{"id":28306,"date":"2023-04-25T20:40:39","date_gmt":"2023-04-25T13:40:39","guid":{"rendered":"http:\/\/noithathoaphat.in\/ctv\/?p=28306"},"modified":"2023-04-25T20:40:39","modified_gmt":"2023-04-25T13:40:39","slug":"tiep-can-con-tim-thieu-oxy","status":"publish","type":"post","link":"http:\/\/noithathoaphat.in\/ctv\/index.php\/2023\/04\/25\/tiep-can-con-tim-thieu-oxy\/","title":{"rendered":"Ti\u1ebfp c\u1eadn c\u01a1n t\u00edm thi\u1ebfu oxy"},"content":{"rendered":"

C\u01a1n t\u00edm thi\u1ebfu oxy l\u00e0 m\u1ed9t t\u00ecnh tr\u1ea1ng thi\u1ebfu oxy m\u00e1u n\u1eb7ng, c\u1ea5p t\u00ednh, nguy hi\u1ec3m v\u1edbi\u00a0 nh\u1eefng bi\u1ec3u hi\u1ec7n l\u00e2m s\u00e0ng \u0111a d\u1ea1ng nh\u01b0 b\u1ee9t r\u1ee9t, qu\u1ea5y kh\u00f3c, th\u1edf nhanh v\u00e0 s\u00e2u k\u1ecbch ph\u00e1t,\u00a0 t\u00edm n\u1eb7ng h\u01a1n ho\u1eb7c xanh t\u00e1i, c\u00f3 th\u1ec3 c\u00f3 ng\u1ea5t. \u0110\u00e2y l\u00e0 m\u1ed9t t\u00ecnh tr\u1ea1ng kh\u1ea9n c\u1ea5p c\u1ea7n ph\u1ea3i\u00a0 \u0111\u01b0\u1ee3c ph\u00e1t hi\u1ec7n nhanh ch\u00f3ng v\u00e0 \u0111i\u1ec1u tr\u1ecb k\u1ecbp th\u1eddi.<\/strong><\/p>\n

1. Sinh b\u1ec7nh h\u1ecdc : <\/strong><\/h2>\n

Trong TOF, th\u00f4ng li\u00ean th\u1ea5t \u0111\u1ee7 l\u1edbn \u0111\u1ec3 c\u00e2n b\u1eb1ng \u00e1p l\u1ef1c t\u00e2m thu \u1edf c\u1ea3 hai th\u1ea5t, th\u1ea5t\u00a0 ph\u1ea3i v\u00e0 th\u1ea5t tr\u00e1i c\u00f3 th\u1ec3 xem nh\u01b0 m\u1ed9t bu\u1ed3ng chung, b\u01a1m m\u00e1u ra v\u00f2ng tu\u1ea7n ho\u00e0n ph\u1ed5i v\u00e0\u00a0 h\u1ec7 th\u1ed1ng. T\u1ec9 l\u1ec7 l\u01b0u l\u01b0\u1ee3ng m\u00e1u l\u00ean ph\u1ed5i v\u00e0 h\u1ec7 th\u1ed1ng (Qp\/Qs) li\u00ean quan \u0111\u1ebfn t\u1ec9 l\u1ec7 kh\u00e1ng\u00a0 l\u1ef1c m\u1ea1ch m\u00e1u ph\u1ed5i (PVR) do h\u1eb9p \u0111\u01b0\u1eddng ra th\u1ea5t ph\u1ea3i v\u00e0 kh\u00e1ng l\u1ef1c m\u1ea1ch m\u00e1u h\u1ec7 th\u1ed1ng\u00a0 (SVR). Do \u0111\u00f3 t\u0103ng kh\u00e1ng l\u1ef1c mach m\u00e1u ph\u1ed5i ho\u1eb7c gi\u1ea3m kh\u00e1ng l\u1ef1c m\u1ea1ch m\u00e1u h\u1ec7 th\u1ed1ng\u00a0 l\u00e0m t\u0103ng shunt P-T, g\u00e2y t\u00edm nhi\u1ec1u h\u01a1n. Ng\u01b0\u1ee3c l\u1ea1i, m\u00e1u l\u00ean ph\u1ed5i nhi\u1ec1u do t\u0103ng kh\u00e1ng\u00a0 l\u1ef1c m\u1ea1ch m\u00e1u h\u1ec7 th\u1ed1ng hay gi\u1ea3m kh\u00e1ng l\u1ef1c m\u1ea1ch m\u00e1u ph\u1ed5i, gi\u00fap t\u0103ng \u0111\u1ed9 b\u00e3o h\u00e0o oxy\u00a0 trong m\u00e1u, l\u00e0m gi\u1ea3m t\u00edm.<\/p>\n

\u0110i\u1ec1u ki\u1ec7n c\u1ea7n: <\/em>nh\u1eefng t\u1eadt tim c\u00f3 h\u1eb9p \u0111\u01b0\u1eddng ra th\u1ea5t ph\u1ea3i k\u1ebft h\u1ee3p v\u1edbi lu\u1ed3ng th\u00f4ng\u00a0 P- T trong tim, th\u01b0\u1eddng g\u1eb7p trong t\u1ee9 ch\u1ee9ng Fallot.<\/p>\n

\u0110i\u1ec1u ki\u1ec7n \u0111\u1ee7: <\/em>c\u00e1c y\u1ebfu t\u1ed1 l\u00e0m t\u0103ng kh\u00e1ng l\u1ef1c m\u1ea1ch m\u00e1u ph\u1ed5i ho\u1eb7c gi\u1ea3m kh\u00e1ng\u00a0 l\u1ef1c m\u1ea1ch m\u00e1u h\u1ec7 th\u1ed1ng g\u00e2y tang shunt P-T.<\/p>\n

\"con-tim-thieu-oxy\"<\/p>\n

2. Ch\u1ea9n \u0111o\u00e1n c\u01a1n t\u00edm thi\u1ebfu oxy<\/strong><\/h2>\n

2.1 L\u00e2m s\u00e0ng:\u00a0 <\/em><\/strong><\/p>\n

Th\u1eddi \u0111i\u1ec3m xu\u1ea5t hi\u1ec7n c\u01a1n t\u00edm :<\/strong><\/p>\n

– S\u00e1ng th\u1ee9c d\u1eady, sau m\u1ed9t gi\u1ea5c ng\u1ee7 d\u00e0i<\/p>\n

– C\u00f3 y\u1ebfu t\u1ed1 thu\u1eadn l\u1ee3i<\/p>\n

o K\u00edch x\u00fac: lo l\u1eafng, \u0111au \u0111\u1edbn, kh\u00f3c b\u00fa, m\u00f3t r\u1eb7n<\/p>\n

o Nhi\u1ec5m tr\u00f9ng: s\u1ed1t, vi\u00eam h\u00f4 h\u1ea5p, ti\u00eau ch\u1ea3y, \u00f3i<\/p>\n

o Toan m\u00e1u: do nguy\u00ean nh\u00e2n b\u1ea5t k\u00ec<\/p>\n

o Thu\u1ed1c: k\u00edch th\u00edch beta (ventoline), d\u00e3n m\u1ea1ch ngo\u1ea1i bi\u00ean<\/p>\n

Tri\u1ec7u ch\u1ee9ng trong c\u01a1n :<\/strong><\/p>\n

– B\u1ee9t r\u1ee9t ho\u1eb7c n\u1eb1m im r\u00ean r\u1ec9<\/p>\n

– T\u00edm n\u1eb7ng h\u01a1n (tr\u01b0\u1edbc \u0111\u00f3 c\u00f3 t\u00edm)<\/p>\n

– Th\u1edf nhanh s\u00e2u, ph\u1ed5i th\u01b0\u1eddng kh\u00f4ng ran<\/p>\n

– M\u1ea1ch v\u00e0 nh\u1ecbp tim th\u01b0\u1eddng kh\u00f4ng t\u0103ng<\/p>\n

– \u00c2m th\u1ed5i t\u00e2m thu gi\u1ea3m ho\u1eb7c kh\u00f4ng nghe \u0111\u01b0\u1ee3c<\/p>\n

– Ng\u1ea5t, co gi\u1eadt, c\u00f3 th\u1ec3 \u0111\u01b0a \u0111\u1ebfn t\u1eed vong<\/p>\n

T\u00e0i li\u1ec7u h\u01b0\u1edbng d\u1eabn l\u00e2m s\u00e0ng sinh vi\u00ean Y4-\u0110H Y D\u01b0\u1ee3c TpHCM Khoa Tim m\u1ea1ch-BV Nhi \u0111\u1ed3ng 2<\/p>\n

2.2 C\u1eadn l\u00e2m s\u00e0ng : <\/em><\/strong><\/p>\n

C\u00f4ng th\u1ee9c m\u00e1u :<\/strong><\/p>\n

– Bi\u1ec3u hi\u1ec7n c\u00f4 \u0111\u1eb7c m\u00e1u<\/p>\n

– Hct, Hb, s\u1ed1 l\u01b0\u1ee3ng h\u1ed3ng c\u1ea7u t\u0103ng, c\u00f3 nguy c\u01a1 l\u00e0m t\u0103ng \u0111\u1ed9 nh\u1edbt m\u00e1u, d\u1ec5 g\u00e2y\u00a0 bi\u1ebfn ch\u1ee9ng t\u1eafc m\u1ea1ch<\/p>\n

Kh\u00ed m\u00e1u \u0111\u1ed9ngm\u1ea1ch<\/strong><\/p>\n

– pH m\u00e1u gi\u1ea3m, toan chuy\u1ec3n h\u00f3a<\/p>\n

– SaO2, PaO2 gi\u1ea3m<\/p>\n

    \n
  1. Xquang ng\u1ef1c th\u1eb3ng: Tu\u1ea7n ho\u00e0n ph\u1ed5i gi\u1ea3m do h\u1eb9p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i d. Si\u00eau \u00e2m tim: gi\u00fap ph\u00e1t hi\u1ec7n t\u1eadt tim b\u1ea9m sinh c\u00f3 h\u1eb9p \u0111\u01b0\u1eddng tho\u00e1t th\u1ea5t ph\u1ea3i v\u00e0 th\u00f4ng li\u00ean th\u1ea5t<\/li>\n<\/ol>\n

    3. Ch\u1ea9n \u0111o\u00e1n<\/h2>\n

    3.<\/strong>1<\/strong> Nguy\u00ean nh\u00e2n <\/strong><\/p>\n

    – Tim b\u1ea9m sinh c\u00f3 h\u1eb9p \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i ho\u1eb7c kh\u00f4ng l\u1ed7 van \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i +\u00a0 lu\u1ed3ng th\u00f4ng trong tim:<\/p>\n

    – T\u1ee9 ch\u1ee9ng Fallot, DORV + VSD + PS, TGA + VSD +PS, teo van 3 l\u00e1, tim m\u1ed9t\u00a0 th\u1ea5t k\u00e8m h\u1eb9p ph\u1ed5i, h\u1ee3p ch\u1ee9ng Eissenmenger.<\/p>\n

    3.2 . Ch\u1ea9n \u0111o\u00e1n ph\u00e2n bi\u1ec7t : <\/strong>c\u01a1n t\u00edm v\u00e0 tim b\u1ea9m sinh t\u00edm c\u00f3 suy tim<\/p>\n\n\n\n\n
    <\/td>\nC\u01a1n t\u00edm <\/strong><\/td>\nTBS t\u00edm c\u00f3 suy tim<\/strong><\/td>\n<\/tr>\n
    Nh\u1ecbp th\u1edf <\/em><\/p>\n

    Nh\u1ecbp tim <\/em><\/p>\n

    Da ni\u00eam <\/em><\/p>\n

    Ph\u1ebf \u00e2m <\/em><\/p>\n

    Gan <\/em><\/p>\n

    X quang ng\u1ef1c<\/em><\/td>\n

    		Nhanh s\u00e2u<\/p>\n

    B\u00ecnh th\u01b0\u1eddng<\/p>\n

    T\u00edm \u0111\u1eadm<\/p>\n

    Th\u00f4, kh\u00f4ng ran<\/p>\n

    Kh\u00f4ng to<\/p>\n

    Tu\u1ea7n ho\u00e0n ph\u1ed5i gi\u1ea3m<\/td>\n

    		Nhanh n\u00f4ng, co l\u00f5m ng\u1ef1c T\u0103ng \u00b1 gallop<\/p>\n

    T\u00edm, \u1ea9m, v\u00e3 m\u1ed3 h\u00f4i<\/p>\n

    Th\u01b0\u1eddng c\u00f3 ran \u1ea9m<\/p>\n

    To<\/p>\n

    Tu\u1ea7n ho\u00e0n ph\u1ed5i t\u0103ng<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

    4. \u0110i\u1ec1u tr\u1ecb c\u01a1n t\u00edm thi\u1ebfu oxy<\/h2>\n

    4.1 Nguy\u00ean t\u1eafc \u0111i\u1ec1u tr\u1ecb<\/strong><\/p>\n

      \n
    • L\u00e0m t\u0103ng oxy m\u00e1u \u0111\u1ed9ng m\u1ea1ch<\/li>\n
    • – L\u00e0m gi\u1ea3m kh\u00e1ng l\u1ef1c m\u1ea1ch m\u00e1u ph\u1ed5i (PVR)<\/li>\n
    • – L\u00e0m t\u0103ng kh\u00e1ng l\u1ef1c m\u1ea1ch m\u00e1u h\u1ec7 th\u1ed1ng (SVR)<\/li>\n
    • – Can thi\u1ec7p k\u1ecbp th\u1eddi: RVOT stent, BT shunt.<\/li>\n<\/ul>\n

      4.2 C\u1ee5 th\u1ec3<\/strong><\/p>\n

      \u00a0L\u00e0m t\u0103ng oxy m\u00e1u \u0111\u1ed9ng m\u1ea1ch:<\/strong><\/p>\n

      – Cung c\u1ea5p oxy: 100%. Th\u1edf oxy qua mask c\u00f3 t\u00fai d\u1ef1 tr\u1eef v\u1edbi l\u01b0u l\u01b0\u1ee3ng 6 \u2013 10 l\u00edt\/ph\u00fat.<\/p>\n

      – Ph\u00f2ng gi\u1ea3m oxy m\u00e1u v\u00e0 toan m\u00e1u.<\/p>\n

      – H\u1ea1n ch\u1ebf c\u00e1c y\u1ebfu t\u1ed1 k\u00edch th\u00edch, g\u1eafng s\u1ee9c.<\/p>\n

      L\u00e0m gi\u1ea3m kh\u00e1ng l\u1ef1c m\u1ea1ch m\u00e1u ph\u1ed5i:<\/strong><\/p>\n

      – L\u00e0m gi\u1ea3m lo l\u1eafng, qu\u1ea5y kh\u00f3c.<\/p>\n

      – Morphin sulfate 0,1 mg\/kg ti\u00eam b\u1eafp ho\u1eb7c ti\u00eam d\u01b0\u1edbi da (d\u00e3n ph\u1ec5u \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i, \u1ee9c ch\u1ebf trung t\u00e2m h\u00f4 h\u1ea5p, gi\u1ea3m kh\u00e1ng l\u1ef1c ngo\u1ea1i bi\u00ean)<\/p>\n

      ho\u1eb7c Diazepam 0,1 \u2013 0,4 mg\/kg ti\u00eam m\u1ea1ch ch\u1eadm.<\/p>\n

      VD: Midazolam (Diazepam) \u1ed1ng 5mg\/ml 0,2 mg\/kg (TMC).<\/p>\n

      – Propranolol ch\u1ec9 \u0111\u1ecbnh khi th\u1ea5t b\u1ea1i v\u1edbi c\u00e1c bi\u1ec7n ph\u00e1p tr\u00ean, 0,05 \u2013 0,1 mg\/kg ti\u00eam m\u1ea1ch ch\u1eadm (t\u1ed5ng li\u1ec1u lu\u00f4n \u2264 1mg). T\u1ed5ng li\u1ec1u \u0111\u01b0\u1ee3c pha trong 10 ml d\u1ecbch v\u00e0 \u2265 50% bolus ti\u00eam m\u1ea1ch. Li\u1ec1u c\u00f2n l\u1ea1i ti\u00eam m\u1ea1ch ch\u1eadm trong v\u00f2ng 5 \u2013 10 ph\u00fat n\u1ebfu li\u1ec1u \u0111\u1ea7u ch\u01b0a hi\u1ec7u qu\u1ea3. V\u00e0 \u0111i\u1ec1u tr\u1ecb d\u1ef1 ph\u00f2ng b\u1eb1ng Propranolol u\u1ed1ng 1 \u2013 4 mg\/kg\/ng\u00e0y, chia 2 \u2013 3 l\u1ea7n, vi\u00ean 40mg -> \u00a0gi\u1ea3m nh\u1ecbp tim, gi\u1ea3m co th\u1eaft ph\u1ec5u \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i, t\u0103ng kh\u00e1ng l\u1ef1c ngo\u1ea1i bi\u00ean, gi\u1ea3m th\u1edf s\u00e2u.<\/p>\n

      L\u00e0m t\u0103ng kh\u00e1ng l\u1ef1c m\u1ea1ch m\u00e1u h\u1ec7 th\u1ed1ng:<\/strong><\/p>\n

      – Gi\u1eef tr\u1ebb \u1edf t\u01b0 th\u1ebf g\u1ed1i \u2013 ng\u1ef1c.<\/p>\n

      – Truy\u1ec1n d\u1ecbch \u0111i\u1ec7n gi\u1ea3i 20 ml\/kg khi Hct > 60% \uf0e0 gi\u1ea3m c\u00f4 \u0111\u1eb7c m\u00e1u, t\u0103ng cung c\u1ea5p oxy m\u00f4.<\/p>\n

      – Phenylephrine Hydrocholride: 0,01 mg\/kg t\u0129nh m\u1ea1ch ch\u1eadm v\u00e0\/ho\u1eb7c Methoxamine: 0,1 mg\/kg t\u0129nh m\u1ea1ch ch\u1eadm ->\u00a0 t\u0103ng kh\u00e1ng l\u1ef1c ngo\u1ea1i bi\u00ean, gi\u1ea3m shunt P \u2013 T, t\u0103ng m\u00e1u l\u00ean ph\u1ed5i.<\/p>\n

      – Ch\u1ed1ng toan: NaHCO3 1 \u2013 2 mEq\/kg\/l\u1ea7n TM khi t\u00edm t\u00e1i n\u1eb7ng k\u00e9o d\u00e0i.<\/p>\n

      5. T\u1ed5ng k\u1ebft ti\u1ebfp c\u1eadn c\u01a1n t\u00edm thi\u1ebfu oxy:<\/h2>\n

      5.1. X\u1eed tr\u00ed c\u01a1n t\u00edm:<\/strong><\/p>\n

      – Gi\u1eef tr\u1ebb \u1edf t\u01b0 th\u1ebf g\u1ed1i \u2013 ng\u1ef1c.<\/p>\n

      – H\u1ea1n ch\u1ebf c\u00e1c y\u1ebfu t\u1ed1 k\u00edch th\u00edch, g\u1eafng s\u1ee9c.<\/p>\n

      – Th\u1edf oxy qua mask c\u00f3 t\u00fai d\u1ef1 tr\u1eef v\u1edbi l\u01b0u l\u01b0\u1ee3ng 6 \u2013 10 l\u00edt\/ph\u00fat.<\/p>\n

      – Diazepam 0,1 \u2013 0,4 mg\/kg ti\u00eam m\u1ea1ch ch\u1eadm.<\/p>\n

      – Truy\u1ec1n d\u1ecbch \u0111i\u1ec7n gi\u1ea3i 20 ml\/kg khi Hct > 60%.<\/p>\n

      – Ch\u1ed1ng toan: NaHCO3 1 \u2013 2 mEq\/kg\/l\u1ea7n TM khi t\u00edm t\u00e1i k\u00e9o d\u00e0i.<\/p>\n

      – Propranolol ch\u1ec9 \u0111\u1ecbnh khi th\u1ea5t b\u1ea1i v\u1edbi c\u00e1c bi\u1ec7n ph\u00e1p tr\u00ean, 0,05 \u2013 0,1<\/p>\n

      mg\/kg ti\u00eam m\u1ea1ch ch\u1eadm (t\u1ed5ng li\u1ec1u lu\u00f4n \u2264 1mg). T\u1ed5ng li\u1ec1u \u0111\u01b0\u1ee3c pha<\/p>\n

      trong 10 ml d\u1ecbch v\u00e0 \u2265 50% bolus ti\u00eam m\u1ea1ch. Li\u1ec1u c\u00f2n l\u1ea1i ti\u00eam m\u1ea1ch<\/p>\n

      ch\u1eadm trong v\u00f2ng 5 \u2013 10 ph\u00fat n\u1ebfu li\u1ec1u \u0111\u1ea7u ch\u01b0a hi\u1ec7u qu\u1ea3.<\/p>\n

      5.2. Ph\u00f2ng ng\u1eeba c\u01a1n t\u00edm:<\/strong><\/p>\n

      – Propranolol u\u1ed1ng 1 \u2013 4 mg\/kg\/ng\u00e0y, chia 2 \u2013 3 l\u1ea7n, vi\u00ean 40mg.<\/p>\n

      – B\u1ed5 sung Fe: Ferlin 30mg\/5ml 10 \u2013 15 mg.<\/p>\n

      T\u00c0I LI\u1ec6U THAM KH\u1ea2O <\/strong><\/p>\n

        \n
      1. Myung K. Park : Tetralogy of Fallot , Pediatric Cardiology for Practitioners, <\/em>5th <\/sup>Edition<\/li>\n
      2. Lucy S. Roche, Steven C. Greenway, Andrew N. Redington : Tetralogy of Fallot with Pulmonary Stenosis and Tetralogy of Fallot with Absent Pulmonary Valve, Moss and Adams’ Heart Disease in Infants, Children, and Adolescents: Including the Fetus and Young Adult<\/em>, 8th Edition.<\/li>\n
      3. Ph\u00e1c \u0111\u1ed3 \u0111i\u1ec1u tr\u1ecb Nhi khoa : B\u1ec7nh vi\u1ec7n Nhi \u0111\u1ed3ng 1<\/li>\n<\/ol>\n

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

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