Giáo trình dược lâm sàng sách đào tạo dược sỹ đại học cao đẳng tập 2

Gicio trinh dwor Lim sang Trtremg Cao DOng K9 Thttcit Y Te 11196 Niing de ucing, sinh kha dyng wan d6i On dinh, it phy thuOc vao baa an hoac nutc u6ng, nhien day la clang thutng dAt DU A THUOC THEO DU'ONG TIEM 2.1/ Rim tat mot so difc diem can thulic diem Day la &rang dua thu6c co sinh kha dyng bao dam nhat va c6 the.' gian xuAt hien tac dyng ngan Dutng tiem duvc dung nhieu benh vien, nhAt la nhung truong hop benh nang hoac cap eau Ve m5t bao che, thu6c tiem c6 the la dang dung dich, h6n dich hay nhit tuong Yeu cdu ciia thuac tiem: ✓ Vo khuAn ✓ MOt so thuic tiem d5c biet ho5c vol thu6c tiem dung riot ran tir l5ml tra len phai khong &roc co chAt gay sit ✓ Thu6c tiem dung dich phai dat quy dinh, thu6c tiem hOn dich hay nhil tuong lac kj", phai tao duvc he phan tan dling nhat ✓ Thu6c tiem phai co pH thich hop de dam bao de ben cua duvc chAt va tiem it gayclau ✓ Thu& tiem truyen vol Itiong phai dAng truong vai mau ✓ Dung moi de hoa tan thu6c tiem phai dat yeti eau "dung pha tiem "theo quy dinh propylene glycol va Cac dung mai thtrerng diing thuac tiem: dau, ethanol, nuOc cat, PEG 300 — 600 Uu diem dm thuac tiem: - Tranh duce su pha buy thu& cac yeu to &trig tieu h6a: dich vi, men Weil h6a - Tranh &roc sir hao hyt phai van chuyen ong tieu h6a - Tranh desc tinh len niem mac tieu hoa (m6t so thu6c ch6ng ung thu Crc the sy phat trien ciia niem mac ing tieu hoa) Nhuvc diem &iv thuac tiem: - Doi hoi dieu kien vo trung nghiem ngat va sty giftp dm can Ix) chuyen mon - Chi phi cao - DO an toan thAp hon so voi cac dung dua thueic khac vi de gay soc (tiem tinh mach), gay dau, th5m chi ap-xe (tiem bAp), de bi nhrem 2.2/1/0/ si) aid, dam thuoc theo dirowg diem: al Dunn tinh mach: Liu diem: - Sinh kha dyng 100% - Tac dung nhanh - CO 11-16 dua vao co th6 I luang thuoc Nhuor diem: phtrc tap, d8 gay tai bin Nhirng thuac hay cliang qua cluVng sinh mach: Cac hoat chat co kich ung cao, gay dau hoac hoai tif co tiem bAp nhu penicillin G, dung dich CaCl2, cac dung dich uu truong, cac chat de bit the tich dich luu hanh nhu cac loai dich truyen tinh the, dung dich dextran, albumin Nang truong hap khong &roc Max thuac qua throng firth mach: cac dung dich dau, h8n dich Cac cach dua thuac vao linh mach: Tiem tinh mach tryc tie)) Tierra sinh mach quang ngAn Truyen sinh mach Ice() dai 27 Trading Cao D/ing Ky Thita:t Y Te II Da Nang GO° trinh dtrov la-m sang b/ Tiem Day la thrtng uu tien cho cac loci dung dich dau, hiSn dich, cac Ong thu6c tiem tac dyng Ice° dai Lint Khong &roc tiem bap: Nhimg chat có tac dyng kick &rig mynh to chirc hoc gay hoyi tir, dung dich uu twang, dung dich co PH qua acid hoc qua kiem Nguti benh dang sir dung thu6c cheng long mau hoac cac thu6c tieu fibrin Kh'Ong &roc tiem > 10 ml vac mot ch& Khong tiem bap cho tre so sinh c/ Tiem dwai da: sir dyng nhCing trutng h9p can Ice° dai tac dyng cua thu6c Ltru Kh6ng nen tiem > ml vao duti da Khong dung cho benh nhan dang a tryng thai soc, co ton thuong mo duai da Nen thuang xuyen thay dei vi tri tiem d/ Tiem da: thu6c hap thu cham, vi tri tiem thuang la mat tarot canh tay, lung e/ Ccic dareeng tiem khdc: - Tiem ngoai mang drng - hiern vao khop 3/ DUA THUOC QUA D1ff6NG HO HAP: Cac thu6c dua qua &rang ho hap vol tac dyng toan than khong nhieu va thuang rat dat Dyng bao the ph6 bin nhat la Ong phun mu, chi" y6u dang qua cluang ho hap de ph6ng ngira va dieu tri benh dutng ho hap Khi dung qua dutng ho hap, sinh kha dyng cua thu6c phun mu phy thu6c rat nhieu vao thiet bi phun ma va cach dung Neu thu6c phun mu la dyng h8n dich hay nhil thong thi phai lac kji trutc dung 28 Giao trinh thror Mtn sang Trzrowg Cao Hang K9 Thuat Y Te 11 Da Ming NGUYEN TAC DUNG THUOC KHANG SINH VA KHANG KHUAN, 111(IC TIEU I Phan lopi Ayr nguyen rex sir dyng khang sinh dieu tri, cho vi du minh hoa Phcin tich cluvc nguyen tijt sz'r dyng khang sinh tong cltr phong nhiim khucin sau phOu thuOt, cho vi du minh hpa NOI DUNG • Cac thu6c khang sinh va khang khan la nhOm thu6c de dieu tri nhigm vi khuAn, dat &roc tac dyng nong d6 rat thap, it anh hudng den co the ngudi benh Chitng ta da Het khang sinh la nhang schat kim hoc diet khuan c6 nguOn gOc vi sinh vat (xa khuan, nam, mac ), nau nhieu chat tong hop tonge hop toan phan a-mg &roc dyng vai mgc dich va hieu qua diet khuan cling dat duoc a rag d6 thap han nhieu so vdi cac chat haa tri lieu trutc Ben canh d6 co nhang nh6m chat trudc khOng duoc dimg de diet khuan nhung &roc phat hien tac dyng diet khuan nhu dAn chat — nitroimidazol Nhu vay danh mgc cita cac thuoc dieu tri nhiem khuan duoc mo r6ng Do do, viec trang bi cho sinh vien MAN nhang nguyen tac ca ban sir dyng khang sinh va cac thu6c khang khuan la viec khang the thieu dude de tao cho cac cluoc si tuang lai nhtIng thOi quen tot nghe nghi'ep sau Khang sinh Trong bai Do th6i quen, thong ta thudng g9i nhOm chi vdi mot danh de de pi, tir khang sinh duoc dung de chi nhOm thu6c NIAING NGUYEN TAC Sir DUNG KHANG SINH TRONG DIEU TRI C6 nguyen tac SC1 dyng khang sinh dieu tri: — Chi sir dyng khang sinh co nhiem khuan - Phai biet Iva chon khang sinh hop IY - Phai biet nguyen tac ph6i hop khang sinh — Phai sir dyng khang sinh dimg thdi gian qui dinh 1.1 Chi ser dyng khdng sinh cd nhiiim khudn Cac tac nhan gay benh cho ngudi co the la virus, vi khuan, nam, sinh vat dan bao hoac ki sinh vat (giun, san ) Cac khang sinh thong dyng chi co tac dyng vai vi khuan, rat it khang sinh co tac dung vdi virus, nam gay benh, sinh vat don bao Mai nh6m khang sinh lai chi c6 tac dyng vdi mot loai vsi khuan nhat dinh; d6, trwoocs quyet dinh sir dyng mot loai khang sinh nao dO can phai lam qua cac budc sau day: 41, • 1.1.1 Than? khan Icim sang Bao gom viec nhiet d6 benh nhan, phOng van va kham benh Day la budc quan nhat va phai,lam moi truang hop Vi sot la dau hieu dien hinh co nhi6m khuan nen viec nhiet d6 g6p phan quan de khAng dinh nhiem khuan s6t vi khuan thtrang gay tang than nhiet tren 39°C sot virus chi c6 nhiet d6 khoang 38 — 38,5°C Nang trtrong hop ngoai le: c6 the chi — NhiZm khuan (5 13'nh nhan suy giam mien dich, benh nhan qua gia sot — Trai lai, nhi8m virus ntur quai bi, thtly clau, sot xuat huyet, bai Rt co the tang than nhiet tren 39°C 29 Giao trinh &rot' Icim sang Trtrong Cao Bang K2Thit4t Y Te II Da Ailing Tham kham lam sang va phOng van benh nhan giup thay thu6c city doan tac nhan gay benh qua &rang tham nhap cua vi khan, qua cac dau hieu dac trung xet nghiem thwang qui 1.1.2 Bao ga gam cong thirc mat!, X quang va cac chi so sinh h6a se gop phan khang dinh than m (loan cua thay thu6c 1.1.3 Tim vi khuOin gciy benh Day IA bien phap chinh xac nhat de tim tac nhan gay benh nhung kh6ng phai mei truang hap deu can Chi trtrang hgp nhi8m khuan rat Wang nhu nhiern khan mau, viem mang nao, ,thtrang han ma tham kham lam san khong tim thay dau hieu dac trung hoac nhiem khuan mac phai o benh vien, benh nhan suy giam mien dich kh6ng co sat hay chi sat, nhe Viec phan lap vi khuan gay benh khong phai dau ang lam dupc, lai phai mat thai gian va ton kern nen mac dau chinh xac nhung, chi xap hang thCr 2, sau tham kham lam sang Neu benh nhan tir tuyen dual chuyen len, da phan da sir dyng khang sinh thi tham kham lam sang va lam cac xet nghiem thuang qui la ,ca ban Trong truang hgp nay, viec sir dyng khang sinh pha lieu tri la hop ly va can thiet rang va phoi hap khang sinh 1.2 Phai bier lira clip kitting sinh hp 1.2.1 Lira chon khang sinh phai pH hap vai vi khud'n gay benh Vi du: Viem hang thuang Streptococcus pyogenes A Nhiem khuan rang mieng thi Streotococcus, Actinomyces, ky, Viem bang quang cap chn CO bien chirng E.coli (80%), Proteus, Kiebsiella 1.2.2 Lwa chow khang sinh theo vi tri nhijm,khucin Milan dieu tri tong, khang sinh phai tharn vao nhiern khuan, nhu• vay ngtrai thay thu6c phai nam vting cac dac tinh dugc dung h9c cua thu6c mai co the ch9n duvc khang sinh phu hgp Mu6n dat dugc hieu qua dieu tri thi khang sinh dat dugc ca dac tinh tren Vi du Trong dieu tri viem mang nao P.aeruginosa, cac khang sinh co tac dyng tat len vi khuan nhis Gentamycin, Amikacin, Colistin lai khong có kha Wang tham qua hang rao mau nao,nhang truang h9p nhu• vay phai phoi hgp them vol khang sinh vira neu thang vao 'Ong song (lieu krang nho han rat nhieu so voi tiem bap) 1.2.3 Lwa chon khang sinh theo ca dia benh nhan o Tre em: — Cac khang sinh phai thong chi dinh vai tre em khang nhieu nhung hau het deu phai hieu chinh la' lieu theo tuoi NhOm khang sinh can luu y nhat sCr citing cho tre de non va tre sa sinh la — Aminosid (Gentamycin, Amikacin ), Glycopeptid (Vancomycin), polypeptid (Colistin) vi day la nhirng khang sinh có kha nang phan b6 nhieu pha mac nen khuyech tan rat rang cac lua tuoi o Nguti gia: dung khang sinh cho nguai cao tuoi khang khac nhieu vol d6i tuvrig Noi chung, viec binh thuang, trir mat s6 di6m can km y sau: 30 Gicio trinh chror him song TrtcOng Cao Diing K9 Thitdt Y Te II DO Niing — Do ski suy giam chirc nang gan — then nen sir chuyen h6a va bai xuat thuoc deu yeti han binh thutng, do can phai hieu chuen lai lieu cila nhungc khang sinh bi chuyen hoa nhieu qua gan hoac bai xuat chi] yeti qua then o' Bang can hoat tinh — Do ty le di irng vdi khang sinh cao han binh thutng (ngirti tren 65 tali co ty le khang sinh nhOm beta — lactam tdi 20%), do can het s(ic than sir dyng di ing khang sinh, nhat la dimg qua throng tiem — Do bi nhieu benh nen thutng phai ding ciing mot luc nhieu thuoc, dO kha nang gap twang tac thu6c cao han binh thirang, vi vey phai than de tranh cac tuang tac gay tang d6c tinh hoac tac dyng phy • Phu nu c6 thai co thai Trong trutng hap NOi Chung khong co ch6ng chi dinh tuyet doi doi vdi tien cho nguti me nhiem khuan nang de d9a den tinh mang thi viec can nhAc luon giam sat chat the chirc VI dy: Trong, dieu tri lao, Rifampicin can c6 the sir dyng vdi nang gan can thiet Tuy nhien, cac khang sinh co d6c tinh cao nhung CO the de dang thay the bang khang sinh khac thi nen tranh tuyet d6i, vi du: Cloramphenicol, tetrcyclin, co — trimoxazol o Suy than: than la nhang khang sinh chua vi chuyen h6a Nhilng khang sinh CO d6c tinh cao qua gan hoac chi chuyen h6a vai ty le nhO nhang trutng hop benh nhan suy then, nen awl De giam d6c tinh cua khang sinh yeu gan, neu khong thyv hien duoc ma phai sir dyng khang cac khang sinh chuyen h6a sinh d6c vai then thi phai hieu chinh lai lieu khang sinh o Suy gan: Nhilng khang sinh chuyen h6a qua gan > 70% la nhang khang sinh CO d6c tinh cao vdi ca quan nhu: Amphotericin B, Griseofulvin,Metronidazol 1.3 Phal hip khdng sinh phai 119p Myc dich cua viec phoi hop khang sinh la: 1.3.1 Tang tar dung len cac chUng de khang nignh Vi du: Ph6i hop oxacillin voi gentamycin dieu tri S.aureus da gram nhay cam vai Peni M - Phi hop Amikacin vol Ciprofloxacin dieu tri P.aeruginosa da khang gentamycin vi khudn de khang 1.3.2 Glom kha nang khang thuoc hoac tranh tgo Ph6i hop khang sinh voi mgc dich thutng duoc ap dyng dieu tri cac nhiem khuan keo dai Vi du: Phoi hap khang sinh dieu tri lao, viem mang tim, viem 1.3.3 Nal rdng tac clung czia khang sinh Ndi r6ng, len vi khuan ky, khi: Da so cac khang sinh thong dung khong co tac dyng hoac tac dung yeu len cac vi khuan ky khi, do viec phoi hap khang sinh chit yeu de diet vi khuan ky vai cac nhiem khuan co nguy co nhiem ky, cao Vi du: phoi hap Metronidazol vdi cac khang sinh khac nhiem khuan viing bung, vung cheu vi Metronidazol la thuoc diet khuan ky, manh thuoc nhom — nitro imidazol 1.4 Phai str dung khdng sinh clang thol gran qui dinh 31 Gido trinh chive lam sang Trtrong Cao Bang Ky Thudt Y Te II Dd Niing m9i loai nhigm khuan nhung Khong co qui dinh cu the ve d6 da cua dpi dieu tri nguyen tac chung la: — Sir dung khang sinh den het vi khuan co the: — o ngtrai binh thuang va — benh nhan suy giam miendich nhi8m khuan nhe, dal dieu tri thtrong Ice° dai khoang — 10 s — — Ngay nay, vai sty xuat hien cau nhieu khang sinh hoac cac clang che pham co thol gian ban thai keo dai TA' cho phep giam &rot clang ke so lAn dimg thuOc dat dieu tri, lam de dang cho viec tuan thir dieu tri cua benh nhan — Dieu tri "chop nhoang": De dieu tri mot so clang nhiem khuan tit nieu, sinh duc sinh thai chua co bien chimg nhu viem bang quang, nieu dao, lau có the sir dung cac lieu nhat manh qua nuk tieu clang hot tinh nhtr Perfloxacin, Spectinomycin mot lieu NHITNG NGUYEN TAC S' DUNG KHANG SINH skr PHONG NHIEM KHUAN TRONG PHAU THUAT Sir dung khang sinh truang hap nham ngan chan qua trinh nhiern khuan co the xay cho ngtrai benh sau phau thuat 2.1 Thai dam (lira thuac phiii thing Thai diem dua thu6c lien quan chat did den du.Ong dua thuoc: co the dua thuoc theo chrang tiem bap, tiem tinh mach, 41 trtics trang hoac ding nhung &rang, tiem tinh mach du.ac khuyen khich hon ca Tuy nhien dua bang throng nao ciing "Nhcit, thiet phdi dtra khcing sinh trtrerc lthc rgch dao nhtmg khong tiemso-11'1km 2h so vai thai diem mo" 2.2 Ch9n khcing Binh phai thing — Nen chon loai du rOng, c6 tac dung dupe len hau het tac nhan gay benh hay gap nhat loai phh thuat dO — Thai gian ban thai khong qua ngan de co the giam dupe so Ian dua thu6c — Phai tham tot vao to chac can phau thuat 2.3 D-9 dai car, dpi (tau tri phdi dung, — Kh6ng keo,dai qua 24h sau mo s s — Trong da so truang hap, chi can I den lieu la dn Ve nguyen tac, chi sir dung khang sinh den het nguy ca tham nhap cua vi khuan gay benh Vi lieu dau tien dupe dung Inc khOi me nen sau mo xong chi can dung tiep I — lieu nira la du Khong nen dung khang sinh kdo dai sau mo vi se lam benh nhan met m6i, kern an, do lau phyc hoi va gay ton kern Ve tai chinh Sau dO dung thuoc tiny thu6c vao loai phau thuat, dai cira cu6c m6, t112 cira khang sinh ch9n 32 Trtrong Cao tang Ky ThuOt Y Te II Do Njng Gicio trinh &rot' lam sang NGUYEN TAC SLY DUNG GLUCOCORTICOID MUC TIE U: Sau hoc xong heti hoc, sinh vien có kha ming: 1- Giai thich throe nhip sinh bi qua trinh tiet glucocorticoid (GC') ccr the 2- Trinh bay cluvr cac chi dinh cua GC die'u tri 3- Phcin tich &roc cac tac dyng phi clia GC va ccich khijc phut NOI DUNG: Glucocorticoid (GC) la mot nh6m , hormon duvc tiet vo, thuong than, co vai tr.?) quan trong dieu chuyen hOa cac chat Ngoai vai tre tren chuyen hOa cac chat, hormon nhom co nhieu tac dyng khac nhtr tac dung ,chong viem, chong di irng, irc che mien dich Hien ngubi ta tao &roc nhimg dan chat loci c6 tac dyng chong viem va the mien dich manh han the pham thien nhien va giam hoac lam mat han tac dyng giu muOinude nen pham vi ap dyng cua cac dart chat loci rat r6ng rai, khong chi bO help pharn vi tac dyng cua m6t chat thay the hormon ma can duoc sir dyng voi nhieu tac dyng khac nhtu• tac dyng,chOng viem,chong di a ng, chong thai ghep ca quan Khi dung vai nhang mgc dich thi lieu thirOng cao han lieu thay the nhieu Ian, dO cac nguy co gap tac dyng khong mong muon nhieu hon lieu thay the Nhirng kien thirc phan nham giup cho viec sir dyng nham thuoc hop ly, an toan hon I/ NHIP SINH LY CUA SIX MEET HYDROCORTISON: Hydrocortisol (Cortisol ) la hormon thu6c nhOm glucocorticoid &roc tiet to phan vO cua tuyen thuong than Nhip sinh ly cua qua trinh tiet hydrocortisol : hinh CO yeu to anh Wang den kha nang tiet hydrocortison: 1.1/ Nhip ngdy-dent: Vao khoang ni:ra dem, luong HC mau gram tai mcrc khong dupc; mac tang dan tir 3-4,h sang va clat cao nhat vao 16c thirc day Luong hormon tiet tir nth dem cho den Itk hormon gia cao cho den giira trim va chiem khoang 1/2 tong so hormon tiet giam dan ye chieu va thap ,nhat vao khoang 3-4 h sau di ngii • Nho nhip sinh hoc nay, tuyen thuong than se &roc nghi ve dem, neu mac hormone van tiep tyc cao thOi gian nay, vi dy nhtr ta dtra corticoid vao cuoi bu6i chieu thi tuyen thuong then bi giam manh sau ngtIrng thuoc DO la co sO• cho se bi C1C che lien, tyc va chirc nang tuyen viec quy dinh uOng glucocorticoid nen chi uOng Ian vao buoi sang hoac che d6 diet, tri each vai nhOng trtrOng hop phial dung keo dai nhieu thang 1.2/Anh !twang cua cac yeu to bot 191: Khi gap cac dieu kien bat Igi nhtr bi doi, sot cao, nhiem khuan, phAu thuet hoac cac stress tam ly nhtr dau bu6n, tirc gian, mire HC c6 the len tai 40-60 p.g/dl co kha nang tang host Trong, nhirng dieu kien neu chirc,nang tuyen thuong then t o t thi the gay suy thong then cap bi suy thi co nhu cau; ngtroc lai neu thuong than d6ng ,dedap,img co the dan den tir vong Suy thuong then thtrang gap dung GC lieu cao, keo dai Chirc nang thtrong then chi trey ye binh thtrang duoc sau 3-4 thang, them chi tai nam sau ngung GC Do dO phai theo dei chat the benh nhan cho tai nam ke to ngimg dieu tri Trong thoi gian neu gap cac stress thi nhat thiet phai cho dung lei GC vai lieu da dung tar& ngimg thu6c 1.3/ Str tang keo dai may GC pilau: Skr, tang luong HC co the xay gap trang thai ctrang thuong then u thuong then u tuyen yen va gay benh, Cushing Khi dung GC lieu cao kelp dai cling gap Cushing thu6c , cua tiet hormon bi mat tryc dual dOiKhi dieu tri bang GC ,lieu cao kdo dai, nhip sinh tuyen yen bi irc, che trien mien b6.i lieu cao cita hormon, da bat bu6c phai giam lieu tir tir muon ngUng dieu tri de tao lai mot skr thich ang dan cila tuyen sau mot the.' gian nghi dai 33 Trtrong Cao gang Ky Thual Y 711 ll Da Nang Gido dinh &toy lam sang H/ CHI DINH VA LicrA CHQN THUOC: 1/ Dieu tri thay the thieu hormon: Thuong clang suy thuong then cap hoac man tinh a/ Vol suy thirceng than man: Dung a mac lieu thap nhat c6 tac dyng Thub.ng thi mac lieu tru.ang hop la 20-30 mg [-IC moi twang img vOi lung HC ti6t trongs Nen dung the c16 dieu tri each bang cach tang lieu met len gap doi va ti6p theo, se nghi de han the duac su suy thuong than ngirng dieu tri b/ Vol suy thuprig than cap: Lieu dung thu.O.ng cao han, vi du 100mg HC kic dau, sau cach 8h lap Iai met Ian cho den trieu chirng duac cai thien Can phai ket hop bia dien giai, ntrac va glucose Nen chon chinh clang hormon thien nhien la loaf HC (succinat hoac phosphate) va du.O.ng dtra thuoc.la tiem finh mach 2/ Dieu tri voi myc dich khong phiii de thay the hormon: Chi dinh theo twang rat rOng bao gem: Cac benh lien quan den co the benh sinh mien dich nhu benh lupus ban dO, than hu nhiem me., viem khop clang thap Benh lien quan den ca dia di ang nhu hen, di ang Chong viem Dung ch6ng thai ghep ghep co quan Trong dieu tri ung thu• c6 rat nhien chi dinh dung GC, dac biet ung thu bach cau Met se benh v'e da: eczema, viem da tie') xoc, viem da di ung III/ TAC DUNG PHU VA CACH KHAC PHVC: 1/ Mc dung tren str tang &tiling tre em: a/ GC gay cham Ion o ire em la C lieu cao, HC Crc the sy tiet hormon tang trudng ire the sy tao xuong lam giam hoat dOng cCia hormone tuyen giap O tu6i day thi, the hoat clOng cua tuyen sinh dyc b/ Khac phyc: - Han the viec ke dan,nhom thuec a tre em tien dung cac th e pham ty nhien nhu ( hydrocortison, cortisone, prednisolon) - Dung lieu thap nhat c6 hieu qua, thoi gian ngan: - Khi bat buec phai dung keg dai thi nen dung kieu dieu tri cach - Khuyen khich tre van deng, chai the dyc the thao - Tang cuang che dO dinh dutng giau chat dam va canxi, tot nhat la dung cac the pham the Nen tir sua 2/ Gay xiip xtro'ng: a/ Nguyen nhan: - GC tang cu.Ong sty htly xuong nhung lai Crc the qua trinh tan xuang - GC ngan can hap thu calci tia ruet va tang thai calci qua nu& tieu b/ Khac phyc: - Tang yen Ong de kith thich tao xuang - Tang cub.ng che de dinh dueng giau canxi - Vai ngu.a.i cao tu6i, sir giam sot luang hormon sinh due nen tang de ?cep xuang, do co the 1)6 sung hormon sinh dgc nhung khong nen dung bien phap cho benh nhan ung thu tuyen sinh due hoac phu da man kinh tren 15 nam de tranh tang sinh nei mac tu cung qua mac 34 Truang Cao Bang Thuat Y Te II Da NZing Ciao trinh &roc lam sang 3/ Loet dy day- to hying: a/ Nguyen nhcin: GC tang twang ti6t dich vi b/ Khac phyc: - Dung thuoc trung hOa dich vi ( antacid ) nhung khOng duvc uOng (fang the.' voi GC - DUng cac thu6c khang thy the H2 - Theo dOi chat the va xCr ly son hoac ngang thuoc kip theyi co tai Hen 4/ Mc dyng phy (fang corticoid tyi chb: a/ Nguyen nhan: GC tac dyng len mo lien ket => teo da, xo et:mg bi, viem da Ong do, chain lien seo, myn trimg ca GC Crc the mien dich => bei nhiem nam va vi khuAn, virus b/ Khac phyc Khong duvc nho mat cac the phAm chCra GC nhie'm vius hoac nam Han the boi Ice° dai va kham k9 benh nhan trirdc ke don Khong tkr y dUng thu6c la bien phap tot nhAt de giam tac dyng phy 3/ Ilifn tuTrng erc chE trot du fl tuyEn yen- tuyEn Untying thOn (IPA): a/ Nguyen nhcin: Khi rnac hormone GC tang se ac the scr hot dOng ctia tuyen yen va \lung cltroi doi theo co the feedback b/ Khac phyc: DOng I lieu nhat vao bu6i sang - Ch9n loci GC CO t1 12 ngan, trung binh - Thai gian dieu tri ngan nhat co the Khi dieu tri keo dai nen diing the dO cach va phai giam lieu ta thuOc tru•dc ngirrig Theo doi chat the nhang benh nhan dOng GC Ice° dai thai gian dieu tri va I nam sau ngang thuOc 6/ Tinh tryng tiara corticoid va Onh Gushing thuac: a/ Nguyen nhan: MOt hinh anh Cushing clay du hiem gap, nhien ding có the gap mot cac hien tisong cua Cushing, vi du nhu phii gia natri va b/ Khac phyc: - Giam lieu ta tru.O.c ngirng thuOc Sau ngang thuOc n6u benh tai phat thi nen sil* dyng cac thu6c dac hieu de dieu tri trieu chang tot Fon Id quay lai ang GC; vi dy giai guy& hen bang thuoc gian, quan, giam dau khOp bang thu6c chOng viem khong steroid IV/ CHONG Cliff DINH: - Loet da day to trang tien trien - Cac trubng hop nhiem Warn va virus ma chin co thu6c dieu tri dac hieu - Tierra chung vaccine vius song Khong co chOng chi dinh tuyet dOi cho nhong twang hop dieu tri ngan ngdy hoac dieu tri cac benh de d9a tinh mang 35 de Trtrong Cao Hang K.P Thuat Y Te II Da Niing Gicio frinh chivy Idni sang NGUYEN TAC Se DUNG THUOC GIAM DAU NGOAI VI I/ SINN L Y BfNH CUA PHAN LNG DAU Dau IA co the tkr ve cua ca the chong Jai nhUng kich thich CO hai, aing co IA trieu chang bao trtrac cua mot benh nao dO Tuy nhien co nhang twang hop dau chi xiic cam, tkr ki am thi cua benh nhan ( dau tam ly) Dau lam cho benh nhan kho chiu, kho sa ye mat tarn ly Dau dai dang, trien mien lam benh nhan hot hoang, lo lang an den mat ngu, suy nhuvc Veng luan quan cang lam cho dau nang them Viec tim nguyen nhan dau se giup loci b6 &roc yeu to gay dau va giai quy6t dau triet de Tuy nhien viec giai quyet nguyen nhan nhieu khong de dang, nhanh chOng nen viec sir dungy thuoc giam dau IA giai phap hang dau Dau kh8ng r6 nguyen nhan hoac khOng the loci b6 dirge nguyen nhan gay dau thi thuoc giam dau IA chi dinh nhat Thu& giam dau chi dieu tri trieu chimg ma kh6ng lam mat duvc nguyen nhan gay dau Thu& co the the lAp cac dau hieu cua benh nhu' viem, sot benh van ti'en trien, do chi nen su dyng that sir thay can thiet va phai loon c6 gang tim de loci boo nguyen nhan gay dau II/ NGUYEN TAC SU DUNG THUOC GIANT DAU NGOAI VI Theo vi tri tac dyng len than kinh cam gide, thuoc giam dau duvc chia lam nhOm: - Thu6c giam dau trung tro'ng - Thu6c giam dau ngoai vi Trong bai chimg to chi tim hieu nguyen tac sir dyng thu6c giam dau ngoai vi 1/ Nguyen tae sii• dung thubc gram dau ngoai vi giim nguyen Vac sau: - Lira chon thuoc phis hop vai ngteeti benh - Tranh viral qua mire lieu giai hon - Ton nguyen roc phai hop thuoc giam clau - Liru y cac Nen phap ho ti-o• khong dung thuoc hock thuoc de giam tac dung khong mong muon 1.10Nguyen tac 1: Loa chon thuoc phis hop vol ngtroi benh Viec danh gia khA nang cua thuoc ho'n thuoc chi co tinh tuong d6i vi dau IA phan Ong phy thu6c nhieu vao tarn ly, dO thuoc dupe chon IA thuoc nao ma benh nhan cho IA thich hop nhat M6t thuoc thich hgp vol benh nhan CO nghia IA: - Thu& sir dyng co hieu qua giam dau tot doi benh nhan - Benh nhan khong man cam vcfri thuoc do: Nhang benh nhan co co' clia di Ong, hen thi phai than dimg cac dan chat salicylat (aspirin ), benh nhan man cam vai sulfonamid thi tranh climg cac an chat thu6c lc* nhu nimesulid, celecoxib - Phu hop vOi (lieu kien kinh to cua benh nhan Nen can nhac ky ve hieu quA/ Kinh to ke don 1.2 Nguyen tae 2: Tranh wro-t qua mire hesu giai han Moi thu6c giam dau nhom deu co mot mire lieu toi da cho phdp Day IA mirc lieu phii hop qua more lieu nguy co g4p tac dyng voi kha nang thai Vb thu6c cua gan va than Khi khong mong muon se tang dap img mong muon Nhirng tru.Vng hop dung den, lieu toi da cho phdp nhu'ng van khong thi khOng, khuyen khich tang lieu ma nen phoi hop cac thuoc giam dau khac nhom hoac thu6c an than de tang tac dyng Tuy nhien phai ton nguyen tac phoi hop ( nguyen tac 3) Lieu khuyencao mot so thuoc giam dau ngoai vi Ten qui6c t6 chong viem Lieu giam dau toi da Lieu toi da giam dau Lieu thubng 24h (mg) thong, I Ian (mg) (mg/Ian ) 36 Trufmg Cao Hang K9 Thuat Y T" II Da Nang aspirin diclofenac etodolac indometacin sulindac ibuprofen naproxen Piroxicam meloxicam celecoxib Paracetamol Giao trinh &for lcim sang 4000 150 600 150 400 1200 1375 40 15 800 4000 650 50 200 50 200 400 550 20 7,5 200 1000 1200-1500 50-75 200-300 50-70 200 600 375 20 7,5-15 100-200 1.3 Nguyen tac 3: Ton nguyen phdi hop thuoc glom dal, Khi tang den lidu tai da cho phep ma van khong du tac dyng thi phai ph6i hop them thu6c Dd chi lam tang tac dyng giam dau ma khong lam tang tac dyng phy, kh6ng duoc ph6i hop thuoc giam dau co cimg kidu ADR nhu Thu& hay cluoc ding moi cong thCrc ph& hop la paracetamol Vi du : Lieu tOi da mot Ian d6i vai aspirin la 650mg, ndu mac lidu van chug du tac dyng thi nen ph6i hop vai paracetamol vi paracetamol c6 kidu tac dyng phy khac aspirin Kh6ng &roc ph6i hop aspirin v6i NSAID 1.4 Nguyen Vac 4: Lzru y cac bin phap ho tro khong dimg thuoc hoac thy& de giant tac dyng khong mong muon Sau day la cac bin phap khac phyc tac dyng khong mong mu6n sir dyng thu6c giam dau ngoai vi: a/ Han the loet Ong lieu hoa: Cac thu6c ch6ng viem khong steroid ( NSAID ) lam giam sit tao prostaglandin nen giam sly tao chat nhay va NaHCO3 tai da day, lam tang nguy co loet 6ng Wet' h6a ma chit yeu hay Op la loet da day Ngoai xuat huyet tieu h6a va loet da day, cac NSAID can gay cac ton thuong o 'Ong tieu h6a dual ( doan cu6i cua runt non va rut gia ), tac 6ng tieu h6a Lao cac chit hp Dd hart the bOt tac dyng phy tren 6ng tieu hOa c6 the co cac,cach xix tri sau: Vai vien nen tran ( khong c6 mang bao dac bidt ): uong thuoc vao baa an va nhai vien thu6c, u6ng kern mot c6c mac to ( > 200 ml ) - Tao vien bao tan runt, lc* vien phai mong xa bira an ne'u la bao ca vien Tao vien sui b9t hoac cac clang dung dich u6ng - Cac clang bao chd SI:t dyng cac to &roc " the cha" nhir 13-cyclodextrin citing nhim myc dich giam sit tip xuc trvc tip cua phan tir thu6c vai niem mac 6ng tieu h6a Luong way u6ng phai Ian ( 200m1- 250m1) Vic dai cua nhang thu6c chon 19c COX-2 nhirng nam gAn day nhu meloxicann ,celecoxib, rofecoxib ang da giam duoc dang kd ( khoang 50% ) ty Id loet da day nhung tinh iru vidt cua nham can co thei gian dd kidm chCing vi (la thay co nhiing ADR khac ang nguy hidm khong kern cho bdnh nhan b/ Han the chay maw Cac NSAID lam giam kdt tap tieu cau nen keo dai thoi gian (long mau, gay chay mau, mat mau keo dai Tac dyng gay nguy hidm sir dyng cho nhang bdrih nhan co tang chay mat' ho4c bdnh xuat huyet Do dO khong su dyng NSAID nhang trU.Ong hop sot co xuat huyet va tang chay mau 37 Trtrong Cao Dcing : Kji- Thu at Y Te II Da Niing Gicio trinh &rot Om sang Dung paracetamol thay the aspirin nhang trubng hop chOng chi Binh aspirin có nguy co xuat huyet VI dy: benh nhan loet da day to trang, benh nhan CO benh ly xuat huyet: sot xuat huyet, chay mau da day, benh tra chay mau c/ Mein cam: Hien Wong man cam hay gap vol ca paracetamol va NSAID, nhat la aspirin : ban do, may day, hen, soc qua man Hien won man cam thu.ang xay o cac benh nhan co tien sir di‘img, có benh hen, polyp rnOi hoac sot Vi vay phai than trang dung cho benh nhan da có tien sir di rng, hen dung aspirin Khong dung cac the pham NSAID de sot cho tre em , thay bang paracetamol d/ Han the viem gan, hogi tfc gan: ngtrai va > 3g vai tre em Paracetamol dung qua lieu gay viem gan Neu dOng > l Og cludi tuoi co the gay hoai to gan Kh6ng chi dOc voi gan, sir dyng paracetamol Ice° dai co the gay ton thirang than 2/ Cac ttrang tic bat kyi can tranh: 2.1/ Cac ttrang tac dtrgr hec hoc: - Kh6ng phoi hop cac NSAID voi vi se lam tang tac dyng phy loet &rang tieu hozia va chay mau -NSAID lam tang nguy co chay mau tram trang dung dOng thai voi cac thuoc ch6ng dung khac xuat huyet tieu hoa - NSAID clang ding vai rtrou lam tang nguy -NSAID lam gram hieu qua dieu tri cua cac thuoc ch6ng tang huyet dp, giam tac dyng cua thuOc loi tieu - KhOng dung cac salicylat de giam dau bi gout vi cac salicylat lam giam bai xuat acid uric qua nu& tieu • 2.2/ Twang tac dtrgc dOng hoc: - Do tji re gan ket protein cao nen lam tang n6ng d6 tkr dm cac thu6c ph6i hop dan d6n tang dOc tinh cua cac thuOc phOi hop - Cac thuoc co the gay kiem h6a nuac tieu ( cac antacid) hoac acid hOa nutc tieu ( vitamin C lieu cao) lam thay dOi thai trir cua cac NSAID co ban chAt acid, do anh twang den dO dai tac dyng 3/ Chang chi dinh: 1/61 paracetamol: - Man cam vai paracetamol - Suy gan - Tien sir eczema tip )(Cie vai paracetamol Vol cac thuac cho'ng viem khong steroid: Tien sir di an vai aspirin Loet da day — to trang Benh 15/ xuat huyet Nhi8m vius CO thai thang cuoi Phoi hop vai vitamin K hoac methotrexat 38 Tricong Cao Dang K9 Thttat Y Te II Da AlcIng Giao trinh &roc him sang NGUYEN TAC SIJ DUNG VITAMIN VA KHOANG CHAT MUC TIED I Trinh bay &tor cac nguyen nhan gay thieu vitamin, chdt khoang va cach khac phuc Trinh bay throe cac nguyen nhan gay thira vitamin, chat khoang va ciach khac phyc MN DUNG Vitamin va chat khoang la nhirng y6u to can thiet cho soy canggio'ng nhu rau, qua, thit, ca, coc Day la nhimg phan khong the thieu duac cho,d6i song so voi thyt ,pham va coc thi so krong can thiet rat nh6 nen g9i la vi chat di dutng Diem giong giCia vitamin va hormon la ca hai loaf deu thu6c nh6m chat co hot tinh sinh h9c cao nhung hormon thi thrac co the t4o vitamin thi duac dua tir ngoai vao theo thac an (trong da so truting hqp) Cac vitamin va khoang chat thuOng dugc ban nhu nhang thu6c kh6ng co don duti dpg don le hoc ph6i hap, voi cac ham luong khac da gay khOng it lung tiing cho ngayi sir dyng Cilng‘do duac ban tkr Ian tran va tuyen truyen khOng chinh xac ve tac ,dyng nen thvc to da skr14rn dyng, gay nhang tai bien nghiem thira vi chat NHU CAU HANG NGAY VE VITAMIN VA KHOANG CHAT Nhu cAu hang ve vitamin va chat khoang d6i ngubi binh thuang khOng nhieu B6 sung vitamin va khoang chat chi can thiet thieu Bang thong ke thrai day la lupng vitamin va chat khoang can b6 sung hang thieu hoan toan dual dpg thuoc hang (US - RDA) Lieu khu En cao bd sung vitamin va khoang Tren tu6i va Vitamin va chat Dan vi Dual Tic I — tu6i ngtrai Ian tuoi khoang dvqt 5.000 Vitamin A 1.500 2.500 Vitamin D dvqt 400 400 400 dvqt 30 Vitamin E 10 Vitamin C mg 35 40 60 Vitamin B, mg 1,5 0,5 0,7 1,7 Vitamin B2 mg 0,6 0,8 20 Vitamin B3 mg 0,7 Vitamin B6 mg 0,4 2,0 Vitamin BI2 1-ig mg 0,2 0,4 Acid folic (B9) 0,1 1.000 Calci (Ca) mg 600 800 15 10 18 Sit (Fe) mg 1.000 Phospho (P) rng 500 800 45 150 ig 70 lod OD 400 rng 70 200 Magie (Mg) mg 15 Kern (Zn) Dong (Cu) mg 0,6 I CO thai va cho b6 8.000 400 30 60 1,7 20 2,5 0,8 1.300 18 1.300 150 450 15 S6 lieu tren dcra theo tieu chuan cith Vien.han lam khoa h9c M5"/ va &lac "Cyc Thyy pham va Thuoc" (FDA) dm Mylay lam thong ,tin de ly'a ch9n 1)6 sung vitamin va cac chat khoang, vi vay Wang ghi bang la tieu chuan bo sung twang hgp thieu hyt vitamin 39 Giao trinh dzrac lam sang Trzrang Cao Dang Kp- Thuat Y Te II Da Adng Hai vitamin c6 pham vi an toan hep nhAt IA vitamin A va D Lieu ttii da cho phdp chi gAp 10 Ian nhu cau bang Vitamin A dac bit nguy hiem dimg lieu cao cho phi nu co thai vi co nguy ca gay quai thai hoac tang dp luc not so thai nhi Phy nix co thai neu can 1)6 sung chi dugc dimg nhang lieu bang lugng ghi bang Trong bang khong trinh bay nhu cau vitamin K vi thkrc to lugng vitamin K can cho nhu Call tre so hang co the bao dam nht he vi khuan runt B6 sung vitamin chi can thie't benh nhan sir dung Ice() sinh vi tugng he vi khuan runt chua Oat trien day dir hoac dai khang sinh throng 'long he vi khuan rut bi khang sinh buy hoai THIEU VITAMIN VA KHOANG CHAT 2.1 Nguyen nhan thik • 2.1.1 Do cling cap Cac nguyen nhan lien quan den viec dua kh6ng du vitamin va chat khoang vao co the bao - - - Chat lugng thkrc pham kh6ng darn bao: Do chat dat va ngu6n mac a tirng dia phuang Do an kieng Nghien rugu 2.1.2 Do rdi loan hcip thu Suy dinh dutng, is chay kdo dal, nghien rtrgu, tac mat deu lam giam hAp thu cac chAt, dO co vi chat dinh &rang C nguti cao tu6i, sir thieu vi chAt IA sir giam chirc nAng cira he tieu h6a: giam sir tie't dich vi, dich mat, dich vi va su hog d6ng kern hieu qua cira cac co the hAp thu tich cuc qua niem mac runt Them vac, do, nhu dOng runt yeu, hay bi tao bon nen cac benh nhan cao,tuoi thuong dung thuoc nhuan trAng Ice° dai cung IA nguyen nhan can trO* hap thu cac.chat R6i loan hap thu co the mgt so benh dueng tieu hoa nhu• viem tyy, tac mat, loet da day — to trAng 2.1.3 Do nhu cau ca the tang nhung.cung cap khOng thieu nien tuoi day thi hoac benh nhan sau Om day, sau mo, co thai, cho Phy Nhang nhiem khuAn keo dAi deuOc nhu cauve vi chAt dinh dung tang han binh twang hgp neu dugc 1)6 sung tot bangthe d6 an uong thi khong can dimg them vitamin Bang uong Uong hoac tiem vitamin chi can khong an dugc rOi loan tieu hoa Mac An kh6ng du (dp met m6i, chan An ) 2.1.4 Cac nguyen nhcin gay thilu clac bier khoc — Benh nhan dupe nuoi duOng hoAn town bang &rang tiem — Benh nhan co khuyet tat di truyen A — Tre so sinh, (lac biet IA so sinh thieu thang hay thieu vitamin K Do do, de tranh nguy co xuat huyet nao, nguti to tiem vitamin K I cho cac chau mai Igt long — Thieu tuung tac thu6c - 2.2 Xer tri thieu vitamin va khocing chat Phat hien nguyen nhan gay thieu va loai b6 no IA viec phai lam !An dau tien Vi du: Neu thieu roi loan hap thu thi phai dieu tri cac lien quan (ia chay, suy ,gan, tac mat ) cho nhu cau thi phai tang cuang them khau phan an hoac Thieu cung cap khong sir dyng them vitamin va khoang chat thieu tram 40 Trirong Cao Hang Ky Thuat Y Te II DO Nang Gicio trinh &roc lam sang bo sung vitamin va khoang chat hop la phai lay Ur thkrc pham vi dO la nguon ap day du va can doi nhat Bo sung dual deng thuoc chi thieu tram hoc trugng cling ccap hop chug c6 dieu kien sira doi lei the d6 an TlitrA VITAMIN VA KHOANG CHAT 3.1 Nguyen nhan gay thira vd lu:iu qua 3.1.1 Thira the dO an • Co mot so tai lieu mO to hien along thira vitamin A, them chi ca ng6 d6c ciia th6 dan phuang Bac (gan !pie ckrc) an gan gau trang — Thira beta — caroten an Ice° dai nhCi.ng thkrc pham giau chat the hien bang hien tuong nhuOm yang da, nh6 nhang twang hap it nguy hiem vi ngugi sir dyng tkr d6ng bo thirc an NOi Chung, thira vitamin an uong it g5p vi co the co the tkr (lieu chinh qua trinh hAp thu qua throng tieu h6a 3.1.2 Thira lam clung vitamin via chth't khoang duai clang flay la nguyen nhan hang dau hay g5p nhat Can nhac lei rang nhang nguti khoe rnanh, kh6ng co r6i loan hap thu va an voi the d6 an du cac chat thi khOng bao gig phai dimg them vitamin hoc chat khoang &Ai deng, thubc Neu nhung doi twang thugng xuyen uong vitamin, d5c bit la vitamin tan dau (A, D) thi de g5p roi loan thira vitamin ▪ MCA s6 nguyen nhan din den thira vitamin — Tre dubi tuoi dirge cho an bang hiin hop thay the sira me co 136 sung vitamin D lieu khong thich hop vai lira tuoi co the bi thira vitamin Viec b6 sung thugng xuyen vitamin D voi lieu > 400IU/ngay cho tre dual nam khOe menh la viec lam nguy hiem vi dan den tang mirc Ca/mau, them chi c6 the gay suy then va tir vong — Tre em dual tuoi thugng xuyen uong vitamin A co ham luong > 5000IU/ngay co the bi ng0 d6c men tinh vgi trieu chirng dau xuang, ban do, viem da trOc vay, viem Neu dung lieu vitamin A > 100000IU/ngay co the gay ph6ng th6p, co giet, tang dp luc s9 nao tre nh6 — Phy nir co thai dimg kdo dai vitamin A > 5000IU/ngay van an uong day du va hAp thu tot se- co nguy co thira vitamin A, gay quai thai - V • • MOt se) nguyen nhan din den thira nguyen to vi Thira sat (Fe): Ng° d6c sat 0' tre dual tali kha bien Luting qua lieu, heu qua dan den tit vong Thira iod (12): Sir dung tren 6mg/ngay se gay irc the hoet d6ng cua tuyen giap, gay nhugc nang giap Neu ngugi me mang thai b6 sung lod kh6ng hop ly, gay thira lod thi nhu' heu qua se xay Ra vai thai nhi: nhugc nang giap o' tre so' sinh, sinh tre dan thieu nguyen to hoc gay phi dai tuyen giap barn sinh Skr thira cac nguyen to vi luong gay heu qua nghiem han so vai thila vitamin vi Chung co pham vi dieu tri help 3.2 C'dc hien phdps trcinh (him vitamin va khoang chat Vi hien tuang thira da phan sir dyng cac chat dugi clang thuOc khong hop ly, do nhang kien thirc ye sir dung nhOm thu6c se gOp phan nang cao tinh an toan clieu — Then dyng cac the phArn co ham lung > !An US — RDA Trong trugng hap can due thkrc S co hien tuong thieu mot chat nao thi t ot nhat nen dung deng dan le de tranh hien along thira cac vitamin tan dau 41 GO° trinh &car lam sang Truerng Cao Hang K2 Thud! Y Te II Da Nang — Khi dimg thu6c dong hon hop vitamin va khoang chit phai phan biet cac cong thac danh cho tre dui tu6i, cho tre dual tuoi va cho nguti Ion thutng duoc tinh cho lira tuoi tir 11 tu6i tra len — Trong nuoi &rang nhan too hoan toan ngoai &rang tieu h6a (TPN), viec 136 sung vitamin la bat buOc d tri kha nag chuyen h6a cac chat nhung ieu luong chat can dua phai &roc tinh toan dlya tren tinh benh ly cita tang benh nhan Co the dung nhung Ong hOn hop vitamin va khoang chat dOng sari hoac lay rieng le tang chat roi phOi hop theo tjf le mong muon LIVA CHON CAC CHE PHAM 4.1 Ctic the pham cluth vitamin Cac the pham china vitamin có phan va ham luting rat da dong nhung tom thti CO the phan lam looi sau: 4.1.1 Cac loci vitamin don le LAI diem cita loci la giA re va phi! hop vai trutng hop chi thieu mot looi vitamin nao VI dy: vai cac looi vitamin de hang the Bien hoac boo quart thirc pham nhu vitamin B1 , B6, C; ft* thieu khuyet tat di truyen gay thieu vitamin D, vitamin B1 LC* don le phyc vu cho myc dick dieu tri voi tac dyng dac hieu co the khong lien quan den cong dyng cua vitamin Vi dy: vitamin PP duai dong acid nicotinic lieu cao de giam lipid mau, vitamin B12 dirai da ng hydroxocobalamin dimg giai dOc cyanua Tren thi trutng c6 nhieu dang vitamin clan le c6 ham luting cao hon nhu cAu hang (RDA) Sir dyng cac dang vitamin don le thutng re tien hon dung cac the pham phial hop nhung chi c6 hieu qua biet chac chart chi thieu nguyen to Ciing c6 nhung trirang hop sit• dung vitamin hoar' toan v6i myc dich khac, vi dy: vitamin B12 dual dong hydroxocobalamin vai lieu rat cao (0,1 g/kg, tiem tinh mach) dirge dung de giai clOc cyanua (dieu tri ph6i hop) 4.1.2 Cac looi vitamin phi hop • CO rat phieu kieu phi hop: — Phoi hop day du cac phan — Ph6i hop chi cac looi vitamin tan dau — Ph6i hop chi cac fool vitamin tan nutc • Mgc dich ,ph6i hop ding rat khac nhan: — Da phan la de bit vitamin thieu tram — Tuy nhien ding c6 nhieu kieu ph6i hop hoan toan de dieu tri vai myc dich khong lien quan den tac dyng tren chuyen h6a Vi dy: hOn hop 3B ham luting cao can dung de giam dau cac trutng hop dau CO lien quan den ton thuong day than kinh — Cac looi ham luting cao clac biet nguy hiem dimg kdo dai kha nang tich luy hoac tac dyng phy 4.2 Cac ch'j pluim china club khoang Phan Ion cac chat khoang rat c6 san thien nhien (ntrac uong, thirc an) va vai troz sinh 1/ thutng di kern vai vitamin Tuy nhien, so vai vitamin, pham vi an toan dm chat khoang,, d4c b* la nguyen, to vi luting rat Cans vi nay, ac cite pham co chcra chat khoang thutng phoi h9p voi cac vitamin Dieu dang luu j/ IA cac chat khoang dung don dOc don tai tai Hen co ham luting kha.cao nen str dyng phai rat than vi nhung nham clang ti6c, tham chi co the tir vong Nhang chat khoang co nhu cau hang duti 100mg &roc goi IA nguyen to vi luting Sau day IA nhang diem can luu y sir dyng cac the pham khoang chat co chaa calci va sat: 4.2.1 Calci (Ca) 42 Trtrovg Cao Hang Ky Thuat Y TA II Da Nang Gicio trinh chivy Lim sang Calci la phan ca ban au too ,c6a, xuang co vai trO quan trong hoat dang cua than kinh va co co., la mat nhang yeu to clang mails Th(rc an hang CO calci cho nhu cau co the Ngu6n calci sib la phong nhat va de hap thu hon ca Luang calci mau &lac diet' h6a bai vitamin D va hormon can giap (PTH) de gia mCc calci huye't hang dinh ta 8,5 — I 0,5mg/ml Thieu calci co the gap o tu6i day thi, phy nG c6 thai, cho btl; nhang trutng hgp nhu cau tang tai 50%; ding corticoid (tang thai calci), nguti cao tuai hoac dung kdo dai antacid (giam hap thu calci)., Thieu calci cap tinh gay co giat kiL tetani; thieu thuang xuyen gay cal xuong tre em) va x6p xuang (a nguoi Ian) Thira calci thuang lam dung thu6c Dau hieu tang calci huye't bat dau xuat shien lung calci dua vao co the tren 4g/ngay (RDA = 1g) Neu thira it co the giai quyet bang cach giam calci the da an, tang cutng an chat xo va uOng nhieu nuac Thira kdo dai hay gap dUng calci carbonat; trieu chimg: clay ho, met mai, than an, nang hon c6 the tang huyet kith d6ng, sal tiet nieu 4.2.2 Sat (Fe) s sAt la , phan cua men ho hap to bao (men cytochrom), dm hemoglobin va myoglobin Dang bien to nhien la sat oxy hoa (Fe3+), de hap thu duac phai chuyen hoa clang khir (Fe2+) Trong thuc pham nguon goc d6ng vat, sat ton tai dual clang hem (Fe++), de hap thu hon sat thuc vat Ian Trai voi cac nguyen to vi lugng khac, sat c6 rat it saa, (lac biet la saa b6 (0,1mg/100m1 sCra) Cac ngu6n tort pham giau sat la: dau Wang (1 I mg), gan Ian (12mg), gan be (10mg) 100g thyc pham Nhang dOi wan de threu sat thuang la: tre em nuoi hoan toan bang saa be, phy nau co thai, nguti an kieng, an chay hoac an khong du ,nhu cau (sat' 6m Ong, tuoi day thi)., Thira sat: 146 dac sat tre em < tuoi gp,kha, bien lam dyn thu6c Cac trieu thong ng6 d6c bao gam: non, is chay, hoai rut (neu Wong), soc qua man (tiem) Giai dloc: Rim da day bang NaHCO3 1% de lao b6 sat Ong tieu h6a Tiem Deferoxamin de loai sat khOi co the co the tao chelat cua thuoc vai sat 43 Tr-yang Cao D: Ong Ky Thudi H Da Wing Giao trinh &ro'c lein? sang NGUYEN TAC Sir DUNG THUOC DIEU TRI TANG HUYET AP DA1 OafNG 1.1 Phan 19i tang huyet ap(HA) Tang HA gom tang huyet ap tam thu, tang huye't ap tam truang hoac ca hai Tang HA nguyen that hay tang HA vo can vi nguyen nhan tang HA khong dugc Loa' tang huyet alp chiem 90% dan so tang HA Tang HA thir phat : HA tang la hau qua cCia cac benh ve than, not ti6t, tim mach nad Dieu tri nguyen nhan huyet ap se tra lai binh thutmg Ngoai co tang HA thai , thu6c ( glucocorticoid, thuoc tranh thai ) Sau day la bang phan loci HA Oa theo JNC-VII 2003: Bang phan loci HA dm nguti Ian HATam truang(mmHg) Phan loci HATam Thu(mmHg) = 100 GD >=160 hoac HA dugc It nhat ran( cach philt), tren cimg mot canh tay rdi lay trung binh HA tam thu don dOc HA tam truong < 90 mmHg va HA tam thu > 140 mmHg, thuOng gap Cr ngudi Ian horn 65 tuoi, la yeu to nguy co cua benh tim mach , Neu HA tam thu va HA tam twang hai giai (loan khac nhauthi dua vao tri so HA cao lion de phan loci Cac yea to nguy co' cua benh tang HA -,Tien sir gia dinh benh tim mach( gia dinh co dan Ong < 55 tuoi hoac clan' ba < 65 tuoi mac benh tim mach) - Hut thu6c - R6i loan lipid huyet - Tieu &Ong - Tu6i tac: 60 - Gidi tinh: Dan ong, phy sau man kinh, Nhang nguOi c6 cac yeu to nguy co chu yeu nhu tren co khuynh hudng tang HA Nhang nguOi c6 bien chirng cua tang HA cling dugc ke la co yeu to nguy co nhu' benh co quan muc tieu nhu: tim, mach mau ngoai Bien, mat , than hay dang co benh tim mach tren lam sang Ditu trg tang HA Myc Wet] lau dai cCia dieu tri la dat HAMT vdi it tac dyng phy nhat de giam ton thuong co quan cudi, giam bien ch&ng tim mach nhO dO thap ti re mac benh va ti re tCr vong *HA myc tieu: La tri so HA ma dieu tri can dat duoc Tang HA khong trieu chimg:HAMT< 140/90 mmHg Tieu duOng, benh than man tinh: HAMT< 130/80 mmHg *Dieu tri khong dung thaw: Thay doi kieu song, thuc hien trudc va khi, sir dyng thuoc Cac benh nhan tien tang HA va Tang HA nen thay ddi kieu song Thay dal kieu song lam giam HA va ngan tien trien tang HA, giam lieu thu6c HA, giam nguy co tim mach Clam can: Neu qua can co the giam SBP 5-20 mmHg/I0 Kg nhOm benh nhan kh6ng dUng thu6c ,ngudi nhe Titt cht tieing ruvu: Dan Ong khong uong qua 30m1 etanol/ngay, phy can kh6ng qua 15m1 etanol/ngay Tiet the rugu lam giam SBP 2-4mmHg 44 Truang Coo Dang K9 Thuat Y 7-A II Da Nang Gi6o trinh clugc Om sang • T4p the dyc deu Gap phan giam can va CO loi cho tim mach Nen di b6, chay b6, boi 16i 30 philtingay, hau het cac tuan lam giam SBP va DBP lOmmHg • An hot che,muOi Na+:< 100mmol/ngay (< g NaCI hoac 2,4g Na+ingay) giam HATth 2-8mmHg Ngagi tieu dirOng, ngagi cao tu6i, ngtrgi da den dap img tot vai sit' an kieng muoi • Thin an ,nen co nhieu K+ (chuoi, nugc cam, khoai tay),Ca2+ ,M42+ Nen an nhieu rau trai, cac san pham cua saa, it m6, giam mo bao Ilea, mo toan phan va cholesterol (< 300mg/ngay) [AL chinh che d6 an lam giam SBP 8-14 mmHg • Bo hat thaw * Dieu tri toing thu6c Khi khOng dot HA myc tieu bang thay cloi kieu song 2.1 PHAN LORI VA CO CHE THUOC TRI TANG HUYET AP: Thuoc Iqi tieu: Thai Na va ntrac nen lam giam the tich mau .Thuoc liet giao cam: Lam giam sirc can ngoai bien Lam giam tau luang tim irc che hoot ding tim Thutic gian mach: Lam giam sac can ngoai bien ThuiSc ac ch4 kenh Canxi Thutic tac Ong len he RAA: (thu6c ac ch6 men chuy6n) Lam giam sac can ngoai bien Lam giam the tich mat' 2.2 CAC THUOC TRI TANG HUYET AP: 2.2.1 Cac thaw Wet giao cam: Methyldopa 2.2.1.1 Tac dung: Ha huyet ap va an than (co che: Liet giao cam) 2.2.1.2 Chi dinh:, Cao huyet ap the vira va nang, co the ph6i hgp vii thutic lgi 2.2.1.3 Tic dyng phy: + Tram cam, an than, met mai + Kho mi'Og + Ha huyet ap the clang + Giam tinh duc 2.2.1.4 Ch6ng chi dinh: + Tram cam nAng gan + Tien sir viem gan thu6c, cac benh ve gan nha viern gan cap, man + Man cam vai gan + Phy nu Bang cho NI 2.2.2 Reserpin (Racedyl, Serpasin): 2.2.2.1 Nguon g6c: Reserpin la alkaloid dm nhieu loci Ba gac Rauwolfia serpentina Benth;, Rauwolfia veticillata (Lour), h9 Troc dao (Apocynaceae); hoac di'eu che bang phirong phap tong hop hga h9c 2.2.2.2 Tac dyng: Reserpin co tac dung chit y6u: - Ha huyet ap - Lam cham nhip tim - An than, gay ngii 2.2 2.3 Chi dinh: Thaang dung ph6i hop vgi thu6c 19'i tieu de cli'L tri cao huye't alp vgi chang tim nhanh Rol loan tam than, cac thai bon chin 2.2 2.4 Dec tinh: Thu'Ong xay nhAt la tram cam ROi loan tieu hoa (buon non, tieu chay, chan An, tang ti6t dich vi, loet day) 2.2.2.5 Ch6ng chi dinh: Ti&i sir man cam vgi cac alkaloid ciia Rauwolfia 45 Githo trinh chivy lam sang Trtrong Cao D r' ing Ky Thuat Y 7-A 11 Da Nang Trang thai trim cam Loet da day, to trang Bang ti6n trien 2.2 Propranolol (Inderal, Detasol, Obsidan) 2.2.3.1 Tic dung-Cling dung: Tri tang huyet ap nhe va vim lam lam giam sac co bOp tim, giam Itru Itrong mau tim Rat hieu qua tang huyet ap r6i loan than kinh giao cam (tim nhanh) Ngoai chong thieu mau ca tim va chong loan nhip 2.2.3.2 DO tinh: - Suy nlitroc co that co tim, gay nhip tim chAm - Gay co that phe quan ngtrai bi hen suyen - Buon non, non, tieu chay - Tram cam, ICI Ian tinh than, mat ngu, dc mOng - Phan ang di ang 2.2.3.3 Chiing chi dinh: - Hen suytn - Block nhi-that,suy tim cap.nhip tim cham (