{"id":24859,"date":"2023-04-19T16:53:23","date_gmt":"2023-04-19T09:53:23","guid":{"rendered":"http:\/\/noithathoaphat.in\/ctv\/?p=24859"},"modified":"2023-04-20T16:33:30","modified_gmt":"2023-04-20T09:33:30","slug":"dieu-tri-sot-xuat-huyet-dengue-nang-tre-em-bo-y-te","status":"publish","type":"post","link":"http:\/\/noithathoaphat.in\/ctv\/index.php\/2023\/04\/19\/dieu-tri-sot-xuat-huyet-dengue-nang-tre-em-bo-y-te\/","title":{"rendered":"\u0110i\u1ec1u tr\u1ecb s\u1ed1t xu\u1ea5t huy\u1ebft Dengue n\u1eb7ng tr\u1ebb em \u2013 B\u1ed9 Y t\u1ebf"},"content":{"rendered":"

S\u1ed1t xu\u1ea5t huy\u1ebft Dengue<\/a> l\u00e0 b\u1ec7nh truy\u1ec1n nhi\u1ec5m g\u00e2y d\u1ecbch do vi r\u00fat Dengue g\u00e2y n\u00ean. Vi r\u00fat Dengue c\u00f3 4 type\u00a0 huy\u1ebft thanh l\u00e0 DEN-1, DEN-2, DEN-3 v\u00e0 DEN-4. Vi r\u00fat truy\u1ec1n t\u1eeb ng\u01b0\u1eddi b\u1ec7nh sang ng\u01b0\u1eddi l\u00e0nh do mu\u1ed7i \u0111\u1ed1t. Mu\u1ed7i Aedes aegypti l\u00e0 c\u00f4n tr\u00f9ng trung gian truy\u1ec1n b\u1ec7nh ch\u1ee7 y\u1ebfu. B\u1ec7nh x\u1ea3y ra quanh n\u0103m, th\u01b0\u1eddng gia t\u0103ng v\u00e0o m\u00f9a m\u01b0a.<\/strong><\/p>\n

\"minh-hoa-sot-xuat-huyet\"<\/p>\n

 <\/p>\n

1. \u0110i\u1ec1u tr\u1ecb s\u1ed1c s\u1ed1t xu\u1ea5t huy\u1ebft Dengue<\/strong><\/h2>\n

1.1 Chu\u1ea9n b\u1ecb c\u00e1c d\u1ecbch truy\u1ec1n sau<\/h3>\n

– Ringer lactate.<\/p>\n

– Ringer acetate trong tr\u01b0\u1eddng h\u1ee3p c\u00f3 t\u1ed5n th\u01b0\u01a1ng gan n\u1eb7ng ho\u1eb7c suy gan c\u1ea5p.<\/p>\n

– Dung d\u1ecbch m\u1eb7n \u0111\u1eb3ng tr\u01b0\u01a1ng (NaCl 0,9%).<\/p>\n

– Dung d\u1ecbch cao ph\u00e2n t\u1eed (dextran 40 ho\u1eb7c 70, hydroxyethyl starch (HES 200.000 dalton)).<\/p>\n

– Dung d\u1ecbch albumin.<\/p>\n

1.2. Th\u1edf oxy qua g\u1ecdng m\u0169i 1 -6 l\u00edt\/ph\u00fat.<\/h3>\n

T\u1ea5t c\u1ea3 c\u00e1c ng\u01b0\u1eddi b\u1ec7nh c\u00f3 s\u1ed1c s\u1ed1t xu\u1ea5t huy\u1ebft c\u1ea7n th\u1edf oxy g\u1ecdng k\u00ednh.<\/p>\n

1.3. B\u00f9 d\u1ecbch nhanh trong s\u1ed1t xu\u1ea5t huy\u1ebft<\/h3>\n

L\u01b0u \u00fd:<\/em>\u00a0\u0110\u1ed1i v\u1edbi tr\u1ebb d\u01b0 c\u00e2n ho\u1eb7c b\u00e9o ph\u00ec, s\u1eed d\u1ee5ng c\u00e2n n\u1eb7ng hi\u1ec7u ch\u1ec9nh \u0111\u1ec3 truy\u1ec1n d\u1ecbch.<\/p>\n

Trong 1 gi\u1edd \u0111\u1ea7u, ph\u1ea3i thay th\u1ebf nhanh ch\u00f3ng l\u01b0\u1ee3ng huy\u1ebft t\u01b0\u01a1ng m\u1ea5t \u0111i b\u1eb1ng Ringer lactate ho\u1eb7c NaCl 0,9% 20ml\/kg\/gi\u1edd sau \u0111\u00f3 \u0111\u00e1nh gi\u00e1 l\u1ea1i l\u00e2m s\u00e0ng, Hct:<\/p>\n

a) N\u1ebfu c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng (m\u1ea1ch gi\u1ea3m, HA b\u00ecnh th\u01b0\u1eddng, h\u1ebft k\u1eb9t)<\/p>\n

– Ti\u1ebfp t\u1ee5c truy\u1ec1n Ringer lactate ho\u1eb7c NaCl 0,9% t\u1ed1c \u0111\u1ed9\u00a010ml\/kg\/gi\u1edd\u00a0x\u00a01-2 gi\u1edd. N\u1ebfu ng\u01b0\u1eddi b\u1ec7nh c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng v\u00e0 hematocrit gi\u1ea3m, gi\u1ea3m t\u1ed1c \u0111\u1ed9 Ringer lactate ho\u1eb7c NaCl 0,9% 7,5ml\/kg\/gi\u1edd trong 1-2 gi\u1edd\u00a0\u2192<\/strong>\u00a05ml\/kg\/gi\u1edd\u00a0x\u00a03-4 gi\u1edd \u2192 3ml\/kg\/gi\u1edd\u00a0x\u00a04-6 gi\u1edd.<\/p>\n

– N\u1ebfu b\u1ec7nh nh\u00e2n sau \u0111\u00f3 ra s\u1ed1c (m\u1ea1ch b\u00ecnh th\u01b0\u1eddng, HA b\u00ecnh th\u01b0\u1eddng, n\u01b0\u1edbc ti\u1ec3u \u2265 0,5ml\/kg\/gi\u1edd) v\u00e0 hematocrit b\u00ecnh th\u01b0\u1eddng, c\u00f3 th\u1ec3 xem x\u00e9t ng\u01b0ng d\u1ecbch truy\u1ec1n sau 24-48 gi\u1edd.<\/p>\n

b) N\u1ebfu kh\u00f4ng c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng (m\u1ea1ch nhanh, nh\u1eb9, HA c\u00f2n t\u1ee5t, k\u1eb9t hi\u1ec7u \u00e1p < 20mmHg)<\/p>\n

N\u1ebfu hematocrit c\u00f2n t\u0103ng cao ho\u1eb7c \u2265 40%<\/p>\n

– Chuy\u1ec3n sang truy\u1ec1n cao ph\u00e2n t\u1eed (CPT) 10-20ml\/kg\/gi\u1edd trong 1 gi\u1edd. Cao ph\u00e2n t\u1eed \u0111\u01b0\u1ee3c ch\u1ecdn trong SXHD l\u00e0 Dextran 40, Dextran 70 ho\u1eb7c 6% HES 200, kh\u00f4ng d\u00f9ng Gelatin do hi\u1ec7u qu\u1ea3 k\u00e9m. T\u00e1c d\u1ee5ng ph\u1ee5 c\u1ee7a HES l\u00e0 r\u1ed1i lo\u1ea1n \u0111\u00f4ng m\u00e1u, t\u1ed5n th\u01b0\u01a1ng gan, th\u1eadn \u0111\u1eb7c bi\u1ec7t l\u00e0 khi t\u1ed5ng li\u1ec1u > 60ml\/kg.<\/p>\n

– N\u1ebfu c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng, hematocrit gi\u1ea3m: gi\u1ea3m t\u1ed1c \u0111\u1ed9 CPT d\u1ea7n\u00a010ml\/kg\/gi\u1edd\u00a0x\u00a01 gi\u1edd \u2192 7,5ml\/kg\/gi\u1edd\u00a0x\u00a01-2 gi\u1edd \u2192 5ml\/kg\/gi\u1edd\u00a0x\u00a01-2 gi\u1edd. \u0110\u00e1nh gi\u00e1 l\u00e2m s\u00e0ng, Hct sau m\u1ed7i l\u1ea7n chuy\u1ec3n t\u1ed1c \u0111\u1ed9 truy\u1ec1n.<\/p>\n

+ N\u1ebfu ra s\u1ed1c v\u00e0 Hct b\u00ecnh th\u01b0\u1eddng: chuy\u1ec3n sang \u0111i\u1ec7n gi\u1ea3i Ringer lactate hay NaCl 0,9% 5ml\/kg\/gi\u1edd trong 3-4 gi\u1edd, sau \u0111\u00f3 3ml\/kg\/gi\u1edd\u00a0x\u00a04-6 gi\u1edd. Ph\u1ea3i theo d\u00f5i s\u00e1t d\u1ea5u hi\u1ec7u sinh t\u1ed3n m\u1ed7i gi\u1edd v\u00e0 l\u1eadp l\u1ea1i hematocrit sau 1 gi\u1edd trong 2 gi\u1edd \u0111\u1ea7u, sau \u0111\u00f3 l\u00e0 m\u1ed7i 4-6 gi\u1edd. C\u00f3 th\u1ec3\u00a0xem x\u00e9t ng\u01b0ng d\u1ecbch truy\u1ec1n sau 24-48 gi\u1edd.<\/p>\n

+ N\u1ebfu kh\u00f4ng c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng, m\u1ea1ch nhanh, HA c\u00f2n t\u1ee5t ho\u1eb7c k\u1eb9t: l\u1eb7p l\u1ea1i truy\u1ec1n CPT 10-20ml\/kg\/gi\u1edd trong 1 gi\u1edd. N\u1ebfu ch\u01b0a c\u00f3 catheter \u0111\u1ed9ng m\u1ea1ch n\u00ean x\u00e9t nghi\u1ec7m kh\u00ed m\u00e1u t\u0129nh m\u1ea1ch \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh toan m\u00e1u d\u1ef1a v\u00e0o pH v\u00e0 HCO3<\/sub>–<\/sup>\u00a0v\u00e0 x\u00e9t nghi\u1ec7m \u0111\u01b0\u1eddng huy\u1ebft, \u0111i\u1ec7n gi\u1ea3i \u0111\u1ed3, lactate m\u00e1u. \u0110i\u1ec1u tr\u1ecb toan, xu\u1ea5t huy\u1ebft, h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft, h\u1ea1 Calci huy\u1ebft n\u1ebfu c\u00f3. \u0110o HA \u0111\u1ed9ng m\u1ea1ch x\u00e2m l\u1ea5n (\u0111\u1ed9ng m\u1ea1ch c\u1ed5 tay), \u0111o \u00e1p l\u1ef1c t\u0129nh m\u1ea1ch trung t\u00e2m (CVP) v\u00e0 x\u1eed tr\u00ed nh\u01b0 s\u1ed1c SXHD n\u1eb7ng.<\/p>\n

– \u0110o \u00e1p l\u1ef1c t\u0129nh m\u1ea1ch trung t\u00e2m (CVP)<\/p>\n

* V\u1ecb tr\u00ed: t\u0129nh m\u1ea1ch \u0111\u01b0\u1ee3c ch\u1ecdn \u0111o CVP trong SXHD l\u00e0 t\u0129nh m\u1ea1ch n\u1ec1n \u1edf khu\u1ef7u tay (kh\u00f4ng d\u00f9ng t\u0129nh m\u1ea1ch c\u1ea3nh trong, t\u0129nh m\u1ea1ch d\u01b0\u1edbi \u0111\u00f2n do nguy c\u01a1 xu\u1ea5t huy\u1ebft) b\u1eb1ng ph\u01b0\u01a1ng ph\u00e1p Seldinger c\u1ea3i ti\u1ebfn d\u01b0\u1edbi h\u01b0\u1edbng d\u1eabn si\u00eau \u00e2m \u0111\u1ec3 t\u0103ng t\u1ec9 l\u1ec7 th\u00e0nh c\u00f4ng, \u00edt bi\u1ebfn ch\u1ee9ng, ho\u1eb7c s\u1eed d\u1ee5ng k\u1ef9 thu\u1eadt b\u1ed9c l\u1ed9 t\u0129nh m\u1ea1ch \u0111\u1ec3 \u0111\u1eb7t CVP.<\/p>\n

* Ph\u01b0\u01a1ng ph\u00e1p \u0111o: C\u00f3 th\u1ec3 qua c\u1ed9t n\u01b0\u1edbc ho\u1eb7c monitor. N\u1ebfu c\u00f3 \u0111i\u1ec1u ki\u1ec7n, n\u00ean \u0111o CVP qua monitor \u0111\u1ec3 theo li\u00ean t\u1ee5c.<\/p>\n

* Ch\u1ec9 \u0111\u1ecbnh \u0111o CVP<\/strong><\/p>\n

+ Qu\u00e1 t\u1ea3i, nghi ng\u1edd qu\u00e1 t\u1ea3i.<\/p>\n

+ S\u1ed1c k\u00e9o d\u00e0i, s\u1ed1c kh\u00f4ng \u0111\u00e1p \u1ee9ng v\u1edbi b\u00f9 d\u1ecbch \u2265 60ml\/kg c\u00e2n n\u1eb7ng.<\/p>\n

+ T\u00e1i s\u1ed1c.<\/p>\n

+ S\u1ed1c k\u00e8m b\u1ec7nh l\u00fd tim, ph\u1ed5i, th\u1eadn.<\/p>\n

+ S\u1ed1c \u1edf tr\u1ebb nh\u0169 nhi, b\u00e9o ph\u00ec.<\/p>\n

* Ph\u00e2n t\u00edch k\u1ebft qu\u1ea3 CVP<\/p>\n

\u25a0 Th\u1ea5p khi CVP \u2264 5cmH2<\/sub>O, cao khi CVP \u2265 15 cmH2<\/sub>O<\/p>\n

\u25a0 X\u1eed tr\u00ed lu\u00f4n ph\u1ea3i k\u1ebft h\u1ee3p gi\u1eefa l\u00e2m s\u00e0ng, hematocrit v\u00e0 CVP.<\/p>\n

– Khi c\u00f3 t\u0129nh m\u1ea1ch trung t\u00e2m n\u00ean x\u00e9t nghi\u1ec7m ScvO2<\/sub>\u00a0\u0111\u1ec3 \u0111\u00e1nh gi\u00e1 s\u1eed d\u1ee5ng\u00a0O2<\/sub>. Tr\u1ecb s\u1ed1 ScvO2<\/sub>\u00a0b\u00ecnh th\u01b0\u1eddng l\u00e0 \u2265 70%.<\/p>\n

– N\u1ebfu kh\u00f4ng \u0111o \u0111\u01b0\u1ee3c CVP th\u00ec d\u00f9ng si\u00eau \u00e2m kh\u1ea3o s\u00e1t s\u1ef1 thay \u0111\u1ed5i \u0111\u01b0\u1eddng k\u00ednh c\u1ee7a t\u0129nh m\u1ea1ch ch\u1ee7 d\u01b0\u1edbi theo nh\u1ecbp th\u1edf \u0111\u1ec3 gi\u00fap \u0111\u00e1nh gi\u00e1 th\u1ec3 t\u00edch d\u1ecbch n\u1ed9i m\u1ea1ch.<\/p>\n

+ N\u1ebfu \u0111\u01b0\u1eddng k\u00ednh c\u1ee7a t\u0129nh m\u1ea1ch ch\u1ee7 d\u01b0\u1edbi nh\u1ecf v\u00e0 x\u1eb9p c\u1ea3 2 th\u00ec h\u00f4 h\u1ea5p l\u00e0 thi\u1ebfu d\u1ecbch.<\/p>\n

+ N\u1ebfu \u0111\u01b0\u1eddng k\u00ednh c\u1ee7a t\u0129nh m\u1ea1ch ch\u1ee7 d\u01b0\u1edbi to v\u00e0 c\u0103ng c\u1ea3 2 th\u00ec h\u00f4 h\u1ea5p l\u00e0 d\u01b0 d\u1ecbch.<\/p>\n

N\u1ebfu hematocrit \u2264 35% ho\u1eb7c gi\u1ea3m 20% so v\u1edbi ban \u0111\u1ea7u.<\/p>\n

C\u1ea7n ph\u1ea3i th\u0103m kh\u00e1m \u0111\u1ec3 ph\u00e1t hi\u1ec7n xu\u1ea5t huy\u1ebft n\u1ed9i v\u00e0 truy\u1ec1n m\u00e1u, t\u1ed1t nh\u1ea5t l\u00e0 truy\u1ec1n h\u1ed3ng c\u1ea7u l\u1eafng 5ml\/kg ho\u1eb7c m\u00e1u to\u00e0n ph\u1ea7n 10ml\/kg, t\u1ed1c \u0111\u1ed9 truy\u1ec1n t\u00f9y t\u00ecnh tr\u1ea1ng ch\u1ea3y m\u00e1u v\u00e0 hematocrit, th\u01b0\u1eddng trong 1-2 gi\u1edd, song song \u0111\u00f3 truy\u1ec1n CPT\u00a010ml\/kg\/gi\u1edd. Xem x\u00e9t truy\u1ec1n huy\u1ebft t\u01b0\u01a1ng \u0111\u00f4ng l\u1ea1nh \u0111\u1ec3\u00a0c\u1ea7m m\u00e1u (xem ph\u1ea7n \u0111i\u1ec1u tr\u1ecb xu\u1ea5t huy\u1ebft n\u1eb7ng). Sau 1 gi\u1edd, \u0111\u00e1nh gi\u00e1 l\u1ea1i t\u00ecnh tr\u1ea1ng l\u00e2m s\u00e0ng, hematocrit.<\/p>\n

– N\u1ebfu c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng, hematocrit > 35%.<\/p>\n

+ Ti\u1ebfp t\u1ee5c gi\u1ea3m d\u1ea7n CPT 7,5ml\/kg\/gi\u1edd\u00a0x\u00a01 -2 gi\u1edd \u2192 5ml\/kg\/gi\u1edd\u00a0x\u00a01 -2 gi\u1edd. Sau \u0111\u00f3 \u0111\u00e1nh gi\u00e1 l\u1ea1i t\u00ecnh tr\u1ea1ng l\u00e2m s\u00e0ng, hematocrit.<\/p>\n

+ N\u1ebfu ra s\u1ed1c (t\u1ec9nh t\u00e1o, tay ch\u00e2n \u1ea5m, th\u1eddi gian \u0111\u1ed5 \u0111\u1ea7y mao m\u1ea1ch < 2 gi\u00e2y, m\u1ea1ch v\u00e0 huy\u1ebft \u00e1p b\u00ecnh th\u01b0\u1eddng theo tu\u1ed5i, n\u01b0\u1edbc ti\u1ec3u \u2265 0,5-1ml\/kg\/gi\u1edd, Hematocrit b\u00ecnh th\u01b0\u1eddng v\u00e0 CVP 10-15cmH2<\/sub>O, ScvO2<\/sub>\u00a0\u2265 70%, Lactate m\u00e1u b\u00ecnh th\u01b0\u1eddng < 2mmol\/L, kh\u00ed m\u00e1u pH v\u00e0 HCO–<\/sup>3<\/sub>\u00a0b\u00ecnh th\u01b0\u1eddng n\u1ebfu c\u00f3): chuy\u1ec3n sang \u0111i\u1ec7n gi\u1ea3i Ringer lactate hay NaCl 0,9% 5ml\/kg\/gi\u1edd trong 3-4 gi\u1edd \u2192\u00a03ml\/kg\/gi\u1edd\u00a0x\u00a04-6 gi\u1edd, c\u00f3 th\u1ec3 xem x\u00e9t ng\u01b0ng d\u1ecbch truy\u1ec1n sau 24-48 gi\u1edd.<\/p>\n

+ N\u1ebfu c\u00f2n s\u1ed1c, l\u1eb7p l\u1ea1i truy\u1ec1n CPT 10-20ml\/kg\/gi\u1edd trong 1 gi\u1edd, \u0111o HA \u0111\u1ed9ng m\u1ea1ch x\u00e2m l\u1ea5n, \u00e1p l\u1ef1c t\u0129nh m\u1ea1ch trung t\u00e2m v\u00e0 x\u1eed tr\u00ed nh\u01b0 s\u1ed1c SXHD n\u1eb7ng.<\/p>\n

– N\u1ebfu kh\u00f4ng c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng, m\u1ea1ch nhanh, HA c\u00f2n t\u1ee5t ho\u1eb7c k\u1eb9t, hematocrit c\u00f2n t\u0103ng cao: l\u1eb7p l\u1ea1i truy\u1ec1n CPT 10-20ml\/kg\/gi\u1edd trong 1 gi\u1edd, \u0111i\u1ec1u tr\u1ecb toan, xu\u1ea5t huy\u1ebft, h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft, h\u1ea1 Calci huy\u1ebft n\u1ebfu c\u00f3. \u0110o HA \u0111\u1ed9ng m\u1ea1ch x\u00e2m l\u1ea5n, \u00e1p l\u1ef1c t\u0129nh m\u1ea1ch trung t\u00e2m v\u00e0 x\u1eed tr\u00ed nh\u01b0 s\u1ed1c SXHD n\u1eb7ng.<\/p>\n

* \u0110\u1ed1i v\u1edbi nh\u0169 nhi \u2264 12 th\u00e1ng tu\u1ed5i<\/p>\n

– Ph\u00e1t hi\u1ec7n s\u1ed1c th\u01b0\u1eddng tr\u1ec5 do \u00edt ngh\u0129 \u0111\u1ebfn ch\u1ea9n \u0111o\u00e1n SXHD v\u00e0 kh\u00f3 \u0111o huy\u1ebft \u00e1p.<\/p>\n

– Hematocrit b\u00ecnh th\u01b0\u1eddng c\u00f3 th\u1ec3 \u1edf m\u1ee9c th\u1ea5p (30-35%) do c\u00f3 thi\u1ebfu m\u00e1u sinh l\u00fd.<\/p>\n

– Ch\u00fa \u00fd l\u01b0\u1ee3ng d\u1ecbch v\u00e0 t\u1ed1c \u0111\u1ed9 d\u1ecbch truy\u1ec1n \u0111\u1ec3\u00a0tr\u00e1nh nguy c\u01a1 d\u01b0 d\u1ecbch, suy h\u00f4 h\u1ea5p.<\/p>\n

– Do \u1edf tr\u1ebb nh\u0169 nhi r\u1ea5t kh\u00f3 \u0111o \u00e1p l\u1ef1c t\u0129nh m\u1ea1ch trung t\u00e2m n\u00ean xem x\u00e9t d\u00f9ng si\u00eau \u00e2m kh\u1ea3o s\u00e1t s\u1ef1 thay \u0111\u1ed5i \u0111\u01b0\u1eddng k\u00ednh c\u1ee7a t\u0129nh m\u1ea1ch ch\u1ee7 d\u01b0\u1edbi theo nh\u1ecbp th\u1edf \u0111\u1ec3\u00a0gi\u00fap \u0111\u00e1nh gi\u00e1 th\u1ec3\u00a0t\u00edch d\u1ecbch n\u1ed9i m\u1ea1ch thay cho CVP.<\/p>\n

NGU\u1ed2N T\u00c0I LI\u1ec6U<\/strong><\/p>\n

    \n
  1. Quy\u1ebft \u0111\u1ecbnh s\u1ed1 3705\/Q\u0110-BYT ng\u00e0y 22 th\u00e1ng 8 n\u0103m 2019 c\u1ee7a B\u1ed9 tr\u01b0\u1edfng B\u1ed9 Y t\u1ebf<\/em><\/li>\n<\/ol>\n

     <\/p>\n

     <\/p>\n","protected":false},"excerpt":{"rendered":"

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