CHONG BS Bi Xun Phc B mn Ni- HYD Tp.HCM

MUC TIEU HOC TAP1. nh ngha.2. Sinh ly benh.3. Nguyn nhn v phn loi.4. Bien chng.5. Chan oan.6. X tr.

I. nh ngha:Chong l tnh trng ti mu cung cp cc cht dinh dng cn thit cho cc m v cc c quan khng . Hu qu cui cng l ri lon chc nng mng t bo, ri lon chuyn ho t bo v cht t bo.

II. Sinh l bnh:c im ca chong l gim ti mu m h thng, mt cn bng cung-cu oxy ca m, thiu oxy cho m (hypoxia).Tn thng t bo trong chong: ri lon chc nng bm ion ca mng t bo, ph ni bo, r r cc thnh phn ni bo vo gian bo, mt iu ho pH ni bo.

Ri lon h thng:Thay i PH mu.Ri lon chc nng ni mc.Kch hot h thng vim v khng vim ca c th.Chong ko di s dn n cht t bo, suy a c quan v t vong. Do cn nhn bit chong sm v iu tr kp thi.

Chong giai on 1: Chong cn b.Tt huyt p c th do gim cung lng tim hoc dn mch ngoi vi.Cc c ch b tr c khi kch nhm phc hi p lc ng mch v ti mu cho cc c quan quan trng nh no, tim.Triu chng kh nhn bit. Nu pht hin v iu tr kp thi th nhiu trng hp qua khi.Nhp tim nhanh, huyt p bnh thng hoc gim nh, hiu p gim, co mch ngoi bin nh, bt rt.

Chong giai on 2: Chong mt b.Tnh trng gim ti mu cc c quan:No: ri lon tri gic.Thn: thiu niu.Tim: thiu mu c tim.Bnh nhn c y triu chng ca chong:Mch nhanh, nh, kh bt. Huyt p tt.Th nhanhCo mch ngoi bin, tm u chi, v m hi.

Chong giai on 3: Chong khng hi phc.Gim ti mu m ko di thay i chc nng mng t bo, kt tp t bo mu trong vi tun hon nghn mao mch tn thng t bo.Huyt p gim nng gim ti mu cc c quan sng cn vng xon bnh l suy sp tun hon suy a c quan.

Multiple Organ System Failure (MOSF)Hoai t ong than cap.Hoai t niem mac ng tieu hoa.Ton thng te bao noi mac mach mau RL tnh tham mang mao mach mat dch va protein ni mch gim th tch tun hon v gim HA.Ton thng te bao noi mac mach mau DIC.oc to cua vi khuan phan ng vi bach cau polypeptides gian mach gim HA.Giam ti mau c tim gim co bp c tim gim cung lng tim v gim HA. Te bao b huy hoai choang khong hoi phuc.

III. Nguyn nhn v Phn loi:Ti mu cho cc c quan ph thuc vo:1/ Tim bm.2/ Trng lc mch mu.3/ Th tch tun hon.4/ S thng sut ca ng dn mu.

Ti mu c quan tht bi khi:

1/ Tim suy: chong tim.2/ Gim hoc mt trng lc mch mu:chong nhim trng, chong phn v.3/ Gim th tch tun hon: chong gim th tch.4/ Tc nghn dng mu: thuyn tc ng mch phi, hp van hai l kht.

Do chong c xp thnh 4 nhm:

1/ Chong tim.2/ Chong phn phi.3/ Chong gim th tch.4/ Chong do tc nghn mch mu ngoi tim.

1. Chong gim th tch:L loi chong thng gp nht. Chong gim th tch l do gim s lng dch ni mch tuyt i (thng t ngt) so vi dung tch ca h mch mu, lm gim lng mu v tht phi cung lng tim gim.Khi th tch ni mch gim 10%: HA gim nh, gim cung lng tim nh.Khi th tch ni mch gim 20%: HA gim va, gim cung lng tim va.

Khi th tch ni mch gim 40%: HA gim nng, gim cung lng tim nng.Nu tnh trng ny ko di vi gi th t vong gn nh chc chn d hi sc tch cc.Bnh nhn c bnh l tim mch, h hp, thn, no i km th tnh trng chong cn nng n hn.

Nguyn nhn:Mt mu: chy mu, xut huyt ni.Mt nc - in gii:ng tiu ho: tiu chy, nn i.ng thn: tiu nhiu.Qua tn thng b mt c th: bng.Thot dch vo ngn th ba: c chng, tc rut.

Lm sng:C bnh NN gy mt mu, mt nc.Gim ti mu cc c quanDu mt nc: mt trng, da kh, mi li kh, vo da(+), TM c xp, nhn cu mmDu mt mu: da xanh, nim nhtCVP gim, ALMP bt gim.CTM: Hct gim khi mt mu. Hct tng khi mt nc lm c c mu. BC bnh thng.

2. Chong tim:

Nguyn nhn: 2 nhma. Nhi mu c tim cp: Khi s lng c tim hoi t 25-40% s lm sc co bp c tim gim nng. Chong cn c th do cc bin chng c hc: thng vch lin tht, h van hai l cp, v tim.

b. Khng do Nhi mu c tim:

Bnh van tim nng: hp kht van M ch.Bnh mng ngoi tim co tht. Bnh c tim tc nghn.Vim c tim.Ri lon nhp tim.

Lm sng chong tim do NMCT cp:Tt HA (HA trung bnh < 60 mmHg). Gim cung lng tim (Ch s tim < 2 l/pht/m2). Tng p lc M phi bt (PAOP > 18 mmHg).Tng sc cn ngoi bin.Gim ti mu cc c quan: thiu niu, ri lon tri gic...

3. Chong do phn phi dch:

Khng lc mch mu gim nng, vt qu s b tr ca tnh trng tng cung lng tim.a. Chong nhim trng: Thng do nhim trng gram m: E.coli, Klebsiella, Enterobacter, Pseudomonas. Bat ky o nhiem trung nao cung co the gay ra chong NT: viem ai be than, viem phoi, viem phuc mac, viem ng mat, viem mo te bao, viem mang nao, cac loai ap xe..

SINH LY BENHO nhiem trungTang sinh va lan rong cua vi khuanHoat hoa he thong khang c cua ky chu Phong thch hoa chat trung gian Anh hng cac c quan Chong nhim trng

Cc giai on ca chong nhim trng:Chong NT c 3 kiu huyt ng hc: Chong m = G 1 Chong lnh = G 2 MOSF = G 3Ranh gii gia cc giai on khng r rng. Cn chn on sm.

NH NGHA (consensus, critical care medicine 2001)SIRS-Systemic Inflammatory Response Syndrome: t nhat co 2 trong 5 tieu chuan: * Tan so tim > 90l/ph* Nhp th > 20/ph hay PaCO2 < 32 mmHg (hay can phai th TKNT)* Tang hay giam than nhiet (T > 38C hay < 36C)* Tang hay giam BC ( > 12000/mm3 hay < 4000/ mm3) hay co >10% dang cha trng thanh.* Cac ch iem sinh hoc cua viem: C-reactive protein, Interleukin-6, D-dimerLam sang:

Sepsis : SIRS + chac chan hay nghi ng do nhiem trung. Severe sepsis: sepsis + suy 1 hay nhieu c quan + giam HA hay giam ti mau (= nhiem toan lactic, thieu nieu va roi loan y thc).Septic Shock: Severe sepsis + Tut HA keo dai khong ap ng vi bu dch ma phai can dung thuoc van mach.

Lam sang:

b. Chong phn v: Phn v (Anaphylaxis):L phn ng d ng cp tnh, ton thn, mc t nh n rt nng v t vong. Bn cht l phn ng min dch, ph thuc vo s thnh lp IgE, l 1 globulin min dch chu trch nhim cc phn ng d ng. Phn ng dng phn v (Anaphylactoid reaction):Khng qua trung gian IgE.Lm sng khng phn bit c vi phn v. iu tr ging phn v.

C che benh sinh cua choang phan ve

Lm sng:Triu chng thng xy ra nhanh sau khi tip xc vi d nguyn.

Da: nga, ni m ay, ph mch.H hp: kh th, th rt (ph thanh qun), kh kh (co tht ph qun).Tun hon: mch nhanh, tt HA, ri lon tri gic.Tiu ho: bun nn, nn, au bng, tiu chy.

T vong thng do suy h hp, tt HA.

4. Chong do tc nghn mch mu ln:

Chn p tim cpTrn kh mng phi p lc.U nhy nh tri.Thuyn tc phi din rng (do huyt khi, kh, nc i...

Chong kt hp: Nhiu c ch chong trn cng 1 bnh nhn.V d: chong NT + Chong gim th tch...

IV. Bin chng:1. DIC: ng mu ni mch lan toL bin chng thng gp trong chong, c bit l chong nhim trng gram m. Khi c HC ny th t l t vong rt cao. L tnh trng ng mu ni mch v tiu fibrin xy ra ng thi. Biu hin lm sng l tnh trng xut huyt. Gy hoi t v thn, tn thng cc c quan, tiu hao yu t ng mu, gp phn gy chong phi.

2. ARDS: Hoi chng nguy ngap ho hap capCn gi l chong phi. L bin chng thng gp ca chong, c bit l chong nhim trng. Lm sng: ph phi cp khng do tim. Suy h hp cp gim oxy mu nng. Km p ng vi iu tr oxy. X quang: thm nhim phi lan rng.

3. Suy than cap:L bin chng thng gp ca chong. Nguyn nhn chnh l do gim ti mu thn trong tnh trng tt huyt p.Lm sng: Thiu niu, v niu. Ur, creatinin mu tng.

4. Bin chng trn gan, tim, no:Gan: tn thng gan cp. Lm sng: tng men gan, tng bilirubin...Tim: nu huyt p gim nng (< 60 mmHg), toan mu nng s gy gim co bp c tim cung lng tim gim. No: khi huyt p gim nng, toan mu nng, gim oxy mu, h ng huyt... bnh nhn s bt rt, vt v, l m, l ln, hn m.

V. Chn on:1. Lm sng:Mch nhanh, nh, kh bt. Huyt p tt (HA tm thu < 90 mmHg), kp. Co mch ngoi bin: da lnh, rn m hi; u chi, mi, tai lnh, tm; thi gian y mao mch ko di > 2 giy.Th nhanh. Thiu niu (V nc tiu < 25 ml/gi).Triu chng ca bnh nguyn nhn. Cn hi k bnh s, tin cn.

2. Cn lm sng- Th thut:

Gip chn on nguyn nhn, chn on phn bit, nh gi tnh trng chong.Cng thc mu. XN ng mu nu nghi ng c DIC. Chc nng gan, thn, ion , kh mu M.o Lactate mu tnh mch.X quang tim phi, ECG.Cy tm vi trng trong m, mu, nc tiu.Siu m tim, men tim...

2. Cn lm sng- Th thut:

o p lc tnh mch trung tm gip nh gi th tch tun hon.o HA ng mch xm ln gip nh gi HA chnh xc.p lc M phi bt tng trong chong tim.t sonde tiu theo di lng nc tiu.t sonde mi- d dy.

VI. X tr:Cc bin php chung:iu tr chong ti Khoa Sn sc c bit (ICU).Th oxy. Th my khi cn.B th tch tun hon.Dng thuc vn mch.iu chnh ri lon in gii, kim-toan...Theo di: DHST (M, HA, T0, Nhp th, Sp02), lng nc tiu, CVP, HA M xm ln.

Nang tuan hoan- Goals of therapyReasonable goals for initial resuscitation include- Muc tieu hoi sc trong 6 gi au:Central venous pressure 8 to 12 mmHg Mean arterial pressure 65 mmHg Urine output 0.5 mL per kg per hour Central venous or mixed venous oxygen saturation 70 percent.

Thuoc van mach: cac loai thu theCac loai thu the giao cam: 1: nam chu yeu thanh mach. Kch thch cac thu the nay gay co c trn thanh mach, tang huyet ap.2: nam tien synap co tac dung ieu hoa ngc am tnh . Kch thch cac thu the nay c che giai phong noradrenaline.1: nam chu yeu tim va c trn thanh ruot. Kch thch thu the nay gay tang co bop c tim, tang nhp tim va gian c trn thanh ruot.2: thng thay phe quan, t cung, c trn thanh mach. Kch thch 2 gay gian mach va gian phe quan.

Thuoc van mach: cac loai thu theCac thu the dopaminergic: Cac loai thu the nay co than kinh trung ng (ni dopamine la mot chat dan truyen than kinh quan trong). ngoai vi cac thu the dopaminergic co :D1: mach mau ngoai bien, mach than, mach mac treo. Kch thch cac thu the nay gay dan mach.D2: tien synap, co tac dung c che phong thch hoa chat trung gian. Cac thu the vasopressine:. V1 nam c trn thanh mach, co tac dung gay co mach.V2 nam ong gop, co tac dung tai hap thu nc.V3 nam tuyen yen co tac dung gay tang tiet ACTH.

1. Chong gim th tch: iu tr ch yu l bi hon th tch tun hon v iu tr nguyn nhn.

Dch truyn:NaCl 0.9%, Lactate Ringer.Dung dch cao phn t (Dextran...).Chong mt mu: truyn mu.Tc truyn: BN khng suy tim sung huyt: c th bolus 500 ml dch, sau iu chnh tc tu theo HA, CVP, tnh trng ti mu c quan.ng truyn: ng tnh mch ngoi bin, kim ln.Th tch b: tu thuc lng dch mt v p ng BN.

2. Chong phn phi:a. Chong nhim trng:Bi hon dch.Thuc vn mch: Khi b dch hoc gn (CVP bnh thng hoc hi cao) m HA khng ln, tnh trng ti mu c quan khng ci thin.Dopamin:Liu thp (2-3 g/kg/p): tc dng Dopaminergic gy dn mch thn.Liu trung bnh (4-5 g/kg/p): tc dng ln th th 1 lm tng co bp c tim, tng cung lng tim.Liu cao (> 10 g/kg/p): tc dng ln th th gy co mch, tng huyt p.

Noradrenaline: tc dng v 1.L thuc gy co mch mnh, dng khi HA gim nng, hay khi dng Dopamin khng c p ng.Liu: 2-20 g/pGii quyt tnh trng nhim trng:Khng sinh.Phu thut khi c ch nh.

b. Chong phn v:

ADRENALINE: Thuoc hang au trong ieu tr phan ve.Giup on nh huyet ong, dan phe quan, ngan phong thch hoa chat trung gian them t te bao mast. Lieu: 0.3- 0.5 ml Adrenaline 1/1000 (tre em: 0.01 ml/Kg) IM, SC.Tiem bap (vung ui trc- ben) tot hn tiem di da.Lap lai moi 10-15 phut khi can.BN nang (co trieu chng ho hap nang hay co tut huyet ap): Adrenaline IV 0.1mg (1ml dung dch 1/10.000) moi 5 phut.BN tut huyet ap keo dai: Adrenaline truyen tnh mach lieu khi au 1-4 g/phut va tang lieu dan e at HA thch hp.

3. Chong do tc nghn mch mu ln:

Cn tm ra nguyn nhn gii quyt, v iu tr ni khoa t mang li kt qu.Trn dch mng ngoi tim:Truyn dch tng sc y tm tht.Chc tho mng ngoi tim.Thuyn tc phi din rng:Truyn dch.Thuc vn mch (Dopamin, Noradrenalin) nng HA ln tm thi.Thuc tiu si huyt, phu thut ly huyt khi.

4. Chong tim:

Th oxy. Th my khi cn.Truyn dch cn thn. Trnh thiu dch hay d dch.Thuc tng co bp c tim, thuc vn mch: Dopamin, Dobutamin.Dng c h tr tun hon: t bng di nghch trong M ch gip gim cng ca tim v ti mu mch vnh tt hn.iu tr trit : thng M vnh, phu thut bt cu M vnh, thay van tim, thay tim.

****CAP is a common condition and continues to be an important cause of mortality. In the United States, CAP is the 6th leading cause of death. More than 80% of cases of CAP are managed in the community, where the mortality rate is around 1%. Among those approximately 500,000 patients admitted to the hospital each year, 10%-14% will die, with the mortality rate rising to 30%-40% for those requiring intensive care.

Bartlett JG, Dowell SF, Mandell LA, File Jr TM, Musher DM, Fine MJ. Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America. Clin Infect Dis. 2000;31:347-382.******************