{"id":32194,"date":"2023-05-07T13:28:10","date_gmt":"2023-05-07T06:28:10","guid":{"rendered":"http:\/\/noithathoaphat.in\/ctv\/?p=32194"},"modified":"2023-05-17T01:59:51","modified_gmt":"2023-05-16T18:59:51","slug":"dieu-tri-thuyen-tac-phoi-giai-doan-cap-esc-2019","status":"publish","type":"post","link":"http:\/\/noithathoaphat.in\/ctv\/index.php\/2023\/05\/07\/dieu-tri-thuyen-tac-phoi-giai-doan-cap-esc-2019\/","title":{"rendered":"\u0110i\u1ec1u tr\u1ecb thuy\u00ean t\u1eafc ph\u1ed5i giai \u0111o\u1ea1n c\u1ea5p – ESC 2019"},"content":{"rendered":"

Thuy\u00ean t\u1eafc m\u1ea1ch ph\u1ed5i (Pulmonary Embolism) l\u00e0 m\u1ed9t t\u00ecnh tr\u1ea1ng y t\u1ebf nghi\u00eam tr\u1ecdng, g\u00e2y ra t\u1edbi 85.000 ng\u01b0\u1eddi ch\u1ebft\/n\u0103m. T\u1eafc m\u1ea1ch ph\u1ed5i ch\u1ee7 y\u1ebfu t\u00e1c \u0111\u1ed9ng \u0111\u1ebfn ng\u01b0\u1eddi tr\u01b0\u1edfng th\u00e0nh, vi\u1ec7c ch\u1ea9n \u0111o\u00e1n v\u00e0 \u0111i\u1ec1u tr\u1ecb k\u1ecbp thuy\u00ean t\u1eafc ph\u1ed5i giai \u0111o\u1ea1n c\u1ea5p v\u00f4 c\u00f9ng quan tr\u1ecdng,\u00a0 c\u1ea7n \u0111\u01b0\u1ee3c c\u00e1c nh\u00e2n vi\u00ean y t\u1ebf v\u00e0 ng\u01b0\u1eddi b\u1ec7nh \u0111\u1eb7c bi\u1ec7t quan t\u00e2m.<\/strong><\/p>\n

\"thuyen-tac-phoi\"
Thuy\u00ean t\u1eafc ph\u1ed5i<\/figcaption><\/figure>\n

1. H\u1ed7 tr\u1ee3 huy\u1ebft \u0111\u1ed9ng v\u00e0 h\u00f4 h\u1ea5p<\/strong><\/h2>\n

1.1. Oxy li\u1ec7u ph\u00e1p v\u00e0 th\u00f4ng kh\u00ed <\/a><\/em><\/strong><\/h3>\n

Thi\u1ebfu oxy m\u00e1u<\/strong><\/a> l\u00e0 m\u1ed9t trong nh\u1eefng \u0111\u1eb7c \u0111i\u1ec3m c\u1ee7a thuy\u00ean t\u1eafc ph\u1ed5i n\u1eb7ng, v\u00e0 ch\u1ee7 y\u1ebfu l\u00e0 do s\u1ef1 b\u1ea5t t\u01b0\u01a1ng h\u1ee3p gi\u1eefa th\u00f4ng kh\u00ed v\u00e0 t\u01b0\u1edbi m\u00e1u. Cung c\u1ea5p oxy \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n PE c\u00f3 SaO2 <90%. T\u00ecnh tr\u1ea1ng thi\u1ebfu oxy m\u00e1u\/suy h\u00f4 h\u1ea5p n\u1eb7ng kh\u00e1ng tr\u1ecb v\u1edbi h\u1ed7 tr\u1ee3 oxy th\u00f4ng th\u01b0\u1eddng c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c gi\u1ea3i th\u00edch b\u1eb1ng shunt ph\u1ea3i-tr\u00e1i qua l\u1ed7 b\u1ea7u d\u1ee5c ho\u1eb7c th\u00f4ng li\u00ean nh\u0129. C\u00e1c k\u1ef9 thu\u1eadt cung c\u1ea5p oxy cao h\u01a1n c\u0169ng n\u00ean \u0111\u01b0\u1ee3c xem x\u00e9t, bao g\u1ed3m oxy l\u01b0u l\u01b0\u1ee3ng cao (ngh\u0129a l\u00e0 cannula m\u0169i l\u01b0u l\u01b0\u1ee3ng cao) v\u00e0 th\u00f4ng kh\u00ed c\u01a1 h\u1ecdc (kh\u00f4ng x\u00e2m l\u1ea5n ho\u1eb7c x\u00e2m l\u1ea5n) trong tr\u01b0\u1eddng h\u1ee3p huy\u1ebft \u0111\u1ed9ng c\u1ef1c k\u1ef3 m\u1ea5t \u1ed5n \u0111\u1ecbnh (t\u1ee9c l\u00e0 ng\u1eebng tim), l\u00e0 nh\u1eefng tr\u01b0\u1eddng h\u1ee3p m\u00e0 c\u1ea3i thi\u1ec7n oxy m\u00e1u s\u1ebd kh\u00f4ng th\u1ec3 th\u1ef1c hi\u1ec7n \u0111\u01b0\u1ee3c n\u1ebfu kh\u00f4ng \u0111\u1ed3ng th\u1eddi t\u01b0\u1edbi m\u00e1u ph\u1ed5i. <\/span><\/p>\n

B\u1ec7nh nh\u00e2n suy RV th\u01b0\u1eddng b\u1ecb t\u1ee5t huy\u1ebft \u00e1p ho\u1eb7c d\u1ec5 ti\u1ebfn tri\u1ec3n \u0111\u1ebfn t\u1ee5t huy\u1ebft \u00e1p nghi\u00eam tr\u1ecdng trong qu\u00e1 tr\u00ecnh g\u00e2y m\u00ea, \u0111\u1eb7t n\u1ed9i kh\u00ed qu\u1ea3n v\u00e0 th\u00f4ng kh\u00ed \u00e1p l\u1ef1c d\u01b0\u01a1ng. Do \u0111\u00f3, ch\u1ec9 n\u00ean \u0111\u1eb7t n\u1ed9i kh\u00ed qu\u1ea3n n\u1ebfu b\u1ec7nh nh\u00e2n kh\u00f4ng th\u1ec3 ch\u1ecbu \u0111\u01b0\u1ee3c th\u00f4ng kh\u00ed kh\u00f4ng x\u00e2m l\u1ea5n. Khi kh\u1ea3 thi, th\u00f4ng kh\u00ed kh\u00f4ng x\u00e2m l\u1ea5n ho\u1eb7c th\u1edf oxy qua cannula m\u0169i l\u01b0u l\u01b0\u1ee3ng cao c\u1ea7n \u0111\u01b0\u1ee3c \u01b0u ti\u00ean; n\u1ebfu th\u00f4ng kh\u00ed c\u01a1 h\u1ecdc ph\u1ea3i d\u00f9ng th\u00ec c\u1ea7n theo d\u00f5i \u0111\u1ec3 h\u1ea1n ch\u1ebf t\u00e1c d\u1ee5ng b\u1ea5t l\u1ee3i l\u00ean huy\u1ebft \u0111\u1ed9ng c\u1ee7a n\u00f3. \u0110\u1eb7c bi\u1ec7t, \u00e1p l\u1ef1c d\u01b0\u01a1ng trong l\u1ed3ng ng\u1ef1c g\u00e2y ra b\u1edfi th\u00f4ng kh\u00ed c\u01a1 h\u1ecdc c\u00f3 th\u1ec3 l\u00e0m gi\u1ea3m m\u00e1u t\u0129nh m\u1ea1ch tr\u1edf v\u1ec1 v\u00e0 l\u00e0m t\u1ec7 h\u01a1n cung l\u01b0\u1ee3ng tim v\u1ed1n d\u0129 th\u1ea5p do suy RV \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n PE nguy c\u01a1 cao; do \u0111\u00f3, \u00e1p l\u1ef1c d\u01b0\u01a1ng cu\u1ed1i th\u00ec th\u1edf ra n\u00ean \u0111\u01b0\u1ee3c \u00e1p d\u1ee5ng m\u1ed9t c\u00e1ch th\u1eadn tr\u1ecdng. N\u00ean \u00e1p d\u1ee5ng c\u00e0i \u0111\u1eb7t th\u1ec3 t\u00edch kh\u00ed th\u01b0\u1eddng l\u01b0u x\u1ea5p x\u1ec9 6mL\/kg tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 c\u1ee7a c\u01a1 th\u1ec3 \u0111\u1ec3 c\u1ed1 g\u1eafng gi\u1eef \u00e1p l\u1ef1c b\u00ecnh nguy\u00ean cu\u1ed1i th\u00ec h\u00edt v\u00e0o <30 cm H2O. N\u1ebfu c\u1ea7n thi\u1ebft \u0111\u1eb7t n\u1ed9i kh\u00ed qu\u1ea3n, n\u00ean tr\u00e1nh d\u00f9ng c\u00e1c thu\u1ed1c m\u00ea d\u1ec5 g\u00e2y h\u1ea1 huy\u1ebft \u00e1p.<\/span><\/p>\n

1.2 \u0110i\u1ec1u tr\u1ecb b\u1eb1ng thu\u1ed1c trong suy th\u1ea5t ph\u1ea3i c\u1ea5p t\u00ednh<\/em><\/strong><\/h3>\n

\u00a0Suy RV c\u1ea5p t\u00ednh d\u1eabn \u0111\u1ebfn cung l\u01b0\u1ee3ng h\u1ec7 th\u1ed1ng th\u1ea5p l\u00e0 nguy\u00ean nh\u00e2n t\u1eed vong h\u00e0ng \u0111\u1ea7u \u1edf b\u1ec7nh nh\u00e2n PE nguy c\u01a1 cao. C\u00e1c nguy\u00ean t\u1eafc qu\u1ea3n l\u00fd suy tim ph\u1ea3i c\u1ea5p<\/strong> \u0111\u00e3 \u0111\u01b0\u1ee3c xem x\u00e9t trong m\u1ed9t tuy\u00ean b\u1ed1 t\u1eeb Hi\u1ec7p h\u1ed9i suy tim v\u00e0 nh\u00f3m l\u00e0m vi\u1ec7c v\u1ec1 Tu\u1ea7n ho\u00e0n ph\u1ed5i v\u00e0 ch\u1ee9c n\u0103ng t\u00e2m th\u1ea5t ph\u1ea3i c\u1ee7a ESC. T\u1ed5ng quan v\u1ec1 c\u00e1c l\u1ef1a ch\u1ecdn \u0111i\u1ec1u tr\u1ecb hi\u1ec7n t\u1ea1i cho suy RV c\u1ea5p t\u00ednh \u0111\u01b0\u1ee3c cung c\u1ea5p trong B\u1ea3ng 9. <\/span><\/p>\n

N\u1ebfu \u00e1p l\u1ef1c t\u0129nh m\u1ea1ch trung t\u00e2m th\u1ea5p, c\u00f3 th\u1ec3 s\u1eed d\u1ee5ng test d\u1ecbch truy\u1ec1n h\u1ea1n ch\u1ebf (\u2264500 mL)<\/strong> v\u00ec n\u00f3 c\u00f3 th\u1ec3 l\u00e0m t\u0103ng ch\u1ec9 s\u1ed1 tim \u1edf b\u1ec7nh nh\u00e2n thuy\u00ean t\u1eafc ph\u1ed5i c\u1ea5p. Tuy nhi\u00ean, th\u1ec3 t\u00edch d\u1ecbch \u0111\u1ed5 v\u00e0o c\u00f3 th\u1ec3 l\u00e0m c\u0103ng qu\u00e1 m\u1ee9c RV v\u00e0 cu\u1ed1i c\u00f9ng g\u00e2y ra gi\u1ea3m CO h\u1ec7 th\u1ed1ng. C\u00e1c nghi\u00ean c\u1ee9u th\u1ef1c nghi\u1ec7m cho th\u1ea5y \u0111\u1ed5 d\u1ecbch qu\u00e1 m\u1ee9c th\u00ec kh\u00f4ng c\u00f3 l\u1ee3i \u00edch v\u00e0 th\u1eadm ch\u00ed c\u00f3 th\u1ec3 l\u00e0m x\u1ea5u \u0111i ch\u1ee9c n\u0103ng RV. B\u00f9 d\u1ecbch th\u1eadn tr\u1ecdng khi \u00e1p su\u1ea5t \u0111\u1ed9ng m\u1ea1ch th\u1ea5p c\u00f3 th\u1ec3 ph\u00f9 h\u1ee3p m\u00e0 kh\u00f4ng c\u00f3 t\u0103ng \u00e1p l\u1ef1c \u0111\u1ed5 \u0111\u1ea7y. \u0110\u00e1nh gi\u00e1 \u00e1p l\u1ef1c t\u0129nh m\u1ea1ch trung t\u00e2m b\u1eb1ng h\u00ecnh \u1ea3nh si\u00eau \u00e2m IVC (IVC nh\u1ecf v\u00e0\/ho\u1eb7c \u0111\u00e8 x\u1eb9p \u0111\u01b0\u1ee3c trong thuy\u00ean t\u1eafc ph\u1ed5i c\u1ea5p nguy c\u01a1 cao cho th\u1ea5y t\u00ecnh tr\u1ea1ng th\u1ec3 t\u00edch tu\u1ea7n ho\u00e0n th\u1ea5p) ho\u1eb7c, c\u00e1ch kh\u00e1c l\u00e0 theo d\u00f5i \u00e1p l\u1ef1c t\u0129nh m\u1ea1ch trung t\u00e2m c\u00f3 th\u1ec3 gi\u00fap h\u01b0\u1edbng d\u1eabn truy\u1ec1n d\u1ecbch. N\u1ebfu c\u00f3 d\u1ea5u d\u1ea5u hi\u1ec7u t\u0103ng \u00e1p l\u1ef1c t\u0129nh m\u1ea1ch trung t\u00e2m, n\u00ean ho\u00e3n truy\u1ec1n d\u1ecbch th\u00eam. <\/span><\/p>\n

S\u1eed d\u1ee5ng thu\u1ed1c v\u1eadn m\u1ea1ch<\/strong><\/a> th\u01b0\u1eddng l\u00e0 c\u1ea7n thi\u1ebft, song song (ho\u1eb7c trong khi ch\u1edd \u0111\u1ee3i) v\u1edbi \u0111i\u1ec1u tr\u1ecb t\u00e1i t\u01b0\u1edbi m\u00e1u b\u1eb1ng thu\u1ed1c, ph\u1eabu thu\u1eadt ho\u1eb7c can thi\u1ec7p. Norepinephrine<\/strong> c\u00f3 th\u1ec3 c\u1ea3i thi\u1ec7n huy\u1ebft \u0111\u1ed9ng h\u1ecdc to\u00e0n th\u00e2n b\u1eb1ng c\u00e1ch c\u1ea3i thi\u1ec7n t\u01b0\u01a1ng h\u1ee3p t\u00e2m th\u1ea5t k\u1ef3 t\u00e2m thu v\u00e0 t\u01b0\u1edbi m\u00e1u m\u1ea1ch v\u00e0nh, m\u00e0 kh\u00f4ng thay \u0111\u1ed5i kh\u00e1ng l\u1ef1c m\u1ea1ch m\u00e1u ph\u1ed5i (PVR). N\u00ean gi\u1edbi h\u1ea1n s\u1eed d\u1ee5ng norepinephrine \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ecb s\u1ed1c tim. D\u1ef1a v\u00e0o k\u1ebft qu\u1ea3 c\u1ee7a lo\u1ea1t nghi\u00ean c\u1ee9u nh\u1ecf, vi\u1ec7c s\u1eed d\u1ee5ng dobutamine<\/strong> c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c xem x\u00e9t \u0111\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n PE c\u00f3 ch\u1ec9 s\u1ed1 tim th\u1ea5p v\u00e0 HA b\u00ecnh th\u01b0\u1eddng; tuy nhi\u00ean, t\u0103ng ch\u1ec9 s\u1ed1 tim c\u00f3 th\u1ec3 l\u00e0m tr\u1ea7m tr\u1ecdng th\u00eam s\u1ef1 b\u1ea5t t\u01b0\u01a1ng h\u1ee3p th\u00f4ng kh\u00ed\/t\u01b0\u1edbi m\u00e1u v\u00ec t\u00e1i ph\u00e2n b\u1ed1 d\u00f2ng ch\u1ea3y chuy\u1ec3n m\u00e1u t\u1eeb nh\u1eefng m\u1ea1ch m\u00e1u b\u1ecb t\u1eafc ngh\u1ebdn (m\u1ed9t ph\u1ea7n) \u0111\u1ebfn nh\u1eefng m\u1ea1ch m\u00e1u kh\u00f4ng b\u1ecb t\u1eafc ngh\u1ebdn.<\/span><\/p>\n

M\u1eb7c d\u00f9 d\u1eef li\u1ec7u th\u1ef1c nghi\u1ec7m cho th\u1ea5y levosimendan c\u00f3 th\u1ec3 h\u1ed3i ph\u1ee5c ch\u1ec9 s\u1ed1 t\u01b0\u01a1ng h\u1ee3p RV-\u0111\u1ed9ng m\u1ea1ch ph\u1ed5i (RV \u2013 pulmonary arterial coupling) trong PE c\u1ea5p t\u00ednh b\u1eb1ng c\u00e1ch k\u1ebft h\u1ee3p gi\u00e3n m\u1ea1ch ph\u1ed5i v\u1edbi t\u0103ng kh\u1ea3 n\u0103ng co b\u00f3p RV, nh\u01b0ng hi\u1ec7n kh\u00f4ng c\u00f3 b\u1eb1ng ch\u1ee9ng v\u1ec1 l\u1ee3i \u00edch l\u00e2m s\u00e0ng.<\/span><\/p>\n

Thu\u1ed1c gi\u00e3n m\u1ea1ch<\/a><\/strong> l\u00e0m gi\u1ea3m PAP v\u00e0 PVR, nh\u01b0ng c\u00f3 th\u1ec3 g\u00e2y t\u1ee5t huy\u1ebft \u00e1p v\u00e0 gi\u1ea3m t\u01b0\u1edbi m\u00e1u to\u00e0n th\u00e2n do \u00edt \u0111\u1eb7c hi\u1ec7u \u0111\u1ed1i v\u1edbi m\u1ea1ch m\u00e1u ph\u1ed5i khi v\u00e0o b\u1eb1ng \u0111\u01b0\u1eddng to\u00e0n th\u00e2n [\u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch (i.v.)]. M\u1eb7c d\u00f9 c\u00e1c nghi\u00ean c\u1ee9u l\u00e2m s\u00e0ng nh\u1ecf \u0111\u00e3 g\u1ee3i \u00fd r\u1eb1ng nitric oxit h\u00edt c\u00f3 th\u1ec3 c\u1ea3i thi\u1ec7n t\u00ecnh tr\u1ea1ng huy\u1ebft \u0111\u1ed9ng v\u00e0 trao \u0111\u1ed5i kh\u00ed c\u1ee7a b\u1ec7nh nh\u00e2n PE, nh\u01b0ng cho \u0111\u1ebfn nay kh\u00f4ng c\u00f3 b\u1eb1ng ch\u1ee9ng v\u1ec1 hi\u1ec7u qu\u1ea3 l\u00e2m s\u00e0ng hay t\u00ednh an to\u00e0n.<\/span><\/p>\n

\"dieu-tri-that-phai-trong-thuyen-tac-phoi-cap\"<\/p>\n

1.3 H\u1ed7 tr\u1ee3 tu\u1ea7n ho\u00e0n v\u00e0 oxy h\u00f3a m\u00e1u c\u01a1 h\u1ecdc<\/em><\/strong><\/h3>\n

\u00a0Vi\u1ec7c s\u1eed d\u1ee5ng t\u1ea1m th\u1eddi h\u1ed7 tr\u1ee3 tim ph\u1ed5i c\u01a1 h\u1ecdc, ch\u1ee7 y\u1ebfu l\u00e0 v\u1edbi oxy h\u00f3a m\u00e1u qua m\u00e0ng ngo\u00e0i c\u01a1 th\u1ec3 (ECMO) t\u0129nh m\u1ea1ch \u2013 \u0111\u1ed9ng m\u1ea1ch<\/strong>, c\u00f3 th\u1ec3 h\u1eefu \u00edch \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n thuy\u00ean t\u1eafc ph\u1ed5i nguy c\u01a1 cao v\u00e0 suy s\u1ee5p tu\u1ea7n ho\u00e0n ho\u1eb7c ng\u1eebng tim. M\u1ed9t s\u1ed1 b\u1ec7nh nh\u00e2n nguy k\u1ecbch s\u1ed1ng s\u00f3t \u0111\u01b0\u1ee3c m\u00f4 t\u1ea3 trong m\u1ed9t v\u00e0i b\u00e1o c\u00e1o lo\u1ea1t ca, nh\u01b0ng cho \u0111\u1ebfn nay kh\u00f4ng c\u00f3 RCT n\u00e0o \u0111\u01b0\u1ee3c ti\u1ebfn h\u00e0nh \u0111\u1ec3 ki\u1ec3m tra hi\u1ec7u qu\u1ea3 v\u00e0 an to\u00e0n c\u1ee7a c\u00e1c thi\u1ebft b\u1ecb n\u00e0y trong tr\u01b0\u1eddng h\u1ee3p thuy\u00ean t\u1eafc ph\u1ed5i nguy c\u01a1 cao. <\/span><\/p>\n

S\u1eed d\u1ee5ng ECMO c\u00f3 li\u00ean quan \u0111\u1ebfn t\u1ef7 l\u1ec7 bi\u1ebfn ch\u1ee9ng cao<\/strong>, ngay c\u1ea3 khi s\u1eed d\u1ee5ng trong th\u1eddi gian ng\u1eafn v\u00e0 k\u1ebft qu\u1ea3 ph\u1ee5 thu\u1ed9c v\u00e0o kinh nghi\u1ec7m c\u1ee7a trung t\u00e2m c\u0169ng nh\u01b0 s\u1ef1 l\u1ef1a ch\u1ecdn b\u1ec7nh nh\u00e2n. C\u1ea7n xem x\u00e9t kh\u1ea3 n\u0103ng t\u0103ng nguy c\u01a1 ch\u1ea3y m\u00e1u li\u00ean quan \u0111\u1ebfn vi\u1ec7c thi\u1ebft l\u1eadp \u0111\u01b0\u1eddng truy\u1ec1n, \u0111\u1eb7c bi\u1ec7t \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 s\u1eed d\u1ee5ng ti\u00eau s\u1ee3i huy\u1ebft. Hi\u1ec7n nay, vi\u1ec7c s\u1eed d\u1ee5ng ECMO nh\u01b0 m\u1ed9t k\u1ef9 thu\u1eadt ri\u00eang l\u1ebb v\u1edbi ch\u1ed1ng \u0111\u00f4ng m\u00e1u \u0111ang g\u00e2y tranh c\u00e3i v\u00e0 c\u00e1c ph\u01b0\u01a1ng ph\u00e1p \u0111i\u1ec1u tr\u1ecb b\u1ed5 sung, ch\u1eb3ng h\u1ea1n nh\u01b0 ph\u1eabu thu\u1eadt l\u1ea5y huy\u1ebft kh\u1ed1i, ph\u1ea3i \u0111\u01b0\u1ee3c xem x\u00e9t. <\/span><\/p>\n

M\u1ed9t v\u00e0i tr\u01b0\u1eddng h\u1ee3p \u0111\u00e3 \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o cho th\u1ea5y k\u1ebft qu\u1ea3 t\u1ed1t khi s\u1eed d\u1ee5ng catheter Impella<\/strong> \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n s\u1ed1c do PE c\u1ea5p<\/span><\/p>\n

1.4. H\u1ed3i sinh tim ph\u1ed5i n\u00e2ng cao trong ng\u1eebng tim<\/em><\/strong><\/a><\/h3>\n

Thuy\u00ean t\u1eafc ph\u1ed5i c\u1ea5p t\u00ednh l\u00e0 m\u1ed9t trong nh\u1eefng ch\u1ea9n \u0111o\u00e1n ph\u00e2n bi\u1ec7t c\u1ee7a ho\u1ea1t \u0111\u1ed9ng \u0111i\u1ec7n v\u00f4 m\u1ea1ch trong ph\u1ea7n ng\u1eebng tim v\u1edbi nh\u1ecbp tim kh\u00f4ng s\u1ed1c \u0111\u01b0\u1ee3c. Trong ng\u1eebng tim \u0111\u01b0\u1ee3c cho l\u00e0 do PE c\u1ea5p t\u00ednh, n\u00ean tu\u00e2n theo c\u00e1c h\u01b0\u1edbng d\u1eabn h\u1ed3i sinh tim ph\u1ed5i n\u00e2ng cao. Quy\u1ebft \u0111\u1ecbnh \u0111i\u1ec1u tr\u1ecb PE c\u1ea5p t\u00ednh ph\u1ea3i \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n s\u1edbm, khi v\u1eabn c\u00f2n c\u00f3 th\u1ec3 c\u00f3 k\u1ebft c\u1ee5c t\u1ed1t. <\/span><\/p>\n

\u0110i\u1ec1u tr\u1ecb ti\u00eau s\u1ee3i huy\u1ebft n\u00ean \u0111\u01b0\u1ee3c xem x\u00e9t; m\u1ed9t khi thu\u1ed1c ti\u00eau s\u1ee3i huy\u1ebft \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng, h\u1ed3i s\u1ee9c tim ph\u1ed5i n\u00ean \u0111\u01b0\u1ee3c ti\u1ebfp t\u1ee5c trong \u00edt nh\u1ea5t 60-90 ph\u00fat tr\u01b0\u1edbc khi ch\u1ea5m d\u1ee9t n\u1ed7 l\u1ef1c h\u1ed3i s\u1ee9c.<\/span><\/p>\n

2. Ch\u1ed1ng \u0111\u00f4ng m\u00e1u ban \u0111\u1ea7u<\/strong><\/h2>\n

\u00a02.1. Thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng m\u00e1u \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch <\/a><\/em><\/strong><\/h3>\n

\u1ede nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 x\u00e1c su\u1ea5t l\u00e2m s\u00e0ng PE cao ho\u1eb7c trung b\u00ecnh, n\u00ean b\u1eaft \u0111\u1ea7u ch\u1ed1ng \u0111\u00f4ng trong khi ch\u1edd k\u1ebft qu\u1ea3 c\u00e1c c\u1eadn l\u00e2m s\u00e0ng ch\u1ea9n \u0111o\u00e1n. Thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng th\u01b0\u1eddng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng l\u00e0 heparin ti\u00eam d\u01b0\u1edbi da tr\u1ecdng l\u01b0\u1ee3ng ph\u00e2n t\u1eed th\u1ea5p (LMWH)<\/strong> ho\u1eb7c fondaparinux<\/strong><\/a>, ho\u1eb7c heparin kh\u00f4ng ph\u00e2n \u0111o\u1ea1n (UFH) ti\u00eam t\u0129nh m\u1ea1ch. D\u1ef1a tr\u00ean d\u1eef li\u1ec7u d\u01b0\u1ee3c \u0111\u1ed9ng h\u1ecdc, thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng m\u00e1u \u0111\u01b0\u1eddng u\u1ed1ng kh\u00f4ng \u0111\u1ed1i kh\u00e1ng vitamin K (NOAC) c\u00f3 t\u00e1c d\u1ee5ng ch\u1ed1ng \u0111\u00f4ng m\u00e1u nhanh t\u01b0\u01a1ng \u0111\u01b0\u01a1ng, v\u00e0 c\u00e1c th\u1eed nghi\u1ec7m l\u00e2m s\u00e0ng giai \u0111o\u1ea1n III \u0111\u00e3 ch\u1ee9ng minh hi\u1ec7u qu\u1ea3 kh\u00f4ng thua k\u00e9m c\u1ee7a chi\u1ebfn l\u01b0\u1ee3c ch\u1ed1ng \u0111\u00f4ng b\u1eb1ng \u0111\u01b0\u1eddng u\u1ed1ng li\u1ec1u cao khi s\u1eed d\u1ee5ng apixaban trong 7 ng\u00e0y ho\u1eb7c rivaroxaban trong 3 tu\u1ea7n.<\/span><\/p>\n

LMWH v\u00e0 fondaparinux \u0111\u01b0\u1ee3c \u01b0u ti\u00ean h\u01a1n UFH v\u1ec1 ch\u1ed1ng \u0111\u00f4ng m\u00e1u ban \u0111\u1ea7u trong PE, v\u00ec ch\u00fang \u00edt c\u00f3 nguy c\u01a1 g\u00e2y ch\u1ea3y m\u00e1u nghi\u00eam tr\u1ecdng v\u00e0 gi\u1ea3m ti\u1ec3u c\u1ea7u do heparin h\u01a1n. C\u1ea3 LMWH c\u0169ng nh\u01b0 fondaparinux \u0111\u1ec1u kh\u00f4ng c\u1ea7n theo d\u00f5i th\u01b0\u1eddng quy n\u1ed3ng \u0111\u1ed9 anti-Xa. Vi\u1ec7c s\u1eed d\u1ee5ng UFH hi\u1ec7n nay b\u1ecb gi\u1edbi h\u1ea1n ph\u1ea7n l\u1edbn, ch\u1ec9 s\u1eed d\u1ee5ng \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 r\u1ed1i lo\u1ea1n huy\u1ebft \u0111\u1ed9ng ho\u1eb7c huy\u1ebft \u0111\u1ed9ng s\u1eafp m\u1ea5t b\u00f9 c\u1ea7n \u0111i\u1ec1u tr\u1ecb t\u00e1i t\u01b0\u1edbi m\u00e1u ban \u0111\u1ea7u. UFH c\u0169ng \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o cho b\u1ec7nh nh\u00e2n suy th\u1eadn n\u1eb7ng [\u0111\u1ed9 thanh th\u1ea3i creatinin (CrCl) \u226430 mL\/ph\u00fat] ho\u1eb7c b\u00e9o ph\u00ec n\u1eb7ng. N\u1ebfu s\u1eed d\u1ee5ng LMWH \u1edf b\u1ec7nh nh\u00e2n c\u00f3 CrCl 15 – 30 mL\/ph\u00fat th\u00ec n\u00ean s\u1eed d\u1ee5ng s\u01a1 \u0111\u1ed3 \u0111i\u1ec1u ch\u1ec9nh li\u1ec1u theo ch\u1ee9c n\u0103ng th\u1eadn. Li\u1ec1u UFH \u0111\u01b0\u1ee3c \u0111i\u1ec1u ch\u1ec9nh d\u1ef1a tr\u00ean th\u1eddi gian thromboplastin ho\u1ea1t h\u00f3a t\u1eebng ph\u1ea7n (aPTT).<\/span><\/p>\n

2.2 Thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng m\u00e1u kh\u00f4ng \u0111\u1ed1i kh\u00e1ng vitamin K \u0111\u01b0\u1eddng u\u1ed1ng (NOAC) <\/em><\/strong><\/a><\/h3>\n

NOAC l\u00e0 c\u00e1c ph\u00e2n t\u1eed nh\u1ecf \u1ee9c ch\u1ebf tr\u1ef1c ti\u1ebfp m\u1ed9t y\u1ebfu t\u1ed1 \u0111\u00f4ng m\u00e1u \u0111\u01b0\u1ee3c k\u00edch ho\u1ea1t, \u0111\u00f3 l\u00e0 y\u1ebfu t\u1ed1 thrombin \u0111\u1ed1i v\u1edbi dabigatran v\u00e0 y\u1ebfu t\u1ed1 Xa \u0111\u1ed1i v\u1edbi apixaban, edoxaban v\u00e0 rivaroxaban. C\u00e1c \u0111\u1eb7c t\u00ednh c\u1ee7a NOAC \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng trong \u0111i\u1ec1u tr\u1ecb PE c\u1ea5p t\u00ednh \u0111\u01b0\u1ee3c t\u00f3m t\u1eaft trong ph\u1ea7n b\u1ed5 sung d\u1eef li\u1ec7u B\u1ea3ng 6. Nh\u1edd c\u00f3 sinh kh\u1ea3 d\u1ee5ng v\u00e0 d\u01b0\u1ee3c \u0111\u1ed9ng h\u1ecdc c\u00f3 th\u1ec3 d\u1ef1 \u0111o\u00e1n \u0111\u01b0\u1ee3c, NOAC c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c d\u00f9ng v\u1edbi li\u1ec1u c\u1ed1 \u0111\u1ecbnh m\u00e0 kh\u00f4ng c\u1ea7n x\u00e9t nghi\u1ec7m theo d\u00f5i th\u01b0\u1eddng quy. So v\u1edbi thu\u1ed1c kh\u00e1ng vitamin K (VKA), NOAC \u00edt t\u01b0\u01a1ng t\u00e1c v\u1edbi c\u00e1c thu\u1ed1c kh\u00e1c h\u01a1n khi u\u1ed1ng \u0111\u1ed3ng th\u1eddi. <\/span><\/p>\n

Trong c\u00e1c th\u1eed nghi\u1ec7m VTE giai \u0111o\u1ea1n III, li\u1ec1u dabigatran, rivaroxaban v\u00e0 apixaban<\/strong><\/a> kh\u00f4ng gi\u1ea3m \u1edf b\u1ec7nh nh\u00e2n c\u00f3 suy ch\u1ee9c n\u0103ng th\u1eadn nh\u1eb9 \u0111\u1ebfn trung b\u00ecnh (CrCl trong kho\u1ea3ng 30-60 mL\/ph\u00fat), trong khi edoxaban \u0111\u01b0\u1ee3c d\u00f9ng v\u1edbi li\u1ec1u 30mg<\/strong> \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n n\u00e0y. B\u1ec7nh nh\u00e2n c\u00f3 CrCl <25 mL\/ph\u00fat \u0111\u00e3 \u0111\u01b0\u1ee3c lo\u1ea1i tr\u1eeb kh\u1ecfi nghi\u00ean c\u1ee9u th\u1eed nghi\u1ec7m v\u1edbi apixaban, trong khi b\u1ec7nh nh\u00e2n c\u00f3 CrCl <30 mL\/ph\u00fat \u0111\u00e3 \u0111\u01b0\u1ee3c lo\u1ea1i kh\u1ecfi nghi\u00ean c\u1ee9u v\u1edbi rivaroxaban, edoxaban v\u00e0 dabigatran.<\/span><\/p>\n

\"Apixaban\"
M\u00f4 h\u00ecnh ph\u00e2n t\u1eed Apixaban<\/figcaption><\/figure>\n

C\u00e1c th\u1eed nghi\u1ec7m giai \u0111o\u1ea1n III v\u1ec1 \u0111i\u1ec1u tr\u1ecb VTE c\u1ea5p t\u00ednh, c\u0169ng nh\u01b0 nh\u1eefng th\u1eed nghi\u1ec7m v\u1ec1 \u0111i\u1ec1u tr\u1ecb duy tr\u00ec k\u00e9o d\u00e0i h\u01a1n 6 th\u00e1ng \u0111\u1ea7u ti\u00ean, \u0111\u00e3 ch\u1ee9ng minh NOAC kh\u00f4ng thua k\u00e9m so v\u1edbi s\u1ef1 k\u1ebft h\u1ee3p gi\u1eefa LMWH v\u00e0 VKA trong ph\u00f2ng ng\u1eeba t\u00e1i ph\u00e1t VTE c\u00f3 tri\u1ec7u ch\u1ee9ng ho\u1eb7c VTE g\u00e2y t\u1eed vong, k\u00e8m theo gi\u1ea3m \u0111\u00e1ng k\u1ec3 t\u1ef7 l\u1ec7 xu\u1ea5t huy\u1ebft n\u1eb7ng. Trong m\u1ed9t ph\u00e2n t\u00edch g\u1ed9p, t\u1ef7 su\u1ea5t ph\u00e1t sinh k\u1ebft c\u1ee5c ch\u00ednh v\u1ec1 hi\u1ec7u qu\u1ea3 l\u00e0 2.0% cho b\u1ec7nh nh\u00e2n \u0111i\u1ec1u tr\u1ecb NOAC v\u00e0 2.2% cho b\u1ec7nh nh\u00e2n \u0111i\u1ec1u tr\u1ecb VKA [t\u1ef7 s\u1ed1 nguy c\u01a1 (RR) 0.88, 95% CI 0.74-1.05]. Ch\u1ea3y m\u00e1u n\u1eb7ng x\u1ea3y ra \u1edf 1.1% b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb b\u1eb1ng NOAC v\u00e0 1.7% b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb b\u1eb1ng VKA v\u1edbi RR 0.60 (95% CI 0.41-0.88). Ch\u1ea3y m\u00e1u n\u1eb7ng t\u1ea1i v\u1ecb tr\u00ed nguy hi\u1ec3m \u00edt g\u1eb7p h\u01a1n khi \u0111i\u1ec1u tr\u1ecb NOAC so v\u1edbi \u0111i\u1ec1u tr\u1ecb VKA, (RR 0.38, 95% CI 0.23-0.62); \u0111\u1eb7c bi\u1ec7t, c\u00f3 s\u1ef1 gi\u1ea3m \u0111\u00e1ng k\u1ec3 ch\u1ea3y m\u00e1u n\u1ed9i s\u1ecd (RR 0.37, 95% CI 0.21-0.68) v\u00e0 ch\u1ea3y m\u00e1u g\u00e2y t\u1eed vong (RR 0.36, 95% CI 0.15-0.87) c\u1ee7a NOAC so v\u1edbi VKA.<\/span><\/p>\n

\u0110\u1ec1 xu\u1ea5t v\u1ec1 qu\u1ea3n l\u00fd ch\u1ed1ng \u0111\u00f4ng c\u1ee7a PE trong t\u1eebng t\u00ecnh hu\u1ed1ng l\u00e2m s\u00e0ng c\u1ee5 th\u1ec3, \u0111\u01b0\u1ee3c tr\u00ecnh b\u00e0y trong d\u1eef li\u1ec7u b\u1ed5 sung B\u1ea3ng 9, nh\u01b0ng thi\u1ebfu b\u1eb1ng ch\u1ee9ng k\u1ebft lu\u1eadn.<\/span><\/p>\n

H\u01b0\u1edbng d\u1eabn th\u1ef1c h\u00e0nh cho b\u00e1c s\u0129 l\u00e2m s\u00e0ng v\u1ec1 vi\u1ec7c cho thu\u1ed1c NOAC<\/strong> v\u00e0 qu\u1ea3n l\u00fd c\u00e1c t\u00ecnh hu\u1ed1ng kh\u1ea9n c\u1ea5p li\u00ean quan \u0111\u1ebfn vi\u1ec7c s\u1eed d\u1ee5ng ch\u00fang \u0111\u01b0\u1ee3c c\u1eadp nh\u1eadt th\u01b0\u1eddng xuy\u00ean b\u1edfi Hi\u1ec7p h\u1ed9i nh\u1ecbp tim ch\u00e2u \u00c2u.<\/span><\/p>\n

\u00a02.3 Thu\u1ed1c kh\u00e1ng vitamin K ( Vitamin K antagonist – VKA)<\/a><\/strong><\/span><\/em><\/h3>\n

VKA l\u00e0 ti\u00eau chu\u1ea9n v\u00e0ng trong ch\u1ed1ng \u0111\u00f4ng \u0111\u01b0\u1eddng u\u1ed1ng h\u01a1n 50 n\u0103m nay. Khi VKA \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng, ch\u1ed1ng \u0111\u00f4ng m\u00e1u v\u1edbi UFH, LMWH, ho\u1eb7c fondaparinux n\u00ean \u0111\u01b0\u1ee3c ti\u1ebfp t\u1ee5c song song v\u1edbi thu\u1ed1c ch\u1ed1ng \u0111\u00f4ng \u0111\u01b0\u1eddng u\u1ed1ng trong \u22655 ng\u00e0y v\u00e0 cho \u0111\u1ebfn khi gi\u00e1 tr\u1ecb ch\u1ec9 s\u1ed1 chu\u1ea9n h\u00f3a c\u1ee7a prothrombin (INR) \u0111\u1ea1t \u0111\u01b0\u1ee3c 2.0-3.0 trong 2 ng\u00e0y li\u00ean ti\u1ebfp. Warfarin c\u00f3 th\u1ec3 kh\u1edfi \u0111\u1ed9ng v\u1edbi li\u1ec1u 10 mg \u1edf ng\u01b0\u1eddi tr\u1ebb (v\u00ed d\u1ee5: <60 tu\u1ed5i) ho\u1eb7c b\u1ec7nh nh\u00e2n kh\u1ecfe m\u1ea1nh v\u00e0 li\u1ec1u \u22645mg \u1edf b\u1ec7nh nh\u00e2n l\u1edbn tu\u1ed5i. Li\u1ec1u \u0111\u01b0\u1ee3c \u0111i\u1ec1u ch\u1ec9nh h\u00e0ng ng\u00e0y theo ch\u1ec9 s\u1ed1 INR trong 5-7 ng\u00e0y ti\u1ebfp theo, nh\u1eafm \u0111\u1ebfn m\u1ee9c INR 2.0-3.0. X\u00e9t nghi\u1ec7m d\u01b0\u1ee3c di truy\u1ec1n h\u1ecdc c\u00f3 th\u1ec3 l\u00e0m t\u0103ng \u0111\u1ed9 ch\u00ednh x\u00e1c li\u1ec1u warfarin. Khi \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng c\u00f9ng v\u1edbi c\u00e1c th\u00f4ng s\u1ed1 l\u00e2m s\u00e0ng, x\u00e9t nghi\u1ec7m d\u01b0\u1ee3c di truy\u1ec1n h\u1ecdc c\u1ea3i thi\u1ec7n ki\u1ec3m so\u00e1t ch\u1ed1ng \u0111\u00f4ng m\u00e1u v\u00e0 c\u00f3 th\u1ec3 li\u00ean quan \u0111\u1ebfn vi\u1ec7c gi\u1ea3m nguy c\u01a1 ch\u1ea3y m\u00e1u, nh\u01b0ng kh\u00f4ng l\u00e0m gi\u1ea3m nguy c\u01a1 bi\u1ebfn c\u1ed1 thuy\u00ean t\u1eafc huy\u1ebft kh\u1ed1i ho\u1eb7c t\u1ef7 l\u1ec7 t\u1eed vong. <\/span><\/p>\n

Vi\u1ec7c \u0111i\u1ec1u tr\u1ecb b\u1eb1ng d\u1ecbch v\u1ee5 ch\u1ed1ng \u0111\u00f4ng m\u00e1u c\u00f3 t\u1ed5 ch\u1ee9c (h\u1ea7u h\u1ebft l\u00e0 c\u00e1c trung t\u00e2m ch\u1ed1ng \u0111\u00f4ng m\u00e1u) d\u01b0\u1eddng nh\u01b0 c\u00f3 li\u00ean quan \u0111\u1ebfn t\u0103ng th\u1eddi gian INR trong ng\u01b0\u1ee1ng \u0111i\u1ec1u tr\u1ecb v\u00e0 c\u1ea3i thi\u1ec7n k\u1ebft c\u1ee5c l\u00e2m s\u00e0ng, so v\u1edbi ki\u1ec3m so\u00e1t \u0111i\u1ec1u tr\u1ecb b\u1edfi b\u00e1c s\u0129 \u0111a khoa. Cu\u1ed1i c\u00f9ng, \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c l\u1ef1a ch\u1ecdn v\u00e0 \u0111\u01b0\u1ee3c h\u01b0\u1edbng d\u1eabn t\u1ed1t, t\u1ef1 theo d\u00f5i \u0111i\u1ec1u tr\u1ecb VKA c\u00f3 li\u00ean quan \u0111\u1ebfn \u00edt bi\u1ebfn c\u1ed1 thuy\u00ean t\u1eafc huy\u1ebft kh\u1ed1i h\u01a1n v\u00e0 t\u0103ng th\u1eddi gian h\u01a1n trong ph\u1ea1m vi \u0111i\u1ec1u tr\u1ecb so v\u1edbi ch\u0103m s\u00f3c th\u00f4ng th\u01b0\u1eddng.\u00a0<\/span><\/p>\n

3. \u0110i\u1ec1u tr\u1ecb t\u00e1i t\u01b0\u1edbi m\u00e1u\u00a0<\/strong><\/h2>\n

3.1 Ti\u00eau s\u1ee3i huy\u1ebft h\u1ec7 th\u1ed1ng<\/em><\/strong><\/h3>\n

\u0110i\u1ec1u tr\u1ecb ti\u00eau s\u1ee3i huy\u1ebft s\u1ebd c\u1ea3i thi\u1ec7n t\u1eafc ngh\u1ebdn ph\u1ed5i, \u00e1p l\u1ef1c \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i (PAP) v\u00e0 kh\u00e1ng l\u1ef1c m\u1ea1ch m\u00e1u ph\u1ed5i (PVR) \u1edf b\u1ec7nh nh\u00e2n PE nhanh h\u01a1n so v\u1edbi UFH \u0111\u01a1n tr\u1ecb li\u1ec7u; nh\u1eefng c\u1ea3i thi\u1ec7n n\u00e0y \u0111i k\u00e8m v\u1edbi vi\u1ec7c gi\u1ea3m \u0111\u1ed9 gi\u00e3n th\u1ea5t ph\u1ea3i tr\u00ean si\u00eau \u00e2m tim. L\u1ee3i \u00edch l\u1edbn nh\u1ea5t \u0111\u01b0\u1ee3c quan s\u00e1t th\u1ea5y khi \u0111i\u1ec1u tr\u1ecb \u0111\u01b0\u1ee3c b\u1eaft \u0111\u1ea7u trong v\u00f2ng 48 gi\u1edd k\u1ec3 t\u1eeb khi kh\u1edfi ph\u00e1t tri\u1ec7u ch\u1ee9ng, nh\u01b0ng thu\u1ed1c ti\u00eau s\u1ee3i huy\u1ebft v\u1eabn c\u00f3 th\u1ec3 h\u1eefu \u00edch \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 tri\u1ec7u ch\u1ee9ng trong 6-14 ng\u00e0y. Ti\u00eau s\u1ee3i huy\u1ebft kh\u00f4ng th\u00e0nh c\u00f4ng, \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 b\u1edfi l\u00e2m s\u00e0ng kh\u00f4ng \u1ed5n \u0111\u1ecbnh dai d\u1eb3ng v\u00e0 r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng RV kh\u00f4ng thay \u0111\u1ed5i tr\u00ean si\u00eau \u00e2m tim sau 36 gi\u1edd, \u0111\u00e3 \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o \u1edf 8% b\u1ec7nh nh\u00e2n PE nguy c\u01a1 cao.<\/span><\/p>\n

M\u1ed9t ph\u00e2n t\u00edch g\u1ed9p c\u00e1c th\u1eed nghi\u1ec7m ti\u00eau s\u1ee3i huy\u1ebft trong \u0111\u00f3 c\u00f3 (nh\u01b0ng kh\u00f4ng ch\u1ec9 gi\u1edbi h\u1ea1n \u1edf) b\u1ec7nh nh\u00e2n PE nguy c\u01a1 cao, \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh ch\u1ee7 y\u1ebfu b\u1edfi s\u1ed1c tim, cho th\u1ea5y gi\u1ea3m \u0111\u00e1ng k\u1ec3 k\u1ebft c\u1ee5c ph\u1ed1i h\u1ee3p c\u1ee7a t\u1eed vong v\u00e0 PE t\u00e1i ph\u00e1t (D\u1eef li\u1ec7u b\u1ed5 sung B\u1ea3ng 10). \u0110i k\u00e8m v\u1edbi t\u1ef7 l\u1ec7 9.9% ch\u1ea3y m\u00e1u nghi\u00eam tr\u1ecdng v\u00e0 t\u1ef7 l\u1ec7 xu\u1ea5t huy\u1ebft n\u1ed9i s\u1ecd l\u00e0 1.7%. <\/span><\/p>\n

\u1ede nh\u1eefng b\u1ec7nh nh\u00e2n PE nguy c\u01a1 trung b\u00ecnh c\u00f3 huy\u1ebft \u00e1p b\u00ecnh th\u01b0\u1eddng, \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a khi c\u00f3 s\u1ef1 hi\u1ec7n di\u1ec7n c\u1ee7a r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng RV v\u00e0 n\u1ed3ng \u0111\u1ed9 troponin t\u0103ng cao, th\u00ec t\u00e1c \u0111\u1ed9ng c\u1ee7a \u0111i\u1ec1u tr\u1ecb ti\u00eau s\u1ee3i huy\u1ebft \u0111\u01b0\u1ee3c nghi\u00ean c\u1ee9u trong Th\u1eed nghi\u1ec7m ti\u00eau s\u1ee3i huy\u1ebft trong thuy\u00ean t\u1eafc ph\u1ed5i (PEITHO). \u0110i\u1ec1u tr\u1ecb ti\u00eau s\u1ee3i huy\u1ebft c\u00f3 li\u00ean quan \u0111\u1ebfn vi\u1ec7c gi\u1ea3m \u0111\u00e1ng k\u1ec3 nguy c\u01a1 m\u1ea5t b\u00f9 ho\u1eb7c suy s\u1ee5p huy\u1ebft \u0111\u1ed9ng, nh\u01b0ng song song l\u1ea1i t\u0103ng nguy c\u01a1 ch\u1ea3y m\u00e1u ngo\u1ea1i s\u1ecd v\u00e0 n\u1ed9i s\u1ecd nghi\u00eam tr\u1ecdng. Trong th\u1eed nghi\u1ec7m PEITHO, t\u1ef7 l\u1ec7 t\u1eed vong 30 ng\u00e0y \u0111\u1ec1u th\u1ea5p \u1edf c\u1ea3 hai nh\u00f3m \u0111i\u1ec1u tr\u1ecb, m\u1eb7c d\u00f9 c\u00e1c ph\u00e2n t\u00edch g\u1ed9p \u0111\u00e3 cho th\u1ea5y gi\u1ea3m t\u1ef7 l\u1ec7 t\u1eed vong chung v\u00e0 t\u1ef7 l\u1ec7 t\u1eed vong li\u00ean quan \u0111\u1ebfn PE l\u00ean t\u1edbi 50-60% sau khi \u0111i\u1ec1u tr\u1ecb ti\u00eau s\u1ee3i huy\u1ebft trong nh\u00f3m nguy c\u01a1 trung b\u00ecnh (d\u1eef li\u1ec7u b\u1ed5 sung B\u1ea3ng 10)<\/span><\/p>\n

\"chong-chi-dinh-<\/p>\n

Li\u1ec7u tr\u00ecnh v\u00e0 li\u1ec1u thu\u1ed1c ti\u00eau s\u1ee3i huy\u1ebft \u0111\u01b0\u1ee3c ph\u00ea duy\u1ec7t cho PE, c\u0169ng nh\u01b0 c\u00e1c ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh v\u1edbi lo\u1ea1i \u0111i\u1ec1u tr\u1ecb n\u00e0y, \u0111\u01b0\u1ee3c tr\u00ecnh b\u00e0y trong B\u1ea3ng 10. Truy\u1ec1n nhanh ch\u1ea5t ho\u1ea1t h\u00f3a plasminogen m\u00f4 t\u00e1i t\u1ed5 h\u1ee3p (rtPA; 100 mg trong 2 gi\u1edd) \u0111\u01b0\u1ee3c \u01b0a chu\u1ed9ng h\u01a1n truy\u1ec1n k\u00e9o d\u00e0i c\u00e1c thu\u1ed1c ti\u00eau s\u1ee3i huy\u1ebft th\u1ebf h\u1ec7 \u0111\u1ea7u ti\u00ean (streptokinase v\u00e0 urokinase). C\u00e1c b\u00e1o c\u00e1o ban \u0111\u1ea7u v\u1ec1 hi\u1ec7u qu\u1ea3 v\u00e0 t\u00ednh an to\u00e0n c\u1ee7a gi\u1ea3m li\u1ec1u rtPA c\u1ea7n \u0111\u01b0\u1ee3c x\u00e1c nh\u1eadn v\u1edbi b\u1eb1ng ch\u1ee9ng ch\u1eafc ch\u1eafn tr\u01b0\u1edbc khi c\u00f3 th\u1ec3 th\u1ef1c hi\u1ec7n b\u1ea5t k\u1ef3 khuy\u1ebfn c\u00e1o n\u00e0o v\u1ec1 v\u1ea5n \u0111\u1ec1 n\u00e0y. UFH c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c d\u00f9ng trong khi truy\u1ec1n li\u00ean t\u1ee5c alteplase, nh\u01b0ng n\u00ean ng\u01b0ng s\u1eed d\u1ee5ng n\u1ebfu truy\u1ec1n streptokinase ho\u1eb7c urokinase. Reteplase, desmoteplase ho\u1eb7c tenecteplase c\u0169ng \u0111ang \u0111\u01b0\u1ee3c nghi\u00ean c\u1ee9u; hi\u1ec7n t\u1ea1i, ch\u01b0a c\u00f3 thu\u1ed1c n\u00e0o trong s\u1ed1 \u0111\u00f3 \u0111\u01b0\u1ee3c ph\u00ea duy\u1ec7t s\u1eed d\u1ee5ng trong PE c\u1ea5p t\u00ednh. <\/span><\/p>\n

Hi\u1ec7n v\u1eabn ch\u01b0a r\u00f5 li\u1ec7u s\u1eed d\u1ee5ng ti\u00eau s\u1ee3i huy\u1ebft s\u1edbm cho PE c\u1ea5p t\u00ednh (nguy c\u01a1 trung b\u00ecnh ho\u1eb7c cao) c\u00f3 \u1ea3nh h\u01b0\u1edfng \u0111\u1ebfn c\u00e1c tri\u1ec7u ch\u1ee9ng l\u00e2m s\u00e0ng, s\u1ef1 h\u1ea1n ch\u1ebf ch\u1ee9c n\u0103ng, ho\u1eb7c CTEPH khi theo d\u00f5i l\u00e2u d\u00e0i hay kh\u00f4ng. M\u1ed9t th\u1eed nghi\u1ec7m ng\u1eabu nhi\u00ean nh\u1ecf tr\u00ean 83 b\u1ec7nh nh\u00e2n cho th\u1ea5y ti\u00eau s\u1ee3i huy\u1ebft c\u00f3 th\u1ec3 c\u1ea3i thi\u1ec7n kh\u1ea3 n\u0103ng sinh ho\u1ea1t \u1edf 3 th\u00e1ng so v\u1edbi ch\u1ec9 d\u00f9ng ch\u1ed1ng \u0111\u00f4ng m\u00e1u. Trong th\u1eed nghi\u1ec7m PEITHO, tri\u1ec7u ch\u1ee9ng nh\u1eb9 k\u00e9o d\u00e0i, ch\u1ee7 y\u1ebfu l\u00e0 kh\u00f3 th\u1edf, v\u1eabn c\u00f2n k\u00e9o d\u00e0i \u1edf 33% b\u1ec7nh nh\u00e2n (\u1edf m\u1ee9c 41.6 \u00b1 15.7 th\u00e1ng) theo d\u00f5i l\u00e2m s\u00e0ng. Tuy nhi\u00ean, ph\u1ea7n l\u1edbn b\u1ec7nh nh\u00e2n (85% \u1edf nh\u00e1nh tenecteplase v\u00e0 96% \u1edf nh\u00e1nh gi\u1ea3 d\u01b0\u1ee3c) c\u00f3 x\u00e1c su\u1ea5t th\u1ea5p ho\u1eb7c trung b\u00ecnh \u2013 d\u1ef1a tr\u00ean \u0111\u1ecbnh ngh\u0129a H\u01b0\u1edbng d\u1eabn ESC \u2013 c\u1ee7a t\u0103ng \u00e1p ph\u1ed5i (PH) dai d\u1eb3ng ho\u1eb7c m\u1edbi kh\u1edfi ph\u00e1t khi theo d\u00f5i tr\u00ean si\u00eau \u00e2m tim. Do \u0111\u00f3, nh\u1eefng ph\u00e1t hi\u1ec7n c\u1ee7a nghi\u00ean c\u1ee9u n\u00e0y kh\u00f4ng h\u1ed7 tr\u1ee3 vai tr\u00f2 c\u1ee7a ti\u00eau s\u1ee3i huy\u1ebft v\u1edbi m\u1ee5c \u0111\u00edch ng\u0103n ng\u1eeba di ch\u1ee9ng l\u00e2u d\u00e0i (ph\u1ea7n 10) sau PE nguy c\u01a1 trung b\u00ecnh, m\u1eb7c d\u00f9 nghi\u00ean c\u1ee9u b\u1ecb h\u1ea1n ch\u1ebf b\u1edfi ch\u1ec9 c\u00f3 62% d\u00e2n s\u1ed1 nghi\u00ean c\u1ee9u l\u00e0 ti\u1ebfp t\u1ee5c theo d\u00f5i<\/span><\/p>\n

3.2 \u0110i\u1ec1u tr\u1ecb tr\u1ef1c ti\u1ebfp b\u1eb1ng catheter qua da<\/em><\/strong><\/h3>\n

\u00a0T\u00e1i t\u01b0\u1edbi m\u00e1u c\u01a1 h\u1ecdc \u0111\u01b0\u1ee3c d\u1ef1a v\u00e0o vi\u1ec7c \u0111\u1eb7t \u1ed1ng th\u00f4ng (catheter)<\/a> v\u00e0o c\u00e1c \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i th\u00f4ng qua t\u0129nh m\u1ea1ch \u0111\u00f9i. C\u00e1c lo\u1ea1i catheter kh\u00e1c nhau (\u0111\u01b0\u1ee3c t\u00f3m t\u1eaft trong d\u1eef li\u1ec7u b\u1ed5 sung B\u1ea3ng 11) \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng \u0111\u1ec3 l\u00e0m v\u1ee1 huy\u1ebft kh\u1ed1i, h\u00fat huy\u1ebft kh\u1ed1i, ho\u1eb7c ph\u1ed5 bi\u1ebfn h\u01a1n l\u00e0 ti\u1ebfp c\u1eadn d\u01b0\u1ee3c c\u01a1 h\u1ecdc ngh\u0129a l\u00e0 l\u00e0m v\u1ee1 huy\u1ebft kh\u1ed1i b\u1eb1ng c\u01a1 h\u1ecdc ho\u1eb7c b\u1eb1ng si\u00eau \u00e2m k\u1ebft h\u1ee3p v\u1edbi thu\u1ed1c ti\u00eau s\u1ee3i huy\u1ebft t\u1ea1i ch\u1ed7 gi\u1ea3m li\u1ec1u. <\/span><\/p>\n

H\u1ea7u h\u1ebft ki\u1ebfn th\u1ee9c v\u1ec1 vi\u1ec7c l\u1ea5y huy\u1ebft kh\u1ed1i b\u1eb1ng catheter \u0111\u01b0\u1ee3c l\u1ea5y t\u1eeb c\u00e1c \u0111\u0103ng b\u1ed9 (registration) v\u00e0 k\u1ebft qu\u1ea3 g\u1ed9p t\u1eeb c\u00e1c b\u00e1o c\u00e1o lo\u1ea1t ca. T\u1ef7 l\u1ec7 chung v\u1ec1 th\u1ee7 thu\u1eadt th\u00e0nh c\u00f4ng (\u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 \u1ed5n \u0111\u1ecbnh huy\u1ebft \u0111\u1ed9ng, kh\u00f4ng c\u00f2n thi\u1ebfu oxy v\u00e0 s\u1ed1ng s\u00f3t khi xu\u1ea5t vi\u1ec7n) khi \u0111i\u1ec1u tr\u1ecb b\u1eb1ng catheter qua da \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o trong c\u00e1c nghi\u00ean c\u1ee9u n\u00e0y \u0111\u1ea1t t\u1edbi 87%, tuy nhi\u00ean, nh\u1eefng k\u1ebft qu\u1ea3 n\u00e0y c\u00f3 th\u1ec3 kh\u00f4ng \u0111\u1ee7 m\u1ea1nh \u0111\u1ec3 c\u00f4ng b\u1ed1. M\u1ed9t RCT so s\u00e1nh gi\u1eefa \u0111i\u1ec1u tr\u1ecb heparin th\u00f4ng th\u01b0\u1eddng v\u1edbi \u0111i\u1ec1u tr\u1ecb b\u1eb1ng catheter bao g\u1ed3m l\u00e0m v\u1ee1 huy\u1ebft kh\u1ed1i b\u1eb1ng si\u00eau \u00e2m v\u00e0 ti\u00eau s\u1ee3i huy\u1ebft t\u1ea1i ch\u1ed7 li\u1ec1u th\u1ea5p v\u1edbi 59 b\u1ec7nh nh\u00e2n c\u00f3 PE nguy c\u01a1 trung b\u00ecnh. Trong nghi\u00ean c\u1ee9u \u0111\u00f3, ti\u00eau s\u1ee3i huy\u1ebft c\u00f3 tr\u1ee3 gi\u00fap c\u1ee7a si\u00eau \u00e2m c\u00f3 li\u00ean quan \u0111\u1ebfn gi\u1ea3m t\u1ef7 l\u1ec7 \u0111\u01b0\u1eddng k\u00ednh RV\/LV \u1edf gi\u1edd th\u1ee9 24 nhi\u1ec1u h\u01a1n, m\u00e0 kh\u00f4ng t\u0103ng nguy c\u01a1 ch\u1ea3y m\u00e1u. D\u1eef li\u1ec7u t\u1eeb hai nghi\u00ean c\u1ee9u \u0111o\u00e0n h\u1ec7 ti\u1ebfn c\u1ee9u v\u00e0 m\u1ed9t \u0111\u0103ng b\u1ed9, v\u1edbi t\u1ed5ng s\u1ed1 352 b\u1ec7nh nh\u00e2n, cho k\u1ebft qu\u1ea3 c\u1ea3i thi\u1ec7n ch\u1ee9c n\u0103ng RV, t\u01b0\u1edbi m\u00e1u ph\u1ed5i v\u00e0 PAP \u1edf b\u1ec7nh nh\u00e2n PE nguy c\u01a1 trung b\u00ecnh ho\u1eb7c cao khi s\u1eed d\u1ee5ng ph\u01b0\u01a1ng ph\u00e1p tr\u00ean. Xu\u1ea5t huy\u1ebft n\u1ed9i s\u1ecd l\u00e0 r\u1ea5t hi\u1ebfm, m\u1eb7c d\u00f9 t\u1ef7 l\u1ec7 bi\u1ebfn ch\u1ee9ng ch\u1ea3y m\u00e1u n\u1eb7ng v\u00e0 v\u1eeba l\u00e0 10% trong m\u1ed9t trong nh\u1eefng k\u1ebft qu\u1ea3 c\u1ee7a nghi\u00ean c\u1ee9u Vi\u1ec7c s\u1eed d\u1ee5ng Streptokinase v\u00e0 Ch\u1ea5t ho\u1ea1t h\u00f3a Plasminogen m\u00f4 cho \u0111\u1ed9ng m\u1ea1ch v\u00e0nh b\u1ecb t\u1eafc tr\u00ean to\u00e0n c\u1ea7u (GUSTO). <\/span><\/p>\n

Nh\u1eefng k\u1ebft qu\u1ea3 n\u00e0y c\u1ea7n \u0111\u01b0\u1ee3c gi\u1ea3i th\u00edch m\u1ed9t c\u00e1ch th\u1eadn tr\u1ecdng, do s\u1ed1 l\u01b0\u1ee3ng b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb t\u01b0\u01a1ng \u0111\u1ed1i nh\u1ecf, thi\u1ebfu c\u00e1c nghi\u00ean c\u1ee9u so s\u00e1nh tr\u1ef1c ti\u1ebfp gi\u1eefa \u0111i\u1ec1u tr\u1ecb b\u1eb1ng catheter tr\u1ef1c ti\u1ebfp v\u1edbi \u0111i\u1ec1u tr\u1ecb tan huy\u1ebft kh\u1ed1i to\u00e0n th\u00e2n, v\u00e0 thi\u1ebfu d\u1eef li\u1ec7u t\u1eeb RCT v\u1ec1 k\u1ebft c\u1ee5c hi\u1ec7u qu\u1ea3 l\u00e2m s\u00e0ng.<\/span><\/p>\n

3.3 Ph\u1eabu thu\u1eadt l\u1ea5y huy\u1ebft kh\u1ed1i<\/a><\/em><\/strong><\/h3>\n

Ph\u1eabu thu\u1eadt l\u1ea5y huy\u1ebft kh\u1ed1i trong PE c\u1ea5p t\u00ednh th\u01b0\u1eddng \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n v\u1edbi tu\u1ea7n ho\u00e0n ngo\u00e0i c\u01a1 th\u1ec3 m\u00e0 kh\u00f4ng k\u1eb9p \u0111\u1ed9ng m\u1ea1ch ch\u1ee7 v\u00e0 g\u00e2y ng\u01b0ng tim, sau \u0111\u00f3 r\u1ea1ch 2 \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i ch\u00ednh, l\u1ea5y v\u00e0 h\u00fat huy\u1ebft kh\u1ed1i. C\u00e1c b\u00e1o c\u00e1o g\u1ea7n \u0111\u00e2y \u0111\u00e3 ch\u1ec9 ra k\u1ebft qu\u1ea3 c\u00f3 l\u1ee3i khi ph\u1eabu thu\u1eadt \u1edf PE nguy c\u01a1 cao, c\u00f3 ho\u1eb7c kh\u00f4ng c\u00f3 ng\u1eebng tim v\u00e0 m\u1ed9t s\u1ed1 tr\u01b0\u1eddng h\u1ee3p PE nguy c\u01a1 trung b\u00ecnh. Trong s\u1ed1 174 322 b\u1ec7nh nh\u00e2n nh\u1eadp vi\u1ec7n t\u1eeb n\u0103m 1999 \u0111\u1ebfn 2013 v\u1edbi ch\u1ea9n \u0111o\u00e1n PE \u1edf bang New York, t\u1ef7 su\u1ea5t s\u1ed1ng c\u00f2n v\u00e0 t\u1ef7 su\u1ea5t t\u00e1i ph\u00e1t \u0111\u01b0\u1ee3c so s\u00e1nh gi\u1eefa b\u1ec7nh nh\u00e2n s\u1eed d\u1ee5ng ti\u00eau s\u1ee3i huy\u1ebft (n = 1854) v\u00e0 b\u1ec7nh nh\u00e2n ph\u1eabu thu\u1eadt l\u1ea5y huy\u1ebft kh\u1ed1i (n = 257) nh\u01b0 tr\u1ecb li\u1ec7u \u0111\u1ea7u tay. Nh\u00ecn chung, kh\u00f4ng c\u00f3 s\u1ef1 kh\u00e1c bi\u1ec7t gi\u1eefa hai lo\u1ea1i \u0111i\u1ec1u tr\u1ecb t\u00e1i t\u01b0\u1edbi m\u00e1u li\u00ean quan \u0111\u1ebfn t\u1eed vong trong 30 ng\u00e0y (t\u01b0\u01a1ng \u1ee9ng 15 v\u00e0 13%), nh\u01b0ng ti\u00eau s\u1ee3i huy\u1ebft c\u00f3 li\u00ean quan \u0111\u1ebfn nguy c\u01a1 \u0111\u1ed9t qu\u1ef5 v\u00e0 t\u00e1i can thi\u1ec7p cao h\u01a1n sau 30 ng\u00e0y. Kh\u00f4ng c\u00f3 s\u1ef1 kh\u00e1c bi\u1ec7t v\u1ec1 t\u1ef7 su\u1ea5t s\u1ed1ng c\u00f2n 5 n\u0103m \u01b0\u1edbc t\u00ednh, nh\u01b0ng \u0111i\u1ec1u tr\u1ecb ti\u00eau s\u1ee3i huy\u1ebft c\u00f3 li\u00ean quan v\u1edbi t\u1ef7 l\u1ec7 PE t\u00e1i ph\u00e1t c\u1ea7n t\u00e1i nh\u1eadp vi\u1ec7n cao h\u01a1n so v\u1edbi ph\u1eabu thu\u1eadt (7.9 so v\u1edbi 2.8%). <\/span><\/p>\n

Tuy nhi\u00ean, hai ph\u01b0\u01a1ng ph\u00e1p \u0111i\u1ec1u tr\u1ecb kh\u00f4ng ph\u00e2n b\u1ed5 ng\u1eabu nhi\u00ean trong nghi\u00ean c\u1ee9u quan s\u00e1t h\u1ed3i c\u1ee9u n\u00e0y v\u00e0 b\u1ec7nh nh\u00e2n \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ecdn l\u1ecdc \u0111\u1ec3 h\u1ed9i ch\u1ea9n ph\u1eabu thu\u1eadt. M\u1ed9t ph\u00e2n t\u00edch c\u1ee7a Hi\u1ec7p h\u1ed9i c\u01a1 s\u1edf d\u1eef li\u1ec7u ph\u1eabu thu\u1eadt l\u1ed3ng ng\u1ef1c v\u1edbi b\u1ed9 h\u1ed3 s\u01a1 d\u1eef li\u1ec7u \u0111a trung t\u00e2m, bao g\u1ed3m 214 b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c ph\u1eabu thu\u1eadt l\u1ea5y huy\u1ebft kh\u1ed1i trong PE nguy c\u01a1 cao (n = 38) ho\u1eb7c trung b\u00ecnh (n = 176), cho th\u1ea5y t\u1ef7 l\u1ec7 t\u1eed vong trong b\u1ec7nh vi\u1ec7n l\u00e0 12%, v\u1edbi k\u1ebft c\u1ee5c x\u1ea5u nh\u1ea5t l\u00e0 (32%) b\u1ec7nh nh\u00e2n trong nh\u00f3m b\u1ecb ng\u1eebng tim tr\u01b0\u1edbc ph\u1eabu thu\u1eadt.<\/span><\/p>\n

Kinh nghi\u1ec7m g\u1ea7n \u0111\u00e2y c\u00f3 v\u1ebb nh\u01b0 \u1ee7ng h\u1ed9 s\u1ef1 k\u1ebft h\u1ee3p ECMO v\u1edbi ph\u1eabu thu\u1eadt l\u1ea5y huy\u1ebft kh\u1ed1i, \u0111\u1eb7c bi\u1ec7t \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 PE nguy c\u01a1 cao c\u00f3 ho\u1eb7c kh\u00f4ng c\u00f3 h\u1ed3i s\u1ee9c tim ph\u1ed5i. Trong s\u1ed1 nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 PE nguy c\u01a1 trung b\u00ecnh (n = 28), PE c\u00f3 nguy c\u01a1 cao kh\u00f4ng b\u1ecb ng\u1eebng tim (n = 18) v\u00e0 PE b\u1ecb ng\u1eebng tim (n = 9), t\u1ef7 su\u1ea5t s\u1ed1ng c\u00f2n trong b\u1ec7nh vi\u1ec7n v\u00e0 t\u1ef7 su\u1ea5t s\u1ed1ng c\u00f2n 1 n\u0103m l\u1ea7n l\u01b0\u1ee3t l\u00e0 93 v\u00e0 91%<\/span><\/p>\n

4. \u0110\u1ed9i thuy\u00ean t\u1eafc ph\u1ed5i \u0111a chuy\u00ean khoa<\/strong><\/h2>\n

Kh\u00e1i ni\u1ec7m v\u1ec1 c\u00e1c \u0111\u1ed9i ph\u1ea3n \u1ee9ng nhanh \u0111a chuy\u00ean khoa trong qu\u1ea3n l\u00fd PE nghi\u00eam tr\u1ecdng (nguy c\u01a1 cao v\u00e0 m\u1ed9t s\u1ed1 tr\u01b0\u1eddng h\u1ee3p PE trung b\u00ecnh) \u0111\u00e3 xu\u1ea5t hi\u1ec7n \u1edf Hoa K\u1ef3, v\u1edbi s\u1ef1 ch\u1ea5p nh\u1eadn ng\u00e0y c\u00e0ng cao c\u1ee7a c\u1ed9ng \u0111\u1ed3ng y t\u1ebf v\u00e0 \u0111\u01b0\u1ee3c tri\u1ec3n khai t\u1ea1i c\u00e1c b\u1ec7nh vi\u1ec7n \u1edf Ch\u00e2u \u00c2u v\u00e0 tr\u00ean to\u00e0n th\u1ebf gi\u1edbi. Vi\u1ec7c thi\u1ebft l\u1eadp c\u00e1c \u0111\u1ed9i ph\u1ea3n \u1ee9ng PE (PERT) \u0111\u01b0\u1ee3c khuy\u1ebfn kh\u00edch, v\u00ec h\u1ecd \u0111\u00e1p \u1ee9ng c\u00e1c nhu c\u1ea7u c\u1ee7a ch\u0103m s\u00f3c s\u1ee9c kh\u1ecfe hi\u1ec7n \u0111\u1ea1i d\u1ef1a tr\u00ean h\u1ec7 th\u1ed1ng. M\u1ed9t PERT t\u1eadp h\u1ee3p m\u1ed9t nh\u00f3m c\u00e1c chuy\u00ean gia t\u1eeb nhi\u1ec1u chuy\u00ean khoa kh\u00e1c nhau bao g\u1ed3m, v\u00ed d\u1ee5, tim m\u1ea1ch, h\u00f4 h\u1ea5p, huy\u1ebft h\u1ecdc, y h\u1ecdc m\u1ea1ch m\u00e1u, g\u00e2y m\u00ea\/h\u1ed3i s\u1ee9c t\u00edch c\u1ef1c, ph\u1eabu thu\u1eadt tim l\u1ed3ng ng\u1ef1c, v\u00e0 h\u00ecnh \u1ea3nh h\u1ecdc (can thi\u1ec7p). \u0110\u1ed9i tri\u1ec7u t\u1eadp trong th\u1eddi gian th\u1ef1c (m\u1eb7t \u0111\u1ed1i m\u1eb7t ho\u1eb7c h\u1ecdp qua web) \u0111\u1ec3 ra quy\u1ebft \u0111\u1ecbnh l\u00e2m s\u00e0ng t\u1ed1t h\u01a1n. \u0110i\u1ec1u n\u00e0y cho ph\u00e9p x\u00e2y d\u1ef1ng k\u1ebf ho\u1ea1ch \u0111i\u1ec1u tr\u1ecb v\u00e0 t\u1ea1o \u0111i\u1ec1u ki\u1ec7n th\u1ef1c hi\u1ec7n ngay l\u1eadp t\u1ee9c. Th\u00e0nh vi\u00ean ch\u00ednh x\u00e1c v\u00e0 ch\u1ebf \u0111\u1ed9 v\u1eadn h\u00e0nh c\u1ee7a m\u1ed9t PERT kh\u00f4ng c\u1ed1 \u0111\u1ecbnh, t\u00f9y thu\u1ed9c v\u00e0o ngu\u1ed3n l\u1ef1c v\u00e0 chuy\u00ean m\u00f4n c\u1ee7a t\u1eebng b\u1ec7nh vi\u1ec7n v\u1ec1 qu\u1ea3n l\u00fd PE c\u1ea5p t\u00ednh.<\/span><\/p>\n

5. L\u01b0\u1edbi l\u1ecdc t\u0129nh m\u1ea1ch ch\u1ee7 d\u01b0\u1edbi <\/a><\/strong><\/h2>\n

M\u1ee5c \u0111\u00edch c\u1ee7a l\u01b0\u1edbi t\u0129nh m\u1ea1ch ch\u1ee7 l\u00e0 \u0111\u1ec3 ng\u0103n c\u01a1 h\u1ecdc c\u1ee5c m\u00e1u \u0111\u00f4ng t\u1eeb t\u0129nh m\u1ea1ch \u0111i \u0111\u1ebfn tu\u1ea7n ho\u00e0n ph\u1ed5i. H\u1ea7u h\u1ebft c\u00e1c thi\u1ebft b\u1ecb \u0111ang s\u1eed d\u1ee5ng hi\u1ec7n t\u1ea1i \u0111\u01b0\u1ee3c \u0111\u01b0a v\u00e0o qua da v\u00e0 c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c l\u1ea5y ra sau v\u00e0i tu\u1ea7n ho\u1eb7c v\u00e0i th\u00e1ng, ho\u1eb7c \u0111\u1ec3 t\u1ea1i ch\u1ed7 trong th\u1eddi gian d\u00e0i, n\u1ebfu c\u1ea7n. Ch\u1ec9 \u0111\u1ecbnh ti\u1ec1m n\u0103ng bao g\u1ed3m thuy\u00ean t\u1eafc huy\u1ebft kh\u1ed1i t\u0129nh m\u1ea1ch (VTE) m\u00e0 c\u00f3 ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh tuy\u1ec7t \u0111\u1ed1i v\u1edbi \u0111i\u1ec1u tr\u1ecb ch\u1ed1ng \u0111\u00f4ng m\u00e1u, PE t\u00e1i ph\u00e1t m\u1eb7c d\u00f9 \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ed1ng \u0111\u00f4ng \u0111\u1ea7y \u0111\u1ee7, v\u00e0 \u0111i\u1ec1u tr\u1ecb d\u1ef1 ph\u00f2ng ti\u00ean ph\u00e1t \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 nguy c\u01a1 m\u1eafc VTE cao. C\u00e1c ch\u1ec9 \u0111\u1ecbnh ti\u1ec1m n\u0103ng kh\u00e1c cho \u0111\u1eb7t l\u01b0\u1edbi l\u1ecdc bao g\u1ed3m huy\u1ebft kh\u1ed1i t\u1ef1 do, ch\u01b0a ch\u1eafc ch\u1eafn b\u1ec7nh nh\u00e2n kh\u00f4ng c\u00f3 ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh v\u1edbi \u0111i\u1ec1u tr\u1ecb kh\u00e1ng \u0111\u00f4ng hay kh\u00f4ng.<\/span><\/p>\n

Ch\u1ec9 c\u00f3 hai th\u1eed nghi\u1ec7m ng\u1eabu nhi\u00ean giai \u0111o\u1ea1n III \u0111\u00e3 so s\u00e1nh vi\u1ec7c ch\u1ed1ng \u0111\u00f4ng m\u00e1u c\u00f3 ho\u1eb7c kh\u00f4ng c\u00f3 l\u01b0\u1edbi l\u1ecdc t\u0129nh m\u1ea1ch ch\u1ee7 \u1edf b\u1ec7nh nh\u00e2n m\u1eafc huy\u1ebft kh\u1ed1i t\u0129nh m\u1ea1ch s\u00e2u (DVT) \u0111o\u1ea1n g\u1ea7n, c\u00f3 ho\u1eb7c kh\u00f4ng c\u00f3 PE. Trong nghi\u00ean c\u1ee9u Ng\u0103n ng\u1eeba thuy\u00ean t\u1eafc ph\u1ed5i t\u00e1i ph\u00e1t b\u1edfi l\u01b0\u1edbi l\u1ecdc t\u0129nh m\u1ea1ch ch\u1ee7 (PREPIC), \u0111\u1eb7t l\u01b0\u1edbi l\u1ecdc t\u0129nh m\u1ea1ch ch\u1ee7 v\u0129nh vi\u1ec5n c\u00f3 li\u00ean quan \u0111\u1ebfn gi\u1ea3m \u0111\u00e1ng k\u1ec3 nguy c\u01a1 PE t\u00e1i ph\u00e1t v\u00e0 t\u0103ng \u0111\u00e1ng k\u1ec3 nguy c\u01a1 m\u1eafc DVT, kh\u00f4ng c\u00f3 s\u1ef1 kh\u00e1c bi\u1ec7t c\u00f3 \u00fd ngh\u0129a th\u1ed1ng k\u00ea v\u1ec1 nguy c\u01a1 t\u00e1i ph\u00e1t VTE ho\u1eb7c t\u1eed vong. Th\u1eed nghi\u1ec7m PREPIC-2 \u0111\u00e3 ch\u1ecdn ng\u1eabu nhi\u00ean 399 b\u1ec7nh nh\u00e2n m\u1eafc PE v\u00e0 huy\u1ebft kh\u1ed1i t\u0129nh m\u1ea1ch \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb ch\u1ed1ng \u0111\u00f4ng m\u00e1u, c\u00f3 ho\u1eb7c kh\u00f4ng c\u00f3 \u0111\u1eb7t l\u01b0\u1edbi l\u1ecdc t\u0129nh m\u1ea1ch ch\u1ee7 l\u1ea5y ra \u0111\u01b0\u1ee3c. Trong nghi\u00ean c\u1ee9u n\u00e0y, t\u1ef7 su\u1ea5t VTE t\u00e1i ph\u00e1t th\u1ea5p \u1edf c\u1ea3 hai nh\u00f3m v\u00e0 kh\u00f4ng kh\u00e1c nhau gi\u1eefa c\u00e1c nh\u00f3m. M\u1ed9t t\u1ed5ng quan h\u1ec7 th\u1ed1ng v\u00e0 ph\u00e2n t\u00edch g\u1ed9p c\u00e1c b\u00e1o c\u00e1o \u0111\u01b0\u1ee3c c\u00f4ng b\u1ed1 v\u1ec1 hi\u1ec7u qu\u1ea3 v\u00e0 an to\u00e0n c\u1ee7a l\u01b0\u1edbi l\u1ecdc t\u0129nh m\u1ea1ch ch\u1ee7 bao g\u1ed3m 11 nghi\u00ean c\u1ee9u, v\u1edbi t\u1ed5ng s\u1ed1 2055 c\u00f3 l\u01b0\u1edbi l\u1ecdc v\u1edbi 2149 b\u1ec7nh nh\u00e2n kh\u00f4ng c\u00f3. V\u1ecb tr\u00ed l\u01b0\u1edbi l\u1ecdc t\u0129nh m\u1ea1ch ch\u1ee7 c\u00f3 li\u00ean quan \u0111\u1ebfn gi\u1ea3m 50% t\u1ef7 l\u1ec7 m\u1eafc PE v\u00e0 t\u0103ng ~70% nguy c\u01a1 m\u1eafc DVT theo th\u1eddi gian. C\u1ea3 t\u1ef7 l\u1ec7 t\u1eed vong do m\u1ecdi nguy\u00ean nh\u00e2n v\u00e0 t\u1ef7 l\u1ec7 t\u1eed vong li\u00ean quan \u0111\u1ebfn PE \u0111\u1ec1u kh\u00f4ng kh\u00e1c bi\u1ec7t gi\u1eefa b\u1ec7nh nh\u00e2n c\u00f3 ho\u1eb7c kh\u00f4ng c\u00f3 l\u01b0\u1edbi l\u1ecdc.<\/span><\/p>\n

Ch\u1ec9 \u0111\u1ecbnh r\u1ed9ng cho vi\u1ec7c \u0111\u1eb7t l\u01b0\u1edbi l\u1ecdc t\u0129nh m\u1ea1ch \u1edf b\u1ec7nh nh\u00e2n m\u1edbi m\u1eafc DVT \u0111o\u1ea1n g\u1ea7n<\/strong> (<1 th\u00e1ng) m\u00e0 c\u00f3 ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh tuy\u1ec7t \u0111\u1ed1i v\u1edbi \u0111i\u1ec1u tr\u1ecb ch\u1ed1ng \u0111\u00f4ng m\u00e1u, ch\u1ee7 y\u1ebfu d\u1ef1a tr\u00ean nguy c\u01a1 PE t\u00e1i ph\u00e1t cao trong b\u1ed1i c\u1ea3nh \u0111\u00f3 v\u00e0 thi\u1ebfu c\u00e1c l\u1ef1a ch\u1ecdn \u0111i\u1ec1u tr\u1ecb kh\u00e1c.<\/span><\/p>\n

C\u00e1c bi\u1ebfn ch\u1ee9ng li\u00ean quan \u0111\u1ebfn l\u01b0\u1edbi l\u1ecdc t\u0129nh m\u1ea1ch ch\u1ee7 l\u00e0 th\u01b0\u1eddng g\u1eb7p v\u00e0 c\u00f3 th\u1ec3 nghi\u00eam tr\u1ecdng. M\u1ed9t t\u1ed5ng quan t\u00e0i li\u1ec7u h\u1ec7 th\u1ed1ng \u0111\u01b0a ra s\u1ed1 li\u1ec7u bi\u1ebfn ch\u1ee9ng xuy\u00ean th\u00e0nh t\u0129nh m\u1ea1ch \u1edf 1699 trong s\u1ed1 9002 th\u1ee7 thu\u1eadt (19%); trong nh\u1eefng tr\u01b0\u1eddng h\u1ee3p n\u00e0y, 19% cho th\u1ea5y c\u00f3 xuy\u00ean \u0111\u1ebfn c\u00e1c c\u01a1 quan l\u00e2n c\u1eadn v\u00e0 \u22658% l\u00e0 c\u00f3 tri\u1ec7u ch\u1ee9ng. Bi\u1ebfn ch\u1ee9ng t\u1eed vong r\u1ea5t hi\u1ebfm (ch\u1ec9 c\u00f3 hai tr\u01b0\u1eddng h\u1ee3p), nh\u01b0ng 5% b\u1ec7nh nh\u00e2n c\u1ea7n can thi\u1ec7p l\u1edbn nh\u01b0 ph\u1eabu thu\u1eadt l\u1ea5y b\u1ecf l\u01b0\u1edbi l\u1ecdc, \u0111\u1eb7t stent n\u1ed9i m\u1ea1ch ho\u1eb7c thuy\u00ean t\u1eafc, l\u1ea5y b\u1ecf l\u01b0\u1edbi l\u1ecdc v\u0129nh vi\u1ec5n \u0111\u01b0\u1eddng n\u1ed9i m\u1ea1ch, ho\u1eb7c ph\u1eabu thu\u1eadt m\u1edf th\u1eadn qua da ho\u1eb7c \u0111\u1eb7t stent ni\u1ec7u qu\u1ea3n. C\u00e1c bi\u1ebfn ch\u1ee9ng \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o th\u00eam bao g\u1ed3m g\u00e3y l\u01b0\u1edbi l\u1ecdc v\u00e0\/ho\u1eb7c thuy\u00ean t\u1eafc v\u00e0 th\u1ec9nh tho\u1ea3ng DVT k\u00e9o d\u00e0i \u0111\u1ebfn t\u1eadn t\u0129nh m\u1ea1ch ch\u1ee7.<\/span><\/p>\n

6. Khuy\u1ebfn c\u00e1o v\u1ec1 \u0111i\u1ec1u tr\u1ecb thuy\u00ean t\u1eafc ph\u1ed5i nguy c\u01a1 cao giai \u0111o\u1ea1n c\u1ea5p t\u00ednh<\/strong><\/h2>\n

\"dieu-tri-thuyen-tac-phoi-nguy-co-cao\"<\/p>\n

7. Khuy\u1ebfn c\u00e1o v\u1ec1 \u0111i\u1ec1u tr\u1ecb thuy\u00ean t\u1eafc ph\u1ed5i nguy c\u01a1 trung b\u00ecnh ho\u1eb7c nguy c\u01a1 th\u1ea5p giai \u0111o\u1ea1n c\u1ea5p.<\/strong><\/h2>\n

\"chong-dong-trong-thuyen-tac-phoi-cap\"<\/p>\n

\"dieu-tri-tai-tuoi-mau\"<\/p>\n

8. Khuy\u1ebfn ngh\u1ecb v\u1ec1 \u0111\u1ed9i thuy\u00ean t\u1eafc ph\u1ed5i \u0111a chuy\u00ean khoa.<\/strong><\/h2>\n

\"doi-da-chuyen-khoa-thuyen-tac\"<\/p>\n

9. Khuy\u1ebfn c\u00e1o v\u1ec1 l\u01b0\u1edbi l\u1ecdc t\u0129nh m\u1ea1ch ch\u1ee7 d\u01b0\u1edbi.<\/strong><\/h2>\n

\"luoi-loc-tinh-mach-chu-duoi\"<\/p>\n

 <\/p>\n

10. Khuy\u1ebfn c\u00e1o v\u1ec1 cho xu\u1ea5t vi\u1ec7n s\u1edbm v\u00e0 \u0111i\u1ec1u tr\u1ecb t\u1ea1i nh\u00e0.<\/strong><\/h2>\n

\"xuat-vien-som-va-dieu-tri-tai-nha\"<\/p>\n

Xem th\u00eam:<\/strong> Thuy\u00ean t\u1eafc \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i trong th\u1ef1c h\u00e0nh l\u00e2m s\u00e0ng (vinmecdr.com)<\/a><\/p>\n

T\u00e0i li\u1ec7u tham kh\u1ea3o:<\/p>\n

2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS): The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC) – PubMed (nih.gov)<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

Thuy\u00ean t\u1eafc m\u1ea1ch ph\u1ed5i (Pulmonary Embolism) l\u00e0 m\u1ed9t t\u00ecnh tr\u1ea1ng y t\u1ebf nghi\u00eam tr\u1ecdng, g\u00e2y ra t\u1edbi 85.000 ng\u01b0\u1eddi ch\u1ebft\/n\u0103m. T\u1eafc m\u1ea1ch ph\u1ed5i ch\u1ee7 y\u1ebfu t\u00e1c \u0111\u1ed9ng \u0111\u1ebfn ng\u01b0\u1eddi tr\u01b0\u1edfng th\u00e0nh, vi\u1ec7c ch\u1ea9n \u0111o\u00e1n v\u00e0 \u0111i\u1ec1u tr\u1ecb k\u1ecbp thuy\u00ean t\u1eafc ph\u1ed5i giai \u0111o\u1ea1n c\u1ea5p v\u00f4 c\u00f9ng quan tr\u1ecdng,\u00a0 c\u1ea7n \u0111\u01b0\u1ee3c c\u00e1c nh\u00e2n vi\u00ean y t\u1ebf […]<\/p>\n","protected":false},"author":17,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":[],"categories":[20,33],"tags":[],"yoast_head":"\n\u0110i\u1ec1u tr\u1ecb thuy\u00ean t\u1eafc ph\u1ed5i giai \u0111o\u1ea1n c\u1ea5p - ESC 2019 - Vinmec<\/title>\n<meta name=\"description\" content=\"\u0110i\u1ec1u tr\u1ecb k\u1ecbp thuy\u00ean t\u1eafc ph\u1ed5i giai \u0111o\u1ea1n c\u1ea5p v\u00f4 c\u00f9ng quan tr\u1ecdng,\u00a0 c\u1ea7n \u0111\u01b0\u1ee3c c\u00e1c nh\u00e2n vi\u00ean y t\u1ebf v\u00e0 ng\u01b0\u1eddi b\u1ec7nh \u0111\u1eb7c bi\u1ec7t quan t\u00e2m.\" \/>\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=\"\u0110i\u1ec1u tr\u1ecb thuy\u00ean t\u1eafc ph\u1ed5i giai \u0111o\u1ea1n c\u1ea5p - 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