{"id":18727,"date":"2023-04-12T19:31:42","date_gmt":"2023-04-12T12:31:42","guid":{"rendered":"http:\/\/noithathoaphat.in\/ctv\/?p=18727"},"modified":"2023-04-13T19:06:21","modified_gmt":"2023-04-13T12:06:21","slug":"bien-chung-xuat-huyet-tieu-hoa-tren-o-benh-nhan-hoi-suc-phau-thuat-tim","status":"publish","type":"post","link":"http:\/\/noithathoaphat.in\/ctv\/index.php\/2023\/04\/12\/bien-chung-xuat-huyet-tieu-hoa-tren-o-benh-nhan-hoi-suc-phau-thuat-tim\/","title":{"rendered":"Bi\u1ebfn ch\u1ee9ng xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a tr\u00ean \u1edf b\u1ec7nh nh\u00e2n h\u1ed3i s\u1ee9c ph\u1eabu thu\u1eadt tim"},"content":{"rendered":"

Xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a l\u00e0 m\u1ed9t bi\u1ebfn ch\u1ee9ng th\u01b0\u1eddng g\u1eb7p \u1edf b\u1ec7nh nh\u00e2n h\u1ed3i s\u1ee9c ph\u1eabu thu\u1eadt tim. T\u00ecnh tr\u1ea1ng n\u00e0y c\u00f3 th\u1ec3 g\u00e2y ra c\u00e1c bi\u1ebfn ch\u1ee9ng nghi\u00eam tr\u1ecdng nh\u01b0 suy h\u00f4 h\u1ea5p, suy th\u1eadn v\u00e0 th\u1eadm ch\u00ed t\u1eed vong. Nguy\u00ean nh\u00e2n c\u1ee7a xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a c\u00f3 th\u1ec3 do vi\u00eam lo\u00e9t d\u1ea1 d\u00e0y t\u00e1 tr\u00e0ng ho\u1eb7c do s\u1eed d\u1ee5ng thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng m\u00e1u. Vi\u1ec7c ch\u1ea9n \u0111o\u00e1n v\u00e0 \u0111i\u1ec1u tr\u1ecb k\u1ecbp th\u1eddi l\u00e0 r\u1ea5t quan tr\u1ecdng \u0111\u1ec3 gi\u1ea3m thi\u1ec3u nguy c\u01a1 c\u00e1c bi\u1ebfn ch\u1ee9ng.<\/strong><\/p>\n

\u0111\u1ec1 m\u1ee5c kh\u00f4ng d\u00f9ng ch\u1eef<\/p>\n

1.Nguy\u00ean nh\u00e2n xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a tr\u00ean<\/strong><\/h2>\n

Xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a tr\u00ean l\u00e0 bi\u1ebfn ch\u1ee9ng ti\u00eau h\u00f3a th\u1ee9 hai ph\u1ed5 bi\u1ebfn sau ph\u1eabu thu\u1eadt v\u1edbi t\u1ef7 l\u1ec7 m\u1eafc b\u1ec7nh t\u1eeb 0,5 \u0111\u1ebfn 1%. Th\u00f4ng th\u01b0\u1eddng, n\u00f3 l\u00e0 k\u1ebft qu\u1ea3 c\u1ee7a lo\u00e9t d\u1ea1 d\u00e0y-t\u00e1 tr\u00e0ng do c\u0103ng th\u1eb3ng v\u00e0 hi\u1ebfm khi l\u00e0 do lo\u00e9t th\u1ef1c qu\u1ea3n. C\u01a1 ch\u1ebf g\u00e2y ra th\u01b0\u1eddng l\u00e0 gi\u1ea3m l\u01b0u l\u01b0\u1ee3ng m\u00e1u \u0111\u1ebfn ni\u00eam m\u1ea1c c\u00f3 th\u1ec3 do b\u1edfi \u0111\u1ed9 axit d\u1ea1 d\u00e0y cao.<\/p>\n

2.Y\u1ebfu t\u1ed1 nguy c\u01a1 xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a tr\u00ean<\/strong><\/h2>\n

-Tr\u01b0\u1edbc ph\u1eabu thu\u1eadt: tu\u1ed5i cao, vi\u00eam-lo\u00e9t d\u1ea1 d\u00e0y c\u00f3 s\u1eb5n, x\u01a1 gan, b\u1ec7nh th\u1eadn m\u1ea1n(CKD), h\u00fat thu\u1ed1c.<\/p>\n

-Trong ph\u1eabu thu\u1eadt:s\u1eed d\u1ee5ng m\u00e1y tu\u1ea7n ho\u00e0n ngo\u00e0i c\u01a1 th\u1ec3 th\u1eddi gian d\u00e0i, ph\u1eabu thu\u1eadt van tim, m\u1ee9c \u0111\u1ed9 acid lactic cao trong qu\u00e1 tr\u00ecnh tu\u1ea7n ho\u00e0n ngo\u00e0i c\u01a1 th\u1ec3 l\u00e0m gi\u1ea3m m\u00e1u \u0111\u1ebfn ni\u00eam m\u1ea1c d\u1ea1 d\u00e0y.<\/p>\n

-Sau ph\u1eabu thu\u1eadt: cung l\u01b0\u1ee3ng tim th\u1ea5p, th\u00f4ng kh\u00ed c\u01a1 h\u1ecdc k\u00e9o d\u00e0i, nhi\u1ec5m tr\u00f9ng ph\u1ed5i, r\u1ed1i lo\u1ea1n \u0111\u00f4ng m\u00e1u ho\u1eb7c kh\u00e1ng \u0111\u00f4ng (kh\u00e1ng vitamin K, thu\u1ed1c heparin, warfarin), truy\u1ec1n m\u00e1u.<\/p>\n

3.Ph\u00f2ng ng\u1eeba xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a tr\u00ean<\/strong><\/h2>\n

B\u1ea5t k\u1ef3 b\u1ec7nh nh\u00e2n n\u00e0o c\u00f3 ti\u1ec1n s\u1eed b\u1ec7nh lo\u00e9t d\u1ea1 d\u00e0y ho\u1eb7c vi\u00eam d\u1ea1 d\u00e0y n\u00ean \u0111\u01b0\u1ee3c cho thu\u1ed1c trong h\u1ed3i s\u1ee9c t\u00edch c\u1ef1c(ICU) \u0111\u1ec3 ng\u0103n ng\u1eeba t\u1ed5n th\u01b0\u01a1ng ni\u00eam m\u1ea1c do c\u0103ng th\u1eb3ng v\u00e0 c\u00f3 th\u1ec3 l\u00e0m gi\u1ea3m nguy c\u01a1 xu\u1ea5t huy\u1ebft \u00a0ti\u00eau h\u00f3a.<\/p>\n

Ngo\u00e0i ra, b\u1ea5t k\u1ef3 b\u1ec7nh nh\u00e2n n\u00e0o c\u1ea7n h\u1ed7 tr\u1ee3 th\u00f4ng kh\u00ed k\u00e9o d\u00e0i, b\u1ecb nhi\u1ec5m tr\u00f9ng huy\u1ebft ho\u1eb7c c\u00f3 r\u1ed1i lo\u1ea1n \u0111\u00f4ng m\u00e1u n\u00ean \u0111\u01b0\u1ee3c ph\u00f2ng ng\u1eeba lo\u00e9t do stress. M\u1eb7c d\u00f9 ph\u00f2ng ng\u1eeba th\u01b0\u1eddng quy c\u00f3 th\u1ec3 kh\u00f4ng c\u1ea7n thi\u1ebft \u0111\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n c\u00f3 nguy c\u01a1 th\u1ea5p, nh\u01b0ng vi\u1ec7c ph\u00f2ng ng\u1eeba th\u01b0\u1eddng xuy\u00ean trong giai \u0111o\u1ea1n sau ph\u1eabu thu\u1eadt s\u1edbm l\u00e0 c\u1ea7n thi\u1ebft.<\/p>\n

-Sucralfate 1 g m\u1ed7i 6 gi\u1edd c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c u\u1ed1ng qua \u0111\u01b0\u1eddng mi\u1ec7ng ho\u1eb7c \u1ed1ng d\u1ea1 d\u00e0y th\u00f4ng qua m\u0169i.Tuy nhi\u00ean, ch\u01b0a c\u00f3 ch\u1ee9ng minh cho th\u1ea5y n\u00f3 gi\u1ea3m nguy c\u01a1 xu\u1ea5t huy\u1ebft ho\u1eb7c t\u1ef7 l\u1ec7 t\u1eed vong \u1edf b\u1ec7nh nh\u00e2n ICU.<\/p>\n

-Thu\u1ed1c \u1ee9c ch\u1ebf b\u01a1m proton (PPI) \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ee9ng minh l\u00e0 hi\u1ec7u qu\u1ea3 h\u01a1n nhi\u1ec1u so v\u1edbi c\u00e1c ch\u1ea5t \u0111\u1ed1i kh\u00e1ng th\u1ee5 th\u1ec3 H2 nh\u01b0 Ranitidin trong vi\u1ec7c gi\u1ea3m nguy c\u01a1 t\u1ed5n th\u01b0\u01a1ng ni\u00eam m\u1ea1c do stress v\u00e0 xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a. Pantoprazole (Pantoloc) 40 mg c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng qua \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch ho\u1eb7c \u0111\u01b0\u1eddng u\u1ed1ng, trong khi c\u00e1c lo\u1ea1i thu\u1ed1c ph\u1ed5 bi\u1ebfn kh\u00e1c nh\u01b0 Omeprazole (Prilosec) 20 mg m\u1ed7i ng\u00e0y, Lansoprazole (Prevacid) 15 mg m\u1ed7i ng\u00e0y ho\u1eb7c rabeprazole (Aciphex) 10 mg m\u1ed7i ng\u00e0y c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng qua \u0111\u01b0\u1eddng u\u1ed1ng \u0111\u1ec3 ph\u00f2ng ng\u1eeba. Ranitidin th\u01b0\u1eddng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng v\u1edbi li\u1ec1u u\u1ed1ng \u0111\u01b0\u1eddng mi\u1ec7ng 150-300 mg m\u1ed7i ng\u00e0y.<\/p>\n

-B\u1ec7nh nh\u00e2n sau ph\u1eabu thu\u1eadt b\u1eafc c\u1ea7u m\u1ea1ch v\u00e0nh(CABG) ho\u1eb7c van tim \u0111\u01b0\u1ee3c k\u00ea \u0111\u01a1n aspirin sau ph\u1eabu thu\u1eadt v\u00ec c\u00f3 hi\u1ec7u qu\u1ea3 kh\u00e1ng k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u cao h\u01a1n khi \u0111\u00f3 s\u1ebd c\u00f3 t\u01b0\u01a1ng t\u00e1c v\u1edbi thu\u1ed1c \u1ee9c ch\u1ebf b\u01a1m proton qua k\u00eanh CYP2C19 ho\u1eb7c CYP3A4.<\/p>\n

-M\u1eb7c d\u00f9 clopidogrel c\u00f3 th\u1ec3 g\u00e2y ra \u00edt bi\u1ebfn ch\u1ee9ng ti\u00eau h\u00f3a h\u01a1n aspirin \u1edf b\u1ec7nh nh\u00e2n kh\u00f4ng c\u00f3 ti\u1ec1n s\u1eed lo\u00e9t, aspirin ho\u1eb7c clopidogrel (ho\u1eb7c c\u1ea3 hai) c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng v\u1edbi PPI n\u1ebfu c\u00f3 ti\u1ec1n s\u1eed lo\u00e9t \u0111\u00e3 l\u00e0nh.<\/p>\n

4.Tri\u1ec7u ch\u1ee9ng.<\/strong><\/h2>\n

D\u1ecbch l\u00e0 m\u00e1u m\u00e0u \u0111\u1ecf t\u01b0\u01a1i qua \u1ed1ng th\u00f4ng d\u1ea1 d\u00e0y ho\u1eb7c n\u00f4n ra m\u00e1u l\u00e0 d\u1ea5u hi\u1ec7u r\u00f5 r\u00e0ng c\u1ee7a xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a. Xu\u1ea5t huy\u1ebft ch\u1eadm th\u01b0\u1eddng g\u00e2y ra t\u00ecnh tr\u1ea1ng ti\u00eau ph\u00e2n \u0111en, nh\u01b0ng xu\u1ea5t huy\u1ebft \u00a0nhanh c\u00f3 th\u1ec3 g\u00e2y ra ph\u00e2n c\u00f3 m\u00e1u m\u00e0u \u0111\u1ecf t\u01b0\u01a1i. Ch\u00fa \u00fd \u0111\u1ebfn kh\u1ea3 n\u0103ng c\u00f3 xu\u1ea5t huy\u1ebft \u00a0ti\u00eau h\u00f3a \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n nguy k\u1ecbch ho\u1eb7c b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c ti\u00eam heparin. N\u1ebfu kh\u00f4ng x\u00e1c \u0111\u1ecbnh \u0111\u01b0\u1ee3c xu\u1ea5t huy\u1ebft \u00a0ti\u00eau h\u00f3a, n\u00ean c\u00e2n nh\u1eafc kh\u1ea3 n\u0103ng xu\u1ea5t huy\u1ebft m\u00e0ng b\u1ee5ng v\u00e0 \u0111\u00e1nh gi\u00e1 b\u1eb1ng c\u00e1ch th\u1ef1c hi\u1ec7n CT b\u1ee5ng.<\/p>\n

5.\u0110\u00e1nh gi\u00e1 v\u00e0 \u0111i\u1ec1u tr\u1ecb.<\/strong><\/h2>\n

Xu\u1ea5t huy\u1ebft \u00a0v\u1eabn ti\u1ebfp di\u1ec5n m\u1eb7c d\u00f9 \u0111\u00e3 \u0111i\u1ec1u ch\u1ec9nh c\u00e1c r\u1ed1i lo\u1ea1n \u0111\u00f4ng m\u00e1u v\u00e0 t\u0103ng c\u01b0\u1eddng ch\u1ebf \u0111\u1ed9 \u0111i\u1ec1u tr\u1ecb c\u1ea7n ph\u1ea3i \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 ti\u1ebfp. Xu\u1ea5t huy\u1ebft \u00a0trong qu\u00e1 tr\u00ecnh truy\u1ec1n ch\u1ea5t \u1ee9c ch\u1ebf \u0111\u00f4ng m\u00e1u th\u01b0\u1eddng li\u00ean quan \u0111\u1ebfn m\u1ed9t s\u1ed1 b\u1ec7nh l\u00fd n\u1ec1n.<\/p>\n

-C\u1ea7n ng\u1eebng t\u1ea5t c\u1ea3 c\u00e1c thu\u1ed1c ch\u1ed1ng ti\u1ec3u c\u1ea7u ho\u1eb7c ch\u1ea5t \u1ee9c ch\u1ebf \u0111\u00f4ng m\u00e1u khi c\u00f3 b\u1eb1ng ch\u1ee9ng v\u1ec1 xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a, s\u1eed d\u1ee5ng ch\u1ea5t \u0111\u1ed1i kh\u00e1ng n\u1ebfu c\u1ea7n thi\u1ebft \u0111\u1ec3 ng\u0103n ch\u1eb7n xu\u1ea5t huy\u1ebft ti\u1ebfp di\u1ec5n. Vi\u1ec7c n\u00e0y c\u00f3 th\u1ec3 bao g\u1ed3m vitamin K, huy\u1ebft t\u01b0\u01a1ng t\u01b0\u01a1i \u0111\u00f4ng l\u1ea1nh cho ch\u1ec9 s\u1ed1INR cao do warfarin<\/p>\n

-PPI hi\u1ec7u qu\u1ea3 h\u01a1n \u1ee9c ch\u1ebf H2 trong vi\u1ec7c ki\u1ec3m so\u00e1t v\u00e0 ng\u0103n ng\u1eeba xu\u1ea5t huy\u1ebft t\u00e1i ph\u00e1t. \u0110\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n \u0111ang xu\u1ea5t huy\u1ebft , c\u00f3 th\u1ec3 ti\u00eam Pantoprazole 80 mg qua \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch, sau \u0111\u00f3 ti\u1ebfp t\u1ee5c truy\u1ec1n li\u00ean t\u1ee5c 8 mg\/gi\u1edd trong v\u00f2ng 72 gi\u1edd v\u00e0 c\u00f3 th\u1ec3 nhanh ch\u00f3ng l\u00e0m t\u0103ng \u0111\u1ed9 pH d\u1ea1 d\u00e0y l\u00ean >6.Ranitidin c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng d\u01b0\u1edbi d\u1ea1ng truy\u1ec1n li\u00ean t\u1ee5c 50 mg\/gi\u1edd.<\/p>\n

-N\u00ean th\u1ef1c hi\u1ec7n n\u1ed9i soi ti\u00eau h\u00f3a tr\u00ean \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh v\u1ecb tr\u00ed xu\u1ea5t huy\u1ebft v\u00e0 c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng k\u1ef9 thu\u1eadt c\u1ea7m m\u00e1u \u0111\u1ec3 ki\u1ec3m so\u00e1t xu\u1ea5t huy\u1ebft . N\u00f3 c\u00f3 th\u1ec3 ng\u1eebng xu\u1ea5t huy\u1ebft \u00a0\u1edf h\u01a1n 90% b\u1ec7nh nh\u00e2n.<\/p>\n

-Somatostatin 250 \u03bcg\/gi\u1edd trong 5 ng\u00e0y \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ee9ng minh l\u00e0 hi\u1ec7u qu\u1ea3 trong \u0111i\u1ec1u tr\u1ecb xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a n\u1eb7ng.<\/p>\n

-Sau khi xu\u1ea5t huy\u1ebft \u0111\u01b0\u1ee3c ki\u1ec3m so\u00e1t, c\u00e1c thu\u1ed1c ch\u1ed1ng ti\u1ec3u c\u1ea7u n\u00ean \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ngl\u1ea1i khi cho ph\u00e9p \u0111\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n sau ph\u1eabu thu\u1eadt CABG ho\u1eb7c thay van tim. Ngay c\u1ea3 \u0111\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n c\u00f3 ti\u1ec1n s\u1eed xu\u1ea5t huy\u1ebft \u00a0ti\u00eau h\u00f3a do aspirin, vi\u1ec7c t\u00e1i s\u1eed d\u1ee5ng aspirin k\u1ebft h\u1ee3p v\u1edbi PPI hi\u1ec7u qu\u1ea3 h\u01a1n vi\u1ec7c s\u1eed d\u1ee5ng clopidogrel l\u00e0m thu\u1ed1c ch\u1ed1ng k\u1ebft t\u1eadp ti\u1ec3u c\u1ea7u thay th\u1ebf. \u0110\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n c\u1ea7n s\u1eed d\u1ee5ng c\u1ea3 aspirin v\u00e0 clopidogrel, c\u1ea3 hai thu\u1ed1c c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng an to\u00e0n v\u1edbi PPI sau khi ng\u1eebng xu\u1ea5t huy\u1ebft \u00a0b\u1eb1ng n\u1ed9i soi c\u1ea7m m\u00e1u.<\/p>\n

6.\u0110\u00e1nh gi\u00e1 k\u1ebft qu\u1ea3:<\/strong><\/h2>\n

T\u1ef7 l\u1ec7 t\u1eed vong chung cho b\u1ec7nh nh\u00e2n xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a sau ph\u1eabu thu\u1eadt tim l\u00e0 kho\u1ea3ng 15%.<\/p>\n

B\u1ec7nh vi\u1ec7n \u0110a khoa Qu\u1ed1c t\u1ebf Vinmec<\/strong><\/a> \u0111\u00e3 \u0111\u01b0a h\u1ec7 th\u1ed1ng m\u00e1y m\u00f3c, thi\u1ebft b\u1ecb hi\u1ec7n \u0111\u1ea1i \u0111\u1ea1t chu\u1ea9n v\u00e0o c\u00f4ng t\u00e1c th\u0103m kh\u00e1m, ch\u1ea9n \u0111o\u00e1n v\u00e0 \u0111i\u1ec1u tr\u1ecb h\u1ed7 tr\u1ee3 c\u00e1c b\u1ec7nh l\u00fd v\u1ec1 h\u1ed3i s\u1ee9c c\u1ea5p c\u1ee9u v\u00e0 c\u00e1c b\u1ec7nh l\u00fd ti\u00eau h\u00f3a.<\/p>\n","protected":false},"excerpt":{"rendered":"

Xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a l\u00e0 m\u1ed9t bi\u1ebfn ch\u1ee9ng th\u01b0\u1eddng g\u1eb7p \u1edf b\u1ec7nh nh\u00e2n h\u1ed3i s\u1ee9c ph\u1eabu thu\u1eadt tim. T\u00ecnh tr\u1ea1ng n\u00e0y c\u00f3 th\u1ec3 g\u00e2y ra c\u00e1c bi\u1ebfn ch\u1ee9ng nghi\u00eam tr\u1ecdng nh\u01b0 suy h\u00f4 h\u1ea5p, suy th\u1eadn v\u00e0 th\u1eadm ch\u00ed t\u1eed vong. 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