Giáo trình dược lâm sàng sách đào tạo dược sỹ đại học cao đẳng tập 2

Gicio trinh dwor Lim sang

Trtremg Cao DOng K9 Thttcit Y Te 11196 Niing

de ucing, sinh kha dyng wan d6i On dinh, it phy thuOc vao baa an hoac nutc u6ng, tuy nhien day
la clang thutng dAt.
2.
DU A THUOC THEO DU'ONG TIEM
2.1/ Rim tat mot so difc diem can thulic diem
Day la &rang dua thu6c co sinh kha dyng bao dam nhat va c6 the.' gian xuAt hien tac dyng
ngan. Dutng tiem duvc dung nhieu trong benh vien, nhAt la nhung truong hop benh nang hoac
cap eau.
Ve m5t bao che, thu6c tiem c6 the la dang dung dich, h6n dich hay nhit tuong.
Yeu cdu ciia thuac tiem:
✓ Vo khuAn
✓ MOt so thuic tiem d5c biet ho5c vol thu6c tiem dung riot ran tir l5ml tra len phai khong &roc
co chAt gay sit.
✓ Thu6c tiem dung dich phai dat do trong quy dinh, thu6c tiem hOn dich hay nhil tuong khi lac kj",
phai tao duvc he phan tan dling nhat.
✓ Thu6c tiem phai co pH thich hop de dam bao de ben cua duvc chAt va khi tiem it gayclau.
✓ Thu& tiem truyen vol khi Itiong
phai dAng truong vai mau.
✓ Dung moi de hoa tan thu6c tiem phai dat yeti eau "dung pha tiem "theo quy dinh.
propylene glycol va
Cac dung mai thtrerng diing trong thuac tiem: dau, ethanol, nuOc cat,
PEG 300 — 600
Uu diem dm thuac tiem:
- Tranh duce su pha buy thu& do cac yeu to &trig tieu h6a: dich vi, men Weil h6a.
- Tranh &roc sir hao hyt khi phai van chuyen trong ong tieu h6a.
- Tranh desc tinh len niem mac tieu hoa (m6t so thu6c ch6ng ung thu. Crc the sy. phat trien ciia
niem mac ing tieu hoa)

Nhuvc diem &iv thuac tiem:
- Doi hoi dieu kien vo trung nghiem ngat va sty giftp do dm can Ix) chuyen mon.
- Chi phi cao
- DO an toan thAp hon so voi cac dung dua thueic khac vi de gay soc (tiem tinh mach), gay dau,
th5m chi ap-xe (tiem bAp), de bi nhrem trong.
2.2/1/0/ si) aid, dam thuoc theo dirowg diem:
al Dunn tinh mach:
Liu diem:
- Sinh kha dyng 100%
- Tac dung nhanh
- CO 11-16 dua vao co th6 I luang thuoc
Nhuor diem: phtrc tap, d8 gay tai bin
Nhirng thuac hay cliang qua cluVng sinh mach: Cac hoat chat co 0 kich ung cao, gay dau hoac
hoai tif co khi tiem bAp nhu. penicillin G, dung dich CaCl2, cac dung dich uu truong, cac chat de
bit the tich dich luu hanh nhu cac loai dich truyen tinh the, dung dich dextran, albumin...
Nang truong hap khong &roc Max thuac qua throng firth mach: cac dung dich dau, h8n dich.

Cac cach dua thuac vao linh mach:
Tiem tinh mach tryc tie))
Tierra sinh mach quang ngAn
Truyen sinh mach Ice() dai
27


Trading Cao D/ing Ky Thita:t Y Te II Da Nang

GO° trinh dtrov la-m sang

b/ Tiem

Day la thrtng uu tien cho cac loci dung dich dau, hiSn dich, cac Ong thu6c tiem
tac dyng Ice° dai
Lint
Khong &roc tiem bap:
Nhimg chat có tac dyng kick &rig mynh to chirc hoc gay hoyi tir, dung dich
uu twang, dung dich co PH qua acid hoc qua kiem
Nguti benh dang sir dung thu6c cheng long mau hoac cac thu6c tieu fibrin
Kh'Ong &roc tiem > 10 ml vac mot ch&
Khong tiem bap cho tre so sinh
c/ Tiem dwai da: sir dyng trong nhCing trutng h9p can Ice° dai tac dyng cua thu6c.
Ltru
Kh6ng nen tiem > 1 ml vao duti da
Khong dung cho benh nhan dang a. tryng thai soc, co ton thuong mo duai da
Nen thuang xuyen thay dei vi tri tiem
d/ Tiem trong da: thu6c hap thu cham, vi tri tiem thuang la mat tarot canh tay, lung
e/ Ccic dareeng tiem khdc:
- Tiem ngoai mang drng
- hiern vao khop
3/ DUA THUOC QUA D1ff6NG HO HAP:
Cac thu6c dua qua &rang ho hap vol tac dyng toan than khong nhieu va thuang rat dat.
Dyng bao the ph6 bin nhat la Ong phun mu, chi" y6u dang qua cluang ho hap de ph6ng ngira
va dieu tri benh dutng ho hap.
Khi dung qua dutng ho hap, sinh kha dyng cua thu6c phun mu phy thu6c rat nhieu vao thiet bi
phun ma va cach dung.
Neu thu6c phun mu la dyng h8n dich hay nhil thong thi phai lac kji trutc khi dung.

28


Giao trinh thror Mtn sang

Trzrowg Cao Hang K9 Thuat Y Te 11 Da Ming

NGUYEN TAC DUNG
THUOC KHANG SINH VA KHANG KHUAN,
111(IC TIEU
I. Phan lopi Ayr 4 nguyen rex sir dyng khang sinh trong dieu tri, cho vi du minh hoa.
2. Phcin tich cluvc 3 nguyen tijt sz'r dyng khang sinh tong cltr phong nhiim khucin sau phOu
thuOt, cho vi du minh hpa.
NOI DUNG

•

Cac thu6c khang sinh va khang khan la
nhOm thu6c de dieu tri khi nhigm vi khuAn,
dat &roc tac dyng nong d6 rat thap, it anh hudng den co the ngudi benh. Chitng ta da Het
khang sinh la nhang schat kim hoc diet khuan c6 nguOn gOc vi sinh vat (xa khuan, nam,
mac...), ngay nau nhieu chat tong hop tonge hop toan phan a-mg &roc dyng vai mgc dich nay
va hieu qua diet khuan cling dat duoc a rag d6 thap han nhieu so vdi cac chat haa tri lieu
trutc kia.
Ben canh d6 co nhang nh6m chat trudc kia khOng duoc dimg de diet khuan nhung ngay
nay &roc phat hien ra tac dyng diet khuan nhu dAn chat 5 — nitroimidazol. Nhu vay danh mgc
cita cac thuoc dieu tri nhiem khuan ngay duoc mo r6ng. Do do, viec trang bi cho sinh vien
MAN nhang nguyen tac ca ban khi sir dyng khang sinh va cac thu6c khang khuan la viec khang
the thieu dude de tao cho cac cluoc si tuang lai nhtIng thOi quen tot trong nghe nghi'ep sau nay.
Khang sinh. Trong bai
Do th6i quen, thong ta thudng g9i nhOm nay chi vdi mot danh
nay de de pi, tir khang sinh duoc dung de chi nhOm thu6c nay.
1. NIAING NGUYEN TAC Sir DUNG KHANG SINH TRONG DIEU TRI.
C6 4 nguyen tac SC1 dyng khang sinh trong dieu tri:

— Chi sir dyng khang sinh khi co nhiem khuan.
- Phai biet Iva chon khang sinh hop IY.
- Phai biet nguyen tac ph6i hop khang sinh.
— Phai sir dyng khang sinh dimg thdi gian qui dinh.

1.1. Chi ser dyng khdng sinh khi cd nhiiim khudn.
Cac tac nhan gay benh cho ngudi co the la virus, vi khuan, nam, sinh vat dan bao hoac
ki sinh vat (giun, san...). Cac khang sinh thong dyng chi co tac dyng vai vi khuan, rat it
khang sinh co tac dung vdi virus, nam gay benh, sinh vat don bao. Mai nh6m khang sinh
lai chi c6 tac dyng vdi mot loai vsi khuan nhat dinh; do d6, trwoocs khi quyet dinh sir
dyng mot loai khang sinh nao dO can phai lam qua cac budc sau day:

41,

•

1.1.1. Than? khan Icim sang.
Bao gom viec do nhiet d6 benh nhan, phOng van va kham benh. Day la budc quan trong
nhat va phai,lam trong moi truang hop.
Vi sot la dau hieu dien hinh khi co nhi6m khuan nen viec do nhiet d6 g6p phan quan
trong de khAng dinh nhiem khuan. s6t do vi khuan thtrang gay tang than nhiet tren 39°C trong
khi sot do virus chi c6 nhiet d6 khoang 38 — 38,5°C.
Nang trtrong hop ngoai le:
c6 the chi
— NhiZm khuan (5. 13'nh nhan suy giam mien dich, benh nhan qua gia
sot
— Trai lai, nhi8m virus ntur quai bi, thtly clau, sot xuat huyet, bai Rt... co the tang than
nhiet
tren 39°C.

29


Giao trinh &rot' Icim sang

Trtrong Cao Bang K2Thit4t Y Te II Da Ailing

Tham kham lam sang va phOng van benh nhan giup thay thu6c city doan tac nhan gay
benh qua &rang tham nhap cua vi khan, qua cac dau hieu dac trung...
xet nghiem thwang qui.
1.1.2.
Bao ga
gam
cong
thirc mat!, X quang va cac chi so sinh h6a se gop phan khang dinh than
m
(loan cua thay thu6c.
1.1.3. Tim vi khuOin gciy benh.
Day IA bien phap chinh xac nhat de tim ra tac nhan gay benh nhung kh6ng phai mei
truang hap deu can. Chi trong trtrang hgp nhi8m khuan rat Wang nhu. nhiern khan mau, viem
mang nao, ,thtrang han... khi ma tham kham lam san khong tim thay dau hieu dac trung hoac
nhiem khuan mac phai o benh vien, benh nhan suy giam mien dich kh6ng co sat hay chi sat,
nhe.
Viec phan lap vi khuan gay benh khong phai dau ang lam dupc, lai phai mat thai gian
va ton kern nen mac dau chinh xac nhung, chi xap hang thCr 2, sau tham kham lam sang. Neu
benh nhan tir tuyen dual chuyen len, da phan da sir dyng khang sinh thi tham kham lam sang va
lam cac xet nghiem thuang qui la ,ca ban. Trong truang hgp nay, viec sir dyng khang sinh pha
lieu tri la hop ly va can thiet.
rang va phoi hap khang sinh
1.2.

Phai bier lira clip kitting sinh hp 0.

1.2.1. Lira chon khang sinh phai pH hap vai vi khud'n gay benh.
Vi du:
Viem hang do thuang do Streptococcus pyogenes A.
Nhiem khuan rang mieng thi do Streotococcus, Actinomyces, ky, khi.
Viem bang quang cap chn CO bien chirng do E.coli (80%), Proteus, Kiebsiella.
1.2.2. Lwa chow khang sinh theo vi tri nhijm,khucin.
Milan dieu tri thanh tong, khang sinh phai tharn vao 6 nhiern khuan, nhu• vay ngtrai thay
thu6c phai nam vting cac dac tinh dugc dung h9c cua thu6c mai co the ch9n duvc khang sinh
phu hgp.
Mu6n dat dugc hieu qua dieu tri thi khang sinh dat dugc ca 2 dac tinh tren.
Vi du
Trong dieu tri viem mang nao do P.aeruginosa, cac khang sinh co tac dyng tat
len vi khuan nay nhis Gentamycin, Amikacin, Colistin... lai khong có kha Wang tham qua
hang rao mau nao,nhang truang h9p nhu• vay phai phoi hgp them vol khang sinh vira
neu thang vao 'Ong song (lieu krang nho han rat nhieu so voi tiem bap).
1.2.3. Lwa chon khang sinh theo ca dia benh nhan
o Tre em:
— Cac khang sinh phai thong chi dinh vai tre em khang nhieu nhung hau het deu
phai hieu chinh la' lieu theo
tuoi.
NhOm
khang
sinh
can luu y nhat khi sCr citing cho tre de non va tre sa sinh la
—
Aminosid (Gentamycin, Amikacin...), Glycopeptid (Vancomycin), polypeptid (Colistin) vi day
la nhirng khang sinh có kha nang phan b6 nhieu trong pha mac nen khuyech tan rat rang 6 cac

lua tuoi nay.
o Nguti gia:
dung khang sinh cho nguai cao tuoi khang khac nhieu vol d6i tuvrig
Noi chung, viec
binh thuang, trir mat s6 di6m can km y sau:

30


Gicio trinh chror him song

TrtcOng Cao Diing K9 Thitdt Y Te II DO Niing

— Do ski. suy giam chirc nang gan — then nen sir chuyen h6a va bai xuat thuoc deu
yeti han binh thutng, do do can phai hieu chuen lai lieu cila nhungc khang sinh bi chuyen hoa
nhieu qua gan hoac bai xuat chi] yeti qua then o' Bang can hoat tinh.
— Do ty le di irng vdi khang sinh cao han binh thutng (ngirti tren 65 tali co ty le
khang sinh nhOm beta — lactam tdi 20%), do do can het s(ic than trong khi sir dyng
di ing
khang sinh, nhat la dimg qua throng tiem.
— Do bi nhieu benh nen thutng phai ding ciing mot luc nhieu thuoc, do dO kha
nang gap twang tac thu6c cao han binh thirang, vi vey phai than trong de tranh cac tuang tac
gay tang d6c tinh hoac tac dyng phy.
• Phu nu c6 thai
co thai. Trong trutng hap
NOi Chung khong co ch6ng chi dinh tuyet doi doi vdi
tien cho nguti me.
nhiem khuan nang de d9a den tinh mang thi viec can nhAc luon
giam sat chat the chirc
VI dy: Trong, dieu tri lao, Rifampicin can c6 the sir dyng vdi

nang gan khi can thiet.
Tuy nhien, cac khang sinh co d6c tinh cao nhung CO the de dang thay the bang khang
sinh khac thi nen tranh tuyet d6i, vi du: Cloramphenicol, tetrcyclin, co — trimoxazol...
o Suy than:
than la nhang khang sinh chua vi chuyen h6a khi
Nhilng khang sinh CO d6c tinh cao
qua gan hoac chi chuyen h6a vai ty le nhO.
nhang trutng hop benh nhan suy then, nen awl
De giam d6c tinh cua khang sinh
yeu gan, neu khong thyv hien duoc ma phai sir dyng khang
cac khang sinh chuyen h6a
sinh d6c vai then thi phai hieu chinh lai lieu khang sinh.
o Suy gan:
Nhilng khang sinh chuyen h6a qua gan > 70% la nhang khang sinh CO d6c tinh cao vdi
ca quan nay nhu: Amphotericin B, Griseofulvin,Metronidazol...
1.3. Phal hip khdng sinh phai 119p

Myc dich cua viec phoi hop khang sinh la:
1.3.1. Tang tar dung len cac chUng de khang nignh.
Vi du:
Ph6i hop oxacillin voi gentamycin trong dieu tri S.aureus da gram nhay cam vai
Peni M.
- Phi hop Amikacin vol Ciprofloxacin trong dieu tri P.aeruginosa da khang
gentamycin.
vi khudn de khang.
1.3.2. Glom kha nang khang thuoc hoac tranh tgo
Ph6i hop khang sinh voi mgc dich nay thutng duoc ap khi dyng dieu tri cac nhiem
khuan keo dai.
Vi du:
Phoi hap khang sinh trong dieu tri lao, viem mang trong tim, viem

1.3.3. Nal rdng pho tac clung czia khang sinh.
Ndi r6ng, pho len vi khuan ky, khi: Da so cac khang sinh thong dung khong co tac dyng
hoac tac dung yeu len cac vi khuan ky khi, do do viec phoi hap khang sinh chit yeu de diet vi
khuan ky khi vai cac nhiem khuan co nguy co nhiem ky, khi cao. Vi du: phoi hap Metronidazol
vdi cac khang sinh khac trong nhiem khuan viing bung, vung cheu vi Metronidazol la thuoc diet
khuan ky, khi manh thuoc nhom 5 — nitro imidazol.
1.4.

Phai str. dung khdng sinh clang thol gran qui dinh.
31


Gido trinh chive lam sang

Trtrong Cao Bang Ky Thudt Y Te II Dd Niing

m9i loai nhigm khuan nhung
Khong co qui dinh cu the ve d6 da cua dpi dieu tri
nguyen tac chung la:
— Sir dung khang sinh den khi het vi khuan trong co the: 2 — 3 ngay o ngtrai binh
thuang va 5 — 7 ngay benh nhan suy giam miendich.
nhi8m khuan nhe, dal dieu tri thtrong Ice° dai khoang 7 — 10 ngay. s
—
— Ngay nay, vai sty xuat hien cau nhieu khang sinh hoac cac clang che pham co thol
gian ban thai keo dai TA' cho phep giam &rot clang ke so lAn dimg thuOc trong dat dieu tri, lam
de dang cho viec tuan thir dieu tri cua benh nhan.
— Dieu tri "chop nhoang": De dieu tri mot so clang nhiem khuan tit nieu, sinh duc
sinh thai
chua co bien chimg nhu viem bang quang, nieu dao, lau... có the sir dung cac

lieu duy nhat.
manh qua nuk tieu clang con hot tinh nhtr Perfloxacin, Spectinomycin mot lieu
2. NHITNG NGUYEN TAC S' DUNG KHANG SINH skr PHONG NHIEM
KHUAN TRONG PHAU THUAT.
Sir dung khang sinh trong truang hap nay nham ngan chan qua trinh nhiern khuan co the
xay ra cho ngtrai benh sau phau thuat.
2.1.
Thai dam (lira thuac phiii thing.
Thai diem dua thu6c lien quan chat did den du.Ong dua thuoc: co the dua thuoc theo
chrang tiem bap, tiem tinh mach, 41 trtics trang hoac ding nhung &rang, tiem tinh mach du.ac
khuyen khich hon ca. Tuy nhien
dua bang throng nao ciing "Nhcit, thiet phdi dtra khcing sinh
trtrerc lthc rgch dao nhtmg khong tiemso-11'1km 2h so vai thai diem mo".
2.2 Ch9n khcing Binh phai thing.
— Nen chon loai pho du rOng, c6 tac dung dupe len hau het tac nhan gay benh hay
gap nhat trong loai phh thuat dO.
— Thai gian ban thai khong qua ngan de co the giam dupe so Ian dua thu6c.
— Phai tham tot vao to chac can phau thuat.
2.3.

D-9 dai car, dpi (tau tri phdi dung,
— Kh6ng keo,dai qua 24h sau mo.
s
s — Trong da so truang hap, chi can I den 2 lieu la dn.
Ve nguyen tac, chi sir dung khang sinh den khi het nguy ca tham nhap cua vi khuan gay
benh. Vi lieu dau tien dupe dung Inc khOi me nen sau khi mo xong chi can dung tiep I — 2 lieu
nira la du. Khong nen dung khang sinh kdo dai sau mo vi se lam benh nhan met m6i, kern an, do
do lau phyc hoi va con gay ton kern Ve tai chinh.
Sau dO dung thuoc tiny thu6c vao loai phau thuat, do dai cira cu6c m6, t112 cira khang sinh
ch9n.

32


Trtrong Cao tang Ky ThuOt Y Te II Do Njng

Gicio trinh &rot' lam sang

NGUYEN TAC SLY DUNG GLUCOCORTICOID
MUC TIE U: Sau khi hoc xong heti hoc, sinh vien có kha ming:
1- Giai thich throe nhip sinh bi qua trinh tiet glucocorticoid (GC') trong ccr the.
2- Trinh bay cluvr cac chi dinh cua GC trong die'u tri.
3- Phcin tich &roc cac tac dyng phi clia GC va ccich khijc phut.

NOI DUNG:
Glucocorticoid (GC) la mot trong 2 nh6m , hormon duvc tiet ra vo, thuong than, co vai tr.?)
quan trong trong dieu
chuyen hOa cac chat. Ngoai vai tre tren chuyen hOa cac chat, hormon
nhom nay con co nhieu tac dyng khac nhtr tac dung ,chong viem, chong di irng, irc che mien
dich. Hien nay ngubi ta
tao ra &roc nhimg dan chat loci nay c6 tac dyng chong viem va
the mien dich manh han the pham thien nhien va giam hoac lam mat han tac dyng giu muOinude nen pham vi ap dyng cua cac dart chat loci nay rat r6ng rai, khong chi bO help trong pharn
vi tac dyng cua m6t chat thay the hormon ma can duoc sir dyng voi nhieu tac dyng khac nhtu• tac
dyng,chOng viem,chong di a ng, chong thai ghep ca quan... Khi dung vai nhang mgc dich nay
thi lieu thirOng cao han lieu thay the nhieu Ian, do dO cac nguy co gap tac dyng khong mong
muon nhieu hon lieu thay the. Nhirng kien thirc trong phan nay nham giup cho viec sir dyng
nham thuoc nay hop ly, an toan hon.
I/ NHIP SINH LY CUA SIX MEET HYDROCORTISON:
Hydrocortisol (Cortisol ) la hormon thu6c nhOm glucocorticoid &roc tiet ra to phan vO cua
tuyen thuong than..

Nhip sinh ly cua qua trinh tiet hydrocortisol : hinh
CO 3 yeu to anh Wang den kha nang tiet hydrocortison:
1.1/ Nhip ngdy-dent:
Vao khoang ni:ra dem, luong HC trong mau gram tai mcrc khong do dupc; mac nay tang dan tir
3-4,h sang va clat cao nhat vao 16c thirc day. Luong hormon tiet ra tir nth dem cho den Itk nay
hormon gia cao cho den giira trim va
chiem khoang 1/2 tong so hormon tiet trong ngay.
giam dan khi ye chieu va thap ,nhat vao khoang 3-4 h sau khi di ngii.
•
Nho nhip sinh hoc nay, tuyen thuong than se &roc nghi ve dem, neu mac hormone van tiep
tyc cao trong thOi gian nay, vi dy nhtr ta dtra corticoid vao cuoi bu6i chieu thi tuyen thuong then
bi giam manh sau khi ngtIrng thuoc. DO la co sO• cho
se bi C1C che lien, tyc va chirc nang tuyen
viec quy dinh uOng glucocorticoid nen chi uOng Ian vao buoi sang hoac che d6 diet, tri each
ngay vai nhOng trtrOng hop phial dung keo dai nhieu thang.
1.2/Anh !twang cua cac yeu to bot 191:
Khi gap cac dieu kien bat Igi nhtr bi doi, sot cao, nhiem khuan, phAu thuet...hoac cac stress
tam ly nhtr dau bu6n, tirc gian, mire HC c6 the len tai 40-60 p.g/dl.
co kha nang tang host
Trong, nhirng dieu kien nay neu chirc,nang tuyen thuong then t o t thi
the
gay
suy thong then cap
bi
suy
thi
co
nhu
cau;
ngtroc

lai
neu
thuong
than
d6ng ,dedap,img
co the dan den tir vong. Suy thuong then thtrang gap khi dung GC lieu cao, keo dai.
Chirc nang thtrong then chi trey ye binh thtrang duoc sau 3-4 thang, them chi tai 1 nam sau khi
ngung GC. Do dO phai theo dei chat the benh nhan cho tai 1 nam ke to khi ngimg dieu tri.
Trong thoi gian nay neu gap cac stress thi nhat thiet phai cho dung lei GC vai lieu da dung tar&
khi ngimg thu6c.
1.3/ Str tang keo dai may GC trong pilau:
Skr, tang luong HC co the xay ra khi gap trang thai ctrang thuong then do u thuong then. u
tuyen yen va gay ra benh, Cushing. Khi dung GC lieu cao kelp dai cling gap Cushing do thu6c. ,
cua
tiet hormon bi mat do tryc dual dOiKhi dieu tri bang GC ,lieu cao kdo dai, nhip sinh
tuyen yen bi irc, che trien mien b6.i lieu cao cita hormon, do da bat bu6c phai giam lieu tir tir khi
muon ngUng dieu tri de tao lai mot skr thich ang dan cila tuyen sau mot the.' gian nghi dai.
33


Trtrong Cao gang Ky Thual Y 711 ll Da Nang

Gido dinh &toy lam sang

H/ CHI DINH VA LicrA CHQN THUOC:
1/ Dieu tri thay the khi thieu hormon:
Thuong clang khi suy thuong then cap hoac man tinh.
a/ Vol suy thirceng than man:
Dung a mac lieu thap nhat c6 tac dyng. Thub.ng thi mac lieu trong tru.ang hop nay la 20-30
mg [-IC moi ngay twang img vOi lung HC ti6t ra trongs ngay.

Nen dung the c16 dieu tri each ngay bang cach tang lieu met ngay len gap doi va ngay ti6p theo,
se nghi de han the duac su suy thuong than khi ngirng dieu tri.
b/ Vol suy thuprig than cap:
Lieu dung thu.O.ng cao han, vi du 100mg HC kic dau, sau do cach 8h lap Iai met Ian cho den
khi trieu chirng duac cai thien. Can phai ket hop bia dien giai, ntrac va glucose.
Nen chon chinh clang hormon thien nhien la loaf HC (succinat hoac phosphate) va du.O.ng dtra
thuoc.la tiem finh mach.
2/ Dieu tri voi myc dich khong phiii de thay the hormon:
Chi dinh theo twang nay rat rOng bao gem:
Cac benh lien quan den co the benh sinh do mien dich nhu benh lupus ban dO, than hu
nhiem me., viem khop clang thap...
Benh lien quan den ca dia di ang nhu hen, di ang...
Chong viem
Dung ch6ng thai ghep trong ghep co quan
Trong dieu tri ung thu• c6 rat nhien chi dinh dung GC, dac biet trong ung thu bach cau
Met se benh v'e da: eczema, viem da tie') xoc, viem da di ung
III/ TAC DUNG PHU VA CACH KHAC PHVC:
1/ Mc dung tren str tang &tiling tre em:
a/ GC gay cham Ion o ire em la
C lieu cao, HC Crc the sy. tiet hormon tang trudng.
ire the sy. tao xuong
lam giam hoat dOng cCia hormone tuyen giap
O tu6i day thi, the hoat clOng cua tuyen sinh dyc
b/ Khac phyc:
- Han the viec ke dan,nhom thuec nay a tre em.
tien dung cac th e pham ty. nhien nhu. ( hydrocortison, cortisone, prednisolon).
- Dung lieu thap nhat c6 hieu qua, thoi gian ngan:
- Khi bat buec phai dung keg dai thi nen dung kieu dieu tri cach ngay.
- Khuyen khich tre van deng, chai the dyc the thao.
- Tang cuang che dO dinh dutng giau chat dam va canxi, tot nhat la dung cac the pham the

Nen tir sua
2/ Gay xiip xtro'ng:
a/ Nguyen nhan:
- GC tang cu.Ong sty htly xuong nhung lai Crc the qua trinh tan xuang.
- GC ngan can hap thu calci tia ruet va tang thai calci qua nu& tieu
b/ Khac phyc:
- Tang yen Ong de kith thich tao xuang.
- Tang cub.ng che de dinh dueng giau canxi.
- Vai ngu.a.i cao tu6i, do sir giam sot luang hormon sinh due nen tang de ?cep xuang, do do
co the 1)6 sung hormon sinh dgc nhung khong nen dung bien phap nay cho benh nhan ung thu
tuyen sinh due hoac phu
da man kinh tren 15 nam de tranh tang sinh nei mac tu. cung qua
mac.
34


Truang Cao Bang Thuat Y Te II Da NZing

Ciao trinh &roc lam sang

3/ Loet dy day- to hying:
a/ Nguyen nhcin: GC tang twang ti6t dich vi.
b/ Khac phyc:
- Dung thuoc trung hOa dich vi ( antacid ) nhung khOng duvc uOng (fang the.' voi GC.
- DUng cac thu6c khang thy the H2.
- Theo dOi chat the va xCr ly son hoac ngang thuoc kip theyi khi co tai Hen.
4/ Mc dyng phy do (fang corticoid tyi chb:
a/ Nguyen nhan:
GC tac dyng len mo lien ket => teo da, xo et:mg bi, viem da Ong do, chain lien seo, myn
trimg ca...

GC Crc the mien dich => bei nhiem nam va vi khuAn, virus...
b/ Khac phyc
Khong duvc nho mat cac the phAm chCra GC khi nhie'm vius hoac nam.
Han the boi Ice° dai va kham k9 benh nhan trirdc khi ke don.
Khong tkr y dUng thu6c la bien phap tot nhAt de giam tac dyng phy nay.
3/ Ilifn tuTrng erc chE trot du fl
tuyEn yen- tuyEn Untying thOn (IPA):
a/ Nguyen nhcin: Khi rnac hormone GC tang se ac the scr hot dOng ctia tuyen yen va \lung cltroi
doi theo co the feedback.
b/ Khac phyc:
DOng I lieu duy nhat vao bu6i sang.
- Ch9n loci GC CO t1 12 ngan, trung binh.
-

Thai gian dieu tri ngan nhat co the
Khi dieu tri keo dai nen diing the dO cach ngay va phai giam lieu ta
thuOc.

tru•dc khi ngirrig

Theo doi chat the nhang benh nhan dOng GC Ice° dai trong thai gian dieu tri va I nam
sau khi ngang thuOc.
6/ Tinh tryng tiara corticoid va Onh Gushing do thuac:
a/ Nguyen nhan: MOt hinh anh Cushing clay du hiem gap, tuy nhien ding có the gap mot trong
cac hien tisong cua Cushing, vi du nhu phii do gia natri va
b/ Khac phyc:
- Giam lieu ta
tru.O.c khi ngirng thuOc.
Sau khi ngang thuOc n6u benh tai phat thi nen sil* dyng cac thu6c dac hieu de dieu tri
trieu chang tot Fon Id quay lai ang GC; vi dy giai guy& hen bang thuoc gian, khi quan,

giam dau khOp bang thu6c chOng viem khong steroid...

IV/ CHONG Cliff DINH:
- Loet da day to trang tien trien
- Cac trubng hop nhiem Warn va virus ma chin co thu6c dieu tri dac hieu
-

Tierra chung vaccine vius song
Khong co chOng chi dinh tuyet dOi cho nhong twang hop dieu tri ngan ngdy hoac
dieu tri cac benh de d9a tinh mang.

35

de


Trtrong Cao Hang K.P Thuat Y Te II Da Niing

Gicio frinh chivy Idni sang

NGUYEN TAC Se DUNG THUOC GIAM DAU NGOAI VI
I/ SINN L Y BfNH CUA PHAN LNG DAU
Dau IA co the tkr ve cua ca the chong Jai nhUng kich thich CO hai, aing co khi IA trieu chang
bao trtrac cua mot benh nao dO. Tuy nhien co nhang twang hop dau chi do xiic cam, tkr ki am
thi cua benh nhan ( dau tam ly).
Dau lam cho benh nhan kho chiu, kho sa ye mat tarn ly. Dau dai dang, trien mien lam benh
nhan hot hoang, lo lang an den mat ngu, suy nhuvc. Veng luan quan do cang lam cho dau nang
them.
Viec tim ra nguyen nhan dau se giup loci b6 &roc yeu to gay dau va giai quy6t dau triet de.
Tuy nhien viec giai quyet nguyen nhan nhieu khi khong de dang, nhanh chOng nen viec sir dungy

thuoc giam dau IA giai phap hang dau. Dau kh8ng r6 nguyen nhan hoac khOng the loci b6 dirge
nguyen nhan gay dau thi thuoc giam dau IA chi dinh duy nhat.
Thu& giam dau chi dieu tri trieu chimg ma kh6ng lam mat duvc nguyen nhan gay dau. Thu&
co the the lAp cac dau hieu cua benh nhu' viem, sot trong khi benh van ti'en trien, do do chi nen
su dyng khi that sir thay can thiet va phai loon c6 gang tim de loci boo nguyen nhan gay dau.
II/ NGUYEN TAC SU. DUNG THUOC GIANT DAU NGOAI VI
Theo vi tri tac dyng len than kinh cam gide, thuoc giam dau duvc chia lam 2 nhOm:
- Thu6c giam dau trung tro'ng
- Thu6c giam dau ngoai vi
Trong bai nay chimg to chi tim hieu nguyen tac sir dyng thu6c giam dau ngoai vi.
1/ Nguyen tae sii• dung thubc gram dau ngoai vi giim 4 nguyen Vac sau:
- Lira chon thuoc phis hop vai ngteeti benh
- Tranh viral qua mire lieu giai hon
- Ton trong nguyen roc phai hop thuoc giam clau
- Liru y cac Nen phap ho ti-o• khong dung thuoc hock thuoc de giam tac dung khong mong
muon.
1.10Nguyen tac 1: Loa chon thuoc phis hop vol ngtroi benh.
Viec danh gia khA nang cua thuoc nay ho'n thuoc kia chi co tinh tuong d6i vi dau IA phan Ong
phy thu6c nhieu vao tarn ly, do dO thuoc dupe chon IA thuoc nao ma benh nhan cho IA thich hop
nhat.
M6t thuoc thich hgp vol benh nhan CO nghia IA:
- Thu& sir dyng co hieu qua giam dau tot doi
benh nhan
- Benh nhan khong man cam vcfri thuoc do: Nhang benh nhan co co' clia di Ong, hen thi phai than
trong khi dimg cac dan chat salicylat (aspirin ), benh nhan man cam vai sulfonamid thi tranh
climg cac an chat thu6c lc* nay nhu nimesulid, celecoxib...
- Phu hop vOi (lieu kien kinh to cua benh nhan. Nen can nhac ky ve hieu quA/ Kinh to khi ke
don.
1.2 Nguyen tae 2: Tranh wro-t qua mire hesu giai han
Moi thu6c giam dau nhom nay deu co mot mire lieu toi da cho phdp. Day IA mirc lieu phii hop

qua more lieu nay nguy co g4p tac dyng
voi kha nang thai Vb. thu6c cua gan va than. Khi
khong mong muon se tang.
dap img mong muon
Nhirng tru.Vng hop dung den, lieu toi da cho phdp nhu'ng van khong
thi khOng, khuyen khich tang lieu ma nen phoi hop cac thuoc giam dau khac nhom hoac thu6c
an than de tang tac dyng. Tuy nhien phai ton trong nguyen tac phoi hop ( nguyen tac 3)
Lieu khuyencao
mot so thuoc giam dau ngoai vi
Ten qui6c t6
chong viem
Lieu giam dau toi da Lieu toi da giam dau Lieu
thubng
24h (mg)
thong,
I Ian (mg)
(mg/Ian
)
36


Trufmg Cao Hang K9 Thuat Y T" II Da Nang
aspirin
diclofenac
etodolac
indometacin
sulindac
ibuprofen
naproxen
Piroxicam

meloxicam
celecoxib
Paracetamol

Giao trinh &for lcim sang
4000
150
600
150
400
1200
1375
40
15
800
4000

650
50
200
50
200
400
550
20
7,5
200
1000

1200-1500

50-75
200-300
50-70
200
600
375
20
7,5-15
100-200

1.3. Nguyen tac 3: Ton trong nguyen
phdi hop thuoc glom dal,
Khi
tang den lidu tai da cho phep ma van khong du tac dyng thi phai ph6i hop them thu6c.
Dd chi lam tang tac dyng giam dau ma khong lam tang tac dyng phy, kh6ng duoc ph6i hop 2
thuoc giam dau co cimg kidu ADR nhu. nhau . Thu& hay cluoc ding trong moi cong thCrc ph&
hop la paracetamol.
Vi du : Lieu tOi da mot Ian d6i vai aspirin la 650mg, ndu 0. mac lidu nay van chug du tac dyng
thi nen ph6i hop vai paracetamol vi paracetamol c6 kidu tac dyng phy khac aspirin. Kh6ng &roc
ph6i hop aspirin v6i NSAID
1.4. Nguyen Vac 4: Lzru y cac bin phap ho tro khong dimg thuoc hoac thy& de giant tac dyng
khong mong muon.

Sau day la cac bin phap khac phyc tac dyng khong mong mu6n khi sir dyng thu6c giam dau
ngoai vi:
a/ Han the loet Ong lieu hoa:
Cac thu6c ch6ng viem khong steroid ( NSAID ) lam giam sit tao thanh prostaglandin nen
giam sly tao thanh chat nhay va NaHCO3 tai da day, lam tang nguy co loet 6ng Wet' h6a ma chit
yeu hay Op la loet da day.
Ngoai xuat huyet tieu h6a va loet da day, cac NSAID can gay cac ton thuong o 'Ong tieu h6a

dual ( doan cu6i cua runt non va rut gia ), tac 6ng tieu h6a do Lao thanh cac chit hp.
Dd hart the bOt tac dyng phy tren 6ng tieu hOa c6 the co cac,cach xix tri sau:
Vai vien nen tran ( khong c6 mang bao dac bidt ): uong thuoc vao baa an va nhai vien
thu6c, u6ng kern mot c6c mac to ( > 200 ml )
- Tao vien bao tan trong runt, lc* vien nay phai mong xa bira an ne'u la bao ca vien
Tao vien sui b9t hoac cac clang dung dich u6ng
- Cac clang bao chd SI:t dyng cac to &roc " the cha" nhir 13-cyclodextrin citing nhim myc
dich giam sit. tip xuc trvc tip cua phan tir thu6c vai niem mac 6ng tieu h6a.
Luong way u6ng phai Ian ( 200m1- 250m1).
Vic ra dai cua nhang thu6c chon 19c COX-2 trong nhirng nam gAn day nhu. meloxicann
,celecoxib, rofecoxib... ang da giam duoc dang kd ( khoang 50% ) ty Id loet da day
nhung tinh iru vidt cua nham nay con can co thei gian dd kidm chCing vi (la thay co
nhiing ADR khac ang nguy hidm khong kern cho bdnh nhan.
b/ Han the chay maw
Cac NSAID lam giam kdt tap tieu cau nen keo dai thoi gian (long mau, gay chay mau, mat
mau keo dai. Tac dyng nay gay nguy hidm khi sir dyng cho nhang bdrih nhan co tang chay
mat' ho4c bdnh
xuat huyet. Do dO khong su. dyng NSAID trong nhang trU.Ong hop sot co
xuat huyet va tang chay mau.

37


Trtrong Cao Dcing
: Kji- Thu at Y Te II Da Niing

Gicio trinh &rot. Om sang

Dung paracetamol thay the aspirin trong nhang trubng hop chOng chi Binh aspirin do có
nguy co xuat huyet. VI dy: benh nhan loet da day to trang, benh nhan CO benh ly xuat huyet:

sot xuat huyet, chay mau da day, benh tra chay mau...

c/ Mein cam:
Hien Wong man cam hay gap vol ca paracetamol va NSAID, nhat la aspirin : ban do, may
day, hen, soc qua man. Hien won man cam thu.ang xay ra o cac benh nhan co tien sir di‘img,
có benh hen, polyp rnOi hoac sot. Vi vay phai than trang khi dung cho benh nhan da có tien sir
di rng, hen do dung aspirin.
Khong dung cac the pham NSAID de ha sot cho tre em , thay bang paracetamol
d/ Han the viem gan, hogi tfc gan:
ngtrai
va > 3g vai tre em
Paracetamol dung qua lieu gay viem gan. Neu dOng > l Og
cludi 2 tuoi co the gay hoai to gan.
Kh6ng chi dOc voi gan, sir dyng paracetamol Ice° dai co the gay ton thirang than.
2/ Cac ttrang tic bat kyi can tranh:

2.1/ Cac ttrang tac dtrgr hec hoc:
- Kh6ng phoi hop cac NSAID voi nhau vi se lam tang tac dyng phy loet &rang tieu hozia va chay
mau.
-NSAID lam tang nguy co chay mau tram trang khi dung dOng thai voi cac thuoc ch6ng dung
khac.
xuat huyet tieu hoa.
- NSAID clang ding vai rtrou lam tang nguy
-NSAID lam gram hieu qua dieu tri cua cac thuoc ch6ng tang huyet dp, giam tac dyng cua thuOc
loi tieu
- KhOng dung cac salicylat de giam dau khi bi gout vi cac salicylat lam giam bai xuat acid uric
qua nu& tieu.
•

2.2/ Twang tac dtrgc dOng hoc:

- Do tji re gan ket protein cao nen lam tang n6ng d6 tkr do dm cac thu6c ph6i hop dan d6n tang
dOc tinh cua cac thuOc phOi hop.
- Cac thuoc co the gay kiem h6a nuac tieu ( cac antacid) hoac acid hOa nutc tieu ( vitamin C
lieu cao) lam thay dOi thai trir cua cac NSAID co ban chAt acid, do do anh twang den dO dai tac
dyng.
3/ Chang chi dinh:

1/61 paracetamol:
- Man cam vai paracetamol
- Suy gan
- Tien sir eczema do tip )(Cie vai paracetamol
Vol cac thuac cho'ng viem khong steroid:
Tien sir di an vai aspirin
Loet da day — to trang
Benh 15/ xuat huyet
Nhi8m vius
CO thai 3 thang cuoi
Phoi hop vai vitamin K hoac methotrexat

38


Tricong Cao Dang K9 Thttat Y Te II Da AlcIng

Giao trinh &roc him sang

NGUYEN TAC SIJ DUNG VITAMIN VA KHOANG CHAT
MUC TIED
I. Trinh bay &tor cac nguyen nhan gay thieu vitamin, chdt khoang va cach khac phuc.
2. Trinh bay throe cac nguyen nhan gay thira vitamin, chat khoang va ciach khac phyc.

MN DUNG
Vitamin va chat khoang la nhirng y6u to can thiet cho soy
canggio'ng
nhu rau, qua, thit, ca,
coc...Day la nhimg phan khong the thieu duac cho,d6i song so
voi thyt ,pham va
coc thi so krong can thiet rat nh6 nen con g9i la vi chat di dutng.
Diem giong nhau giCia vitamin va hormon la ca hai loaf deu thu6c nh6m chat co hot tinh
sinh h9c cao nhung hormon thi thrac co the t4o ra con vitamin thi duac dua tir ngoai vao
theo thac an (trong da so truting hqp).
Cac vitamin va khoang chat thuOng dugc ban nhu nhang thu6c kh6ng co don duti dpg
don le hoc ph6i hap, voi cac ham luong khac nhau da gay khOng it lung tiing cho ngayi sir
dyng. Cilng‘do duac ban tkr do Ian tran va tuyen truyen khOng chinh xac ve tac ,dyng nen
trong thvc to da
skr14rn dyng, gay nhang tai bien nghiem trong do thira vi chat.
1. NHU CAU HANG NGAY VE VITAMIN VA KHOANG CHAT.
Nhu cAu hang ngay ve vitamin va chat khoang d6i
ngubi binh thuang khOng nhieu. B6
sung vitamin va khoang chat chi can thiet khi thieu. Bang thong ke thrai day la lupng vitamin va
chat khoang can b6 sung hang ngay khi thieu hoan toan dual dpg thuoc.
hang ngay (US - RDA)
Lieu khu En cao bd sung vitamin va khoang
Tren 4 tu6i va
Vitamin va chat Dan vi
Dual 1 Tic I — 4 tu6i
ngtrai Ian
tuoi
khoang
dvqt
5.000

Vitamin A
1.500
2.500
Vitamin D
dvqt
400
400
400
dvqt
30
Vitamin E
5
10
Vitamin C
mg
35
40
60
Vitamin B,
mg
1,5
0,5
0,7
1,7
Vitamin B2
mg
0,6
0,8
20
Vitamin B3

mg
8
9
0,7
2
Vitamin B6
mg
0,4
2,0
3
6
Vitamin BI2
1-ig
mg
0,2
0,4
Acid folic (B9)
0,1
1.000
Calci (Ca)
mg
600
800
15
10
18
Sit (Fe)
mg
1.000
Phospho (P)

rng
500
800
45
150
.ig
70
lod OD
400
rng
70
200
Magie (Mg)
mg
5
8
15
Kern (Zn)
2
Dong (Cu)
mg
0,6
I

CO thai va
cho con b6
8.000
400
30
60

1,7
2
20
2,5
8
0,8
1.300
18
1.300
150
450
15
2

S6 lieu tren dcra theo tieu chuan cith Vien.han lam khoa h9c M5"/ va &lac "Cyc Thyy pham
va Thuoc" (FDA) dm Mylay lam thong ,tin de ly'a ch9n 1)6 sung vitamin va cac chat khoang, vi
vay Wang ghi trong bang la tieu chuan bo sung trong twang hgp thieu hyt vitamin.

39


Giao trinh dzrac lam sang

Trzrang Cao Dang Kp- Thuat Y Te II Da Adng

Hai vitamin c6 pham vi an toan hep nhAt IA vitamin A va D. Lieu ttii da cho phdp chi gAp 10
Ian nhu cau trong bang. Vitamin A dac bit nguy hiem khi dimg lieu cao cho phi nu co thai vi
co nguy ca gay quai thai hoac tang dp luc not so thai nhi. Phy nix co thai neu can 1)6 sung chi
dugc dimg nhang lieu bang lugng ghi trong bang.
Trong bang khong trinh bay nhu cau vitamin K vi thkrc to lugng vitamin K can cho nhu Call

tre so
hang ngay co the bao dam nht he vi khuan runt. B6 sung vitamin nay chi can thie't
benh
nhan
sir
dung
Ice()
sinh vi
tugng nay he vi khuan runt chua Oat trien day dir hoac
dai khang sinh throng 'long do he vi khuan rut bi khang sinh buy hoai.
2. THIEU VITAMIN VA KHOANG CHAT.
2.1.

Nguyen nhan thik

•

2.1.1. Do cling cap
Cac nguyen nhan lien quan den viec dua kh6ng du vitamin va chat khoang vao co the
bao
-

-

-

Chat lugng thkrc pham kh6ng darn bao:
Do chat dat va ngu6n mac a tirng dia phuang.
Do an kieng.
Nghien rugu.

2.1.2. Do rdi loan hcip thu.
Suy dinh dutng, is chay kdo dal, nghien rtrgu, tac mat... deu lam giam hAp thu cac chAt,
trong dO co vi chat dinh &rang.
C nguti cao tu6i, sir thieu vi chAt IA do sir giam chirc nAng cira he tieu h6a: giam sir tie't
dich vi, dich mat, dich vi... va su hog d6ng kern hieu qua cira cac co the hAp thu tich
cuc qua niem mac runt. Them vac, do, do nhu dOng runt yeu, hay bi tao bon nen cac
benh nhan cao,tuoi thuong dung thuoc nhuan trAng Ice° dai cung IA nguyen nhan can trO*
hap thu cac.chat.
R6i loan hap thu co the do mgt so benh dueng tieu hoa nhu• viem tyy, tac mat, loet da
day — to trAng.

2.1.3. Do nhu cau ca the tang nhung.cung cap khOng
thieu nien tuoi day thi hoac benh nhan sau Om day, sau mo,
co thai, cho con
Phy
Nhang
nhiem khuAn keo dAi... deuOc nhu cauve vi chAt dinh dung tang han binh
twang hgp nay neu dugc 1)6 sung tot bangthe d6 an uong thi khong can dimg them vitamin
Bang uong. Uong hoac tiem vitamin chi can khi khong an dugc do rOi loan tieu hoa Mac An
kh6ng du (dp met m6i, chan An...).
2.1.4. Cac nguyen nhcin gay thilu clac bier khoc.
— Benh nhan dupe nuoi duOng hoAn town bang &rang tiem.
— Benh nhan co khuyet tat di truyen.
A
— Tre so sinh, (lac biet IA so sinh thieu thang hay thieu vitamin K. Do do, de tranh nguy co
xuat huyet nao, nguti to tiem vitamin K I cho cac chau mai Igt long.
— Thieu do tuung tac thu6c.

-

2.2.
Xer tri khi thieu vitamin va khocing chat.
Phat hien nguyen nhan gay thieu va loai b6 no IA viec phai lam !An dau tien.
Vi du:
Neu thieu do roi loan hap thu thi phai dieu tri cac lien quan (ia chay, suy ,gan, tac mat...).
cho nhu cau thi phai tang cuang them khau phan an hoac
Thieu do cung cap khong
sir dyng them vitamin va khoang chat khi thieu tram trong.
40


Trirong Cao Hang Ky Thuat Y Te II DO Nang

Gicio trinh &roc lam sang

bo sung vitamin va khoang chat hop

la phai lay Ur thkrc pham vi dO la nguon

ap day du va can doi nhat. Bo sung dual deng thuoc chi khi thieu tram trong hoc trugng
cling ccap
hop chug c6 dieu kien sira doi lei the d6 an.
3. TlitrA VITAMIN VA KHOANG CHAT.

3.1. Nguyen nhan gay thira vd lu:iu qua.
3.1.1. Thira do the dO an.
4

•

Co mot so tai lieu mO to hien along thira vitamin A, them chi ca ng6 d6c ciia th6 dan
phuang Bac (gan !pie ckrc) do an gan gau trang.
— Thira beta — caroten do an Ice° dai nhCi.ng thkrc pham giau chat nay the hien bang hien
tuong nhuOm yang da, nh6 do nhang twang hap nay it nguy hiem vi ngugi sir dyng tkr d6ng bo
thirc an do.
NOi Chung, thira vitamin do an uong it g5p vi co the co the tkr (lieu chinh trong qua
trinh hAp thu qua throng tieu h6a.
3.1.2. Thira do lam clung vitamin via chth't khoang duai clang
flay la nguyen nhan hang dau hay g5p nhat. Can nhac lei rang nhang nguti khoe rnanh,
kh6ng co r6i loan hap thu va an voi the d6 an du cac chat thi khOng bao gig phai dimg them
vitamin hoc chat khoang &Ai deng, thubc. Neu nhung doi twang nay thugng xuyen uong
vitamin, d5c bit la vitamin tan trong dau (A, D) thi de g5p roi loan do thira vitamin.
▪ MCA s6 nguyen nhan din den thira vitamin.
— Tre dubi 1 tuoi dirge cho an bang hiin hop thay the sira me co 136 sung vitamin D
lieu khong thich hop vai lira tuoi co the bi thira vitamin nay. Viec b6 sung thugng xuyen
vitamin D voi lieu > 400IU/ngay cho tre dual 1 nam khOe menh la viec lam nguy hiem vi dan
den tang mirc Ca/mau, them chi con c6 the gay suy then va tir vong.
— Tre em dual 4 tuoi thugng xuyen uong vitamin A co ham luong > 5000IU/ngay co
the bi ng0 d6c men tinh vgi trieu chirng dau xuang, ban do, viem da trOc vay, viem
Neu dung lieu vitamin A > 100000IU/ngay co the gay ph6ng th6p, co giet, tang dp luc s9 nao
tre nh6.
— Phy nir co thai dimg kdo dai vitamin A > 5000IU/ngay trong khi van an uong day du
va hAp thu tot se- co nguy co thira vitamin A, gay quai thai.

-

V

•

•
MOt se) nguyen nhan din den thira nguyen to vi
Thira sat (Fe): Ng° d6c sat 0' tre dual 5 tali kha pho bien do Luting qua lieu, heu qua dan
den tit vong.
Thira iod (12): Sir dung tren 6mg/ngay se gay irc the hoet d6ng cua tuyen giap, gay
nhugc nang giap. Neu ngugi me mang thai b6 sung lod kh6ng hop ly, gay thira lod thi
nhu'
heu qua se xay Ra vai thai nhi: nhugc nang giap o' tre so' sinh, sinh ra tre dan
thieu nguyen to nay hoc gay phi dai tuyen giap barn sinh.
Skr thira cac nguyen to vi luong gay heu qua nghiem trong han so vai thila vitamin vi
Chung co pham vi dieu tri help.

3.2.

C'dc hien phdps trcinh (him vitamin va khoang chat

Vi hien tuang thira da phan do sir dyng cac chat nay dugi clang thuOc khong hop ly, do
do nhang kien thirc ye sir dung nhOm thu6c nay se gOp phan nang cao tinh an toan trong clieu
— Then trong khi
dyng cac the phArn co ham lung > 5 !An US — RDA. Trong
trugng hap can due thkrc S co hien tuong thieu mot chat nao do thi t ot nhat nen dung deng dan
le de tranh hien along thira cac vitamin tan trong dau.
41


GO° trinh &car lam sang

Truerng Cao Hang K2 Thud! Y Te II Da Nang

— Khi dimg thu6c dong hon hop vitamin va khoang chit phai phan biet cac cong thac

danh cho tre dui 1 tu6i, cho tre dual 4 tuoi va cho nguti Ion thutng duoc tinh cho lira tuoi tir
11 tu6i tra len.
— Trong nuoi &rang nhan too hoan toan ngoai &rang tieu h6a (TPN), viec 136 sung
vitamin la bat buOc d duy tri kha nag chuyen h6a cac chat nhung ieu luong chat can dua phai
&roc tinh toan dlya tren tinh trong benh ly cita tang benh nhan. Co the dung nhung Ong hOn hop
vitamin va khoang chat dOng sari hoac lay rieng le tang chat roi phOi hop theo tjf le mong muon.
4. LIVA CHON CAC CHE PHAM.

4.1.

Ctic the pham cluth vitamin.

Cac the pham china vitamin có thanh phan va ham luting rat da dong nhung tom thti
CO the phan lam 2 looi sau:
4.1.1. Cac loci vitamin don le.
LAI diem cita loci nay la giA re va phi! hop vai trutng hop chi thieu mot looi vitamin nao
do. VI dy: vai cac looi vitamin de hang do the Bien hoac boo quart thirc pham nhu vitamin B1 ,
B6, C; ft* thieu do khuyet tat di truyen gay thieu vitamin D, vitamin B1 2...
LC* don le con phyc vu cho myc dick dieu tri voi tac dyng dac hieu co the khong lien
quan den cong dyng cua vitamin. Vi dy: vitamin PP duai dong acid nicotinic lieu cao de giam
lipid mau, vitamin B12 dirai da ng hydroxocobalamin dimg trong giai dOc cyanua...
Tren thi trutng c6 nhieu dang vitamin clan le c6 ham luting cao hon nhu cAu hang ngay
(RDA). Sir dyng cac dang vitamin don le thutng re tien hon dung cac the pham phial hop
nhung chi c6 hieu qua khi biet chac chart chi thieu nguyen to do. Ciing c6 nhung trirang hop sit•
dung vitamin hoar' toan v6i myc dich khac, vi dy: vitamin B12 dual dong hydroxocobalamin vai
lieu rat cao (0,1 g/kg, tiem tinh mach) dirge dung de giai clOc cyanua (dieu tri ph6i hop).
4.1.2. Cac looi vitamin phi hop.
• CO rat phieu kieu phi hop:
— Phoi hop day du cac thanh phan.
— Ph6i hop chi cac looi vitamin tan trong dau.

— Ph6i hop chi cac fool vitamin tan trong nutc.
• Mgc dich ,ph6i hop ding rat khac nhan:
— Da phan la de bit vitamin khi thieu tram trong.
— Tuy nhien ding c6 nhieu kieu ph6i hop hoan toan de dieu tri vai myc dich
khong lien quan den tac dyng tren chuyen h6a. Vi dy: hOn hop 3B ham luting cao can dung de
giam dau trong cac trutng hop dau CO lien quan den ton thuong day than kinh..
— Cac looi ham luting cao clac biet nguy hiem khi dimg kdo dai do kha nang
tich luy hoac do tac dyng phy.

4.2. Cac ch'j pluim china club khoang.
Phan Ion cac chat khoang rat c6 san trong thien nhien (ntrac uong, thirc an) va vai troz
sinh 1/ thutng di kern vai vitamin. Tuy nhien, so vai vitamin, pham vi an toan dm chat khoang,,
d4c b* la nguyen, to vi luting rat
Cans vi
do nay, trong ac cite pham co chcra chat
khoang thutng phoi h9p voi cac vitamin. Dieu dang luu j/ IA cac chat khoang khi dung don dOc
don tai tai Hen
co ham luting kha.cao nen khi str dyng phai rat than trong vi nhung nham
clang ti6c, tham chi co the tir vong
Nhang chat khoang co nhu cau hang ngay duti 100mg &roc goi IA nguyen to vi luting.
Sau day IA nhang diem can luu y khi sir dyng cac the pham khoang chat co chaa calci
va sat:
4.2.1. Calci (Ca)
42


Trtrovg Cao Hang Ky Thuat Y TA II Da Nang

Gicio trinh chivy Lim sang

Calci la thanh phan ca ban trong au too ,c6a, xuang co vai trO quan trong trong hoat
dang cua than kinh va co co., la mat trong nhang yeu to clang mails
Th(rc an hang ngay CO
calci cho nhu cau co the. Ngu6n calci
sib la phong pho
nhat va de hap thu hon ca.
Luang calci trong mau &lac diet' h6a bai vitamin D va hormon can giap (PTH) de gia
mCc calci huye't hang dinh ta 8,5 — I 0,5mg/ml.
Thieu calci co the gap o tu6i day thi, phy nG c6 thai, cho con btl; nhang trutng hgp nay
nhu cau tang tai 50%; ding corticoid (tang thai calci), nguti cao tuai hoac dung kdo dai antacid
(giam hap thu calci).,
Thieu calci cap tinh gay co giat kiL tetani; thieu thuang xuyen gay cal xuong
tre em)
va x6p xuang (a. nguoi Ian).
Thira calci thuang do lam dung thu6c. Dau hieu tang calci huye't bat dau xuat shien khi
lung calci dua vao co the tren 4g/ngay (RDA = 1g). Neu thira it co the giai quyet bang cach
giam calci trong the da an, tang cutng an chat xo va uOng nhieu nuac. Thira kdo dai hay gap
khi dUng calci carbonat; trieu chimg: clay ho, met mai, than an, nang hon c6 the tang huyet
kith d6ng, sal tiet nieu.
4.2.2 Sat (Fe)

s

sAt la thanh , phan cua men ho hap to bao (men cytochrom), dm hemoglobin va
myoglobin. Dang pho bien trong to nhien la sat oxy hoa (Fe3+), de hap thu duac phai chuyen
hoa thanh clang khir (Fe2+).
Trong thuc pham nguon goc d6ng vat, sat ton tai dual clang hem (Fe++), de hap thu hon
sat trong thuc vat 5 Ian. Trai voi cac nguyen to vi lugng khac, sat c6 rat it trong saa, (lac biet la
saa b6 (0,1mg/100m1 sCra). Cac ngu6n tort pham giau sat la: dau Wang (1 I mg), gan Ian (12mg),
gan be (10mg) trong 100g thyc pham.

Nhang dOi wan de threu sat thuang la: tre em nuoi hoan toan bang saa be, phy nau co
thai, nguti an kieng, an chay hoac an khong du ,nhu cau (sat' 6m Ong, tuoi day thi).,
Thira sat: 146 dac sat 6. tre em < 5 tuoi gp,kha, pho bien do lam dyn thu6c. Cac trieu
thong ng6 d6c bao gam: non, is chay, hoai rut (neu Wong), soc qua man (tiem).

Giai dloc:
Rim da day bang NaHCO3 1% de lao b6 sat trong Ong tieu h6a.
Tiem Deferoxamin de loai sat ra khOi co the do co the tao chelat cua thuoc nay vai sat.

43


Tr-yang Cao D:
Ong Ky Thudi

H Da Wing

Giao trinh &ro'c lein? sang

NGUYEN TAC Sir DUNG THUOC DIEU TRI TANG HUYET AP
1. DA1 OafNG
1.1 Phan 19i tang huyet ap(HA)
Tang HA gom tang huyet ap tam thu, tang huye't ap tam truang hoac ca hai
Tang HA nguyen that hay tang HA vo can vi nguyen nhan tang HA khong dugc
Loa' tang huyet alp nay chiem 90% dan so tang HA
Tang HA thir phat : HA tang la hau qua cCia cac benh ve than, not ti6t, tim mach nad.
Dieu tri nguyen nhan huyet ap se tra lai binh thutmg.
Ngoai ra con co tang HA do thai nghen , do thu6c ( glucocorticoid, thuoc tranh thai...)
Sau day la bang phan loci HA Oa theo JNC-VII 2003:
Bang phan loci HA dm nguti Ian

HATam truang(mmHg)
Phan loci
HATam Thu(mmHg)
<80
Binh thudng
< 120
va
hoac
80-89
Tien tang HA
120-139
Tang HA
GD 1
hoac
90-99
140-159
>= 100
GD 2
>=160
hoac
HA dugc do It nhat 2 ran( cach nhau 5 philt), tren cimg mot canh tay rdi lay trung binh
HA tam thu don dOc khi HA tam truong < 90 mmHg va HA tam thu > 140 mmHg,
thuOng gap Cr ngudi Ian horn 65 tuoi, la yeu to nguy co cua benh tim mach
, Neu HA tam thu va HA tam twang hai giai (loan khac nhauthi dua vao tri so HA cao
lion de phan loci
Cac yea to nguy co' cua benh tang HA
-,Tien sir gia dinh benh tim mach( trong gia dinh co dan Ong < 55 tuoi hoac clan' ba < 65
tuoi mac benh tim mach)
- Hut thu6c
- R6i loan lipid huyet

- Tieu &Ong
- Tu6i tac: 60
- Gidi tinh: Dan ong, phy
sau man kinh,
Nhang nguOi c6 cac yeu to nguy co chu yeu nhu tren co khuynh hudng tang HA
Nhang nguOi c6 bien chirng cua tang HA cling dugc ke la co yeu to nguy co nhu' benh co
quan muc tieu nhu: tim, mach mau ngoai Bien, mat , than hay dang co benh tim mach tren lam
sang
2. Ditu trg tang HA
Myc Wet] lau dai cCia dieu tri la dat HAMT vdi it tac dyng phy nhat de giam ton thuong co
quan cudi, giam bien ch&ng tim mach nhO dO ha thap ti re mac benh va ti re tCr vong
*HA myc tieu: La tri so HA ma dieu tri can dat duoc
Tang HA khong trieu chimg:HAMT< 140/90 mmHg
Tieu duOng, benh than man tinh: HAMT< 130/80 mmHg
*Dieu tri khong dung thaw:
Thay doi kieu song, thuc hien trudc va trong khi, sir dyng thuoc. Cac benh nhan tien tang
HA va Tang HA nen thay ddi kieu song. Thay dal kieu song lam giam HA va ngan tien trien
thanh tang HA, giam lieu thu6c ha HA, giam nguy co tim mach
Clam can: Neu qua can co the giam SBP 5-20 mmHg/I0 Kg 6. nhOm benh nhan kh6ng
dUng thu6c.
,ngudi nhe
Titt cht tieing ruvu: Dan Ong khong uong qua 30m1 etanol/ngay, phy
can kh6ng qua 15m1 etanol/ngay. Tiet the rugu lam giam SBP 2-4mmHg.
44


Truang Coo Dang K9 Thuat Y 7-A II Da Nang

Gi6o trinh clugc Om sang

• T4p the dyc deu
Gap phan giam can va CO loi cho tim mach. Nen di b6, chay b6,
boi 16i...30 philtingay, hau het cac ngay trong tuan lam giam SBP va DBP lOmmHg.
• An hot che,muOi Na+:< 100mmol/ngay (< 6 g NaCI hoac 2,4g Na+ingay) giam HATth
2-8mmHg. Ngagi tieu dirOng, ngagi cao tu6i, ngtrgi da den dap img tot vai sit' an kieng muoi.
• Thin an ,nen co nhieu K+ (chuoi, nugc cam, khoai tay),Ca2+ ,M42+ . Nen an nhieu rau
trai, cac san pham cua saa, it m6, giam mo bao Ilea, mo toan phan va cholesterol (<
300mg/ngay). [AL chinh che d6 an lam giam SBP 8-14 mmHg.
• Bo hat thaw.
* Dieu tri toing thu6c
Khi khOng dot HA myc tieu bang thay cloi kieu song.
2.1. PHAN LORI VA CO CHE THUOC TRI TANG HUYET AP:
.Thuoc Iqi tieu: Thai Na va ntrac nen lam giam the tich mau.
.Thuoc liet giao cam: Lam giam sirc can ngoai bien
Lam giam tau luang tim do irc che hoot ding tim
.Thutic gian mach: Lam giam sac can ngoai bien
.ThuiSc ac ch4 kenh Canxi
.Thutic tac Ong len he RAA: (thu6c ac ch6 men chuy6n)
Lam giam sac can ngoai bien
Lam giam the tich mat'
2.2. CAC THUOC TRI TANG HUYET AP:
2.2.1. Cac thaw Wet giao cam:
Methyldopa
2.2.1.1 Tac dung:
Ha huyet ap va an than (co che: Liet giao cam)
2.2.1.2 Chi dinh:,
Cao huyet ap the vira va nang, co the ph6i hgp vii thutic lgi
2.2.1.3 Tic dyng phy:
+ Tram cam, an than, met mai
+ Kho mi'Og

+ Ha huyet ap the clang
+ Giam tinh duc
2.2.1.4 Ch6ng chi dinh:
+ Tram cam nAng
gan
+ Tien sir viem gan do thu6c, cac benh ve gan nha viern gan cap, man
+ Man cam vai gan
+ Phy nu Bang cho con NI
2.2.2 Reserpin (Racedyl, Serpasin):
2.2.2.1 Nguon g6c: Reserpin la alkaloid dm nhieu loci Ba gac Rauwolfia serpentina
Benth;, Rauwolfia veticillata (Lour), h9 Troc dao (Apocynaceae); hoac di'eu che. bang phirong
phap tong hop hga h9c
2.2.2.2 Tac dyng: Reserpin co 3 tac dung chit y6u:
- Ha huyet ap
- Lam cham nhip tim
- An than, gay ngii
2.2. 2.3 Chi dinh:
Thaang dung ph6i hop vgi thu6c 19'i tieu de cli'L tri cao huye't alp vgi chang tim nhanh.
Rol loan tam than, cac trong thai bon chin.
2.2. 2.4 Dec tinh:
Thu'Ong xay ra nhAt la tram cam
ROi loan tieu hoa (buon non, tieu chay, chan An, tang ti6t dich vi, loet do day).
2.2.2.5 Ch6ng chi dinh:
Ti&i sir man cam vgi cac alkaloid ciia Rauwolfia
45


Githo trinh chivy lam sang

Trtrong Cao D r' ing Ky Thuat Y 7-A 11 Da Nang

Trang thai trim cam
Loet da day, to trang Bang ti6n trien
2.2. 3. Propranolol (Inderal, Detasol, Obsidan)
2.2.3.1 Tic dung-Cling dung:
Tri tang huyet ap nhe va vim do lam lam giam sac co bOp tim, giam Itru Itrong mau
tim. Rat hieu qua khi tang huyet ap do r6i loan than kinh giao cam (tim nhanh).
Ngoai ra con chong thieu mau ca tim va chong loan nhip.
2.2.3.2 DO tinh:
- Suy nlitroc co that co tim, gay nhip tim chAm
- Gay co that phe quan ngtrai bi hen suyen
- Buon non, non, tieu chay
- Tram cam, ICI Ian tinh than, mat ngu, dc mOng
- Phan ang di ang.
2.2.3.3 Chiing chi dinh:
- Hen suytn
- Block nhi-that,suy tim cap.nhip tim cham (<50 nhip/1')
- Co thai
2.2.3.4 Cach diing-litu dung:
- Tang huyet ap: Ngay 2 lan,uong trudc bira an. Lk dAu 40mg/1 lAn, sau tang lieu n'eu
dung nap tot. Trung binh I 00mg, c6 the den 200mg-300mg/1, lAn. ,
tri:
Thubng phoi hgp
thuoc
tieu. Hieu qua sau 3-4 Ian
- Loan nhip: U6ng 20-40mg/1 Ian x 2-4 Ian/24h, hoc co the uong vien co tac dyng kdo
dai, ngay 1 vien 160mg.
- Dau that ngtrc: Uong 10-20mg/lan x 3-4 lantrong ngay, sau 4-7 ngay tang lieu 1 !An cho '
den khi co hieu qua. CO the &mg tai 160-320mg moi ngay.
- Luu Giam lieu t(r Ur nix& khi dirng han.

2.2.4. Thu& lui
2.2.4.1 Loi tieu thiazid
gian co the nay(nAt do
*Tac dung: Khai dau ha HA do giam the tich ngoai bao, theo
cathe bu. Sau 6-8 tuan, duy tri skr ha huyet ap la do tac dyng gian mach
*U.11 diem:
ch9n hang dAu cho hAu het benh nhan(dac biet ngtroi cao tu6i >50 tu6i, tang
- Thu6c
huyet ap tarn,thu don dOc, benh mach ngoai bien, hen suyen va cac benh phoi man tit-1h khac) de
tin nhat, giam ti le tCr vong. Trong nhieu
dung nap nhat, nhieu kinh nghiem va de sir dung,
thir nghiem day la thu6c hieu qua nhat de ngan cac bien chang cua cao huyet ap, nh6i mau co
tim, dOt quy,
- De dung nap, thtrOng ph6i hop voi cac thu6c khac de loai b6 phan xa bia giir mu6i va
nuac
sau man kinh
- Lam tang.canxi huyet nen tri s6i than va co loi cho phy
*Nhupc diem:
- Ha kali huyet
- Tang lipid huyet
- Chong chi dinh khi suy than(trir indapamid va metolazon), cho con bit, co thai, ( vi, lam,
mang thai khong nhay cam vai cac thuOc tri tang huyet ap
can dich bao thai), tra. khi phy
khac va nhay cam vai Na+ hoAc TA dung thuoc Igi tieu lau dai truck khi mang thai thi co the tiep
tyc sCr dyng loi tieu thiazid.
- Liet duong
- Indapamid khong tac dyng tren lipid huyet, dung nap glucose hoc r6i loan chCre nang •
sinh duc
*ThAn tr9ng:
- Benh th'An nAng( do thiazid lam giam I9c cAu thAn)—*tang nito huyet

- T6n thong gan hoc benh gan tien trien vi co the cilia den hon me gan
46


Gbao trinh &far lam sang

Trtrang Cao D&ig Thztat Y TA II Da Nang

*Thong tac thu6c: Kh6ng nen climg chung:
- Thu& irc the than kinh co (tubocurarin, gallamin) vi ire the than kinh co keo dai( do
can kali)
- Digitalis trgtim: VI tang dgc tinh digitagis ( do can kali)
- Lithium: Vi lam tang dec tinh lithium( do giam dao thai lithium qua then) net.' phai dUng
chung thi giam lieu lithium 50%
- Probenecid: vi lam tang acid uric huyet nhu. thiazid
- NSAIDs: Lai tieu thiazid lam tang nguy co. suy than do NSAIDs
*Cac thu6c: Chlorothiazid natri (Diuril)
Chlorthalidon (Hygroton)
Hydroclorothiazid
Indapamid
Metazolon
2.2.4.2 Lgi tieu quaff
- Tac dyng lgi tieu nhanh, manh, ngen ban han Igi tieu thiazid(
torsemid, bumetanid),
khong co tac dyng gian mach nhu thiazid
- NO)/ clang 2-3 Ian
- De tri tang huyet ap it thOng dyng han LT thiazid
- Dung khi Cr dich nhieu , suy then
- Cac tac dyng phy gi6ng thiazid(
giam canxi huyet)

Cac thu6c: Furosemid
Bumetanid
Torsemid
Acid ethacrynic
: Lai tieu yeu, thu.Ong phoi hap lai tieu mat K
2.2.4.3 Lai tieu tiet kiem
Cac thu6c: Amilorid Hydroclorid
Spironolacton
Triamteren
2.2.5 .Thuoc gian, mach:
- Lam gian try.c tiep co tro'n mach mau ngoai bien (d6ng mach, tinh mach hoac ca hai). Do
do, khi clUng mot minh gay phan xa ba (tang phan xa giao cam) va lam giam tac d6ng ha huyet
ap dm chat $ian mach. Vi vey can phai phoi hgp vai thuoc liet giao cam vai thuoc 19.i tieu
- Thu& gian mach khong gay ha huyet ap the dung va roi loan chCrc nang sinh dyc.
i dau
nh
Lam thuoc dieu tri thay the khi berth nhan khong dap Crng vdi cac tri lieu
khnhu'
thuoc Igi tieu,thuoc
giao cam, thuoc Crc the men chuyen, thuoc Cre the kenh canxi.
- Cac thu6c:
- Hydralazin (Apresoline)
- Minoxidil ( Loniten)
- Diazoxid ( Hyperstat)
- Nitroprussid ( Nipride)
2.2.6.Thu6c
che kenh Canxi:(CCB)
- Tac dyng: Lam giam nong d6 Ca2+ trong to bao cua tieu dgng mach va co tim do dO lam
giam sac can ngoai bien dan den ha huyet ap.
wen.

So vai cac thu6c gian mach khac it gay phan xa tim nhanh va
- Chi Binh: Tri tang huyet ap tir nhe den trung binh
Neu ang mgt minh hieu qua giong Propranolol, hoc thu6c lai tieu
La thuoc thay the cho Propranolol de dieu tri khi dau tang huyet ap khi khong the dung
2 thu6c tren.
- Cac thu6c:
+ Nhom tac dgng uu the tren tim: Gay giam hoat cigng cua tim nen khong dugc ph6i hop
Propranolol. G6m co:
- Diltiazem (Cardiazem)
47


Tricong Cao Dijng Ky Thu"cjt Y Te II Da Nang

Giao trinh chive lam sang

- Verapamil (Calan) ,
+Nhom tac deng uu the tren mach:
- Nifedipin (Adalat)
- Nicardipin( Cardene, Loxen)
- Amlodipin (Norvase)
2.2.7.Thuk ire ate men ehuy'en:(ACEI)
- Lam giam lugng Aldosteron (Chat gia mu8i mac) va lam giam lugng dich a trong ca v
the, do d6 lam ha huyet ap
•
- La thuoc thay the trong truOng hgp tang huyet ap kh6 chaa, dac biet hieu qua trong tang
huyet ap ac tinh.
- Lai diem ctia nhorn nay la:,
+ Khong lam ha huyet AL) the dung
+ Kh6ng rOi loan chac nang sinh dyc

+ Kh6ng chOng chi Binh cho ngubi hen suyen, tieu clubrig
+ Khong gay giam kali huyet.
- Hien nay nhom nay clarac ara chuang vi:
+ Dam,bao cu6c song binh thuerng khong co cam giac kh6 chiu trong thai gian chira tri.
+ It chong chi dinh trig suy than va mang thai
+ Dung nap,tot ke ca ngubi cao tu6i
+ Ket hgp tot voi cac phirong auk dieu tri khac
Cac thu6c:
Captopril (Lopril, Capoten)
Ennalapril (Vasotec)
Cilazapril (Inhibac).
Lena chon thuoc khai dau
• Lya ch9n thuoc kheri dau khong bat buOc.
• Tang HA giai doan 1: Hau het truOng hop ch9n LT thiazil. Ngoai ra con co the ch9n
ACEI, ARB, 13-blocker, CCB, rieng le hoac phoi hgp.
• Tang HA giai doan 2: Hau het truOng hap ph6i hgp 2 thuOc nhtr LT thiazil va ACEI
(thtrong climg) hoac 13-blocker, hoac CCB.
Llya ch9n thuoc khai dau co chi dinh bat buec
Chi dinh bAt bu6e
Suy tim
Sau nhoi mau co tim
Nguy ca benh tim mach cao
Tieu throng
Benh than man tinh
Ngan ngira (let quy, tai Oat

Lira chon di'eu tri kheri clAu
LT thiazil, 13-blocker, ACEI, ARB, ALDO-ANT
B-blocker, ACEI, ALDO-ANT
LT thiazil, f3-blocker, ACEI, CCB

LT thiazil, B-blocker, ACEI, ARB, CCB
ACEI, ARB
LTthiazil, ACEI

Neu van khong dat HAMT: T8i Liu h6a lieu dimg, hoac them thuk cho den khi clat-HATM. Xin y kien chuyen gia vebenh tang huyet
*Chien thu4t sir dyng thaw
Dieu tri kieu bac thang (stepped therapy)
Chgn 1 loci thuoc va tang lieu den khi dat tac dyng mong muon hoac dat lieu to'i da hoac
den khi xuat hien dec tinh.
Neu thu6c this nhat kh6ng lam giam HA den HAMT thi them thuoc tha 2 co co che tac
tiep tuc nhu the den 3-4 thuoc neu can. Kieu dieu tri nay clugc ap dyng khi .
dung
thuOc dau den dung nap tot va co tac dyng ha HA it nhat 1 phan . Theo JNC, neu LT kh6ng phai
la thuoc dau tien thi nen ch9n la thuoc thin 2 (tra khi CO chong chi dinh). Neu lua ch9n thuOc
thich hgp thi hAu het benh nhan khong can hon 2 thuOc tru truOng hgp can ha HA tich cy.c.
ieu tri kieu not tie!) (sequential therapy):
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Triceing Cao Boeing K9 Thu01 Y rd II Da Nang

•

•,

Giao trinh dtrav lam sang

Btrac dau tuong to kieu bee thang, tire la cling chgn mot tha thu6c r6i dieu chinh den lieu
toi da khi can., Neu thuoc dau tien kern dung nap hoac hieu lye Om HA khOng det yeu eau thi
thay bang thuoc khac. Neu t h uoc thay the van khOng lam (let HAMT thi nen phoi hop thuoc.

• Dieu tri phOi iwp H&J that)
Kieu dieu tri nay danh cho benh nhan c6 chi dinh bat buOc 2 thuOc de co tac dyng hiep
lure. Khong clUng kieu lieu tri nay cho tang HA kh6ng trieu chang. Neu LT khong phai la tin&
khdi dau thi JNC khuyen ben nen ch9n LT la thuoc thin 2 nhung vai lieu thap (hydroclorothiazil
12,5-25 mg/ngay).
Trong 3 each ten JNC khuyen dung kieu bac thang hoac kieu not tiep.
3. NGUYEN TAC SIT DVNG THUOC TRI TANG HUYET AP:
• Hai thu6c tri tang buy& ap thutmg dirge ch9n loc khdi ,clau la LT thiazil va B-blocker v i
da dirge chang to lam giam
vong cho benh nhan tang huyet ap. ACEI va CCB la thu6c Itra
ch9n sau LT va B-blocker khi khong dap ang day du hoac khong dung nap vai 2 thuoc nay.
Neu dieu tri khai dau ,bang LT (1-3 thang) van khong kiem soat dupe huyet ap thi thay
bang thu6c khac (kieu not tiep) hoac them thuoc thin hai tit nhOm khac (kieu bee thang). Neu
thu6c khdi dau khong phai la LT thi thuoc thir 2 nen la LT de loci bO phan xe bit gill. nude cua
cac thuoc ,tri tang huyet ap khac.
• Neu LT phoi hgp vol thuoc thin hai van khong kiem soat dirge huyet alp thi them thuee
thu. 3 (hydralazin, methyldopa). Neu phac d6 dieu tri CO LT thiazil van khong thnhf cOng thi
them LT quai (furosemid) trong 3-4 ngay.,
• Hau het thu6c tri tang huyet ap deu dirge khai dau vai lieu hieu lye thap nhat r6i tang
dan tit)/ theo tuoi tac, nhu eau, dap irng va dung nap cOa benh nhan de tranh sy, giam huyet ap
manh va dOt ngOt
dau va cac tac dung phy khac. yi
de han the sy mat K+ va cac tac
dyng phy khac nen dung LT thiazil vol lieu thap nhat,r6i tang dan len de dat hieu qua tri lieu
mong mu6n hoac den khi xuat hien tac dyng phy hoac (let den lieu toi da (tuong dirang
hydroclorothiazid 50mg/ngay)
• Val ngubi cao tuoi,lieu khdi dau thu6ng giam. Lieu LT thiazilcua ngu6i cao tuoi bang'/2
lieu dm ngubi trudng thanh tre tuoi.
• Thu6c nao co th6i gian tac dung tit. 24h tro• len co,the dung ngay 1 Ian dirge xem la thuoc
15/ tuang, nhung thuOng dat tien horn thuoc dung ngay 2 Ian .

• Huyet ap tam thu la tri so cho Met nguy co tim mach chinh xac hon huyet ap tarn truong,
vi vey National High Blood pressure, Education Program khuyen dung huyet Ai) tam thu nhu la
tieu chi de Oat hien, clanh gia va dieu tri tang huyet ap, Ci4C biet o nguoi trung nien va ngudi
cao tuoi
Viec dieu tri de dua ve huyet ap mgc, tieu (HAMT cua nguai tang huyet ap v6 mt]
e
chang la < 140/90 mmHg, HAMT cua nub.' ti eu duOng va suy then man tinh < 130/80
nham muc dick ngan ngt:ra dOt quy, bao ve chin nang then, ngan ngira hoac lam chem Wen
suy tim, nhung tren thyc to rat khO det HAMT. Theo National Kiney Foundation, benh nhan cao
huyet ap kern suy then men ,nen dung it nhat 2 thuoc tri cao huyet ap hoac ACEI hoAc ARB
cong them 1 thu6c Igi tieu, neu clearance creatinin dudi 20-30 ml/phut thi LT thiazil khong hieu
qua nen phai dung LT quai.
Neu huyet ap chua &lye kiem soat day du thi lieu dung dugc dieu chinh rnoi 1-2
thang(khoang each nay ngAn horn 6 benh nhan CO nguy ca cao). Khi huyet ap on dinh it nhat I
nam thi giam lieu.
Sy lya chon thuOc tri tang huyet ap tuy thu6c tac dyng dugc 15/, gia tien, sy tien dyng, tac
dyng phy,dan tOc, Kra tuoi. Vi dy ngir6i da den va nguoi cao tuoi nen ch9n LT va CCB, con
ngu6i tre (<50 tuoi), da trang nen ch9n 13-blocker, ACEI.

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