1. NGOI KHOA LM SNG-2007CHUN B TIN PHU V CHM SC HU PHU cuc phu thut thnh cng, khng th thiu vai tr ca cng vic chun b trc mv chm sc sau m.Cng vic chun b trc m c thc hin bi -kp iu tr (phu thut vin, bc sgy m, chuyn vin v tm l, chuyn vin v vt l tr liu).Mc ch ca cng vic chun b trc m l: o nh gi ton trng v cc bnh l ni khoa m BN mc phi. o Xc nh cc yu t nguy c c th nh hng n kt qu phu thut. o Gio dc BN (cho BN bit v cc phng php iu tr, u v khuyt im ca tng phng php, v phng php ti u i vi BN). BN cng cn c bit mc trm trng ca cn bnh ca mnh v nguy c xy ra bin chng ca cuc phu thut, cng nh cc vn khc c th xy ra trong v sau m, c bit cc vn c lin quan n thm m, vn ng v s ho nhp vi cng ng. o Ti u ho tnh trng ton thn cng nh trng thi tm l, nhm hn ch n mc thp nht nguy c xy ra cc tai bin v bin chng sau m, lm cho cuc phu thut thnh cng tt p.1-Chun b chung trc m:1.1-Thm khm tin phu:Cng vic thm khm tin phu c tin hnh bi phu thut vin v bao gm cc bcsau: o Khai thc tin cn v nh gi ton trng o Thm khm ton thn o Thm khm cc h c quan o Xc nh cc yu t nguy c ca cuc phu thutKhi khai thc tin cn, cn ch n: o Cc bnh l v thn kinh (tai bin mch mu no, co git, tm thn) o Cc ri lon ng mu: Xut huyt di da Chy mu ko di vt thng Rong kinh o Cc bnh l ni khoa: Bnh tim mch (tng huyt p, thiu mu c tim, bnh van tim) Bnh h hp (hen, bnh phi tc nghn) Bnh gan (vim gan, suy gan) Bnh thn (suy thn) Tiu ng56

2. NGOI KHOA LM SNG-2007 Suy gip hay cng gip Bnh v khp (vim khp cp hay mn tnh) o Cc bnh l nhim trng: Vim ng h hp trn Nhim trng ngoi da (Herpes simplex virus) Nhim trng tiu o Sn ph khoa (thai k, kinh nguyt) o Vn dinh dng (chn n, st cn) o Hin tng ngy hay ngng th trong lc ng. o Tin cn phu thut (chn on v phng php phu thut, cc bin chng xy ra trong v sau m). o Cc thit b nhn to: trong c th c mnh ghp (mch mu), c t my to nhp tim hay van tim nhn to. o D ng thuc (khng sinh, thuc gim au, thuc gy t, latex). o Tng tc thuc: Li tiu (c th gy h K+, Mg2+ huyt tng, lm tng nguy c lon nhp khi c tc ng ca epinephrine). MAO, phenothiazine, thuc chng trm cm ba vng (lm tng tc ng ln h tim mch ca epinephrine) Propranolol: lm tng huyt p kch pht v chm nhp tim khi kt hp vi epinephrine. Cc loi thuc c tc ng bt li n cuc phu thut: Aspirin, NSAID (lm tng nguy c chy mu) Corticoid (c th gy suy tuyn thng thn) Hormone tuyn gip (vic ngng s dng cc ch phm ca hormone tuyn gip do bnh l hay phu thut s dn n cc bin chng ca suy gip)Vic nh gi ton trng (bng 1) nhm xc nh kh nng thch nghi v mc chung ca BN i vi cuc phu thut, ng thi gp phn vo vic nh gi cc yu tnguy c ca cc h c quan, c bit nguy c trn h h hp v tim mch. Xut scTrung bnhKmChy b (1,5 km/ pht) p xe pSinh hot hng ngy (n, tm,Lau chi sn nh i b trong khong thi gian mc qun o)nh tennistrn 4 pht i b trong khong thi gian Leo mt tng ludi 2 pht Vit lchBng 1- nh gi ton trng BN1.2-Y lnh tin phu:1-Thuc l: BN cn ngng ht thuc l ti thiu 8 tun trc phu thut. Thuc l lmtng tnh kch thch ca ph qun, tng nguy c co tht ph qun v tng tit m trongv sau phu thut. Tnh trng tng tit m c th dn n xp phi, vim phi. Nghin 57 3. NGOI KHOA LM SNG-2007cu cho thy rng, vic ngng ht thuc l trong thi gian ngn hn 8 tun trc mkhng lm thay i nguy c xy ra cc bin chng v h hp sau m.2-Cc xt nghim tin phu: nu BN kho mnh, cc xt nghim tin phu thng quisau y c ch nh: o Cng thc mu o Nhm mu o ng huyt o Creatinine huyt tng o AST, ALT o ECG (nu BN trn 40 tui) o X-quang phi thng o Tng phn tch nc tiu o Test thai nhanh (QS): cho tt c ph n trong tui sanh n.3-n ung: o Ngy trc m: ch n khng c cht b o Khng n thc c (bao gm c nc cam, soda v sa) ti thiu 6 gi trc phu thut o Khng ung dch trong (bao gm nc v nc to) ti thiu 2 gi trc phu thut4-Vn ng:C ba mc : ngh ngi trn ging, vn ng c gii hn, vn ng bnh thng. Tuthuc vo bnh l v yu cu ca cuc phu thut m BN c yu cu mt trong baphng php vn ng ni trn.Tr trng hp c ch nh c bit, hu ht BN c yu cu vn ng bnh thng.Vic duy tr vn ng bnh thng trc m s lm tng hiu qu hot ng ca h timmch v h hp, tng cng chc nng chuyn ho, ni tit v min dch, gim nguy chuyt khi tnh mch v teo c bp.5-Cc loi thuc:Trong giai on trc trong v mt khong thi gian nht nh sau m, cc loi thucsau y khng c tip tc s dng: o Thuc lm tng nguy c chy mu:Thuc khng ngThuc c ch s kt tp tiu cu (aspirin, clopidogrel, dipyridamole,ticlopidine). Cc loi thuc ny c yu cu ngng s dng 5 ngy trcphu thut.Thuc khng vim non-steroid (NSAID). Cc loi thuc ny c yucu ngng s dng vo ngy phu thut. o Thuc lm tng nguy c huyt khi (tamoxifen) 58 4. NGOI KHOA LM SNG-2007i vi thuc c ch COX-2 (Celebrex, Vioxx), khng cn thit phi ngng s dng vongy phu thut.Vo sng ngy phu thut, mt s loi thuc c th c tip tc s dng (bng 2).c s dng Khng c s dngTt c cc loi thuc tim mch (tr thuc li Thuc khng vim non-steroid (NSAID)tiu)Thuc tr tiu ngThuc chng tro ngc d dy (omeprazol, Thuc li tiu v cc loi thuc lm gim cnranitidin) Vitamine v cc ch phn ca kaliThuc dn ph qunThuc nga thai ungCorticoid hay cc tc nhn c ch min dchLevothyroxineAcetaminophene v thuc gim au gy nghin Bng 2- Vic s dng cc loi thuc vo sng ngy phu thut6-Chun b mu (xem bi huyt hc trong ngoi khoa)7-Nga nhim trng (xem bi bin chng ngoi khoa)8-Nga huyt khi tnh mch su (xem phn sau)9-Chun b ng tiu ho: o Chun b i trng: dnh cho cc phu thut trn i trng. o Chun b trc trng: dnh cho phu thut vng hu mn, tng sinh mn.10-V sinh vng m: thng thng BN s c yu cu tm ra vo ngy trc phuthut v v sinh vng m vo sng ngy phu thut. Tuy nhin, nguy c nhim trngvng m s thp nht khi v sinh vng m bng cch ct lng v cng vic ny c tinhnh ngay trc cuc m.11-Cc cng vic chun b khc (tho t trang, ty sn mng tay).12-Bui sng ngy m: o Thay , tho t trang o t thng d dy c ch nh trong cc trng hp sau: phu thut thc qun, phu thut d dy, BN c bnh l tro ngc. o t mt ng truyn tnh mch ngoi bin. Dung dch c chn la l Ringer- Glucose 5%.13-Ch nn chuyn BN vo phng tin m 1 gi trc khi bt u phu thut.1.3-Chun b tm l:Cc sang chn v tm l (lo lng, xc ng, s hi) c tc ng bt li n kt qu phuthut.Cn thng bo cho BN bit: o Phng php iu tr, hng x tr cng nh kt qu iu tr. o Nu c nhiu phng php iu tr, nu r mt tch cc v mt gii hn ca tng phng php v cho BN bit phng php no thch hp nht cho BN. o Mt phn c th hay mt c quan ni tng s b ct b, c bit cc phn c lin quan n vn ng (chi) v thm m (v). 59 5. NGOI KHOA LM SNG-2007 o Vn bi tit s khng theo cch thc t nhin (hu mn nhn to, m niu qun ra da). o Tin lng ca cuc phu thut (s cho kt qu tt, trung bnh hay km). Nu BN khng n nh v tm l, thng bo iu ny cho thn nhn ca BN.Khng nn thng bo cho BN bit: o Cc bin chng (c bit cc bin chng c nguy him n tnh mng) c th xy ra. o Nguy c t vongm trc phu thut, cho BN mt loi thuc an thn nh (diazepam 10 mg ung).1.4-Mu v dch truyn:L tng nht l duy tr Hct t 30% tr ln, nng Hb t 10 g/dL tr ln, c bit khiBN sp tri qua phu thut ln, BN c bnh l tim mch, h hp.Tuy nhin, nu BN c sinh hiu n nh v khng thiu nc, nng Hb t 7 g/dL trln khng lm tng t l bin chng v t vong hu phu.1.5-Dinh dng:BN c nng albumin di 2 g/dL hay st cn hn 10% trng lng c th cn cnui dng h tr qua ng tnh mch 7-9 ngy. BN bo ph, s gim cn s c tc ng tch cc n h tim mch v h hp trong vsau m cng nh s lnh vt thng.2-Chm sc chung sau m:2.1-Chm sc BN ngay sau m:Cch thc chm sc BN ngay sau m c trnh by y trong y lnh hu phu. Ylnh hu phu c chnh phu thut vin vit, nhm cung cp cho -kp iu dng phtrch chm sc BN cc thng tin v: 1-chn on, 2-phng php phu thut, 3-tnhtrng BN (bnh l ni khoa, tin cn d ng, thuc khng ng ang s dng), 4-ccthng s cn theo di (th d du hiu sinh tn, ECG, SpO2, p lc tnh mch trung tm,kh mu ng mch), 5-cc bin php iu tr (gim au, khng sinh, dch truyn), 6-cc chm sc c bit khc (t th BN, catheter v cc ng dn lu).Tu thuc vo tnh trng v tnh cht ca cuc phu thut, BN ngay sau m c th cchuyn v phng sn sc c bit hay phng hi tnh.Tiu chun tip nhn BN vo phng sn sc c bit: o BN cn ang c thng kh qun o Huyt p tm thu di 90 mmHg o Sau cc phu thut ln (phu thut tim, ct phi, phnh ng mch ch...)Ni dung ca vic chm sc BN trong phng sn sc c bit: o o kh mu ng mch hay bo ho oxy mu ng mch (SpO2) o Cai my th: gim dn tn s ca ch thng kh cng bc (IMV) xung cn 4 nhp/pht. Nu BN khng c biu hin kh th v SpO2 trn 95%, chuyn sang ch thng kh h tr. o Gim dn nng oxy trong kh th xung cn 0,460 6. NGOI KHOA LM SNG-2007 o Ht m nht qua thng kh qun o Nu BN t th bnh thng, nhp th 12-18 ln/pht, khng c biu hin thiu oxy: rt thng kh qun. o Nu huyt p di 90 mmHg, tm v x tr theo nguyn nhnTiu chun tip nhn BN vo phng hi tnh: o BN c rt thng kh qun, t th v th m o Phn x vng hu hng c khi phc o Huyt p tm thu trn hay bng 90 mmHg o Cc ng dn lu khng cn chy muNi dung ca vic chm sc BN trong phng hi tnh: o o huyt p, mch, nhp th, thn nhit o o bo ho oxy (SpO2) o Tip tc cho BN th oxy qua thng mi o nh gi loi dch ang truyn v tc truyn dch o Kim tra vt m o Kim tra s lng v loi ng dn lu o nh gi s lng v tnh cht dch qua ng dn lu o nh gi tri gic o Quan st phn x nut hay ho khc o Kim tra xem c cu bng quang o Kim tra t th ca BN v s thoi mi ca BN i vi t th Vn truyn dch: o i vi cc cuc phu thut khng bin chng, BN cha n ung c v c sinh hiu n nh, lng dch duy tr c tnh ton theo cng thc sau:Vduy tr = Vnc tiu + lng nc mt qua phi, qua da Trung bnh lng dch duy tr khong 1500 mL/24 gi (25 mL/kg/24 gi). Loi dch truyn c chn la l Ringer-Glucose 5%. o Nu c mt dch qua thng d dy, bi hon bng th tch tng ng ca dung dch NaCl 0,9%. o Nu c mt dch qua ng dn lu: : bi hon bng th tch tng ng ca dung dch Lactate-Ringer.2.2-Chm sc BN trong phng hu phu:iu kin chuyn BN v phng hu phu: o BN tnh to hon ton o BN c th t m bo mt t th an ton v thoi mi trn ging bnh o Huyt p tm thu ln hn hay bng 100 mmHg61 7. NGOI KHOA LM SNG-2007Ty thuc vo bnh l, phng php gy m v phng php phu thut m cc BN sc chm sc v mt vn ng khc nhau. Nu phu thut vng bng c gy m tonthn, sau khi chuyn BN v phng hu phu, cho BN nm ngh dng t th Fowler.T th Fowler cng thch hp cho BN sau phu thut lng ngc.Tr mt s trng hp c bit, BN s c yu cu ngi dy vo bui ti ca ngyphu thut v i li vo ngy hm sau. Sau 3-5 ngy sau m, BN s i li bnh thng. ngn nga bin chng h hp c th xy ra sau m, cn thc hin cc bin php sau: o Hn ch vic nm bt ng ko di, c bit nm nga thng trn ging. Cn thay i t th thng xuyn o Tp th su tng cng hot ng c honh o Tp ho khc o Ph dung khuyn khch (hnh 1) o Trnh truyn qu nhiu dch. Hnh 1- Ph dung khuyn khch: bnh nhn c khuyn khch ht su, sao cho qu bng c nng ln ti mt cao cho trcNu khng c ch nh khc, thng tiu c rt khi BN bt u ngi dy.Vn n ung: o Cho n khi BN tnh to hon ton v ng tiu ho bt u hot ng. o C nhu ng rut, BN i bng: cho ung dch long. Trnh cc cht sinh hi hay cn nhiu nng lng tiu ho (m). o Khi c trung tin, cho BN n c dn vi s lng tng dn.2.3-Gim au sau m:Gim au tt sau m s hn ch c nguy c xy ra cc bin chng sau m: o Thiu mu c tim, nhi mu c tim o Nhp tim nhanh v ri lon nhp tim o Chm lnh vt thng o Xp phi, vim phi o Huyt khi tnh mch o Co tht mch mu ngoi bin o Nhim toan chuyn ho62 8. NGOI KHOA LM SNG-2007Thuc gim au thng c cho di liu, do thy thuc s xy ra cc tc dng ph,do 50% BN khng cm thy tho mn.Mc au v mc cn gim au sau m thay i, ph thuc vo: o Tui tc (tui cng cao cng nn gim liu thuc gim au) o Gii tnh (n km chu au hn nam) o Cc bnh l ni khoa (nghin ru, ng c, cng gip...) o Cc trng thi tm l (lo lng, xc ng lm tng nhu cu cn gim au) o S gio dc BN trc phu thut o Mc nhy au ca tng BN o Quan trng nht l tnh cht ca cuc phu thut: cc phu thut lng ngc v vng bng trn rn gy au sau m nhiu nht.Cc phng php gim au: o Gim au qua ng ung o Gim au qua ng tim bp o Gim au qua ng tnh mch o Gim au ngoi mng cng o Gim au bng phong b TK o Gim au qua da v nim mc2.3.1-Thuc gim au gy nghin:Cc loi thuc gim au gy nghin l la chn u tin lm gim au BN hu phu,do c tc dng gim au mnh ng thi c tc dng n nh v tm l.Khi ch nh cc loi thuc gim au gy nghin cn ch n cc tc dng ph mchng c th gy cho BN: o c ch h hp o c ch h thn kinh trung ng o Nn i o Gim nhu ng rut, c th gy lit rut ko di o Nu s dng ko di, c th dn n hi chng ngng thucChng ch nh s dng thuc gim au gy nghin BN b chn thng s no, BNang suy h hp, hi chng bng cp cha c chn on xc nh.Meperidin: o Liu: 50-150 mg, ung hay TB, mi 2-3 gi. Khng dng qu 600 mg/ngy v khng ko di qu 48 gi. o t gy co tht ng mt v rut non hn morphine. o S dng kt hp vi hydroxyzine (25-100 mg TM mi 6 gi) lm gim nn i v tng hiu qu gim au. 63 9. NGOI KHOA LM SNG-2007 o Cht chuyn ho ca meperidine (normeperidine) lm tng tnh khch thch h thn kinh trung ng, c th dn n ng kinh. o Khng s dng meperidine cho BN s dng cc thuc c ch monoamin oxydase (IMAO) trc 2 tun, BN c tin cn ng kinh, BN b suy thn, suy gan.Pethidine (Dolargan): o Liu: 25 mg ung x 2-3 ln/ngy, 50-100 mg TB x 2-3 ln/ngy. Nu cn thit, c th s dng pethidine qua ng tnh mch.Hydromorphone: o L mt dn xut mnh ca morphine. o Liu: 2-4 mg ung mi 4-6 gi, 1-2 mg TB hay TM mi 4-6 gi, 3 mg cho mi ln dng qua ng to dc.Methadone: o Hiu qu tt khi s dng qua ng ung. o Do c thi gian bn hu di, c th dng methadone c ch triu chng ca hi chng ngng cc loi thuc gim au gy nghin khc.Oxycodone, propoxyphene v codein: o C tc dng gim au yu. o c s dng qua ng ung. o Thng c s dng kt hp vi aspirin hay acetaminophene.2.3.2-Tramadol: o C tc dng gim au mnh tng ng pethidine. o C tc dng gy nghin yu. o Khng gy c ch h hp v tim mch. o t tc dng ph. o Cn thn khi ch nh Tramadol trn BN s dng IMAOs.2.3.3-Thuc khng vim non-steroid (NSAID):Thuc Liu s dng (mg) cho ngi ln/ngyLiu ti a (mg) cho ngiln/ngyDiclofenac (Voltarene) 50-75 (ung/TB) x 2 ln 150Ibuprofen200-400 (ung) x 4-6 ln 1200Indomethacin 25 (ung) x 3 200Ketoprofen 50-75 TB x 2-3 ln300Ketorolac10 (ung) x 4, 15-60 (TB/TM) x 440 (ung, 120 (TB)Naproxen 375 (ung) x 2, 750 (ung) x 1 1500Piroxicam (Feldene)10-20 (ung /TB) x 1 ln Bng 3- Mt s NSAID c s dng ph binCc loi thuc NSAID (bng 3) c tc dng gim au nh n trung bnh.So vi thuc gim au gy nghin, NSAID c u im l khng nh hng n huytng, khng c ch h hp, khng lm c ch s tiu thot d dy v khng lm gimnhu ng rut. 64 10. NGOI KHOA LM SNG-2007Tuy nhin, do c tc ng c ch s kt tp tiu cu, NSAID lm tng nguy c chy mut cc vt thng (phu thut) hay vt lot (d dy-t trng).Khng s dng NSAID cho BN ln tui hay cho tr em. Cn thn khi s dng NSAIDi vi BN b suy gan hay suy thn2.3.4-Acetaminophene:Mt s vn cn ch khi ch nh acetaminophene gim au hu phu: o Acetaminophene c tc dng gim au, h st nhng khng c tc dng khng vim. o Acetaminophene khng nh hng n s kt tp tiu cu, khng lm tng nguy c chy mu. o Acetaminophene c c tnh trn gan. Liu 10-15g acetaminophene c th dn n hoi t gan. o Liu s dng: 325-1000 mg mi 4-6 gi. Liu ti a: 4000 mg/ngy.3-Chun b v chm sc BN trong cc hon cnh c bit:3.1-BN mc bnh tim mch:Tim mch l mt trong nhng c quan chu nhiu sang chn nht khi tin hnh gy mv phu thut. Thng k cho thy rng bin chng tim mch xy ra vi t l 1-10% BNngoi khoa. Nguy c nhi mu c tim sau m BN c bnh mch vnh s tng 10-50 lnso vi ngi khng mc bnh mch vnh.Cc thuc m th kh c tnh c ch i vi t bo c tim. Khi bt u tin hnh gy mton thn, cung lng tim s gim 20-30%.ng tc t ni kh qun s lm tng huyt p ton thn 10-15 mmHg.Cc thuc s dng qua ng tnh mch nh fentanyl, sufentanil, alfentanil t c ch tbo c tim hn cc thuc m th kh. Tuy nhin, chng li c tc ng gy dn tnhmch, lm gim tin ti v gim cung lng tim. Nhng bin i ny s r hn BN bsuy tim huyt.Hn na, cc thuc m th kh, v cc thuc m qua ng tnh mch cng nh cc loithuc dn c lm tng tnh nhy cm ca t bo c tim i vi catecholamine, mt chtng hnh vi cc sang chn ni chung v sang chn do phu thut gy ra ni ring.Gy t tu sng v ngoi mng cng gy dn ng v tnh mch (do xung ng giao cmb c ch), dn n gim cung lng tim. S y tnh mch trc m (truyn nhiudch vi tc nhanh) s hn ch bt mc ca s bin i bt li ny, tuy nhin saum nguy c suy tim huyt s tng 10-15%.Khng c s khc bit v bin chng tim mch gia gy t vng (tu sng, ngoi mngcng) vi gy m ton thn. S kt hp gia gy m ton thn v t ngoi mng cng,kt hp vi thuc gim au s dng trong lc phu thut, s hn ch bt mc tnghot ca h thng giao cm, lm gim nhu cu cn gim au v ci thin tnh trngthng kh sau m, rt ngn thi gian BN phi nm trong phng chm sc c bit.3.1.1-nh gi nguy c:Cc yu t nguy c tim mch c chia lm hai nhm: nhm cc yu t c lin quan nBN (bng 4) v nhm cc yu t c lin quan n cuc phu thut.Cc yu t nguy c lin quan n cuc phu thut:65 11. NGOI KHOA LM SNG-2007 o Phu thut c nguy c cao (t l t vong phu thut hay nhi mu c tim > 5%): phu thut ln c thc hin trong cp cu, phu thut trn ng mch ch hay mch mu ngoi bin, phu thut ko di v mt nhiu mu. o Phu thut c nguy c trung bnh (t l t vong phu thut hay nhi mu c tim 1- 5%): cc phu thut ngc, bng, chnh hnh khng bin chng. o Phu thut c nguy c thp (t l t vong phu thut hay nhi mu c tim 110 mmHg)Bng 4- Cc yu t nguy c tim mch c lin quan n BN (theo ACC/AHA-American College ofCardiology/American Heart Association)3.1.2-nh gi chc nng tim mch trc phu thut:Nhm lng gi chc nng ca h tim mch trc phu thut, nhm c bin php cithin chc nng tim mch v chn la phng php v cm cng nh phng php phuthut thch hp, mt s xt nghim nh gi chc nng tim mch c th c ch nh(bng 5).Ch nh ca cc xt nghim nh gi chc nng tim mch:: o Nguy c tim mch thp trn BN c ton trng km v nguy c phu thut cao o Nguy c tim mch trung bnh trn BN c ton trng km hay nguy c phu thut cao o Nguy c tim mch caoSiu m tim gng sc vi dobutamine: dobutamine, cht ng vn receptor beta, lmtng nhp tim v tng co bp t bo c tim. Khi kt hp siu m tim vi s dngdobutamine, cc bt thng khu tr trn thnh tim, th d vng b thiu mu, c th cpht hin.C hiu qu t c hiu quSiu m tim gng sc vi dobutamine Th nghim bng vn ng trn my chy bX hnh tim vi dipyridamole-thallium (Exercise treadmill testing)X-quang ng mch vnhECG gng scBng 5- Cc phng php nh gi chc nng tim mchX hnh tim vi dipyridamole-thallium: dipyridamole, khi c tim truyn vo tnhmch, lm tng lu lng mu ng mch vnh 2-3 ln. Cc t bo c tim kho mnhbt gi thallium 201, mt cht nh du nucleotide phng x. V th, s chm tr trongvic phn phi thallium mt vng no ca c tim sau khi tim dipyridamole-thallium chng t vng ny b thiu mu.X-quang ng mch vnh c ch nh sau khi siu m tim gng sc vi dobutaminehay x hnh tim vi dipyridamole-thallium cho kt qu c vng thiu mu c tim. Trong 66 12. NGOI KHOA LM SNG-2007mt s trng hp, phu thut bc cu ng mch vnh c th c thc hin trc cucphu thut khng phi tim mch trn BN.3.1.3-Chun b trc m v chm sc sau m:Nh trn trnh by, sang chn do phu thut gy ra l hu qu ca s phng thchcatecholamine. T s nhp tim/huyt p cng ln, nguy c xy ra bin chng cng cao.V th, mt s tc nhn c vai tr bo v tim c xut v tc nhn thuc nhmc ch beta (atenolol, bisoprolol) chng minh hiu qu r rng trong vic lm gimnguy c xy ra cc bin chng tim mch sau m. Thng k cho thy atenolol lmgim 15% nguy c nhi mu c tim, cn au tht ngc khng n nh, suy tim huytv t l t vong sau 6 thng v sau 2 nm BN c phu thut. Bisoprolol cng cho ktqu ngon mc tng t.Vai tr ca cc loi thuc tim mch khc (nitrate, digitalis) cha c nghin cu.Trong thi gian hu phu, gim au tt vi thuc gim au thuc nhm gy nghin lyu t quan trng th hai, sau tc nhn c ch beta, gip ci thin tin lng tim mchca BN.Gi m sau m cng c tc ng tch cc.3.2-BN mc bnh h hp:Trong cc bin chng c th xy ra sau m, bin chng h hp chim mt t l ng k.T l xy ra bin chng h hp sau m thay i t 5 n 70%. Bin chng h hp, nuxy ra, c th lm tng thi gian nm vin ca BN t 1-2 tun.Cc bin chng h hp c th l suy h hp, xp phi, nhim trng h hp (vim phi,vim ph qun), thng kh nhn to ko di (BN khng b c my th), co tht phqun, tnh trng nng thm ca bnh phi c sn.Cc loi thuc s dng trong qu trnh gy m c th lm gim p ng ca h h hpi vi tnh trng thiu oxy hay tnh trng u thn. S kt hp thuc m v thuc dn clm gim r rt kh nng d tr chc nng ca lng ngc, dn n gim th tch lngngc. S gim th tch lng ngc c th gy xp phi cc vng m hot ng h hpb hn ch v qu trnh xp phi ny c th ko di 24 gi sau m.Phu thut vng ngc v bng trn c th gy gim th tch sng 50% v th tch cnchc nng 30%. Nguyn nhn ca s gim ny l do ri lon hot ng ca c honh, doau n v do bt ng sau m.Sau cuc phu thut vng bng trn, BN vn duy tr th tch pht bnh thng, nhng thtch sng gim v nhp th tng (kiu th nhanh nng). Kiu th ny, cng vi tc ngcn li ca thuc m v thuc c ch h thn kinh trung ng s dng sau m, lm cch phn x ho khc v hot ng ca cc t bo lng chuyn ca nim mc ng hhp, c th dn n vim phi.Mt s yu t khc cng lm tng nguy c xy ra bin chng h hp sau m nh ri lonin gii (gim kali, phosphate v can-xi huyt tng), BN nm lit ging, bnh l phic sn (bnh phi tc nghn mn tnh)3.2.1-nh gi nguy c:Yu t nguy c lin quan n BN: o Tui trn 80. Cn ch rng tui tc, nu l yu t c lp, khng c nh hng ng k n nguy c xy ra bin chng phu thut. 67 13. NGOI KHOA LM SNG-2007 o Bo ph o Ton trng km o Thuc l: thuc l lm tng nguy c xy ra bin chng phu thut, ngay c khi BN khng c bnh phi tc nghn mn tnh. Nguy c cao nht khi BN ht thuc l trong vng hai thng trc phu thut. BN ngng ht trn 6 thng trc phu thut c nguy c tng ng ngi khng ht thuc. o Bnh phi tc nghn mn tnh o Bnh suyn o Tnh trng ngng th khi ngYu t nguy c lin quan n cuc phu thut: o Tnh cht ca cuc phu thut: nguy c cao nht thuc v cc phu thut lng ngc, k l phu thut vng bng trn. Phu thut ct ti mt ni soi c nguy c thp hn phu thut vng bng trn. o Cuc m ko di trn 3-4 gi o Gy m ton thn3.2.2-nh gi chc nng h hp trc phu thut:Cc xt nghim nh gi chc nng h hp trc m c ch nh trong cc trng hpsau: o Tt c BN c phu thut ct phi o BN, c phu thut vng ngc v bng trn, c biu hin kh th hay c tin cn ht thuc l o BN, c phu thut vng bng di, c biu hin kh th hay c tin cn ht thuc l v cuc m c d tr s phi ko di o BN trn 60 tui o BN ang ht thuc l o BN ang c bnh l phi o BN ang c triu chng bt thng phi, c bit l ho c m v th kh kh trong vng 5 ngy trc phu thut.Cc phng php nh gi chc nng h hp: o X-quang ngc: t c gi tr. o Kh ph dung (spirometry). Nguy c xy ra bin chng h hp sau m s tng khi kt qu kh ph dung cho thy FEV1 v FVC nh hn 70% gi tr tin on, FEV1/FVC nh hn 65% gi tr tin on. Nu FEV1 di 1 lt, nguy c phu thut s rt cao. Nu FEV1 di 0,8 lt, BN khng th chu ng cuc phu thut ln. o Kh mu ng mch: nguy c tng khi PaCO2 trn 45 mmHg. o X hnh phi: c ch nh khi FEV1 di 2 lt v BN chun b c ct phi.3.2.3-Chun b trc m v chm sc sau m:Trc m:68 14. NGOI KHOA LM SNG-2007 o Ngng ht thuc l, ti thiu 8 tun trc phu thut o Ph dung khuyn khch hay tp vt l tr liu v h hp o Ch nh thch hp cc loi thuc dn ph qun o Cho khng sinhTrong lc m: o Gy t tu sng c chn la trc gy m ton thn o Nu gy m ton thn, vic s dng cc loi thuc dn c c thi gian tc dng trung bnh (vecuronium) c chn la trc cc loi thuc dn c c thi gian tc dng di (pancuronium). o BN c nguy c cao, thi gian phu thut khng nn ko di. Phu thut ni soi nn c chn la trc cc phu thut m vng trn rn.Sau m: o Gim au tt o Tp th su, tp ho khc o Ph dung khuyn khch o Thng kh nhn to vi p lc dng cch qung c vai tr tng ng vi tp th su hay ph dung khuyn khch, nhng li gy bt li cho BN phu thut (lm chng bng).3.3-BN mc bnh gan mt:BN mc bnh gan, khi c tin hnh phu thut, s c nguy c chy mu, hn m ganv thm ch t vong trong giai on hu phu.S ri lon chc nng ca gan c nh hng n hu ht cc h c quan trong c th,trong quan trng nht l h tim mch, no, phi v thn. Nguy c t s ri lon thpht cc h c quan ngoi gan khng km phn quan trng so vi nguy c t ri lonnguyn pht ca gan.3.3.1-nh gi nguy c:Nguy c xy ra cc bin chng v t vong BN b x gan t l vi mc suy t bogan ca BN . BN x gan giai on A (theo phn loi ca Child-Pugh), t l binchng v t vong sau phu thut vng bng (phu thut gan v phu thut cc tng khcngoi gan) l 10%. T l ny BN x gan giai on B l 30% v giai on C l 80% .Khi tin hnh gy m BN b suy gim chc nng gan, s hp thu, phn phi, chuynho v o thi cc loi thuc c s dng trong qu trnh gy m (thuc gy m, thucdn c, thuc gim au v an thn) b nh hng. Mt s loi thuc gy m (halothane,enflurane) lm gim lu lng mu ng mch gan. Halothane c c tnh trc tip nt bo gan. Nguy c suy gan st nh khi s dng halothane s xy ra vi t l 1/6000-35000.Loi phu thut l yu t quan trng nht quyt nh n tin lng ca BN b suy gimchc nng gan. S li ko cc tng khi tin hnh phu thut trong xoang bng c th gyh huyt p ton thn do phn x v lm gim lu lng mu n gan. p ng tng titcatecholamine thng b suy gim BN suy gan v do nh hng ca thuc m. Cucphu thut cng mt nhiu mu, nguy c tn thng gan do thiu mu cng cao. Phuthut cp cu c nguy c gy tn thng gan cao hn phu thut chng trnh.69 15. NGOI KHOA LM SNG-20073.3.2-Chun b trc m v chm sc sau m:Chng ch nh phu thut khi BN: o giai on Child-Pugh C o Suy gan cp o Suy gan mn nng o Ri lon ng mu nng o Ri lon nng chc nng ca cc c quan ngoi gan (suy thn cp, suy h hp cp, bnh l c tim).Chun b trc m: o Ch nh vitamine K v huyt tng ti ng lnh phc hi thi gian prothrombin tr v gii hn bnh thng. BN c thi gian prothrombin bnh thng nhng c suy gan , vitamine K v huyt tng ti ng lnh cng c ch trong vic khi phc hi li kho d tr cc yu t ng mu ca c th. o Truyn tiu cu s lng tiu cu trn 100.000/mm3. o Gim ti thiu lng dch bng trnh nguy c xy ra bung thnh bng, h thnh bng v cc vn v h hp sau m. o Dinh dng h tr qua ng tnh mch kt hp tng cng dinh dng qua ng ming. o nh gi chc nng thn c bin php iu chnh thch hp nu c suy gim chc nng thn. o nh gi v iu chnh cc ri lon v in gii, c bit l tnh trng gim kali huyt tng v nhim kim chuyn hoKhi gy m: o Isoflurane l loi thuc m c chn la v loi thuc ny lm tng lng mu n gan. o Trong cc loi thuc dn c, atracurium, do khng ph thucvo s bi tit qua gan hay thn, thch hp vi BN b suy gan. o Cc loi thuc nh morphine, meperidine, benzodiazepine, and barbiturate phi c s dng ht sc cn thn v chng c chuyn ho gan. Ni chung, liu lng ca chngnn c gim 50%. Trong cc loi thuc gim au gy nghin, fentanyl l tc nhn c chn la.Khi tin hnh phu thut: o Hn ch li ko nhiu cc tng trong xoang bng o Cm mu cn thn o Kt thc sm cuc m o Vic truyn huyt tng giu tiu cu c th lm gim nguy c xy ra bin chng chy mu trm trng.Chm sc sau m: o BN x gan, sau cuc phu thut ko di, c mt nhiu mu v tt huyt p trong lc phu thut nn c lu li v c chm sc trong phng sn sc c bit. 70 16. NGOI KHOA LM SNG-2007 Cn ch n cc biu hin ca suy gan nh vng mt, ri lon tri gic (bnh l no) v bng bng. Cn thn khi ch nh cc loi thuc an thn v c ch thn kinh c trong lc phu thut. Cc loi thuc ny nn c trung ho sm sau m. Cn thn khi ch nh cc thuc gim au gy nghin trong giai on sau m. o Cn nh gi sm chc nng thn, bi v hi chng gan thn c th xy ra, cng nh s chuyn dch ca cc ngn dch sau m BN suy gan c th dn n suy thn. o Duy tr thi gian prothrombin trong gii hn bnh thng bng vitamine K v huyt tng ti ng lnh. Duy tr s lng tiu cu trn gii hn 100.000. o Cho n sm l mt bin php lm ci thin kt qu phu thut BN x gan. o Xt nghim in gii chn on v x tr cc ri lon v in gii, c bit l gim kali huyt tng v nhim kim chuyn ho.3.4-H thn kinh:Tai bin mch mu no c th xy ra BN c tin cn cao huyt p, x va mch mu(c bit BN c biu hin hp ng mch cnh do x va).Siu m Doppler ng mch cnh c ch nh khi: o Nghe c ting thi ca ng mch cnh o BN c cn thong thiu mu no o BN c bnh l mch mu do x va.Nu ng mch cnh hp trn 70%, phu thut lt ni mc ng mch cnh c th cch nh ci thin lu lng mu no.3.5-BN b suy thn mn:3.5.1-Sinh l bnh v nh gi nguy c:Suy thn mn c nh ngha l s suy gim tc lc cu thn. Nguyn nhn ca suythn mn c th l tiu ng, bnh vim cu thn hay bnh thn a nang. Mt t l ngk BN b suy thn mn c cao huyt p, bnh mch vnh v bnh mch mu ngoi bin,bi v cc yu t nguyn nhn ca suy thn mn cng c th l cc yu t nguyn nhnca cc bnh l ny.BN b suy thn mn c th mt trong cc giai on sau: giai on nh (tc lc cuthn, GFR, bng 60-89 mL/pht/1,73m2), giai on trung bnh (GFR bng 30-59mL/pht/1,73m2), giai on nng (GFR bng 15-29 mL/pht/1,73m2) v giai on cui(GFR nh hn 15 mL/pht/1,73m2). Thm phn lc mu v thm phn phc mc thngc bt u khi GFR nh hn 15 mL/pht/1,73m2. BN b suy thn mn chun b cho cuc m chng trnh, cc vn sau y c th xyra: o Bin chng ca bnh mch vnh (nhi mu c tim) o Cao huyt p khng kim sot o Suy tim o Lon nhp tim (rung nh) o Thiu mu71 17. NGOI KHOA LM SNG-2007 o Gim can-xi huyt tng (c th gy cng cn gip th pht) o Gim o thi mui, nc v kali (gy tng kali, nhim toan chuyn ho, cao huyt p v ph) o Ri lon chc nng tiu cu (tng nguy c chy mu sau m)Tc ng ca gy m v phu thut i vi BN b suy thn mn: o Khi s dng cc loi thuc, s gim o thi ca chng l cho chng b li trong mu, gy c cho thn v cc tng khc. S tch lu ca normeperidine, cht chuyn ho ca meperidine (Demerol) trong c th c th gy co git. Cc thuc c ch thn kinh c c th gy lit c h hp ko di sau m. Methoxyflurane and enflurane l cc cht gy c thn v nn trnh s dng cho BN suy thn. Succinylcholine, mt loi thuc dn c kh cc, c th gy tng kali huyt tng (bng 6). o Khi phu thut, cc loi thuc m c th lm gim lu lng mu n thn 50% BN. Thao tc phu thut c th lm dp nt m, gy phng thch kali vo tun hon. Truyn mu hay dung dch Lactate Riger c th gy nhim toan chuyn ho. S ph hu c vn c th dn n tng phosphate huyt tng v gim can- xi huyt tng.Thuc c ch h thng renin-angiotensin-aldosterone: o c ch tng hp renin: c ch beta (metoprolol, atenolol), clonidine, methyldopa, thuc khng vim non-steroid (ibuprofen, naproxen), thuc c ch cyclooxygenase-2 (COX-2) (celecoxib) o c ch tng hp angiotensin II: thuc c ch men chuyn (losartan, candesartan) o c ch tng hp aldosterone: thuc c ch receptor angiotensin II (losartan, candesartan), heparin trng lng phn t thp (enoxaparin, nadroparin calcium), thuc c ch min dch (cyclosporin, tacrolimus) o c ch receptor aldosterone: thuc li tiu tit kim kali (spironolactone) o c ch knh K+/Na+ ng ln xa: thuc li tiu tit kim kali (triamterene, amiloride), khng sinh (trimethoprim/sulfamethoxazole, pentamidine)Thuc lm gii phng K+ t c: succinylcholine, haloperidolDigoxin (qu liu)Bng 6- Cc loi thuc c th gy tng kali huyt tngCc xt nghim cn c thc hin trcmt BN b suy thn mn: o Cng thc mu (nh gi mc thiu mu) o Nng st huyt thanh ( chn on phn bit gia thiu mu do thiu st hay gim tng hp erythropoietin) o in gii o Tng phn tch nc tiu (pht hin nhim trng tiu hay bnh cu thn ang din tin nh hng cu, bch cu v cc tr ca chng). o in tm (nh gi ri lon nhp, ri lon dn truyn, thiu mu c tim) o X-quang ngc thng (loi tr qu ti nc hay cc bnh phi ang din tin) o Cc xt nghim khc: in tm gng sc, siu m tim, X-quang ng mch vnh3.5.2-Chun b trc m v chm sc sau m:72 18. NGOI KHOA LM SNG-2007Vic chun b trc m cng nh chm sc sau m i hi phi c s phi hp giaphu thut vin, bc s tim mch, bc s thn hc, bc s gy m hi sc (v bc s ghptng, nu BN c hay sp sa c ghp thn).BN phi c nh gi v chun b v tim mch nu c bt thng v tim mch.i vi nhng BN c th tch cc ngn dch bnh thng, khng c cc ri lon in giiv khng c xu hng chy mu, vic thm phn mu trc m khng cn thit.Nu chc nng tim bnh thng, nhng BN ph ton thn v ph phi l hu qu catnh trng qu ti nc. BN cn c iu tr bng cc loi thuc li tiu tr v trngthi ng tch. Nu BN khng p ng vi thuc li tiu, thm phn mu nn c cnnhc n.Cc tc nhn gy c thn c th lm cho chc nng thn suy gim thm. i vi ccloi khng sinh (aminoglycoside, acyclovir, amphotericin), thuc an thn hay dn c, cniu chnh liu hay s dng cc thuc khc thay th. Nn trnh s dng thuc khngvim non-steroid, thuc c ch COX-2 cng nh cc loi thuc cn quang. Thuc cnquang c th gy suy thn cp do lm co tht mch mu thn v lm tn thng t bobiu m ng thn. Nu bt buc phi s dng thuc cn quang, c th gim nguy c suythn cp bng cch cho BN ung acetylcysteine v truyn dch (NaCl 0,45%). Khng sdng meperidine (Demerol) gim au cho BN.Cc ri lon v in gii phi c iu chnh trc v sau m.Nu BN ang c thm phn nh k, thi im thm phn trc v sau m, cng nhvic iu chnh cc loi thuc phi c ln k hoch c th. Nu thm phn mu, BN cth cn c thm phn trong vng 24 gi trc m gim thiu nguy c qu ti nc,tng kali huyt tng v tnh trng chy mu. Thm phn phc mc s c chuynsang thm phn mu i vi BN chun b cho cuc phu thut vng bng, cho n khivt m lnh hon ton.Nu BN c phu thut cp cu, cc nh gi v tim mch trc m c th khng cnthit nhng bt buc phi c thc hin sau m. Cn theo di in tm lin tc vxt nghim men tim thng xuyn pht hin thiu mu/ nhi mu c tim sau m (xemthm phn chun b h tim mch). Nng creatine-kinase (CK) c th tng BN b suythn nhng nng CK-MB th khng. V th, s tng CK-MB phn nh tn thng cac tim. Cn nh rng vic chn on nhi mu c tim sau m, c bit BN suy thnmn, khng th da n thun vo mt m phi c ba yu t phi hp (lm sng, xtnghim v ECG).Khi ch nh thuc c ch beta, cn cn nhc n li ch (gim nguy c xy ra binchng tim mch sau m) vi bt li (tng kali huyt tng) m n mang n cho BN bsuy thn mn.3.6-BN b tiu ng:Bnh tiu ng ngy cng ph bin v v th t l BN ngoi khoa b tiu ng cngngy cng tng.T l t vong BN b tiu ng cao gp 5 ln BN khng b tiu ng. Nguyn nhn tvong ch yu do tn thng cc c quan tn.BN ngoi khoa b tiu ng lun ng trc nguy c tng ng huyt. Cc sang chndo cuc phu thut gy ra s lm tng phng thch cortison v catecholamine, trong khi tc nhn i trng l insulin b suy gim tng i (tp 2) hay tuyt i (tp 1). Cc73 19. NGOI KHOA LM SNG-2007loi thuc m th kh cng c tc ng c ch s gii phng insulin. Tuy nhin, ccphng php v cm vng khng ci thin tin lng hu phu ca BN tiu ng.Cc bin chng ca BN tiu ng c phu thut ch yu lin quan n nhim trngv bnh l mch mu. Bnh l mch mu BN tiu ng bao gm bnh vi mch (dnn bnh l thn kinh, bnh l thn v bnh l vng mc) v bnh mch mu ln (x vamch mu v cc bin chng ca n).3.6.1-Thm khm trc m BN tiu ng:Khi khai thc bnh s mt BN tiu ng, cn ch n: o Triu chng kht nhiu, tiu nhiu, gim st th lc o S thch n ung, trng thi ton thn, mc vn ng v cn nng o Ch iu tr hin ti, bao gm thuc, ch n v ch theo di ng huyt o Tn sut, mc trm trng v nguyn nhn ca cc bin chng (nhim keton, h ng huyt) o Tnh trng nhim trng trc (da, bn chn, rng, niu dc) o Triu chng ca bnh l mt, thn, thn kinh mn tnh; tnh trng chc nng ca h tiu ho, bng quang v sinh dc; tnh trng tim mch, bn chn, mch mu ngoi bin; tai bin mch mu no. o Cc yu t nguy c ca x va mch mu, nh ht thuc l, bo ph, ri lon chuyn ho lipid, v yu t gia nh o Trnh hc vn, li sng, iu kin kinh tKhi thm khm lm sng, cn ch n: o Huyt p, tnh trng h huyt p t th o Khm tim o Khm kh o o Khm bng (gan to) o Khm y mt o Khm mch mu ngoi bin o Khm thn kinh o Khm bn chn o Khm da (vt chch insulin)Cc xt nghim cn c thc hin: o ng huyt, HbA1C o Lipid huyt tng (cholesterol, HDL cholesterol, triglycerides, LDL cholesterol) o Chc nng gan (nu c bt thng, nh gi gan nhim m v vim gan) o Tng phn tch nc tiu (ketone, protein, cn lng) o Creatinin huyt thanh v tc lc cu thn o in gii 74 20. NGOI KHOA LM SNG-2007 o in tm 3.6.2-Chun b trc m v chm sc sau m BN tiu ng:Quan trng nht l kim sot ng huyt gii hn cho php. i vi HbA1c, mc l tng l di 6%.Mc tiu kim sot ng huyt s thay i, ph thuc vo mt s yu t, th d nh loiphu thut, tnh trng BN, tui tc v mc nhy cm vi insulin (bng 7). i tngNng ng huyt phn u Gii thcht c(mg/dL)Phu thut tng qutLc i: 90-126Kt qu phu thut tt hn,Bt k: < 180gim t l nhim trngPhu thut tim < 150 Gim t l t vong, gim t l nhim trng vt m xng cBN nng80-110Gim t l bin chng v t vong, gim thi gian nm vinBN b bnh l thn kinh cp < 110T l t vong cao hn nutnh ng huyt khi nhp vin trn 110 mg/dLBng 7- Mc tiu kim sot ng huyt BN tiu ng chun b cho cuc phu thut (theoHip Hi Tiu ng Hoa K). Nhiu tiu chun cht ch hn c xut, tuy nhin nguyc h ng huyt s tng v chi ph iu tr s tng nu xy ra bin chng h ng huyt. BN c tin cn nhiu ln b h ng huyt hay h ng huyt mc trm trng, cc tiuchun s c ni lng hn. Mt s i tng BN c bit, th d ngi gi hay thai ph, cn cnhng cn nhc ring bit. Ni chung, mc tiu kim sot ng huyt c th thay i tu thucvo tng c nhn BN.Trong giai on chu phu, c rt nhiu yu t lm tng ng huyt. V th, theo di stv kim sot cht ch ng huyt l yu cu cp thit. BN b tiu ng c th s dngthuc h ng huyt ung trc cuc m v s dng tr li sau m. Tuy nhin, cc loithuc h ng huyt ung c mt s bt li khi s dng (bng 8). V th, insulin, dngqua ng tnh mch, tc nhn h ng huyt c ng nht v d c ho gii nht,c xem l l tng i vi BN b tiu ng trong giai on ny. Loi Th dBt li Seretagogue Glyburide, glimepirideGy h ng huyt, tc ng ko di, kh c ho gii Biguanide MetformminNhim toan lactide, s dng cn thn i vi BN suy gan, suy thn hay suy tim huytThiazolidinedione RosiglitazoneLm tng th tch trong lng mch (c th gy suy tim huyt), tc dng chm, kh c ho giiBng 8- Cc bt li ca thuc h ng huyt ung i vi BN ngoi khoaBN b tiu ng tp 1 nn c sp xp m sm v m ca u hn ch ti a s ginon ch iu tr tiu ng. Tu thuc vo mc v thi gian phu thut, BN cth c cho liu insulin tc dng di sau c chuyn xung phng tin m vimt ng truyn dung dch Glucose 5% v nng glucose c theo di cho n khiphu thut. kim sot nng glucose trong gii hn 80-110 mg/dL, c th thc hin theo phc sau: t mt ng truyn tnh mch ring bit truyn regular insulin (5-10 U chomi 50-100 mL dung dch NaCl 0,9%). Tc truyn insulin c xc nh bi cngthc sau: insulin (U/gi) = glucose (mg/dL)/150. Bt u truyn dung dch Glucose khi75 21. NGOI KHOA LM SNG-2007nng glucose gim n 150 mg/dL trnh h ng huyt. Nn t mt catheterng mch ly mu mu xt nghim nng glucose mi 1-2 gi trong lc phu thutv sau m cho n khi chuyn sang ch iu tr bng insulin tim di da hay thuch ng huyt ung (BN n ung tr li). Trong thi gian ny, mt ng truyndung dch NaCl 0,9% c s dng bi hon s thiu ht trong lng mch.3.7-BN ang s dng khng ng:3.7.1-i cng:Thuc khng ng c ch nh trong mt s trng hp sau y:o iu tr huyt khi tnh mch (huyt khi tnh mch su, huyt khi ng mchphi).o Phng nga huyt khi (huyt khi tnh mch su, huyt khi ng mch phi).o Thiu ht antithrombin III (AT III), protein C, protein So Bnh l tc ng mch do huyt khi (van tim nhn to, bnh van hai l, nhimu c tim, rung nh, bnh c tim c huyt, huyt khi trong bung tim)o Bnh ng mu ni mch lan to.o Duy tr s thng thng ca cc thng ni mch mu t thn hay nhn to (ngghp).Chng ch nh s dng thuc khng ng trong cc trng hp sau:o BN c nguy c chy mu (gim s lng v cht lng tiu cu, lot d dy-ttrng).o Sang thng trn h thn kinh trung ng (chn thng hay phu thut s no, taibin mch mu no).o Cc th thut trn ct sng (gy t tu sng, chc d tu sng).o Cao huyt p c tnho Bnh vng mc ang din tinNi chung, cc chng ch nh ni trn c tnh cht tng i. Vic ch nh cc thuckhng ng s l kt qu ca s cn nhc gia li ch v bt li m chng mang n choBN.Ring warfarin b chng ch nh s dng i vi thai ph trong ba thng u v bathng cui thai k, BN khng hp tc v nguy c v ngh nghip.Heparin trng lng phn t thp b chng ch nh cho BN suy thn. nh gi hiu qu s dng ca warfarin v cc thuc khng ng ung, xt nghimINR. Trong trng hp heparin l aPTT v heparin trng lng phn t thp (LMWH) lyu t khng yu t Xa (bng 9).Gii hn bnh thngGii hn iu trINR0,8-1,2 2-3 cho hu ht cc trng hp. Gii hn 2,5- 3,5 c ch nh cho cc trng hp sau: van tim nhn to, hi chng khng phospholipid, phng nga nhi mu c tim ti pht Ch : 76 22. NGOI KHOA LM SNG-2007-Nng warfarin s t n ngng iu trsau 2 n 7 ngy-Xt nghim INR mi ngy cho n khi INR tn ngng iu tr, sau 2 ln mi tun trong2 tun, v 1 ln mi thng.aPTT25-41 giy1,5-2,5 ln gi tr bnh thng ca BNCh :-Xt nghim sau 6 gi k t liu u tin caLMWH.Yu t khng Xa Phng nga: 0,2-0,4 U/mLiu tr: 0.5-1.5 U/mLCh : nu cn thit phi nh gi hiu qu iutr, xt nghim yu t khng Xa sau 4 gi k tliu u tin ca LMWH. Tuy nhin, khng cnthit phi xt nghim yu t khng Xa nu khngc bin chng chy mu Bng 9- Cc thng s theo di hiu qu iu tr ca cc loi thuc khng ng3.7.2-nh gi nguy c:Phu thut cho BN ang s dng thuc khng ng l mt vn ln trong ngoi khoa.Khi tin hnh phu thut (khng phi phu thut tim) mt BN ang s dng thuc khngng, mi quan tm ln nht ca phu thut vin l lm sao c th tin hnh cuc phuthut an ton v cho kt qu tt m khng lm tng nguy c chy mu hay nguy c lpmch do huyt khi trong v sau m. Vic ngng s dng thuc khng ng c th to ranguy c lp mch. S lp mch c ngun gc t tim, nu xy ra, s c d hu ht scnng n (40% t vong v 20% gy tn ph). Ngc li, nu thuc khng ng cn phthuy tc dng trong lc phu thut, BN s c nguy c chy mu trong v sau m.Theo kin ca phn ln cc phu thut vin, i vi BN chun b tri qua cc th thuthay phu thut nh (ni soi, nh rng, sinh thit) c nguy c chy mu thp (bng 10),khng cn thit phi gin on vic s dng thuc khng ng. Chy mu rng sau mc th c kim sot bng cch cho BN ngm dung dch tranexamic acid hoc epsilonamino caproic acid. Nguy c thp Nguy c caoNi soi thc qun, d dy, t trng khng c Ct polyp qua ni soisinh thit t laser qua ni soiNi soi i trng khng c sinh thitCt c vng qua ni soiNi soi chp hay t stent ng mt khng c Nong ng tiu ho bng hi hay bougiect c vngM d dy ra da qua ni soiSiu m qua ni soi khng c sinh thit bng Cc th thut can thip trn dn tnh mchkimthc qun.Bng 10- Nguy c chy mu ca cc th thut ni soiC mt s phc x tr BN ang dng thuc khng ng chun b cho cuc phu thut.Theo phc ca Kearon (1998), thi x tr s ph thuc vo v tr huyt khi v thigian k t khi hin tng lp mch do huyt khi xy ra ln cui cho n thi im dtr phu thut.3.7.3-Chun b trc m v chm sc sau m:3.7.3.1-BN b huyt khi ng mch:Nu thi im d tr phu thut cch thi im BN b lp ng mch do huyt khi trnmt thng, ngng 4 liu cui ca warfarin trc ngy m. Nu din tin thun li, INR 77 23. NGOI KHOA LM SNG-2007s gim dn v t gi tr bnh thng vo ngy m. Vo ngy trc m, xt nghim INR quyt nh c nn ch nh vitamine K hay khng. Nu INR trn 1,7, cho BN 1 mgvitamine K tim di da v xt nghim li INR vo sng ngy m. Nu INR bng 1,3n 1,7, truyn cho BN mt n v huyt tng ti ng lnh. Truyn hai n v huyttng ti ng lnh nu INR bng 1,7-2.Sau m, s dng tr li warfarin vo ngy hu phu 2-3.Nu thi im d tr phu thut cch thi im BN b lp ng mch do huyt khi nhhn mt thng, khi INR bt u gim di 2, s dng heparin qua ng tnh mch gim nguy c lp ng mch do huyt khi ti pht. Ngng heparin 6 gi trc phuthut. S dng tr li heparin 12 gi sau m vi liu lng khng qu 18 U/kg/gi. Xtnghim aPTT sau 12 gi xc nh hiu qu iu tr ca heparin. Nu BN tri qua phuthut ln hay c nguy c chy mu sau m do heparin, khng s dng heparin m thaybng LMWH khi INR bt u gim di 1,8.3.7.3.2-BN b huyt khi tnh mch:Bn thn cuc phu thut cng c nguy c gy huyt khi tnh mch, ngay c ngibnh thng. Do , c gng tr hon cuc phu thut, nu c th, ti thiu mt thng kt lc BN b huyt khi tnh mch cp tnh (l tng nht l hai thng).Ngng 4 liu cui ca warfarin trc ngy m nu BN b huyt khi tnh mch t 1 n3 thng trc , ngng 5 liu nu BN b huyt khi tnh mch trn 3 thng. Ch nhheparin hay LMWH nu BN phi bt ng trc m v INR nh hn 1,8.Nu BN b huyt khi tnh mch trong vng 1 thng trc , ch nh heparin khi INRnh hn 2.Sau m 12 gi, nu BN b huyt khi tnh mch trong vng 3 thng trc , heparinc ch nh khi INR di 2. Nu BN khng b huyt khi tnh mch trong vng 3thng trc , LMWH c ch nh khi INR di 2.3.8-Phng nga huyt khi tnh mch su sau m:Nguy c thp Nguy c trung bnhNguy c caoPhu thut nh trn BN nh Phu thut nh trn BN nh Phu thut ln trn BN trnhn 40 tui v khng c cchn 40 tui v c cc yu t 60 tui v khng c cc yu tyu t nguy c trn lm sng nguy c. nguy c.(xem bi huyt hc trong Phu thut ln trn BN nh Phu thut ln trn BN nhngoi khoa). hn 40 tui v khng c cc hn 40 tui v c cc yu tThi gian gy m ton thn yu t nguy c.nguy c.di 30 pht.Bt k BN ngoi khoa no c Phu thut vng chu, khp tui t 40-60. hng hay phu thut chi di Thi gian gy m trn 30 pht. Bng 11- Nguy c xy ra huyt khi tnh mch su sau m o Phu thut c nguy c thp (bng 11): cho BN vn ng sm sau m. o Phu thut c nguy c trung bnh: heparin liu thp (5000 U mi 8-12 gi), LMWH (bng 12), p chn bng bm hi cch qung kt hp mang v n hi. o Phu thut c nguy c cao: heparin liu thp (5000 U, 2 gi trc m v sau m mi 8 gi), LMWH, p chn bng bm hi cch qung. o Phu thut c nguy c rt cao: LMWH, warfarin (INR t 2-3), LMWH kt hp p chn bng bm hi cch qung, heparin liu thp (iu chnh liu). 78 24. NGOI KHOA LM SNG-2007 o Phu thut c nguy c cao v BN c nguy c b t mu vng m sau m (th d bc tch nhiu khoang sau phc mc): p chn bng bm hi cch qung.Trong phng nga huyt khi tnh mch su sau m, cc LMWH c xem l c hiuqu hn heparin (t l huyt khi tnh mch su sau m l 10%, so vi 15,3% caheparin), t c bin chng chy mu hn (t l 0,9%, so vi 3,5% ca heparin).Enoxaparin (Lovenox)Phu thut tng qut (nguy c trung bnh): 2000 U (20 mg)TDD 1-2 gi trc m v mi ngy sau m.Phu thut tng qut (nguy c cao): 4000 U (20 mg) TDD 1-2gi trc m v mi ngy sau m.Phu thut chnh hnh: 3000 U TDD mi 12 gi, bt u t 12-24 gi sau m.Dalteparin (Fragmin)Phu thut tng qut (nguy c trung bnh): 2500 U TDD 1-2gi trc m v mi ngy sau m.Phu thut tng qut (nguy c cao): 5000 U (20 mg) TDD 8-12gi trc m v mi ngy sau m.Phu thut chnh hnh: 5000 U TDD 8-12 gi trc m v mingy sau m (bt u t 12-24 gi sau m).Bng 12- Cch s dng mt s heparin trng lng phn t thp (LMWH) trong phng ngahuyt khi tnh mch su sau m.3.9-Thuc v BN ngoi khoa:Nhiu loi thuc m BN s dng thng dng trc phu thut c th c tng tc vi ccloi thuc c s dng trong qu trnh gy m v phu thut. Bc s iu tr cn nmc thi gian bn hu, s iu chnh liu cng nh thi kho biu cho vic s dngchng.Mt s loi thuc c th c s dng tip tc trong giai on chu phu. BN c th sdng liu cui cng vi mt ngm nh nc 2 gi trc m v s dng tr li sau m.Mt s loi thuc khc li c th c ngng s dng, c chuyn sang loi thuc thayth khc hay chuyn i ng s dng.3.9.1-Thuc tim mch:3.9.1.1-Thuc iu tr thiu mu c tim (bng 13):Thuc Ngy trc PT Ngy PTTrong lc PTSau PTNitroglycerin Liu BT Liu BTTruyn TM nu Tip tc liu TM cho c biu hin thiun khi c th s dng mu c tim r qua ng mingc ch betaLiu BTLiu TM theo Liu TM theoLiu TM theo phc phc phc cho n khi c th s dng quang mingc ch knhLiu BT Tip tc liu TM chocan-xi n khi c th s dng qua ng mingAspirin Ngng 1 tun S dng tr li tutrc PT theo ch nh ca thy thucTiclopidine Ngng 1 tun S dng tr li tutrc PT theo ch nh ca thy thuc Bng 13- Cch s dng thuc trong giai on chu phu BN mc bnh mch vnh(BT: bnh thng, PT: phu thut, TM: tnh mch) 79 25. NGOI KHOA LM SNG-2007Cc loi thuc tim mch l thuc c s dng ph bin nht trc m. i vi BN mcbnh mch vnh, c ch be-ta l thuc c ch nh rng ri nht v c chngminh l lm gim nguy c xy ra nhi mu c tim sau m. t hiu qu ti u, thucc ch beta c ch nh hai tun hay hn trc m, duy tr trong lc m v ko di n14 ngy sau m. Vic ngng t ngt thuc c ch beta c th lm thay i nhp tim vhuyt p v c th lm tin cho nhi mu c tim xy ra. Mc ch ca thuc c chbeta l duy tr nhp tim trong khong 65-70 nhp mi pht. Nu nhp tim di 65 nhpmi pht, hay huyt p tm thu di 100 mmHg, hay BN gi yu suy kit, gim liuthuc c ch beta. Nu nhp tim di 50 nhp mi pht, ngng s dng thuc c chbeta.Hin nay, mt s bnh vin c phc s dng thuc c ch beta trong giai on chuphu.3.9.1.2-Thuc iu tr cao huyt p (bng 14): ThucNgy trc PT Ngy PT Trong lc PTSau PTc ch beta Liu BTLiu BT voLiuTM Tip tc liu s dng sng ngy m (thng khng qua ng tnh mch vi mt ngm cn thit) cho n khi BN n nh ncung cc ch can-xiLiu BT Liu BT voLiuTM Tip tc liu s dng sng ngy m (thng khng qua ng tnh mch vi mt ngm cn thit) cho n khi BN n nh ncung cc chmenLiu BTLiuTM Tip tc liu s dngchuyn(thng khng qua ng tnh mchcn thit) cho n khi BN n ung cThuc li tiuNgng vo c ch beta Bt u tr li khi BNngytrc hay c ch ung cphu thutknh can-xi TMCh phm kali Ngng voBt u tr li khi BNngytrcung cphu thut. Xtnghim nng kaliThuc hu giao Liu BT Liu BT vo LiuTM Bt u tr li khi BNcm tc ng sng ngy m (thng khng ung ctrung ng vi mt ngm cn thit) nh ncc ch alphaLiu BTLiu BT vo LiuTM Bt u tr li khi BN sng ngy m (thng khng ung c vi mt ngm cn thit) nh ncThuc dn mch Liu BT Liu BT vo LiuTM Bt u tr li khi BN sng ngy m (thng khng ung c vi mt ngm cn thit) nh ncBng 14- Cch s dng thuc h p trong giai on chu phu (BT: bnh thng, PT: phu thut, TM: tnh mch) 80 26. NGOI KHOA LM SNG-2007Cao huyt p l yu t nguy c ca bnh mch vnh (v tai bin mch mu no). Ccloi thuc h p s c s dng xuyn sut giai on chu phu, vi mt s thay i vcch thc s dng hay thay th khi cn thit.Cc loi thuc h p vn c tip tc s dng cho n ngy phu thut, tr thuc litiu. Methyldopa s c ngng s dng trong giai on chu phu. Reserpine andprazosin c ngng vo ngy trc m v tip tc s dng tr li sau m.Cc loi thuc h p phi c s dng lin tc s c chuyn i ng s dng. Tiubiu nht phi k n thuc c ch beta (propranolol, atenolol, and metoprolol). Cc loithuc h p khc c th s dng qua ng tnh mch l enalapril, verapamil vdiltiazem. Clonidin c ch phm dn ngoi da (tc dng y ch t n sau 48 gi) .Nu tnh trng cao huyt p trm trng hn, c th ch nh labetalol, nitroglycerin, vnitroprusside.Cn ch n tc dng ph ca cc loi thuc h p khi ch nh chng. Khng s dnghydralazin truyn tnh mch v phn x nhp tim nhanh ca loi thuc ny c th gythiu mu c tim. Nifedipine ngm di li c th gy tai bin mch mu no, nhimu c tim. nhng BN ch cao huyt p nh, trong giai on ngay sau hu phu, c th tm thingng s dng cc thuc h p dng qua ng tnh mch cho n khi BN c th nung c. Gim au tch cc kt hp vi thuc an du v hn ch mui l bin php ttngn nga tnh trng tng huyt p.3.9.1.3-Thuc iu tr suy tim:Suy tim huyt trong giai on tin phu l yu t nguy c ca bin chng ph phitrong giai on hu phu. Hu ht cc trng hp suy tim huyt xy ra trong vng 1gi sau phu thut trong 50% cc trng hp l do truyn dch khng thch hp.Tnh trng suy tim huyt cn phi c duy tr n nh bng thuc li tiu, c ch menchuyn v digoxin.3.9.2-Thuc h hp:Trong giai on chu phu, cc thuc ng vn beta v thuc dn ph qun khng nnc ngng s dng. BN tip tc liu kh dung v liu ung bnh thng vo ngy trcm v sng ngy phu thut.Cc loi thuc dn ph qun nn c ch nh trc m nu nh dung tch sng ti adi 1000 mL v th tch th ra ti a trong giy u di 500 mL. Nhng BN ho cm nn c ngng cuc phu thut v c k toa mt t thuc khng sinh lmgim nguy c co tht ph qun.Trong iu kin ti u, ngng ht thuc l ti thiu 8 tun trc phu thut. Nhng BNch ngng ht thuc mt vi ngy trc m cng c ch, v cc tc ng trn tim mchdo CO gy ra s c hn ch phn no. Cn ch l nhng BN ch ngng thuc l mtthi gian ngn trc m nn c ch nh ming dn nicotine trnh xy ra hi chngngng thuc.Nhng BN ang s dng steroid di ngy nn c tng liu thuc vo ngy phu thut,sau gim 50% liu mi ngy cho n khi t n liu s dng bnh thng.Trong khi tin hnh phu thut, cc loi thuc ni trn khng cn thit. Sau m, nu BNcn c lu ni kh qun, cc liu kh dung c th c s dng tip tc. 81 27. NGOI KHOA LM SNG-2007Sau m, vn gim au chim vai tr ht sc quan trong. Vic ch nh thuc gim augy nghin phi ht sc cn trng v BN cn c theo di st tnh trng c ch h hp.3.9.3-Ch phm hormone tuyn gip v thuc khng gip:Nhng BN b nhc gip c triu chng cng nh b cng gip nn c hon cucphu thut.Trong trng hp phu thut cp cu, BN nhc gip c ch nh L-thyroxin quang tnh mch, bt u bng liu bolus 500 mcg, sau 50-100 mcg mi ngy. Cntheo di tnh trng h thn nhit, h natri huyt tng, h ng huyt v gim thngkh.Nhng BN b nhc gip nng nn c ch nh steroid trong giai on chu phu trnh nguy c suy tuyn thng thn.i vi nhng BN ang s dng thyroxine, thuc c th tip tc c s dng trc m(ung vi mt ngm nh nc vo sng ngy m) v bt u s dng tr li sau m, khic th ung c. Tuy nhin, BN c th ngng s dng chng trong vng 1 tun v thucc thi gian bn hu di (7 ngy). nhng BN cng gip, tnh trng cng gip phi c kim sot tt trc khi tinhnh phu thut.Trong trng hp phu thut khng phi trn tuyn gip, BN ung liu cui ca thuckhng gip v propranolol vo sng ngy m vi mt ngm nh nc. Cc thuc nyc s dng trong vng 24 gi sau m (qua ng ung hay thng d dy).Trong trng hp phu thut truyn gip, iodine c ch nh 10 ngy trc m, cngthuc khng gip v propranolol. iu ny lm gim nguy c chy mu t tuyn gip.Propranolol c th c tip tc vi ngy say m trc khi ngng s dng.3.9.4-Thuc nga thai v cc ch phm thay th ca estrogen:Nhng BN ang s dng thuc nga thai hay cc ch phm ca estrogen c nguy c bhuyt khi tnh mch sau m.BN ang s dng thuc nga thai c khuyn chuyn sang bin php trnh thai khc 4-6 tun trc phu thut v ch s dng tr li chng ti thiu 2 tun k t khi vn ngv sinh hot tr li bnh thng. Nhng BN khng bo m bin php nga thai thay thphi c loi tr kh nng mang thai trc m.i vi BN ang giai on sau mn kinh v ang dng ch phm ca estrogen, nungng thuc, c th ti xut hin cc triu chng. Trong cc trng hp ny, thay vngng thuc, c th p dng cc bin php nga huyt khi tnh mch sau m.Cc bin php nga huyt khi tnh mch sau m cng c p dng i vi cc BNang s dng thuc nga thai hay cc ch phm ca estrogen c phu thut cp cu.3.9.5-Steroid:BN ang s dng steroid ko di s c tnh trng c ch trc h i-tuyn yn-tuynthng thn vi cc mc khc nhau. Sau khi ngng thuc (th d do phu thut), thigian phc hi chc nng ca tuyn thng thn c th ko di t vi ngy n vi thng.Nh vy, cc BN ny phi c b xung steroid trong thi gian trc trong v sau m.Khi ch nh corticosteroid trong giai on chu phu, cc liu thuc phi song song vip ng bnh thng ca tuyn thng thn i vi cuc phu thut.82 28. NGOI KHOA LM SNG-2007Tu thuc vo liu lng thuc m BN ang s dng trc khi phu thut v tnh chtca cuc phu thut, phc sau c th c p dng:i vi cuc phu thut nh v BN ang s dng 10 mg prednisone (hay liu tngng) mi ngy, liu 25-100 mg hydrocortisone TM khi dn m l va .i vi cuc phu thut ln, ch nh 100 mg hydrocortisone TM x 3 mi ngy, sau gim nhanh liu prednisone (50% mi ngy) t liu thng thng (5 mg/ngy) vongy m. Thuc corticosteroid ung s c s dng tr li khi ng tiu ho hotng.BN ang s dng corticosteroid liu cao ( c ch min dch) s c duy tr liu caotng ng trong giai on chu phu. 60 mg prednisone c s dng mi ngy s cthay th bng 250-300 mg hydrocortisone cho n khi BN c th ung liu hng ngyqua ng ming (vi cng mt liu lng, prednisone c dc tnh mnh hnhydrocortisone 4 ln).3.9.6-Thuc chng ng kinh:ng kinh cn ln c th gy ra mt s bin chng trong giai on chu phu, th d vimphi ht, bung vt m, gy xng v di lch cc vt liu nhn to c t trong c th.Phenytoin v phenobarbital nn c tip tc s dng trong giai on chu phu. Cc loithuc khng c ch phm dng qua ng tnh mch (carbamazepine v valproic acid)s c chuyn sang phenytoin v phenobarbital. BN b d ng vi phenytoin s chuynsang s dng phenobarbital. Nu BN d ng vi c hai loi thuc ny, prednisone 60mg/ngy trong 2 ngy trc c th ngn chn phn ng d ng ca phenytoin vphenobarbital.Do thuc iu tr Parkinson (dopamine, thuc kt hp gia L-dopa and carbidopa) khngc ch phm s dng qua ng tnh mch, BN b Parkinson ang s dng dopaminenn kt thc s dng cng mun cng tt trc m v s dng tr li cng sm cng ttsau m, trnh xy ra c run git ca Parkinsonian.3.9.7-Thuc hng tn thn:Thuc khng trm cm ba vng c th c cho liu cui ngay trc cuc m v sdng tr li khi BN c th ung c. Cha c ghi nhn no v s tng tc ca thuckhng trm cm ba vng v cc loi thuc c s dng trong qu trnh gy m.Vic s dng thuc c ch monoamine oxidase (IMAOs) trong giai on chu phu cngging nh vic s dng thuc khng trm cm ba vng. Tuy nhin, BN ang s dngIMAOs s c chng ch nh s dng meperidine v c th dn n hi chng tm thnc tnh (biu hin bng st, o gic v gng cng).Cc loi thuc khng tm thn (phenothiazines, butyrophenones, thioxanthenes,indolones, and dibenzoxazepines) phi c m bo s dng xuyn sut trong giai onchu phu, trnh nguy c xy ra cc ri lon tm thn.Lithium c th lm tng dc tnh ca cc tc nhn c ch thn kinh c. Mt khc, so thi ca lithium c th gim (dn n ng c lithium) trong cc trng hp cnbng dch m tnh, cn bng natri m tnh v gim tc lc cu thn. Do , c thngng s dng lithium 2-3 ngy trc m v s dng tr li khi chc nng thn v ingii tr v bnh thng sau m. Trong trng hp cuc m nh v nng huytthanh ca lithium trc m bnh thng, c th s dng lithium trong giai on chuphu.83 29. NGOI KHOA LM SNG-2007Cc loi thuc gy an du (phenothiazine, butyrophenones, benzodiazepine) c th gyh huyt p v c ch t bo c tim. Cc loi thuc ny c th c ngng s dng mtvi ngy trc m v s dng sau m 2-3 ngy.3.9.8-Thuc khng vim non-steroid (NSAID) (bng 15): ThucNgy trc Ngy PT Trong lcSau PTThuc thay th PT PTNSAIDcNgng1 Ch phm TBthi gian bntun trc cho n khi BNhu diPT ung cNSAIDcNgng 2-3Ch phm TBthi gian bnngy trc cho n khi BNhu ngn PT ung cNSAIDtrSteroidLiuvim khp thpBng 15- Cch s dng thuc khng vim non-steroid (NSAID) trong giai on chu phu(PT: phu thut, TB: tim bp)Cc NSAID c th c BN s dng di ngy trc m iu tr bnh vim khp. Ccloi thuc ny c th gy ra cc bin chng chy mu sau m. S ngng s dng thuctrong giai on chu phu, c xem l vn hp l, c th lm cho BN au khp tipht, cng khp, hn ch vn ng sau m. Vic ch nh cc NSAID c ch chn lctrn COX-2 c th trnh c bin chng chy mu. Tuy nhin, vai tr ca cc loithuc ny i vi s lnh nim mc vn cha c nghin cu. Cc loi thuc gim aukhc hay corticosteroid thay th cho NSAID c th lm chm li qu trnh phc hi caBN.3.9.9-Thuc gim tit d dy: BN b vim lot d dy-t trng, chy mu ng tiu ho v cc bnh l khc (th dbnh tro ngc) nn c ch nh cc tc nhn c ch H2 trong giai on chu phu.Nu BN ang s dng tc nhn c ch bm proton, chng s c tip tc s dng tronggiai on chu phu.84