongvic phn phi thallium mt vng no ca c tim sau khi tim dipyridamole-thallium chng tvng ny b thiu mu.

X-quangng mch vnh c ch nh sau khi siu m tim gng sc v i dobutaminehay xhnh tim v i dipyridamole-thallium cho k t quc vng thiu mu c tim. Trong

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o Bo pho Ton tr ng kmo Thuc l: thuc l lm tng nguy c xy ra bin chng phu thut, ngay ckhi

BN khng c bnh phi tc nghn mn tnh. Nguy c cao nht khi BN ht thuc

l trong vng hai thng tr c phu thut. BN ngng ht trn 6 thng tr c phu thut c nguy c t ng ng ng i khng ht thuc.o Bnh phi tc nghn mn tnho Bnh suyno Tnh tr ng ngng th khi ng

Yu tnguy c lin quann cuc phu thut:o Tnh cht ca cuc phu thut: nguy c cao nht thuc vcc phu thut lng

ngc, k l phu thut vng bng trn. Phu thut ct ti mt ni soi c nguyc th p h n phu thut vng bng trn.

o Cuc mko di trn 3-4 gi o Gy m ton thn

3.2.2-nh gi ch c nng h hp tr c phu thut:Cc xt nghim nh gi chc nng h h p tr c m c ch nh trong cc tr ng h psau:

o Tt cBN c phu thut ct phio BN, c phu thut vng ngc v bng trn, c biu hin kh th hay c tin

cn ht thuc lo BN, c phu thut vng bng d i, c biu hin kh th hay c tin cn ht

thuc l v cuc m c dtr sphi ko dio BN trn 60 tuio BNang ht thuc lo BNang c bnh l phio BNang c triu chng bt th ng phi, c bit l ho cm v th kh kh

trong vng 5 ngy tr c phu thut.Cc ph ng phpnh gi chc nng h h p:

o X-quang ngc: t c gi tr .o Kh phdung (spirometry). Nguy c xy ra bin chng h h p sau mstng khi

k t qukh phdung cho thy FEV1 v FVC nh h n 70% gi tr tin on,FEV1/FVC nhh n 65% gi tr tin on. Nu FEV1 d i 1 lt, nguy c phuthut sr t cao. Nu FEV1 d i 0,8 lt, BN khng thchu ng cuc phu thutl n.

o Kh mung mch: nguy c tng khi PaCO2 trn 45 mmHg.o Xhnh phi: c ch nh khi FEV1 d i 2 lt v BN chun b c ct phi.

3.2.3-Chun b tr c mv chm sc sau m:Tr c m:

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o Ngng ht thuc l, ti thiu 8 tun tr c phu thuto Phdung khuyn khch hay t p vt l tr liu vh h po Ch nh thch h p cc loi thuc dn phquno Cho khng sinh

Trong lc m:o Gy t tusng c chn la tr c gy m ton thno Nu gy m ton thn, vic sdng cc loi thuc dn c c th i gian tc dng

trung bnh (vecuronium) c chn la tr c cc loi thuc dn c c th i giantc dng di (pancuronium).

o BN c nguy c cao, th i gian phu thut khng nn ko di. Phu thut ni soinn c chn la tr c cc phu thut m vng trn r n.

Sau m:o Gim au tto T p th su, t p ho khco Phdung khuyn khcho Thng kh nhn to v i p lc d ng cch qung c vai tr t ng ng v i t p

th su hay phdung khuyn khch, nhng li gy bt l i cho BN phu thut(lm ch ng bng).

3.3-BN mc bnh gan mt:BN mc bnh gan, khi c tin hnh phu thut, sc nguy c chy mu, hn m ganv thm ch tvong trong giaion hu phu.S r i lon chc nng ca gan cnh h ng n hu ht cc hc quan trong c th,trong quan tr ng nht l htim mch, no, phi v thn. Nguy c t s r i lon th pht cc hc quan ngoi gan khng km phn quan tr ng so v i nguy c t r i lonnguyn pht ca gan.3.3.1-nh gi nguy c : Nguy c xy ra cc bin chng v tvong BN b x gan t lv i mc suy tbogan ca BN.BN x gan giaion A (theo phn loi ca Child-Pugh), t lbinchng v tvong sau phu thut vng bng (phu thut gan v phu thut cc tng khcngoi gan) l 10%. T lny BN x gan giaion B l 30% v giaion C l 80% .Khi tin hnh gy m BN b suy gim chc nng gan, sh p thu, phn phi, chuynho vo thi cc loi thuc c sdng trong qu trnh gy m (thuc gy m, thucdn c , thuc gim au v an thn) b nh h ng. Mt s loi thuc gy m (halothane,enflurane) lm gim lu l ng mung mch gan. Halothane cc tnh tr c ti p ntbo gan. Nguy c suy gan stnh khi sdng halothane sxy ra v i t l1/6000-35000.Loi phu thut l yu tquan tr ng nht quyt nh n tin l ng ca BN b suy gimchc nng gan. Sli ko cc tng khi tin hnh phu thut trong xoang bng c thgyhhuyt p ton thn do phn xv lm gim lu l ng mun gan.png tng titcatecholamine th ng b suy gim BN suy gan v donh h ng ca thuc m. Cuc phu thut cng mt nhiu mu, nguy c tn th ng gan do thiu mu cng cao. Phuthut c p cu c nguy c gy tn th ng gan cao h n phu thut ch ng trnh.

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3.3.2-Chun b tr c mv chm sc sau m:Chng ch nh phu thut khi BN:

o giaion Child-Pugh Co Suy gan c po Suy gan mn nngo R i lon ng mu nngo R i lon nng chc nng ca cc c quan ngoi gan (suy thn c p, suy h h p

c p, bnh l c tim).Chun b tr c m:

o Ch nh vitamine K v huyt t ng t i ng lnh phc hi th i gian prothrombin tr vgi i hn bnh th ng.BN c th i gian prothrombin bnhth ng nhng c suy gan , vitamine K v huyt t ng t i ng lnh cng c ch

trong vic khi phc hi li kho dtr cc yu t ng mu ca c th.o Truyn tiu cu sl ng tiu cu trn 100.000/mm3.o Gim ti thiu l ng dch bngtrnh nguy c xy ra bung thnh bng, h

thnh bng v cc vn vh h p sau m.o Dinh d ng h tr qua ng t nh mch k t h p tng c ng dinh d ng qua

ng ming.o nh gi chc nng thn c bin phpiu chnh thch h p nu c suy gim

chc nng thn.o nh gi viu chnh cc r i lon v in gii, c bit l tnh tr ng gim kali

huyt t ng v nhim kim chuyn hoKhi gy m:

o Isoflurane l loi thuc m c chn la v loi thuc ny lm tng l ng mun gan.

o Trong cc loi thuc dn c , atracurium, do khng ph thucvo sbi tit quagan hay thn, thch h p v i BN b suy gan.

o Cc loi thuc nhmorphine, meperidine, benzodiazepine, and barbiturate phi c sdng ht sc cn thn v chng c chuyn ho gan. Ni chung, liul ng ca chngnn c gim 50%. Trong cc loi thuc gim au gy nghin,fentanyl l tc nhn c chn la.

Khi tin hnh phu thut:o Hn chli ko nhiu cc tng trong xoang bngo Cm mu cn thno K t thc s m cuc m o Vic truyn huyt t ng giu tiu cu c thlm gim nguy c xy ra bin chng

chy mu tr m tr ng.Chm sc sau m:

o BN x gan, sau cuc phu thut ko di, c mt nhiu mu v tt huyt p tronglc phu thut nn c lu li v c chm sc trong phng sn scc bit.

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o Gim can-xi huyt t ng (c thgy c ng cn gip thpht)o Gim o thi mui, n c v kali (gy tng kali, nhim toan chuyn ho, cao

huyt p v ph)o R i lon chc nng tiu cu (tng nguy c chy mu sau m)

Tcng ca gy m v phu thut i v i BN b suy thn mn:o Khi s dng cc loi thuc, s gim o thi ca chng l cho chng b li

trong mu, gyc cho thn v cc tng khc. S tch lu ca normeperidine,cht chuyn ho ca meperidine (Demerol) trong c thc thgy co git. Ccthuc c ch thn kinh c c th gy lit c h h p ko di sau m.Methoxyflurane and enflurane l cc cht gyc thn v nn trnh sdng choBN suy thn. Succinylcholine, mt loi thuc dn c kh cc, c thgy tngkali huyt t ng (bng 6).

o Khi phu thut, cc loi thuc m c thlm gim lu l ng mun thn 50%BN. Thao tc phu thut c th lm d p nt m, gy phng thch kali vo tunhon. Truyn mu hay dung dch Lactate Riger c thgy nhim toan chuynho. Sph huc vn c thdn n tng phosphate huyt t ng v gim can-xi huyt t ng.

Thu c c ch hth ng renin-angiotensin-aldosterone:o c ch t ng h p renin: c ch beta (metoprolol, atenolol), clonidine, methyldopa, thu c

khng vim non-steroid (ibuprofen, naproxen), thu c c ch cyclooxygenase-2 (COX-2)(celecoxib)

o c ch t ng h p angiotensin II: thu c c ch men chuy n (losartan, candesartan)o c ch t ng h p aldosterone: thu c c ch receptor angiotensin II (losartan,

candesartan), heparin tr ng l ng phn t th p (enoxaparin, nadroparin calcium),thu c c ch mi n d ch (cyclosporin, tacrolimus)

o c ch receptor aldosterone: thu c l i ti u ti t kim kali (spironolactone)o c ch knh K+/Na+ ng l n xa: thu c l i ti u ti t kim kali (triamterene,

amiloride), khng sinh (trimethoprim/sulfamethoxazole, pentamidine)Thu c lm gii phng K+ t c : succinylcholine, haloperidol Digoxin (qu li u)

Bng 6- Cc loi thu c c th gy t ng kali huy t t ng Cc xt nghim cn c thc hin tr cmt BN b suy thn mn:

o Cng thc mu (nh gi mc thiu mu)o Nng st huyt thanh (chn on phn bit gia thiu mu do thiu st hay

gim tng h p erythropoietin)o in gii o Tng phn tch n c tiu (pht hin nhim trng tiu hay bnh cu thn ang

din tin nhhng cu, bch cu v cc tr ca chng).o in tm(nh gi r i lon nh p, r i lon dn truyn, thiu mu c tim)o X-quang ngc thng (loi tr qu ti n c hay cc bnh phi ang din tin)o Cc xt nghim khc:in tmgng sc, siu m tim, X-quangng mch

vnh3.5.2-Chun b tr c mv chm sc sau m:

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Vic chun b tr c m cng nh chm sc sau m i hi phi c s phi h p gia phu thut vin, bc s tim mch, bc s thn hc, bc s gy m hi sc (v bc s ghptng, nu BN c hay s p sa c ghp thn).BN phi c nh gi v chun b vtim mch nu c bt th ng vtim mch.

i v i nhng BN c thtch cc ngn dch bnh th ng, khng c cc r i lon in giiv khng c xu h ng chy mu, vic thm phn mu tr c mkhng cn thit. Nu chc nng tim bnh th ng, nhng BN ph ton thn v ph phi l hu qucatnh tr ng qu ti n c. BN cn c iu tr bng cc loi thuc l i tiu tr vtr ngthi ng tch. Nu BN khngpng v i thuc l i tiu, thm phn mu nn c cnnhc n.Cc tc nhn gyc thn c thlm cho chc nng thn suy gim thm.i v i ccloi khng sinh (aminoglycoside, acyclovir, amphotericin), thuc an thn hay dn c , cniu chnh liu hay s dng cc thuc khc thay th. Nn trnh s dng thuc khngvim non-steroid, thuc c chCOX-2 cng nh cc loi thuc cn quang. Thuc cn

quang c thgy suy thn c p do lm co tht mch mu thn v lm tn th ng tbo biu mng thn. Nu bt buc phi sdng thuc cn quang, c thgim nguy c suythn c p bng cch cho BN ung acetylcysteine v truyn dch (NaCl 0,45%). Khng s dng meperidine (Demerol)gim au cho BN.Cc r i lon v in gii phi c iu chnh tr c v sau m. Nu BNang c thm phnnh k , th i im thm phn tr c v sau m, cng nh vic iu chnh cc loi thuc phi c ln k hoch cth. Nu thm phn mu, BN cthcn c thm phn trong vng 24 gi tr c m gim thiu nguy c qu ti n c,tng kali huyt t ng v tnh tr ng chy mu. Thm phn phc mc s c chuynsang thm phn mui v i BN chun b cho cuc phu thut vng bng, chon khivt mlnh hon ton. Nu BN c phu thut c p cu, ccnh gi vtim mch tr c mc thkhng cnthit nhng bt buc phi c thc hin sau m. Cn theo diin tmlin tc vxt nghim men tim th ng xuynpht hin thiu mu/ nhi mu c tim sau m(xemthm phn chun b htim mch). Nngcreatine-kinase (CK) c thtng BN b suythn nhng nngCK-MB th khng. V th, stng CK-MB phn nh tn th ng cac tim. Cn nh r ng vic chn on nhi mu c tim sau m, c bit BN suy thnmn, khng thda n thun vo mt m phi cba yu t phi h p (lm sng, xtnghim v ECG).Khi ch nh thuc c chbeta, cn cn nhc n l i ch (gim nguy c xy ra binchng tim mch sau m) v i bt l i (tng kali huyt t ng) m n mangn cho BN b suy thn mn.3.6-BN b tiu ng:Bnh tiu ng ngy cng phbin v v tht lBN ngoi khoa b tiu ng cngngy cng tng.T ltvong BN b tiu ng cao g p 5 ln BN khng b tiu ng. Nguyn nhn t vong chyu do tn th ng cc c quan tn.BN ngoi khoa b tiu ng lunng tr c nguy c tng ng huyt. Cc sang chndo cuc phu thut gy ra slm tng phng thch cortison v catecholamine, trong khi tc nhn i tr ng l insulin b suy gim t ngi (tp 2) hay tuyt i (tp 1). Cc

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loi thuc m thkh cng c tcng c ch s gii phng insulin. Tuy nhin, cc ph ng php v cm vng khng ci thin tin l ng hu phu ca BN tiu ng.Cc bin chng ca BN tiu ng c phu thut chyu lin quann nhim trngv bnh l mch mu. Bnh l mch mu BN tiu ng bao gm bnh vi mch (dnn bnh l thn kinh, bnh l thn v bnh l vng mc) v bnh mch mu l n (x vamch mu v cc bin chng ca n).3.6.1-Thm khm tr c mBN tiu ng:Khi khai thc bnh smt BN tiu ng, cn ch n:

o Triu chng kht nhiu, tiu nhiu, gim st th lco S thchn ung, tr ng thi ton thn, mc vn ng v cn nngo Ch iu tr hin ti, bao gm thuc, ch n v ch theo di ng

huyto Tn sut, mc tr m tr ng v nguyn nhn ca cc bin chng (nhim keton,

h ng huyt)o Tnh tr ng nhim trng tr c (da, bn chn, r ng, niu dc)o Triu chng ca bnh l mt, thn, thn kinh mn tnh; tnh tr ng chc nng ca

h tiu ho, bng quang v sinh dc; tnh tr ng tim mch, bn chn, mch mungoi bin; tai bin mch mu no.

o Cc yu t nguy c ca x va mch mu, nh ht thuc l, bo ph, r i lonchuyn ho lipid, v yu tgianh

o Trnhhc vn, li sng,iu kin kinh t

Khi thm khm lm sng, cn ch n:o Huyt p, tnh tr ng hhuyt p tth o Khm timo Khm khoo Khm bng (gan to)o Khmy mto Khm mch mu ngoi bino Khm thn kinho Khm bn chno Khm da (vt chch insulin)

Cc xt nghim cn c thc hin:o ng huyt, HbA1Co Lipid huyt t ng (cholesterol, HDL cholesterol, triglycerides, LDL cholesterol)o Chc nng gan (nu c bt th ng,nh gi gan nhim m v vim gan)o Tng phn tch n c tiu (ketone, protein, cn lng)o

Creatinin huyt thanh v tc lc cu thno in gii

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o in tm 3.6.2-Chun b tr c mv chm sc sau mBN tiu ng:Quan tr ng nht l kim sot ng huyt gi i hn cho php.i v i HbA1c, mc l t ng l d i 6%.

Mc tiu kim sot ng huyt sthayi, phthuc vo mt syu t, th dnhloi phu thut, tnh tr ng BN, tui tc v mc nhy cm v i insulin (bng 7).

i t ng N ng ng huy t ph n ut c(mg/dL)

Gii thch

Ph u thut t ng qut Lc i: 90-126 B t k : < 180

K t qu ph u thut t t h n, gim t l nhi m trng

Ph u thut tim < 150 Gim t l t vong, gim t l nhi m trng v t m x ng c

BN n ng 80-110 Gim t l bi n ch ng v t vong, gim th i gian n m vin

BN b bnh l thn kinh c ptnh

< 110 T l t vong cao h n n u ng huy t khi nh p vintrn 110 mg/dL

Bng 7- M c tiu ki m sot ng huy t BN ti u ng chu n b cho cuc ph u thut (theo Hi p H i Ti u ng Hoa K ). Nhi u tiu chu n ch t ch h n c xu t, tuy nhin nguyc h ng huy t s t ng v chi ph i u tr s t ng n u x y ra bi n ch ng h ng huy t. BN c ti n c n nhi u l n b h ng huy t hay h ng huy t m c tr m tr ng, cc tiuchu n s c n i l ng h n. M t s i t ng BN c bit, th d ng i gi hay thai ph , cn cnh ng cn nh c ring bit. Ni chung, mc tiu ki m sot ng huy t c th thay i tu thucvo t ng c nhn BN.Trong giaion chu phu, c r t nhiu yu t lm tng ng huyt. V th, theo di stv kim sot cht ch ng huyt l yu cu c p thit. BN b tiu ng c thsdngthuc h ng huyt ung tr c cuc mv sdng tr li sau m. Tuy nhin, cc loithuc h ng huyt ung c mt sbt l i khi sdng (bng 8). V th, insulin, dngqua ng t nh mch, tc nhn h ng huyt c ng nht v d c ho gii nht, c xem l l t ngi v i BN b tiu ng trong giaion ny.

Loi Th d B t l iSeretagogue Glyburide, glimepiride Gy h ng huy t, tcng ko di, kh c

ho gii Biguanide Metformmin Nhi m toan lactide, s d ng c n thn i v i BN

suy gan, suy thn hay suy tim huy t Thiazolidinedione Rosiglitazone Lm t ng th tch trong lng mch (c th gy

suy tim huy t), tc d ng chm, kh c ho gii Bng 8- Cc b t l i ca thu c h ng huy t u ng i v i BN ngoi khoa

BN b tiu ng tp 1 nn c s p x p ms m v mca u hn chti a sginon ch iu tr tiu ng. Tu thuc vo mc v th i gian phu thut, BN cth c cho liu insulin tc dng di sau c chuyn xung phng tin m v imt ng truyn dung dch Glucose 5% v nng glucose c theo di chon khi phu thut.kim sot nng glucose trong gi i hn 80-110 mg/dL, c ththc hin theo phcsau:t mt ng truyn t nh mch ring bit truyn regular insulin (5-10 U chomi 50-100 mL dung dch NaCl 0,9%). Tc truyn insulin c xcnh b i cngthc sau: insulin (U/gi ) = glucose (mg/dL)/150. Bt u truyn dung dch Glucose khi

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-N ng warfarin s t n ng ng i u tr sau 2 n 7 ngy-Xt nghim INR m i ngy cho n khi INRt n ng ng i u tr , sau 2 l n m i tun trong 2 tun, v 1 l n m i thng.

aPTT 25-41 giy 1,5-2,5 l n gi tr bnh th ng ca BN Ch :-Xt nghim sau 6 gi k t li u u tin ca LMWH.

Y u t khng Xa Phng ng a: 0,2-0,4 U/mL i u tr : 0.5-1.5 U/mLCh : n u cn thi t phi nh gi hiu qu i utr , xt nghim y u t khng Xa sau 4 gi k t li u u tin ca LMWH. Tuy nhin, khng cnthi t phi xt nghim y u t khng Xa n u khng c bi n ch ng ch y mu

Bng 9- Cc thng s theo di hiu qu i u tr ca cc loi thu c khng ng

3.7.2-nh gi nguy c :Phu thut cho BNang sdng thuc khngng l mt vn l n trong ngoi khoa.Khi tin hnh phu thut (khng phi phu thut tim) mt BNang sdng thuc khngng, mi quan tm l n nht ca phu thut vin l lm sao c thtin hnh cuc phuthut an ton v cho k t qutt m khng lm tng nguy c chy mu hay nguy c l pmch do huyt khi trong v sau m. Vic ngng sdng thuc khngng c thto ranguy c l p mch. S l p mch c ngun gc t tim, nu xy ra, sc d hu ht scnng n(40% tvong v 20% gy tn ph). Ng c li, nu thuc khngng cn phthuy tc dng trong lc phu thut, BN sc nguy c chy mu trong v sau m.Theo kin ca phn l n cc phu thut vin,i v i BN chun b tri qua cc ththuthay phu thut nh(ni soi, nhr ng, sinh thit) c nguy c chy mu th p (bng 10),khng cn thit phi ginon vic sdng thuc khngng. Chy mu r ng sau m c th c kim sot bng cch cho BN ngm dung dch tranexamic acid hoc epsilonamino caproic acid.

Nguy c th p Nguy c cao N i soi th c qun, d dy, t trng khng c sinh thi t N i soii trng khng c sinh thi t N i soi ch p hay t stent ng mt khng cc t c vng

Siu m qua ni soi khng c sinh thi t b ng kim

C t polyp qua ni soi t laser qua ni soiC t c vng qua ni soi Nong ng tiu ho b ng h i hay bougieM d dy ra da qua ni soi

Cc th thut can thi p trn dn t nh mchth c qun. Bng 10- Nguy c ch y mu ca cc ththut ni soi

C mt sphcxtr BNang dng thuc khngng chun b cho cuc phu thut.Theo phcca Kearon (1998), thixtr sphthuc vo v tr huyt khi v th igian k tkhi hin t ng l p mch do huyt khi xy ra ln cui chon th i im d tr phu thut.3.7.3-Chun b tr c mv chm sc sau m:3.7.3.1-BN b huyt khi ng mch: Nu th i im dtr phu thut cch th i im BN b l p ng mch do huyt khi trnmt thng, ngng 4 liu cui ca warfarin tr c ngy m. Nu din tin thun l i, INR

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sgim dn vt gi tr bnh th ng vo ngy m. Vo ngy tr c m, xt nghim INR quyt nh c nn ch nh vitamine K hay khng. Nu INR trn 1,7, cho BN 1 mgvitamine K tim d i da v xt nghim li INR vo sng ngy m. Nu INR bng 1,3n 1,7, truyn cho BN mt n v huyt t ng t i ng lnh. Truyn hai n v huytt ng t i ng lnh nu INR bng 1,7-2.Sau m, sdng tr li warfarin vo ngy hu phu 2-3. Nu th i im d tr phu thut cch th i im BN b l p ng mch do huyt khi nh h n mt thng, khi INR bt u gim d i 2, sdng heparin qua ng t nh mch gim nguy c l p ng mch do huyt khi ti pht. Ngng heparin 6 gi tr c phuthut. Sdng tr li heparin 12 gi sau mv i liu l ng khng qu 18 U/kg/gi . Xtnghim aPTT sau 12 gi xcnh hiu qu iu tr ca heparin. Nu BN tri qua phuthut l n hay c nguy c chy mu sau mdo heparin, khng sdng heparin m thay bng LMWH khi INR bt u gim d i 1,8.3.7.3.2-BN b huyt khi t nh mch:

Bn thn cuc phu thut cng c nguy c gy huyt khi t nh mch, ngay c ng i bnh th ng. Do, cgng tr hon cuc phu thut, nu c th, ti thiu mt thng k tlc BN b huyt khi t nh mch c p tnh (l t ng nht l hai thng). Ngng 4 liu cui ca warfarin tr c ngy mnu BN b huyt khi t nh mch t1 n3 thng tr c , ngng 5 liu nu BN b huyt khi t nh mch trn 3 thng. Ch nhheparin hay LMWH nu BN phi bt ng tr c mv INR nhh n 1,8. Nu BN b huyt khi t nh mch trong vng 1 thng tr c , ch nh heparin khi INR nhh n 2.Sau m12 gi , nu BN b huyt khi t nh mch trong vng 3 thng tr c , heparin c ch nh khi INR d i 2. Nu BN khng b huyt khi t nh mch trong vng 3thng tr c , LMWH c ch nh khi INR d i 2.3.8-Phng ng a huyt khi t nh mch su sau m:

Nguy c th p Nguy c trung bnh Nguy c cao Ph u thut nh trn BN nh h n 40 tu i v khng c cc y u t nguy c trn lm sng (xem bi huy t hc trong ngoi khoa).Th i gian gy m ton thnd i 30 pht.

Ph u thut nh trn BN nh h n 40 tu i v c cc y u t nguy c . Ph u thut l n trn BN nh h n 40 tu i v khng c cc y u t nguy c . B t k BN ngoi khoa no c

tu i t 40-60.Th i gian gy m trn 30 pht.

Ph u thut l n trn BN trn60 tu i v khng c cc y u t nguy c . Ph u thut l n trn BN nh h n 40 tu i v c cc y u t nguy c . Ph u thut vng chu, kh p

hng hay ph u thut chi d i

Bng 11- Nguy c x y ra huy t kh i t nh mch su sau m o Phu thut c nguy c th p (bng 11): cho BN vn ng s m sau m.o Phu thut c nguy c trung bnh: heparin liu th p (5000 U mi 8-12 gi ),

LMWH (bng 12), p chn bng b m h i cch qung k t h p mang v n hi.o Phu thut c nguy c cao: heparin liu th p (5000 U, 2 gi tr c mv sau m

mi 8 gi ), LMWH, p chn bng b m h i cch qung.o

Phu thut c nguy c r t cao: LMWH, warfarin (INR t 2-3), LMWH k t h pp chn bng b m h i cch qung, heparin liu th p (iu chnh liu).

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o Phu thut c nguy c cao v BN c nguy c b tmu vng msau m(th d bc tch nhiu khoang sau phc mc): p chn bng b m h i cch qung.

Trong phng nga huyt khi t nh mch su sau m, cc LMWH c xem l c hiuqu h n heparin (t l huyt khi t nh mch su sau m l 10%, so v i 15,3% caheparin), t c bin chng chy mu h n (t l0,9%, so v i 3,5% ca heparin). Enoxaparin (Lovenox) Ph u thut t ng qut (nguy c trung bnh): 2000 U (20 mg)

TDD 1-2 gi tr c m v m i ngy sau m . Ph u thut t ng qut (nguy c cao): 4000 U (20 mg) TDD 1-2 gi tr c m v m i ngy sau m . Ph u thut ch nh hnh: 3000 U TDD m i 12 gi , b t u t 12-24 gi sau m .

Dalteparin (Fragmin) Ph u thut t ng qut (nguy c trung bnh): 2500 U TDD 1-2 gi tr c m v m i ngy sau m . Ph u thut t ng qut (nguy c cao): 5000 U (20 mg) TDD 8-12 gi tr c m v m i ngy sau m . Ph u thut ch nh hnh: 5000 U TDD 8-12 gi tr c m v m ingy sau m (b t u t 12-24 gi sau m ).

Bng 12- Cch s d ng mt s heparin tr ng l ng phn t th p (LMWH) trong phng ng ahuy t kh i t nh mch su sau m .3.9-Thuc v BN ngoi khoa: Nhiu loi thuc m BN sdng thng dng tr c phu thut c thc t ng tc v i ccloi thuc c sdng trong qu trnh gy m v phu thut. Bc s iu tr cn nm c th i gian bn hu, s iu chnh liu cng nh th i kho biu cho vic s dngchng.Mt s loi thuc c th c sdng ti p tc trong giaion chu phu. BN c ths

dng liu cui cng v i mt ngm nhn c 2 gi tr c mv sdng tr li sau m.Mt sloi thuc khc li c th c ngng sdng, c chuyn sang loi thuc thaythkhc hay chuyn i ng sdng.3.9.1-Thuc tim mch:3.9.1.1-Thuc iu tr thiu mu c tim (bng 13):

Thu c Ngy tr c PT Ngy PT Trong lc PT Sau PT Nitroglycerin Li u BT Li u BT Truy n TM n u

c bi u hin thi umu c tim r

Ti p t c li u TM cho n khi c th s d ng qua ng ming

c ch beta Li u BT Li u TM theo

phc

Li u TM theo

phc

Li u TM theo phc

cho n khi c th s d ng qua ng ming

c ch knhcan-xi

Li u BT Ti p t c li u TM cho n khi c th s d ng qua ng ming

Aspirin Ng ng 1 tuntr c PT

S d ng tr l i tu theo ch nh ca th ythu c

Ticlopidine Ng ng 1 tuntr c PT

S d ng tr l i tu theo ch nh ca th ythu c

Bng 13- Cch s d ng thu c trong giai on chu ph u BN m c bnh mch vnh(BT: bnh th ng, PT: ph u thut, TM: t nh mch)

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Cc loi thuc tim mch l thuc c sdng phbin nht tr c m. i v i BN mc bnh mch vnh,c chbe-ta l thuc c ch nh r ng ri nht v c chngminh l lm gim nguy c xy ra nhi mu c tim sau m. t hiu quti u, thucc chbeta c ch nh hai tun hay h n tr c m, duy tr trong lc mv ko din14 ngy sau m. Vic ngng t ngt thuc c chbeta c thlm thayi nh p tim vhuyt p v c thlm tin cho nhi mu c tim xy ra. Mc ch ca thuc c ch beta l duy tr nh p tim trong khong 65-70 nh p mi pht. Nu nh p tim d i 65 nh pmi pht, hay huyt p tm thu d i 100 mmHg, hay BN gi yu suy kit, gim liuthuc c chbeta. Nu nh p tim d i 50 nh p mi pht, ngng s dng thuc c ch beta.Hin nay, mt sbnh vin c phcsdng thuc c chbeta trong giaion chu phu.3.9.1.2-Thuc iu tr cao huyt p (bng 14):

Thu c Ngy tr c PT Ngy PT Trong lc PT Sau PT c ch beta Li u BT Li u BT vo

sng ngy m v i mt ng mnhn c

Li u TM (th ng khng cn thi t)

Ti p t c li u s d ng qua ng t nh mchcho n khi BN nu ng c

c ch can-xi Li u BT Li u BT vo sng ngy m v i mt ng mnhn c



c ch menchuy n

Li u BT Li u TM (th ng khng cn thi t)


Thu c l i ti u Ng ng vongy tr c ph u thut

c ch betahay c ch knh can-xi TM

B t u tr l i khi BN u ng c

Ch ph m kali Ng ng vongy tr c ph u thut. Xt nghim nng kali


Thu c hu giaocm tc ng

trung ng

Li u BT Li u BT vo sng ngy m

v i mt ng mnhn c

Li u TM (th ng khng

cn thi t)


c ch alpha Li u BT Li u BT vo sng ngy m v i mt ng mnhn c



Thu c dn mch Li u BT Li u BT vo sng ngy m v i mt ng mnhn c



Bng 14- Cch s d ng thu c hp trong giai on chu ph u(BT: bnh th ng, PT: ph u thut, TM: t nh mch)

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Cao huyt p l yu tnguy c ca bnh mch vnh (v tai bin mch mu no). Ccloi thuc hp s c sdng xuyn sut giaion chu phu, v i mt s thayi v cch thc sdng hay thay thkhi cn thit.Cc loi thuc hp vn c ti p tc s dng chon ngy phu thut, tr thuc l itiu. Methyldopa s c ngng s dng trong giaion chu phu. Reserpine and prazosin c ngng vo ngy tr c mv ti p tc sdng tr li sau m.Cc loi thuc hp phi c sdng lin tc s c chuyn i ng sdng. Tiu biu nht phi k n thuc c chbeta (propranolol, atenolol, and metoprolol). Cc loithuc h p khc c th s dng qua ng t nh mch l enalapril, verapamil vdiltiazem. Clonidin c chphm dn ngoi da (tc dng y ch t n sau 48 gi ) . Nu tnh tr ng cao huyt p tr m tr ng h n, c thch nh labetalol, nitroglycerin, vnitroprusside.Cn ch n tc dng phca cc loi thuc hp khi ch nh chng. Khng sdnghydralazin truyn t nh mch v phn xnh p tim nhanh ca loi thuc ny c thgythiu mu c tim. Nifedipine ngm d i l i c thgy tai bin mch mu no, nhimu c tim.nhng BN ch cao huyt p nh, trong giaion ngay sau hu phu, c thtm th ingng s dng cc thuc hp dng qua ng t nh mch chon khi BN c th nung c. Gim au tch cc k t h p v i thuc an du v hn chmui l bin php ttngn nga tnh tr ng tng huyt p.3.9.1.3-Thuc iu tr suy tim:Suy tim huyt trong giaion tin phu l yu tnguy c ca bin chng ph phitrong giaion hu phu. Hu ht cc tr ng h p suy timhuyt xy ra trong vng 1gi sau phu thut trong 50% cc tr ng h p l do truyn dch khng thch h p.Tnh tr ng suy timhuyt cn phi c duy trn nh bng thuc l i tiu,c chmenchuyn v digoxin.3.9.2-Thuc h hp:Trong giaion chu phu, cc thuc ng vn beta v thuc dn phqun khng nn c ngng sdng. BN ti p tc liu kh dung v liu ung bnh th ng vo ngy tr cmv sng ngy phu thut.Cc loi thuc dn phqun nn c ch nh tr c mnu nhdung tch sng ti ad i 1000 mL v th tch th ra ti a trong giyu d i 500 mL. Nhng BN ho cm nn c ngng cuc phu thut v c k toa mt t thuc khng sinhlmgim nguy c co tht phqun.Trongiu kin ti u, ngng ht thuc l ti thiu 8 tun tr c phu thut. Nhng BNch ngng ht thuc mt vi ngy tr c mcng c ch, v cc tcng trn tim mchdo CO gy ra s c hn chphn no. Cn ch l nhng BN ch ngng thuc l mtth i gian ngn tr c mnn c ch nh ming dn nicotinetrnh xy ra hi chngngng thuc. Nhng BNang sdng steroid di ngy nn c tng liu thuc vo ngy phu thut,sau gim 50% liu mi ngy chon khit n liu sdng bnh th ng.Trong khi tin hnh phu thut, cc loi thuc ni trn khng cn thit. Sau m, nu BN

cn c lu ni kh qun, cc liu kh dung c th c sdng ti p tc.

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Sau m, vn gim au chim vai tr ht sc quan trong. Vic ch nh thuc gim augy nghin phi ht sc cn tr ng v BN cn c theo di st tnh tr ngc chh h p.3.9.3-Chphm hormone tuyn gip v thuc khng gip: Nhng BN b nh c gip c triu chng cng nh b c ng gip nn c hon cuc

phu thut.Trong tr ng h p phu thut c p cu, BN nh c gip c ch nh L-thyroxin qua ng t nh mch, bt u bng liu bolus 500 mcg, sau 50-100 mcg mi ngy. Cntheo di tnh tr ng h thn nhit, hnatri huyt t ng, h ng huyt v gim thngkh. Nhng BN b nh c gip nng nn c ch nh steroid trong giaion chu phu trnh nguy c suy tuyn th ng thn.i v i nhng BNang sdng thyroxine, thuc c thti p tc c sdng tr c m (ung v i mt ngm nhn c vo sng ngy m) v bt u sdng tr li sau m, khic thung c. Tuy nhin, BN c thngng sdng chng trong vng 1 tun v thucc th i gian bn hudi (7 ngy).nhng BN c ng gip, tnh tr ng c ng gip phi c kim sot tt tr c khi tinhnh phu thut.Trong tr ng h p phu thut khng phi trn tuyn gip, BN ung liu cui ca thuckhng gip v propranolol vo sng ngy m v i mt ngm nh n c. Cc thuc ny c sdng trong vng 24 gi sau m(qua ng ung hay thng ddy).Trong tr ng h p phu thut truyn gip, iodine c ch nh 10 ngy tr c m, cngthuc khng gip v propranolol.iu ny lm gim nguy c chy mu t tuyn gip.Propranolol c th c ti p tc vi ngy say mtr c khi ngng sdng.

3.9.4-Thuc ng a thai v cc chphm thay thca estrogen: Nhng BNang sdng thuc nga thai hay cc chphm ca estrogen c nguy c b huyt khi t nh mch sau m.BNang sdng thuc nga thai c khuyn chuyn sang bin php trnh thai khc 4-6 tun tr c phu thut v ch sdng tr li chng ti thiu 2 tun k tkhi vn ngv sinh hot tr li bnh th ng. Nhng BN khng bo m bin php nga thai thay th phi c loi tr khnng mang thai tr c m.i v i BNang giai on sau mn kinh vang dng chphm ca estrogen, nungng thuc, c th ti xut hin cc triu chng. Trong cc tr ng h p ny, thay v

ngng thuc, c thp dng cc bin php nga huyt khi t nh mch sau m.Cc bin php nga huyt khi t nh mch sau m cng c p dng i v i cc BNang sdng thuc nga thai hay cc chphm ca estrogen c phu thut c p cu.3.9.5-Steroid:BN ang s dng steroid ko di sc tnh tr ng c ch tr c h i-tuyn yn-tuynth ng thn v i cc mc khc nhau. Sau khi ngng thuc (th ddo phu thut), th igian phc hi chc nng ca tuyn th ng thn c thko di tvi ngyn vi thng. Nhvy, cc BN ny phi c bxung steroid trong th i gian tr c trong v sau m.Khi ch nh corticosteroid trong giaion chu phu, cc liu thuc phi song song v i

png bnh th ng ca tuyn th ng thn i v i cuc phu thut.

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Tu thuc vo liu l ng thuc m BNang sdng tr c khi phu thut v tnh chtca cuc phu thut, phcsau c th c p dng:i v i cuc phu thut nh v BNang s dng 10 mg prednisone (hay liu t ng ng) mi ngy, liu 25-100 mg hydrocortisone TM khi dn m l va .

i v i cuc phu thut l n, ch nh 100 mg hydrocortisone TM x 3 mi ngy, saugim nhanh liu prednisone (50% mi ngy) t liu thng th ng (5 mg/ngy) vongy m. Thuc corticosteroid ung s c s dng tr li khi ng tiu ho hotng.BNang sdng corticosteroid liu cao ( c chmin dch) s c duy tr liu caot ngng trong giaion chu phu. 60 mg prednisone c sdng mi ngy s cthay thbng 250-300 mg hydrocortisone chon khi BN c thung liu hng ngyqua ng ming (v i cng mt liu l ng, prednisone c d c tnh mnh h nhydrocortisone 4 ln).3.9.6-Thuc chng ng kinh:ng kinh c n l n c thgy ra mt sbin chng trong giaion chu phu, th dvim phi ht, bung vt m, gy x ng v di lch cc vt liu nhn to c t trong c th.Phenytoin v phenobarbital nn c ti p tc sdng trong giaion chu phu. Cc loithuc khng c chphm dng qua ng t nh mch (carbamazepine v valproic acid)s c chuyn sang phenytoin v phenobarbital. BN b d ng v i phenytoin schuynsang s dng phenobarbital. Nu BN d ng v i chai loi thuc ny, prednisone 60mg/ngy trong 2 ngy tr c c thngn chn phn ng d ng ca phenytoin v phenobarbital.Do thuc iu tr Parkinson (dopamine, thuc k t h p gia L-dopa and carbidopa) khngc chphm s dng qua ng t nh mch, BN b Parkinsonang s dng dopaminenn k t thc sdng cng mun cng tt tr c mv sdng tr li cng s m cng ttsau m, trnh xy ra c run git ca Parkinsonian.3.9.7-Thuc h ng tn thn:Thuc khng tr m cm ba vng c th c cho liu cui ngay tr c cuc m v s dng tr li khi BN c thung c. Cha c ghi nhn no vs t ng tc ca thuckhng tr m cm ba vng v cc loi thuc c sdng trong qu trnh gy m.Vic sdng thuc c chmonoamine oxidase (IMAOs) trong giaion chu phu cngging nh vic s dng thuc khng tr m cm ba vng. Tuy nhin, BNang s dngIMAOs sc chng ch nh sdng meperidine v c thdn n hi chng tm thnc tnh (biu hin bng st,o gic v gng cng).Cc loi thuc khng tm thn (phenothiazines, butyrophenones, thioxanthenes,indolones, and dibenzoxazepines) phi c m bo sdng xuyn sut trong giaionchu phu, trnh nguy c xy ra cc r i lon tm thn.Lithium c thlm tng d c tnh ca cc tc nhnc chthn kinh c . Mt khc, s o thi ca lithium c thgim (dn n ng c lithium) trong cc tr ng h p cn bng dch m tnh, cn bng natri m tnh v gim tc lc cu thn. Do, c th ngng sdng lithium 2-3 ngy tr c mv sdng tr li khi chc nng thn vingii tr vbnh th ng sau m. Trong tr ng h p cuc m nh v nng huytthanh ca lithium tr c m bnh th ng, c th s dng lithium trong giaion chu phu.

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Cc loi thuc gy an du (phenothiazine, butyrophenones, benzodiazepine) c thgyhhuyt p vc chtbo c tim. Cc loi thuc ny c th c ngng sdng mtvi ngy tr c mv sdng sau m2-3 ngy.3.9.8-Thuc khng vim non-steroid (NSAID) (bng 15):

Thu c Ngy tr c PT Ngy PT Trong lc PT Sau PT Thu c thay th NSAID cth i gian bnhu di

Ng ng 1tun tr c PT

Ch ph m TBcho n khi BN u ng c

NSAID cth i gian bnhu ng n

Ng ng 2-3ngy tr c PT

Ch ph m TBcho n khi BN u ng c

NSAID tr vim kh p

Steroid Li uth p

Bng 15- Cch s d ng thu c khng vim non-steroid (NSAID) trong giai on chu ph u(PT: ph u thut, TB: tim b p)

Cc NSAID c th c BN sdng di ngy tr c m iu tr bnh vim kh p. Ccloi thuc ny c thgy ra cc bin chng chy mu sau m. Sngng sdng thuctrong giaion chu phu, c xem l vn h p l, c thlm cho BNau kh p ti pht, cng kh p, hn chvn ng sau m. Vic ch nh cc NSAIDc chchn lctrn COX-2 c th trnh c bin chng chy mu. Tuy nhin, vai tr ca cc loithuc nyi v i s lnh nim mc vn cha c nghin cu. Cc loi thuc gim aukhc hay corticosteroid thay thcho NSAID c thlm chm li qu trnh phc hi caBN.3.9.9-Thuc gim tit ddy:

BN b vim lot ddy-t trng, chy mu ng tiu ho v cc bnh l khc (th d bnh tro ng c) nn c ch nh cc tc nhnc chH2 trong giaion chu phu. Nu BNang sdng tc nhnc chb m proton, chng s c ti p tc sdng tronggiaion chu phu.

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