{"id":22016,"date":"2023-04-17T12:32:03","date_gmt":"2023-04-17T05:32:03","guid":{"rendered":"http:\/\/noithathoaphat.in\/ctv\/?p=22016"},"modified":"2023-04-17T12:34:18","modified_gmt":"2023-04-17T05:34:18","slug":"thuoc-chong-dong","status":"publish","type":"post","link":"http:\/\/noithathoaphat.in\/ctv\/index.php\/2023\/04\/17\/thuoc-chong-dong\/","title":{"rendered":"Thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng trong \u0111i\u1ec1u tr\u1ecb COVID 19"},"content":{"rendered":"

Trong qu\u00e1 tr\u00ecnh \u0111i\u1ec1u tr\u1ecb b\u1ec7nh COVID-19, b\u1ec7nh nh\u00e2n c\u00f3 nguy c\u01a1 cao b\u1ecb \u0111\u00f4ng m\u00e1u do t\u00e1c \u0111\u1ed9ng c\u1ee7a virus l\u00ean h\u1ec7 th\u1ed1ng m\u00e1u v\u00e0 m\u1ea1ch m\u00e1u trong c\u01a1 th\u1ec3.\u00a0 Do \u0111\u00f3, vi\u1ec7c s\u1eed d\u1ee5ng thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng trong \u0111i\u1ec1u tr\u1ecb COVID-19 l\u00e0 m\u1ed9t ph\u01b0\u01a1ng ph\u00e1p quan tr\u1ecdng \u0111\u1ec3 ng\u0103n ng\u1eeba v\u00e0 \u0111i\u1ec1u tr\u1ecb c\u00e1c bi\u1ebfn ch\u1ee9ng do \u0111\u00f4ng m\u00e1u. Tuy nhi\u00ean, quy\u1ebft \u0111\u1ecbnh s\u1eed d\u1ee5ng thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng c\u1ea7n \u0111\u01b0\u1ee3c \u0111\u01b0a ra d\u1ef1a tr\u00ean t\u00ecnh tr\u1ea1ng b\u1ec7nh c\u1ee7a t\u1eebng b\u1ec7nh nh\u00e2n.<\/strong><\/p>\n

1. \u0110i\u1ec1u tr\u1ecb\u00a0 b\u1eb1ng thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng<\/strong><\/h2>\n

1.1. D\u1ef1a v\u00e0o ph\u00e2n lo\u1ea1i m\u1ee9c \u0111\u1ed9 n\u1eb7ng ng\u01b0\u1eddi b\u1ec7nh COVID-19<\/strong><\/h3>\n

1.1.1. Ng\u01b0\u1eddi nhi\u1ec5m kh\u00f4ng tri\u1ec7u ch\u1ee9ng, m\u1ee9c \u0111\u1ed9 nh\u1eb9<\/em><\/strong><\/p>\n

– Ch\u01b0a \u0111i\u1ec1u tr\u1ecb.<\/p>\n

– N\u1ebfu ng\u01b0\u1eddi b\u1ec7nh \u0111ang duy tr\u00ec thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng theo b\u1ec7nh l\u00fd n\u1ec1n: ti\u1ebfp t\u1ee5c duy tr\u00ec.<\/p>\n

– D\u00f9ng li\u1ec1u d\u1ef1 ph\u00f2ng n\u1ebfu ng\u01b0\u1eddi b\u1ec7nh c\u00f3 nguy c\u01a1 cao: b\u1ec7nh l\u00fd n\u1ec1n: t\u0103ng HA, ti\u1ec3u \u0111\u01b0\u1eddng, ung th\u01b0, b\u1ec7nh ph\u1ed5i m\u1ea1n t\u00ednh, b\u1ec7nh l\u00fd m\u1ea1ch v\u00e0nh, ti\u1ec1n s\u1eed huy\u1ebft kh\u1ed1i, b\u00e9o ph\u00ec.<\/p>\n

– Ph\u1ee5 n\u1eef c\u00f3 thai xem x\u00e9t ph\u1ed1i h\u1ee3p th\u00eam aspirin (n\u1ebfu l\u00e0m \u0111\u01b0\u1ee3c x\u00e9t nghi\u1ec7m D- dimer)<\/p>\n

– D\u00f9ng li\u1ec1u d\u1ef1 ph\u00f2ng khi \u0111i\u1ec3m Modified IMPROVE-VTE 2 ho\u1eb7c 3.<\/p>\n

1.1.2<\/strong>. M\u1ee9c \u0111\u1ed9 trung b\u00ecnh<\/em><\/strong><\/p>\n

D\u00f9ng li\u1ec1u d\u1ef1 ph\u00f2ng t\u0103ng c\u01b0\u1eddng\/ho\u1eb7c li\u1ec1u \u0111i\u1ec1u tr\u1ecb n\u1ebfu c\u00f3 x\u00e9t nghi\u1ec7m theo d\u00f5i \u0111i\u1ec1u tr\u1ecb.<\/p>\n

1.1.3<\/strong>. \u00a0M\u1ee9c \u0111\u1ed9 n\u1eb7ng<\/em><\/strong><\/p>\n

D\u00f9ng li\u1ec1u \u0111i\u1ec1u tr\u1ecb\/ho\u1eb7c \u0111i\u1ec1u ch\u1ec9nh theo quy tr\u00ecnh c\u1ee7a m\u00e1y l\u1ecdc m\u00e1u (n\u1ebfu ng\u01b0\u1eddi b\u1ec7nh \u0111ang l\u1ecdc m\u00e1u).<\/p>\n

1.1.4. M\u1ee9c \u0111\u1ed9 nguy k\u1ecbch (ph\u1ee5 thu\u1ed9c t\u00ecnh tr\u1ea1ng ng\u01b0\u1eddi b\u1ec7nh)<\/em><\/strong><\/p>\n

– D\u00f9ng li\u1ec1u d\u1ef1 ph\u00f2ng n\u1ebfu ng\u01b0\u1eddi b\u1ec7nh c\u00f3 gi\u1ea3m \u0111\u00f4ng.<\/p>\n

– Ho\u1eb7c li\u1ec1u \u0111i\u1ec1u tr\u1ecb.<\/p>\n

1.2. D\u1ef1a v\u00e0o k\u1ebft qu\u1ea3 x\u00e9t nghi\u1ec7m<\/strong><\/h3>\n

1.3. Ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng<\/strong><\/h3>\n

– Kh\u00f4ng s\u1eed d\u1ee5ng ch\u1ed1ng \u0111\u00f4ng n\u1ebfu ng\u01b0\u1eddi b\u1ec7nh c\u00f3 m\u1ed9t trong nh\u1eefng y\u1ebfu t\u1ed1 sau: \u0111ang c\u00f3 ch\u1ea3y m\u00e1u, m\u1edbi xu\u1ea5t huy\u1ebft n\u00e3o, Fibrinogen < 0,5 g\/l, vi\u00eam n\u1ed9i t\u00e2m m\u1ea1c nhi\u1ec5m khu\u1ea9n c\u1ea5p.<\/p>\n

– Th\u1eadn tr\u1ecdng d\u00f9ng ch\u1ed1ng \u0111\u00f4ng n\u1ebfu ng\u01b0\u1eddi b\u1ec7nh c\u00f3 m\u1ed9t trong nh\u1eefng y\u1ebfu t\u1ed1 sau: \u0111i\u1ec3m HAS-BLED \u2265 3, ti\u1ec3u c\u1ea7u < 25G\/l. V\u1edbi ng\u01b0\u1eddi b\u1ec7nh c\u00f3 ti\u1ec3u c\u1ea7u < 50G\/l: kh\u00f4ng d\u00f9ng UFH.<\/p>\n

B\u1ea3ng 1. S\u1eed d\u1ee5ng thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng m\u00e1u d\u1ef1a tr\u00ean x\u00e9t nghi\u1ec7m<\/em><\/p>\n\n\n\n\n\n\n\n\n\n\n\n
C\u0103n c\u1ee9 x\u00e9t nghi\u1ec7m<\/strong><\/td>\nLi\u1ec1u d\u1ef1 ph\u00f2ng<\/strong>
\n(ch\u1ec9nh li\u1ec1u theo BMI v\u00e0 ch\u1ee9c n\u0103ng th\u1eadn – xem B\u1ea3ng<\/em>)<\/td>\n		Li\u1ec1u \u0111i\u1ec1u tr\u1ecb<\/strong>
\n(ch\u1ec9nh li\u1ec1u theo BMI v\u00e0 ch\u1ee9c n\u0103ng th\u1eadn -xem B\u1ea3ng<\/em>)<\/td>\n<\/tr>\n
CRP<\/strong><\/td>\nT\u0103ng \u2264 15 mg\/L<\/td>\n> 15 mg\/L<\/td>\n<\/tr>\n
Ferritin<\/strong><\/td>\nT\u0103ng \u2264 1.000 ng\/ml<\/td>\n> 1.000ng\/ml<\/td>\n<\/tr>\n
D-dimer<\/strong><\/td>\nD-dimer t\u0103ng t\u1eeb > 2 \u0111\u1ebfn < 5 l\u1ea7n ng\u01b0\u1ee1ng b\u00ecnh th\u01b0\u1eddng<\/td>\n\u25cf \u2265 5 l\u1ea7n ng\u01b0\u1ee1ng b\u00ecnh th\u01b0\u1eddng;<\/p>\n

\u25cf T\u0103ng nhanh g\u1ea5p 2 l\u1ea7n trong v\u00f2ng 24-48h;<\/p>\n

\u25cf G\u1ea5p 2 b\u00ecnh th\u01b0\u1eddng + \u0111i\u1ec3m Modified Improve = 2-3.<\/td>\n<\/tr>\n

IL-6<\/strong><\/td>\n15 – 40 pg\/ml<\/td>\n> 40 pg\/ml<\/td>\n<\/tr>\n
B\u1ea1ch c\u1ea7u Lympho<\/strong><\/td>\nCh\u01b0a gi\u1ea3m \u2192 tham kh\u1ea3o c\u00e1c ti\u00eau chu\u1ea9n kh\u00e1c<\/td>\n\u2264 0,8 G\/l<\/td>\n<\/tr>\n
B\u1ea1ch c\u1ea7u trung t\u00ednh<\/strong><\/td>\nT\u0103ng \u2264 10 G\/l<\/td>\n> 10 G\/l<\/td>\n<\/tr>\n
Huy\u1ebft kh\u1ed1i \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh b\u1eb1ng ch\u1ea9n \u0111o\u00e1n h\u00ecnh \u1ea3nh<\/strong><\/td>\nKh\u00f4ng c\u00f3 huy\u1ebft kh\u1ed1i \u2192 tham kh\u1ea3o c\u00e1c ti\u00eau chu\u1ea9n kh\u00e1c<\/td>\nC\u00f3<\/td>\n<\/tr>\n
T\u1ed5n th\u01b0\u01a1ng ph\u1ed5i tr\u00ean XQ<\/strong><\/td>\nCh\u01b0a t\u1ed5n th\u01b0\u01a1ng \u2192 tham kh\u1ea3o c\u00e1c ti\u00eau chu\u1ea9n kh\u00e1c<\/td>\nC\u00f3<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

1.4. Li\u1ec1u d\u00f9ng c\u00e1c thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng<\/strong><\/h3>\n

– L\u1ef1a ch\u1ecdn m\u1ed9t trong c\u00e1c thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng v\u00e0 li\u1ec1u nh\u01b0 sau (\u01b0u ti\u00ean d\u00f9ng enoxaparin li\u1ec1u t\u0103ng c\u01b0\u1eddng)<\/p>\n

B\u1ea3ng 2. C\u00e1c thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng s\u1eed d\u1ee5ng d\u1ef1 ph\u00f2ng v\u00e0 \u0111i\u1ec1u tr\u1ecb COVID-19<\/em><\/p>\n\n\n\n\n\n\n\n\n\n
<\/td>\nBMI v\u00e0 ch\u1ee9c n\u0103ng th\u1eadn<\/strong><\/td>\nHeparin standard<\/strong>
\n(UFH)<\/strong><\/td>\n		LMWH<\/strong>
\n(Enoxaparin)<\/strong><\/td>\n		C\u00e1c thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng kh\u00e1c<\/strong>
\n(n\u1ebfu kh\u00f4ng c\u00f3 Heparin)<\/strong><\/td>\n<\/tr>\n
Li\u1ec1u d\u1ef1 ph\u00f2ng<\/strong><\/p>\n

D\u00f9ng t\u1eeb 7-10 ng\u00e0y<\/td>\n

BMI \u2264 30kg\/m2 v\u00e0 CrCl \u2265 30ml\/ph\u00fat<\/td>\n5000U, hai l\u1ea7n\/ng\u00e0y TDD<\/td>\n*Li\u1ec1u chu\u1ea9n: 40mg x 1 l\u1ea7n\/ng\u00e0y (TDD)<\/p>\n

*Li\u1ec1u t\u0103ng c\u01b0\u1eddng: 0,5mg\/kg, 2 l\u1ea7n\/ng\u00e0y<\/td>\n

– C\u00f3 th\u1ec3 l\u1ef1a ch\u1ecdn 1 trong c\u00e1c lo\u1ea1i ch\u1ed1ng \u0111\u00f4ng kh\u00e1c sau \u0111\u00e2y \u0111\u1ec3 thay th\u1ebf heparin:<\/p>\n

+ Rivaroxaban 10-20mg, u\u1ed1ng 1 l\u1ea7n\/ng\u00e0y<\/p>\n

+ Apixaban 2,5mg, u\u1ed1ng 2 l\u1ea7n\/ng\u00e0y<\/p>\n

+Dabigatran 220mg, u\u1ed1ng 1 l\u1ea7n\/ng\u00e0y<\/td>\n<\/tr>\n

BMI > 30kg\/m2 v\u00e0 CrCl \u2265 30ml\/ph\u00fat<\/td>\n7500U, hai l\u1ea7n\/ng\u00e0y TDD<\/td>\n*Li\u1ec1u chu\u1ea9n: 40mg TDD, c\u00f3 th\u1ec3 t\u0103ng l\u00ean 2 l\u1ea7n\/ng\u00e0y<\/p>\n

*Li\u1ec1u t\u0103ng c\u01b0\u1eddng: 0,5mg\/kg, 2 l\u1ea7n\/ng\u00e0y<\/td>\n<\/tr>\n

<\/td>\nCrCl < 30ml\/ph\u00fat<\/td>\n5000-7500U TDD m\u1ed7i 8-12h<\/td>\n*Li\u1ec1u chu\u1ea9n: 30mg x 1 l\u1ea7n\/ng\u00e0y (TDD).<\/p>\n

*Li\u1ec1u t\u0103ng c\u01b0\u1eddng: 0,5mg\/kg x 1 l\u1ea7n\/ng\u00e0y (TDD)<\/td>\n

+ Dabigatran 75mg, u\u1ed1ng 2 l\u1ea7n\/ng\u00e0y<\/p>\n

+ Rivaroxaban 15mg, u\u1ed1ng 1 l\u1ea7n\/ng\u00e0y<\/p>\n

Kh\u00f4ng d\u00f9ng DOACs khi CrCl < 15ml\/ph\u00fat<\/td>\n<\/tr>\n

Li\u1ec1u \u0111i\u1ec1u tr\u1ecb<\/strong><\/p>\n

D\u00f9ng t\u1eeb 2-6 tu\u1ea7n, n\u1ebfu c\u00f3 b\u1eb1ng ch\u1ee9ng huy\u1ebft kh\u1ed1i d\u00f9ng t\u1eeb 3-6 th\u00e1ng<\/td>\n

BMI \u2264 30kg\/m2 v\u00e0 CrCl \u2265 30ml\/ph\u00fat<\/td>\nC\u00f3 th\u1ec3 xem x\u00e9t ti\u00eam bolus 5000UI (ho\u1eb7c 80UI\/kg), sau \u0111\u00f3 18UI\/kg\/h ho\u1eb7c 250U\/kg, TDD m\u1ed7i 12h.<\/td>\n*Kh\u1edfi \u0111\u1ea7u b\u1eb1ng 1mg\/kg x 2 l\u1ea7n\/ng\u00e0y (TDD)<\/td>\n+ Nh\u00f3m acecumarol, warfarin: \u0110\u1ea1t INR 2-3;<\/p>\n

+ Rivaroxaban 15mg, u\u1ed1ng 2 l\u1ea7n\/ng\u00e0y;<\/p>\n

+ Dabigatran 150mg, u\u1ed1ng 2 l\u1ea7n\/ng\u00e0y;<\/p>\n

\u1ede ng\u01b0\u1eddi b\u1ec7nh cao tu\u1ed5i, c\u00f3 \u00edt nh\u1ea5t 1 y\u1ebfu t\u1ed1 nguy c\u01a1 ch\u1ea3y m\u00e1u, d\u00f9ng li\u1ec1u 110mg, u\u1ed1ng, 2 l\u1ea7n\/ng\u00e0y.<\/p>\n

+ Apixaban 5-10mg, u\u1ed1ng 2 l\u1ea7n\/ng\u00e0y;<\/p>\n

+ Endoxaban 30mg -60mg, u\u1ed1ng ng\u00e0y 1 l\u1ea7n;<\/p>\n

+ Warfarin: \u0110\u1ea1t INR 2-3. Kh\u00f4ng d\u00f9ng DOACs khi CrCl < 15ml\/ph\u00fat<\/td>\n<\/tr>\n

BMI > 30kg\/m2 v\u00e0 CrCl \u2265 30ml\/ph\u00fat<\/td>\n<\/td>\n*Kh\u1edfi \u0111\u1ea7u b\u1eb1ng li\u1ec1u 0,8mg\/kg, TDD 2 l\u1ea7n\/ng\u00e0y<\/p>\n

Li\u1ec1u 1 l\u1ea7n\/ng\u00e0y kh\u00f4ng \u00e1p d\u1ee5ng v\u1edbi ng\u01b0\u1eddi b\u1ec7nh BMI > 30kg\/m2 v\u00e0 CrCl \u2265 30ml\/ph\u00fat<\/td>\n<\/tr>\n

CrCl < 30ml\/ph\u00fat<\/td>\nLi\u1ec1u \u0111i\u1ec1u tr\u1ecb, c\u00f3 th\u1ec3 bolus sau \u0111\u00f3 truy\u1ec1n t\u0129nh m\u1ea1ch<\/td>\n1mg\/kg\/ng\u00e0y<\/td>\n+ Warfarin: \u0110\u1ea1t INR 2-3;<\/p>\n

+ Dabigatran 75mg, u\u1ed1ng 2 l\u1ea7n\/ng\u00e0y;<\/p>\n

+ Rivaroxaban 15mg, u\u1ed1ng 1 l\u1ea7n\/ng\u00e0y;<\/p>\n

+Endoxaban 30mg, u\u1ed1ng ng\u00e0y 1 l\u1ea7n.<\/p>\n

Kh\u00f4ng d\u00f9ng DOACs khi CrCl < 15ml\/ph\u00fat<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

* Ghi ch\u00fa:<\/em><\/strong><\/p>\n

– Ng\u01b0\u1eddi b\u1ec7nh \u0111ang d\u00f9ng aspirin th\u00ec khi v\u1eabn ti\u1ebfp t\u1ee5c d\u00f9ng aspirin n\u1ebfu d\u00f9ng ch\u1ed1ng \u0111\u00f4ng li\u1ec1u d\u1ef1 ph\u00f2ng, ng\u1eebng aspirin n\u1ebfu d\u00f9ng li\u1ec1u \u0111i\u1ec1u tr\u1ecb.<\/p>\n

– N\u1ebfu ng\u01b0\u1eddi b\u1ec7nh \u0111ang d\u00f9ng thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng \u0111\u01b0\u1eddng u\u1ed1ng, ng\u1eebng l\u1ea1i chuy\u1ec3n sang d\u00f9ng heparin.<\/p>\n

1.5. Th\u1eddi gian \u0111i\u1ec1u tr\u1ecb thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng<\/strong><\/h3>\n

– S\u1eed d\u1ee5ng thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng \u0111\u1ebfn khi l\u00e2m s\u00e0ng v\u00e0 x\u00e9t nghi\u1ec7m \u1ed5n \u0111\u1ecbnh ho\u1eb7c D- dimer gi\u1ea3m < 2 l\u1ea7n, v\u00e0 c\u00f3 th\u1ec3 duy tr\u00ec ch\u1ed1ng \u0111\u00f4ng sau khi xu\u1ea5t vi\u1ec7n c\u0103n c\u1ee9 v\u00e0o nguy c\u01a1 huy\u1ebft kh\u1ed1i c\u1ee7a ng\u01b0\u1eddi b\u1ec7nh d\u1ef1a v\u00e0o 1 trong c\u00e1c \u0111i\u1ec1u ki\u1ec7n nh\u01b0 sau:<\/p>\n

– Nh\u00f3m nguy c\u01a1 cao huy\u1ebft kh\u1ed1i:<\/p>\n

+ Modified IMPROVE-VTE score \u2265 4;<\/p>\n

+ Modified IMPROVE-VTE score \u2265 2 v\u00e0 D-dimer > 2 l\u1ea7n b\u00ecnh th\u01b0\u1eddng<\/p>\n

+ \u2265 75 tu\u1ed5i;<\/p>\n

+ > 60 tu\u1ed5i v\u00e0 D-dimer > 2 l\u1ea7n b\u00ecnh th\u01b0\u1eddng;<\/p>\n

+ 40 – 60 tu\u1ed5i, D-dimer > 2 l\u1ea7n b\u00ecnh th\u01b0\u1eddng, c\u00f3 ti\u1ec1n s\u1eed huy\u1ebft kh\u1ed1i ho\u1eb7c b\u1ec7nh n\u1ec1n ung th\u01b0;<\/p>\n

– Nh\u00f3m huy\u1ebft kh\u1ed1i: c\u00f3 b\u1eb1ng ch\u1ee9ng c\u1ee7a huy\u1ebft kh\u1ed1i d\u1ef1a tr\u00ean ch\u1ea9n \u0111o\u00e1n h\u00ecnh \u1ea3nh.<\/p>\n

– Thu\u1ed1c v\u00e0 li\u1ec1u d\u00f9ng:\u00a0<\/strong>Ch\u1ed1ng \u0111\u00f4ng \u0111\u01b0\u1eddng u\u1ed1ng li\u1ec1u d\u1ef1 ph\u00f2ng (rivaroxaban 10mg\/ng\u00e0y, apixaban 5mg\/ng\u00e0y ho\u1eb7c dabigatran 110mg\/ng\u00e0y) v\u1edbi th\u1eddi gian d\u00f9ng:<\/p>\n

+ Nh\u00f3m nguy c\u01a1 huy\u1ebft kh\u1ed1i cao: 2-6 tu\u1ea7n.<\/p>\n

+ Nh\u00f3m huy\u1ebft kh\u1ed1i: 3-6 th\u00e1ng.<\/p>\n

* Ch\u00fa \u00fd:<\/em><\/strong><\/p>\n

– N\u1ebfu c\u00f3 b\u1ea5t k\u1ef3 tri\u1ec7u ch\u1ee9ng ch\u1ea3y m\u00e1u ho\u1eb7c \u0111au ng\u1ef1c, s\u01b0ng n\u1ec1 chi th\u00ec c\u1ea7n kh\u00e1m l\u1ea1i ngay.<\/p>\n

– Lu\u00f4n ph\u1ea3i \u0111\u00e1nh gi\u00e1 theo c\u00e1 th\u1ec3 ng\u01b0\u1eddi b\u1ec7nh v\u1ec1 nguy c\u01a1 huy\u1ebft, nguy c\u01a1 ch\u1ea3y m\u00e1u c\u1ee7a ng\u01b0\u1eddi b\u1ec7nh.<\/p>\n

1.6. Theo d\u00f5i \u0111i\u1ec1u tr\u1ecb thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng<\/strong><\/h3>\n

– Th\u1ef1c hi\u1ec7n c\u00e1c x\u00e9t nghi\u1ec7m theo d\u00f5i nh\u01b0 sau (t\u1ea7n su\u1ea5t x\u00e9t nghi\u1ec7m t\u00f9y t\u00ecnh tr\u1ea1ng ng\u01b0\u1eddi b\u1ec7nh v\u00e0 \u0111i\u1ec1u ki\u1ec7n c\u01a1 s\u1edf \u0111i\u1ec1u tr\u1ecb): T\u1ed5ng ph\u00e2n t\u00edch t\u1ebf b\u00e0o m\u00e1u ngo\u1ea1i vi, PT, APTT, Fibrinogen, D-dimer, anti-Xa, FM, ROTEM.<\/p>\n

– Khi d\u00f9ng heparin ti\u00eau chu\u1ea9n: theo d\u00f5i b\u1eb1ng x\u00e9t nghi\u1ec7m anti-Xa c\u1ea7n \u0111\u1ea1t l\u00e0 0,3-0,7 UI\/ml (n\u00ean theo d\u00f5i b\u1eb1ng antiXa, kh\u00f4ng n\u00ean s\u1eed d\u1ee5ng APTT v\u00ec y\u1ebfu t\u1ed1 VIII \u1edf ng\u01b0\u1eddi b\u1ec7nh COVID-19 t\u0103ng r\u1ea5t cao, > 70% ng\u01b0\u1eddi b\u1ec7nh c\u00f3 kh\u00e1ng \u0111\u00f4ng n\u1ed9i sinh l\u01b0u h\u00e0nh v\u00e0 sai l\u1ec7ch khi ng\u01b0\u1eddi b\u1ec7nh suy th\u1eadn). Tr\u01b0\u1eddng h\u1ee3p ch\u1ec9 c\u00f3 x\u00e9t nghi\u1ec7m APTT th\u00ec c\u1ea7n ch\u1ec9nh li\u1ec1u v\u1edbi m\u1ee5c ti\u00eau rAPTT t\u1eeb 1,5 -2 (t\u1ed1i \u0111a \u0111\u1ebfn 2,5). L\u1ea5y m\u1eabu x\u00e9t sau ti\u00eam 4h.<\/p>\n

– Khi d\u00f9ng enoxaparin: theo d\u00f5i b\u1eb1ng anti-Xa v\u1edbi m\u1ee5c ti\u00eau c\u1ea7n \u0111\u1ea1t l\u00e0 0,5-1 UI\/ml (t\u1ed1i \u0111a \u0111\u1ebfn 1,5 UI\/ml). L\u1ea5y m\u1eabu x\u00e9t nghi\u1ec7m sau ti\u00eam d\u01b0\u1edbi da 3-4h.<\/p>\n

– Kh\u00f4ng khuy\u1ebfn c\u00e1o theo d\u00f5i anti-Xa v\u1edbi li\u1ec1u UFH hay LMWH d\u1ef1 ph\u00f2ng, tuy nhi\u00ean v\u1edbi ng\u01b0\u1eddi b\u1ec7nh c\u00f3 ClCr < 30ml c\u1ea7n ki\u1ec3m tra sau 10 li\u1ec1u. C\u00e2n n\u1eb7ng < 50kg: theo d\u00f5i sau ti\u00eam 10 li\u1ec1u. C\u00e2n n\u1eb7ng > 120kg: theo d\u00f5i sau ti\u00eam 3 li\u1ec1u. M\u1ee5c ti\u00eau anti Xa c\u1ea7n \u0111\u1ea1t: 0,1-0,4 UI\/ml.<\/p>\n

– N\u1ebfu c\u00f3 t\u00ecnh tr\u1ea1ng gi\u1ea3m ti\u1ec3u c\u1ea7u do heparin (HIT) c\u1ea7n d\u1eebng heparin v\u00e0 d\u00f9ng ch\u1ed1ng \u0111\u00f4ng kh\u00e1c thay th\u1ebf nh\u01b0 agatroban, fondaparinux ho\u1eb7c DOACs.<\/p>\n

2. C\u00e1c tr\u01b0\u1eddng h\u1ee3p \u0111\u1eb7c bi\u1ec7t c\u1ea7n d\u00f9ng thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng<\/strong><\/h2>\n

2.1. \u00a0V\u1edbi ng\u01b0\u1eddi b\u1ec7nh L\u1ecdc m\u00e1u hay ECMO: d\u00f9ng heparin ti\u00eau chu\u1ea9n<\/em><\/strong><\/h3>\n

– Ch\u1ec9nh li\u1ec1u heparin theo APTT<\/p>\n

\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 B\u1ea3ng 3. Nguy\u00ean t\u1eafc ch\u1ec9nh li\u1ec1u heparin theo m\u1ee9c rAPTT<\/em><\/p>\n\n\n\n\n\n\n\n\n\n
M\u1ee9c rAPTT (b\u1ec7nh\/ ch\u1ee9ng)<\/strong><\/td>\nBolus ti\u00eam t\u0129nh m\u1ea1ch<\/strong><\/td>\nLi\u1ec1u truy\u1ec1n t\u0129nh m\u1ea1ch<\/strong><\/td>\n<\/tr>\n
Li\u1ec1u kh\u1edfi \u0111\u1ea7u<\/td>\n80 UI\/kg<\/td>\n18 UI\/kg\/h<\/td>\n<\/tr>\n
< 1,2<\/td>\n80 UI\/kg<\/td>\nT\u0103ng 4 UI\/kg\/h<\/td>\n<\/tr>\n
1,2 – 1,5<\/td>\n40 UI\/kg<\/td>\nT\u0103ng 2 UI\/kg\/h<\/td>\n<\/tr>\n
1,5 – 2,5<\/td>\nKh\u00f4ng ti\u00eam<\/td>\nKh\u00f4ng thay \u0111\u1ed5i<\/td>\n<\/tr>\n
2,5 – 3<\/td>\nKh\u00f4ng ti\u00eam<\/td>\nGi\u1ea3m 2 UI\/kg\/h<\/td>\n<\/tr>\n
> 3<\/td>\nKh\u00f4ng ti\u00eam<\/td>\nD\u1eebng 1h sau \u0111\u00f3 gi\u1ea3m 3 UI\/kg\/h<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

– Ch\u1ec9nh li\u1ec1u heparin theo anti-Xa<\/p>\n

B\u1ea3ng 4. Nguy\u00ean t\u1eafc ch\u1ec9nh li\u1ec1u heparin theo m\u1ee9c anti-Xa<\/em><\/p>\n\n\n\n\n\n\n\n\n\n\n
M\u1ee9c anti-Xa (UI\/ml)<\/strong><\/td>\nLi\u1ec1u \u0111i\u1ec1u ch\u1ec9nh<\/strong><\/td>\nKhuy\u1ebfn c\u00e1o kh\u00e1c<\/strong><\/td>\n<\/tr>\n
< 0,1<\/td>\nT\u0103ng 400 UI\/h<\/td>\nC\u00f3 th\u1ec3 xem x\u00e9t bolus 2000 UI<\/td>\n<\/tr>\n
0,1 – 0,19<\/td>\nT\u0103ng 200 UI\/h<\/td>\n<\/td>\n<\/tr>\n
0,2 – 0,29<\/td>\nT\u0103ng 100 UI\/h<\/td>\n<\/td>\n<\/tr>\n
0,3 – 0,7<\/td>\nKh\u00f4ng thay \u0111\u1ed5i<\/td>\n<\/td>\n<\/tr>\n
0,71 – 0,8<\/td>\nGi\u1ea3m 100 UI\/h<\/td>\nT\u1ea1m ng\u1eebng truy\u1ec1n trong 30p<\/td>\n<\/tr>\n
0,81 – 1,7<\/td>\nGi\u1ea3m 200 UI\/h<\/td>\nT\u1ea1m ng\u1eebng truy\u1ec1n trong 1h<\/td>\n<\/tr>\n
> 1,7<\/td>\nGi\u1ea3m 300 UI\/h<\/td>\nT\u1ea1m ng\u1eebng truy\u1ec1n trong 1h<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

2.2. \u00a0V\u1edbi nh\u00f3m ph\u1ee5 n\u1eef mang thai: d\u00f9ng enoxaparin theo b\u1ea3ng sau n\u1ebfu x\u00e9t nghi\u1ec7m D-dimer<\/em><\/strong><\/h3>\n

B\u1ea3ng 5. S\u1eed d\u1ee5ng enoxaparin cho ph\u1ee5 n\u1eef c\u00f3 thai<\/em><\/p>\n\n\n\n\n\n\n\n\n\n\n
M\u1ee9c D-dimer<\/strong><\/td>\nCrCl<\/strong><\/td>\nCh\u1ec9 \u0111\u1ecbnh aspirin<\/strong><\/td>\nBMI \u2264 40kg\/m2<\/strong><\/td>\nBMI \u2265 40kg\/m2<\/strong><\/td>\n<\/tr>\n
M\u1eafc COVID-19\u00a0<\/strong>v\u00e0\/ ho\u1eb7c D-dimer t\u0103ng < 7 l\u1ea7n so v\u1edbi ng\u01b0\u1ee1ng b\u00ecnh th\u01b0\u1eddng:\u00a0d\u00f9ng li\u1ec1u d\u1ef1 ph\u00f2ng chu\u1ea9n<\/strong><\/td>\nCrCl \u2265 30ml\/ph\u00fat<\/td>\nC\u00f3 th\u1ec3<\/strong><\/td>\nEnoxaparin 40mg TDD h\u00e0ng ng\u00e0y<\/td>\nEnoxaparin 40mg TDD m\u1ed7i 12h<\/td>\n<\/tr>\n
CrCl \u2264 30ml\/ph\u00fat<\/td>\nC\u00f3 th\u1ec3<\/strong><\/td>\nEnoxaparin 30mg TDD h\u00e0ng ng\u00e0y<\/td>\nEnoxaparin 40mg TDD h\u00e0ng ng\u00e0y<\/td>\n<\/tr>\n
7-10 l\u1ea7n:\u00a0d\u00f9ng li\u1ec1u d\u1ef1 ph\u00f2ng t\u0103ng c\u01b0\u1eddng<\/strong><\/td>\nCrCl \u2265 30ml\/ph\u00fat<\/td>\nC\u00f3 th\u1ec3<\/strong><\/td>\nEnoxaparin 0,5mg\/kg TDD m\u1ed7i 12h<\/td>\nEnoxaparin 0,5mg\/kg TDD m\u1ed7i 12h<\/td>\n<\/tr>\n
CrCl \u2264 30ml\/ph\u00fat<\/td>\nC\u00f3 th\u1ec3<\/strong><\/td>\nEnoxaparin 0,5mg\/kg TDD m\u1ed7i 12h<\/td>\nEnoxaparin 0,5mg\/kg TDD m\u1ed7i 12h<\/td>\n<\/tr>\n
> 10 l\u1ea7n ho\u1eb7c \u0111\u00e3 c\u00f3 huy\u1ebft kh\u1ed1i \u0111\u01b0\u1ee3c ch\u1ea9n \u0111o\u00e1n h\u00ecnh \u1ea3nh:\u00a0d\u00f9ng li\u1ec1u \u0111i\u1ec1u tr\u1ecb<\/strong><\/td>\nCrCl \u2265 30ml\/ph\u00fat<\/td>\nKh\u00f4ng<\/strong><\/td>\nEnoxaparin 1mg\/kg TDD m\u1ed7i 12h<\/td>\nEnoxaparin 1mg\/kg TDD m\u1ed7i 12h<\/td>\n<\/tr>\n
CrCl \u2264 30ml\/ph\u00fat<\/td>\nKh\u00f4ng<\/strong><\/td>\nEnoxaparin 1mg\/kg TDD m\u1ed7i 24h<\/td>\nEnoxaparin 1mg\/kg TDD m\u1ed7i 24h<\/td>\n<\/tr>\n
– N\u1ebfu can thi\u1ec7p s\u1ea3n khoa c\u1ea7n d\u1eebng ch\u1ed1ng \u0111\u00f4ng tr\u01b0\u1edbc t\u1ed1i thi\u1ec3u 12h ho\u1eb7c d\u00f9ng ch\u1ea5t trung h\u00f2a<\/p>\n

– N\u1ebfu ti\u00ean l\u01b0\u1ee3ng ng\u01b0\u1eddi b\u1ec7nh c\u00f3 th\u1ec3 \u0111\u1ebb th\u01b0\u1eddng ho\u1eb7c can thi\u1ec7p s\u1ea3n khoa th\u00ec kh\u00f4ng d\u00f9ng aspirin<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

\u00a0<\/em><\/strong><\/p>\n

2.3. V\u1edbi huy\u1ebft kh\u1ed1i \u1edf c\u00e1c v\u1ecb tr\u00ed nguy hi\u1ec3m ho\u1eb7c ch\u1ed1ng \u0111\u00f4ng kh\u00f4ng hi\u1ec7u qu\u1ea3<\/em><\/strong><\/h3>\n

– C\u00f3 th\u1ec3 d\u00f9ng ti\u00eau s\u1ee3i huy\u1ebft b\u1eb1ng r-tPA v\u1edbi \u0111i\u1ec1u ki\u1ec7n Fibrinogen > 0,5g\/l; TC > 50 G\/l.<\/p>\n

– Khuy\u1ebfn kh\u00edch li\u1ec1u th\u1ea5p: TM 0,6mg\/kg\/15 ph\u00fat.<\/p>\n

\"\"
S\u01a1 \u0111\u1ed3 ch\u1ec9 \u0111\u1ecbnh v\u00e0 li\u1ec1u d\u00f9ng thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng. Ngu\u1ed3n<\/strong>: B\u1ed9 Y t\u1ebf 2022<\/em><\/figcaption><\/figure>\n

Ngu\u1ed3n<\/strong>: H\u01b0\u1edbng d\u1eabn ch\u1ea9n \u0111o\u00e1n v\u00e0 \u0111i\u1ec1u tr\u1ecb COVID 19 c\u1ee7a B\u1ed9 Y t\u1ebf 2022<\/p>\n","protected":false},"excerpt":{"rendered":"

Trong qu\u00e1 tr\u00ecnh \u0111i\u1ec1u tr\u1ecb b\u1ec7nh COVID-19, b\u1ec7nh nh\u00e2n c\u00f3 nguy c\u01a1 cao b\u1ecb \u0111\u00f4ng m\u00e1u do t\u00e1c \u0111\u1ed9ng c\u1ee7a virus l\u00ean h\u1ec7 th\u1ed1ng m\u00e1u v\u00e0 m\u1ea1ch m\u00e1u trong c\u01a1 th\u1ec3.\u00a0 Do \u0111\u00f3, vi\u1ec7c s\u1eed d\u1ee5ng thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng trong \u0111i\u1ec1u tr\u1ecb COVID-19 l\u00e0 m\u1ed9t ph\u01b0\u01a1ng ph\u00e1p quan tr\u1ecdng \u0111\u1ec3 ng\u0103n ng\u1eeba v\u00e0 \u0111i\u1ec1u tr\u1ecb […]<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":[],"categories":[12,33],"tags":[3],"yoast_head":"\nThu\u1ed1c ch\u1ed1ng \u0111\u00f4ng trong \u0111i\u1ec1u tr\u1ecb COVID 19 - Vinmec<\/title>\n<meta name=\"description\" content=\"vi\u1ec7c s\u1eed d\u1ee5ng thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng trong \u0111i\u1ec1u tr\u1ecb COVID-19 l\u00e0 m\u1ed9t ph\u01b0\u01a1ng ph\u00e1p quan tr\u1ecdng \u0111\u1ec3 ng\u0103n ng\u1eeba v\u00e0 \u0111i\u1ec1u tr\u1ecb c\u00e1c bi\u1ebfn ch\u1ee9ng do \u0111\u00f4ng m\u00e1u\" \/>\n<meta name=\"robots\" content=\"noindex, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng trong \u0111i\u1ec1u tr\u1ecb COVID 19 - 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