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 Kh
Trang 1Trtremg Cao DOng K9 Thttcit Y Te 11196 Niing Gicio trinh dwor Lim sang
de ucing, sinh kha dyng wan d6i On dinh, it phy thuOc vao baa an hoac nutc u6ng, tuy nhien day
la clang thutng dAt
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 trong 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 do trong quy dinh, thu6c tiem hOn dich hay nhil tuong khi 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 khi tiem it gayclau
✓ Thu& tiem truyen vol khi Itiong phai dAng truong vai mau
✓ Dung moi de hoa tan thu6c tiem phai dat yeti eau "dung pha tiem "theo quy dinh
Cac dung mai thtrerng diing trong thuac tiem: dau, ethanol, nuOc cat, propylene glycol va PEG 300 — 600
Uu diem dm thuac tiem:
- Tranh duce su pha buy thu& do cac yeu to &trig tieu h6a: dich vi, men Weil h6a
- Tranh &roc sir hao hyt khi phai van chuyen trong 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 do 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 trong
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 0 kich ung cao, gay dau hoac
hoai tif co khi 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
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Trang 2Trading 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 trong nhCing trutng h9p can Ice° dai tac dyng cua thu6c
Ltru
Kh6ng nen tiem > 1 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 trong 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 khi dung
Trang 3Trzrowg Cao Hang K9 Thuat Y Te 11 Da Ming Giao trinh thror Mtn sang
I Phan lopi Ayr 4 nguyen rex sir dyng khang sinh trong dieu tri, cho vi du minh hoa
2 Phcin tich cluvc 3 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 khi 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 ), ngay nau nhieu chat tong hop tonge hop toan phan a-mg &roc dyng vai mgc dich nay
va hieu qua diet khuan cling dat duoc a rag d6 thap han nhieu so vdi cac chat haa tri lieu trutc kia
Ben canh d6 co nhang nh6m chat trudc kia khOng duoc dimg de diet khuan nhung ngay nay &roc phat hien ra tac dyng diet khuan nhu dAn chat 5 — nitroimidazol Nhu vay danh mgc cita cac thuoc dieu tri nhiem khuan ngay duoc mo r6ng Do do, viec trang bi cho sinh vien MAN nhang nguyen tac ca ban khi 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 trong nghe nghi'ep sau nay
Do th6i quen, thong ta thudng g9i nhOm nay chi vdi mot danh Khang sinh Trong bai nay de de pi, tir khang sinh duoc dung de chi nhOm thu6c nay
1 NIAING NGUYEN TAC Sir DUNG KHANG SINH TRONG DIEU TRI
C6 4 nguyen tac SC1 dyng khang sinh trong dieu tri:
— Chi sir dyng khang sinh khi 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 khi 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 vs i khuan nhat dinh; do d6, trwoocs khi quyet dinh sir
dyng mot loai khang sinh nao dO can phai lam qua cac budc sau day:
1.1.1 Than? khan Icim sang
Bao gom viec do nhiet d6 benh nhan, phOng van va kham benh Day la budc quan trong nhat va phai,lam trong moi truang hop
Vi sot la dau hieu dien hinh khi co nhi6m khuan nen viec do nhiet d6 g6p phan quan trong de khAng dinh nhiem khuan s6t do vi khuan thtrang gay tang than nhiet tren 39°C trong khi sot do virus chi c6 nhiet d6 khoang 38 — 38,5°C
Nang trtrong hop ngoai le:
— NhiZm khuan (5.13'nh nhan suy giam mien dich, benh nhan qua gia c6 the chi sot
— Trai lai, nhi8m virus ntur quai bi, thtly clau, sot xuat huyet, bai Rt co the tang than nhiet tren 39°C
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Trang 4Trtrong Cao Bang K2Thit4t Y Te II Da Ailing Giao trinh &rot' Icim sang
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
1.1.2
gam
xet nghiem thwang qui
Bao gam cong thirc mat!, X quang va cac chi so sinh h6a se gop phan khang dinh than (loan cua thay thu6c
1.1.3 Tim vi khuOin gciy benh
Day IA bien phap chinh xac nhat de tim ra tac nhan gay benh nhung kh6ng phai mei truang hap deu can Chi trong trtrang hgp nhi8m khuan rat Wang nhu nhiern khan mau, viem mang nao, ,thtrang han khi 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 rang va phoi hap khang sinh lieu tri la hop ly va can thiet
1.2 Phai bier lira clip kitting sinh hp 0
1.2.1 Lira chon khang sinh phai pH hap vai vi khud'n gay benh
Vi du:
Viem hang do thuang do Streptococcus pyogenes A
Nhiem khuan rang mieng thi do Streotococcus, Actinomyces, ky, khi
Viem bang quang cap chn CO bien chirng do E.coli (80%), Proteus, Kiebsiella
1.2.2 Lwa chow khang sinh theo vi tri nhijm,khucin
Milan dieu tri thanh tong, khang sinh phai tharn vao 6 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 2 dac tinh tren
Vi du
Trong dieu tri viem mang nao do P.aeruginosa, cac khang sinh co tac dyng tat len vi khuan nay 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
Trang 5TrtcOng Cao Diing K9 Thitdt Y Te II DO Niing Gicio trinh chror him song
— Do ski suy giam chirc nang gan — then nen sir chuyen h6a va bai xuat thuoc deu yeti han binh thutng, do 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
di ing khang sinh nhOm beta — lactam tdi 20%), do do can het s(ic than trong khi sir dyng khang sinh, nhat la dimg qua throng tiem
— Do bi nhieu benh nen thutng phai ding ciing mot luc nhieu thuoc, do dO kha nang gap twang tac thu6c cao han binh thirang, vi vey phai than trong de tranh cac tuang tac gay tang d6c tinh hoac tac dyng phy
o Suy gan:
Nhilng khang sinh chuyen h6a qua gan > 70% la nhang khang sinh CO d6c tinh cao vdi
ca quan nay 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
1.3.2 Glom kha nang khang thuoc hoac tranh tgo vi khudn de khang
Ph6i hop khang sinh voi mgc dich nay thutng duoc ap khi dyng dieu tri cac nhiem khuan keo dai
Vi du:
Phoi hap khang sinh trong dieu tri lao, viem mang trong tim, viem
1.3.3 Nal rdng pho tac clung czia khang sinh
Ndi r6ng, pho 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 do viec phoi hap khang sinh chit yeu de diet vi khuan ky khi vai cac nhiem khuan co nguy co nhiem ky, khi cao Vi du: phoi hap Metronidazol vdi cac khang sinh khac trong nhiem khuan viing bung, vung cheu vi Metronidazol la thuoc diet
khuan ky, khi manh thuoc nhom 5 — nitro imidazol
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Trang 6Trtrong Cao Bang Ky Thudt Y Te II Dd Niing Gido trinh chive lam sang
Khong co qui dinh cu the ve d6 da cua dpi dieu tri m9i loai nhigm khuan nhung nguyen tac chung la:
— Sir dung khang sinh den khi het vi khuan trong co the: 2 — 3 ngay o ngtrai binh thuang va 5 — 7 ngay benh nhan suy giam miendich
— nhi8m khuan nhe, dal dieu tri thtrong Ice° dai khoang 7 — 10 ngay 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 trong 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 chua co bien chimg nhu viem bang quang, nieu dao, lau có the sir dung cac
lieu
sinh thai manh qua nuk tieu clang con hot tinh nhtr Perfloxacin, Spectinomycin mot lieu duy nhat
2 NHITNG NGUYEN TAC S' DUNG KHANG SINH skr PHONG NHIEM KHUAN TRONG PHAU THUAT
Sir dung khang sinh trong truang hap nay nham ngan chan qua trinh nhiern khuan co the xay ra 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 pho du rOng, c6 tac dung dupe len hau het tac nhan gay benh hay gap nhat trong 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 2 lieu la dn
Ve nguyen tac, chi sir dung khang sinh den khi het nguy ca tham nhap cua vi khuan gay benh Vi lieu dau tien dupe dung Inc khOi me nen sau khi mo xong chi can dung tiep I — 2 lieu nira la du Khong nen dung khang sinh kdo dai sau mo vi se lam benh nhan met m6i, kern an, do
do lau phyc hoi va con gay ton kern Ve tai chinh
Sau dO dung thuoc tiny thu6c vao loai phau thuat, do dai cira cu6c m6, t112 cira khang sinh ch9n
Trang 7Trtrong Cao tang Ky ThuOt Y Te II Do Njng Gicio trinh &rot' lam sang
NGUYEN TAC SLY DUNG GLUCOCORTICOID
MUC TIE U: Sau khi hoc xong heti hoc, sinh vien có kha ming:
1- Giai thich throe nhip sinh bi qua trinh tiet glucocorticoid (GC') trong ccr the
2- Trinh bay cluvr cac chi dinh cua GC trong die'u tri
3- Phcin tich &roc cac tac dyng phi clia GC va ccich khijc phut
NOI DUNG:
Glucocorticoid (GC) la mot trong 2 nh6m , hormon duvc tiet ra vo, thuong than, co vai tr.?) quan trong trong dieu chuyen hOa cac chat Ngoai vai tre tren chuyen hOa cac chat, hormon nhom nay con co nhieu tac dyng khac nhtr tac dung ,chong viem, chong di irng, irc che mien
dich Hien nay ngubi ta tao ra &roc nhimg dan chat loci nay c6 tac dyng chong viem va the mien dich manh han the pham thien nhien va giam hoac lam mat han tac dyng giu muOi-nude nen pham vi ap dyng cua cac dart chat loci nay rat r6ng rai, khong chi bO help trong 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 nay thi lieu thirOng cao han lieu thay the nhieu Ian, do dO cac nguy co gap tac dyng khong mong muon nhieu hon lieu thay the Nhirng kien thirc trong phan nay nham giup cho viec sir dyng nham thuoc nay hop ly, an toan hon
I/ NHIP SINH LY CUA SIX MEET HYDROCORTISON:
Hydrocortisol (Cortisol ) la hormon thu6c nhOm glucocorticoid &roc tiet ra to phan vO cua tuyen thuong than
Nhip sinh ly cua qua trinh tiet hydrocortisol : hinh
CO 3 yeu to anh Wang den kha nang tiet hydrocortison:
1.1/ Nhip ngdy-dent:
Vao khoang ni:ra dem, luong HC trong mau gram tai mcrc khong do dupc; mac nay tang dan tir 3-4,h sang va clat cao nhat vao 16c thirc day Luong hormon tiet ra tir nth dem cho den Itk nay chiem khoang 1/2 tong so hormon tiet trong ngay hormon gia cao cho den giira trim va giam dan khi ye chieu va thap ,nhat vao khoang 3-4 h sau khi di ngii
Nho nhip sinh hoc nay, tuyen thuong than se &roc nghi ve dem, neu mac hormone van tiep • tyc cao trong thOi gian nay, vi dy nhtr ta dtra corticoid vao cuoi bu6i chieu thi tuyen thuong then
se bi C1C che lien, tyc va chirc nang tuyen bi giam manh sau khi ngtIrng thuoc DO la co sO• cho viec quy dinh uOng glucocorticoid nen chi uOng Ian vao buoi sang hoac che d6 diet, tri each ngay 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
Trong, nhirng dieu kien nay neu chirc,nang tuyen thuong then tot thi co kha nang tang host
d6ng ,dedap,img nhu cau; ngtroc lai neu thuong than bi suy thi co the gay suy thong then cap
co the dan den tir vong Suy thuong then thtrang gap khi dung GC lieu cao, keo dai
Chirc nang thtrong then chi trey ye binh thtrang duoc sau 3-4 thang, them chi tai 1 nam sau khi ngung GC Do dO phai theo dei chat the benh nhan cho tai 1 nam ke to khi ngimg dieu tri Trong thoi gian nay neu gap cac stress thi nhat thiet phai cho dung lei GC vai lieu da dung tar& khi ngimg thu6c
1.3/ Str tang keo dai may GC trong pilau:
Skr, tang luong HC co the xay ra khi gap trang thai ctrang thuong then do u thuong then u tuyen yen va gay ra benh, Cushing Khi dung GC lieu cao kelp dai cling gap Cushing do thu6c , Khi dieu tri bang GC ,lieu cao kdo dai, nhip sinh cua tiet hormon bi mat do tryc dual dOi- tuyen yen bi irc, che trien mien b6.i lieu cao cita hormon, do da bat bu6c phai giam lieu tir tir khi
muon ngUng dieu tri de tao lai mot skr thich ang dan cila tuyen sau mot the.' gian nghi dai
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Trang 8Trtrong Cao gang Ky Thual Y 71 1 ll Da Nang Gido dinh &toy lam sang
H/ CHI DINH VA LicrA CHQN THUOC:
1/ Dieu tri thay the khi thieu hormon:
Thuong clang khi 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 trong tru.ang hop nay la 20-30
mg [-IC moi ngay twang img vOi lung HC ti6t ra trongs ngay
Nen dung the c16 dieu tri each ngay bang cach tang lieu met ngay len gap doi va ngay ti6p theo,
se nghi de han the duac su suy thuong than khi ngirng dieu tri
b/ Vol suy thuprig than cap:
Lieu dung thu.O.ng cao han, vi du 100mg HC kic dau, sau do cach 8h lap Iai met Ian cho den khi 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 nay rat rOng bao gem:
Cac benh lien quan den co the benh sinh do 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 trong ghep co quan
Trong dieu tri ung thu• c6 rat nhien chi dinh dung GC, dac biet trong 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 nay a tre em
- tien dung cac the 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 ngay
- 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, do sir giam sot luang hormon sinh due nen tang de ?cep xuang, do do
co the 1)6 sung hormon sinh dgc nhung khong nen dung bien phap nay 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
Trang 9Truang 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 khi co tai Hen
4/ Mc dyng phy do (fang corticoid tyi chb:
Khong duvc nho mat cac the phAm chCra GC khi nhie'm vius hoac nam
Han the boi Ice° dai va kham k9 benh nhan trirdc khi ke don
Khong tkr y dUng thu6c la bien phap tot nhAt de giam tac dyng phy nay
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 duy 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 ngay va phai giam lieu ta tru•dc khi ngirrig thuOc
Theo doi chat the nhang benh nhan dOng GC Ice° dai trong thai gian dieu tri va I nam sau khi ngang thuOc
6/ Tinh tryng tiara corticoid va Onh Gushing do thuac:
cac hien tisong cua Cushing, vi du nhu phii do gia natri va
b/ Khac phyc:
- Giam lieu ta tru.O.c khi ngirng thuOc
Sau khi 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, khi 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 de dieu tri cac benh de d9a tinh mang
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Trang 10Trtrong 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 khi IA trieu chang bao trtrac cua mot benh nao dO Tuy nhien co nhang twang hop dau chi do 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 do cang lam cho dau nang them
Viec tim ra 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 khi 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 duy 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 trong khi benh van ti'en trien, do do chi nen
su dyng khi 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 2 nhOm:
- Thu6c giam dau trung tro'ng
- Thu6c giam dau ngoai vi
Trong bai nay 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 4 nguyen Vac sau:
- Lira chon thuoc phis hop vai ngteeti benh
- Tranh viral qua mire lieu giai hon
- Ton trong 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 nay ho'n thuoc kia chi co tinh tuong d6i vi dau IA phan Ong phy thu6c nhieu vao tarn ly, do 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 trong khi dimg cac dan chat salicylat (aspirin ), benh nhan man cam vai sulfonamid thi tranh climg cac an chat thu6c lc* nay nhu nimesulid, celecoxib
- Phu hop vOi (lieu kien kinh to cua benh nhan Nen can nhac ky ve hieu quA/ Kinh to khi ke don
1.2 Nguyen tae 2: Tranh wro-t qua mire hesu giai han
Moi thu6c giam dau nhom nay deu co mot mire lieu toi da cho phdp Day IA mirc lieu phii hop voi kha nang thai Vb thu6c cua gan va than Khi qua more lieu nay nguy co g4p tac dyng khong mong muon se tang
Nhirng tru.Vng hop dung den, lieu toi da cho phdp nhu'ng van khong dap img mong muon 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 trong nguyen tac phoi hop ( nguyen tac 3)
Lieu khuyencao mot so thuoc giam dau ngoai vi
Ten qui6c t6 Lieu giam dau toi da Lieu toi da giam dau Lieu chong viem
I Ian (mg) 24h (mg) thong, thubng
(mg/Ian)
Trang 11Trufmg Cao Hang K9 Thuat Y T" II Da Nang Giao trinh &for lcim sang
1.3 Nguyen tac 3: Ton trong 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 2 thuoc giam dau co cimg kidu ADR nhu nhau Thu& hay cluoc ding trong moi cong thCrc ph& hop la paracetamol
Vi du : Lieu tOi da mot Ian d6i vai aspirin la 650mg, ndu 0 mac lidu nay 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 khi 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 thanh prostaglandin nen giam sly tao thanh 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 do Lao thanh 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 trong runt, lc* vien nay 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 ra dai cua nhang thu6c chon 19c COX-2 trong 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 nay con 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 nay gay nguy hidm khi sir dyng cho nhang bdrih nhan co tang chay mat' ho4c bdnh xuat huyet Do dO khong su dyng NSAID trong nhang trU.Ong hop sot co xuat huyet va tang chay mau
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Trang 12Trtrong Cao D : cing Kji- Thu at Y Te II Da Niing Gicio trinh &rot Om sang
Dung paracetamol thay the aspirin trong nhang trubng hop chOng chi Binh aspirin do 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 ra o cac benh nhan co tien sir di‘img,
có benh hen, polyp rnOi hoac sot Vi vay phai than trang khi dung cho benh nhan da có tien sir
di rng, hen do dung aspirin
Khong dung cac the pham NSAID de ha sot cho tre em , thay bang paracetamol
d/ Han the viem gan, hogi tfc gan:
Paracetamol dung qua lieu gay viem gan Neu dOng > l Og ngtrai va > 3g vai tre em cludi 2 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 nhau vi se lam tang tac dyng phy loet &rang tieu hozia va chay mau
-NSAID lam tang nguy co chay mau tram trang khi dung dOng thai voi cac thuoc ch6ng dung khac
- NSAID clang ding vai rtrou lam tang nguy xuat huyet tieu hoa
-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 khi 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 do 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 do anh twang den dO dai tac dyng
3/ Chang chi dinh:
1/61 paracetamol:
- Man cam vai paracetamol
- Suy gan
- Tien sir eczema do 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 3 thang cuoi
Phoi hop vai vitamin K hoac methotrexat