DTQGVN

1 Gii thch mt
s thut ng 39
Gii thch mt s thut ng

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1Adrenergic 45th th trn b mt t bo i vi

21. c hot ha, hoc c c tnh 46cc hormon peptid, cc cht dn
3ca adrenalin hoc tit ra 47truyn thn kinh, khng nguyn,
4adrenalin (c bit khi ni v cc 48cc on b th, globulin min
5si thn kinh giao cm tit ra 49dch v cc th th nm trong bo
6adrenalin v noradrenalin ti xinap 50tng i vi hormon steroid.
7khi c mt xung ng thn kinh i 51Th th adrenergic
8qua). 52C hai loi p ng chnh i vi
92. Tc dng ging adrenalin (khi ni 53catecho-
10v thuc). Cn gi l thuc ging 54lamin, phn nh s hot ha ca hai
11giao cm. 55nhm th th adrenergic, c gi
12Cholinergic 56l alpha v beta. C hai nhm th
131. c kch thch, hot ha hoc 57th alpha v beta u c chia
14dn truyn bi acetylcholin: p 58tip thnh cc phn nhm c chc
15dng cho si thn kinh giao cm v 59nng khc nhau, v c th b kch
16i giao cm tit ra acetylcholin 60thch v c ch khc nhau.
17ti xinap khi c mt xung ng
61Cc th th adrenergic alpha
18thn kinh i qua. Xem thm th
62Gy co mch, th gin rut v gin
19th.
63ng t. Cn phn bit hai phn
202. Thuc c tc dng ging nh
21acetylcholin. Cn gi l thuc ging 64nhm l th th alpha1 v alpha2.
22i giao cm. 65Th th adrenergic beta
23Dopaminergic 66Cc tc dng sinh l gn lin vi
241. c kch thch, hot ha hoc 67p ng ca th th adrenergic
25dn truyn bi dopamin. 68beta gm kch thch tn s tim v
262. Ni v cc m hoc c quan 69co c tim, gin mch, gin ph
27chu tc ng ca dopamin. 70qun. Cc p ng ca th th
283. Ni v nron tit dopamin v 71beta cng c th chia thnh 2 loi.
29tc dng ca dopamin. 72Th th beta1 p ng vi
73adrenalin v noradrenalin ngang
30Serotoninergic
311. Cha hoc hot ha bi 74nhau v kch thch tim. Th th
32serotonin, th d nh cc nron ca 75beta2 p ng vi adrenalin mnh
33nhn gia thn no. 76hn noradrenalin v gy gin mch
342. Ni v nron tit serotonin, 77v gin ph qun.
35cht ny kch thch gii phng cc 78Th th cholinergic
36hormon tuyn yn. 79Cc phn t th th trn b mt
37Th th (receptor) 80t bo gn vi cht dn truyn
38Mt cu trc phn t trn b mt 81thn kinh acetylcholin th hin tc
39hoc trong t bo c c im 82dng trn cc t bo sau xinap bao
40l: 83gm cc t bo ch t ng i
41Gn chn lc vi mt cht c 84giao cm, t bo hch t ng
42hiu. 85giao cm v i giao cm, c vn
43Km theo s gn ny l mt tc 86v mt s nron trung ng. Thng
44dng sinh l c hiu. Th d cc

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87c chia thnh hai loi: th th 131 AUC tnh mch

88muscarinic v th th nicotinic. 132Kh dng sinh hc tng i
89Th th dopaminergic 133(relative bioa-
90Cc th th dopaminergic c mt134vailability) l t l so snh gia 2
91trong h thng thn kinh trung -135gi tr kh dng sinh hc ca cng
92ng v ngoi bin v trong nhiu136mt thuc nhng khc nhau v dng
93m khng thuc thn kinh. C hai137bo ch v cng c a qua ng
94loi th th dopaminergic vi chc138ung.
95nng khc nhau. Th th D1 gy 139 140 F ca dng bo ch
96gin mch thn, mc treo rut, 141A
97mch vnh v mch no. Th th D 2 142F tng i:
F ca dng bo ch B
98c ch s dn truyn trong cc 143
99hch giao cm, c ch gii phng144 thanh thi, h s thanh thi
100noradrenalin t cc u tn dy145(clearance, Cl)
101thn kinh giao cm, c ch tuyn146Biu th kh nng ca mt c
102yn tit prolactin v gy nn. 147quan (thng l gan, thn) lc sch
40AUC
Gii thchUnder
mt s thut ng
148mt thuc ra khi huyt tng khi
103 (Area the Curve) 149mu tun hon qua c quan .
DTQGVN
104Din tch di ng cong: 150Cl c tnh bng ml/pht, biu th
105L din tch di ng cong ca 151s ml huyt tng c gan hoc
106th biu din s bin thin ca152thn lc sch thuc trong thi gian
107nng thuc trong mu theo thi1531 pht. Cng c khi Cl c tnh cho
108gian, biu th tng trng cho lng1541 kg th trng ml/pht/kg.
109thuc vo c i tun hon
155Th tch phn b
110dng cn hot tnh sau mt thi156Th tch phn b Vd biu th mi
111gian t. 157lin quan gia lng thuc trong c
112T gi tr ca AUC, c th tnh c158th v nng ca thuc trong
113tr s sinh kh dng ca thuc. 159huyt tng trng thi cn bng.
114Kh dng sinh hc (F) hoc 160 Lng thuc trong c th
161Vd =
115sinh kh dng (Bioavailability). 162 Nng thuc trong
116Mc v tc (tnh theo %) 163huyt tng
117ca hot cht vo c i tun164
118hon so vi liu dng. Nu thuc165Vd biu th mt th tch cn phi
119c a vo bng ng tnh mch166c ton b lng thuc a vo
120th F = 1. Nu thuc c a bng167c th phn b nng bng
121ng khc th F lun di 1. 168nng trong huyt tng, nn
122Kh dng sinh hc tuyt i169cn gi l th tch phn b biu
123(absolute bioa-170kin.
124vailability) l t l so snh gia171n v ca Vd l lt hoc lt/kg.
125kh dng sinh hc ca cng mt172 ngha ca Vd: T th tch phn
126thuc a qua ng ung so vi a173b cho trc, ta c th tnh c liu
127qua ng tnh mch. 174lng thuc cn a vo t mt
128 175nng no trong huyt t-
129 AUC ung 176ng.
130F tuyt i: 177 Vd x Cp

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178D =
179 F
180D: Liu thuc cn a (g hoc mg)
181F: Kh dng sinh hc ca thuc (%)
182Cp: Nng thuc trong huyt t-
183ng (g/l hoc mg/l)
184Na i (half-life)
185Na i thi tr (t1/2) l thi gian
186cn thit nng thuc trong
187huyt tng gim xung cn mt
188na (50%). Khi thuc thi tr vi 1
189tc t l vi nng thuc.
190Chuyn ha bc u (first pass
191metabolism)
192Trong qu trnh hp thu, thuc c
193th b chuyn ha mt phn -
194ng tiu ha v/hoc gan trc khi
195vo i tun hon. Chuyn ha bc
196u ny lm gim sinh kh dng
197ca thuc.

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DTQGVN Hng dn s dng Dc th quc gia
Vit Nam 41

198 hng dn s dng 2558. Chng ch nh: Nu cc trng hp cn

199 dc th quc gia vit nam 256trnh dng thuc.
2579. Thn trng: Cc trng hp cn thn trng
200 258khi dng thuc, v d i vi ngi cao tui,
201Nhiu nc trn th gii xut bn Dc th quc 259ngi c bnh v gan, thn v. v.
202gia. Mt s nc ch son tho Dc th quc 26010. Thi k mang thai.
203gia ngn gn loi b ti gip thy 26111. Thi k cho con b.
204thuc tra cu khi lm vic. Dc th quc gia 26212. Tc dng khng mong mun (Adverse
205Vit Nam l sch hng dn s dng thuc 263drug reactions: ADR): Bao gm nhng
206an ton, hp l, hiu qu do B Y t ban 264phn ng ph v cc phn ng i nghch
207hnh. Dc th quc gia Vit Nam ln xut 265c hi. Trong phn ny chia lm ba loi theo
208bn th nht c bin son trong khun 266thng k ca T chc y t th gii: Loi th-
209kh chng trnh hp tc y t Vit Nam- 267ng gp l ADR xy ra trn 1 phn trm s
210Thy in theo mt quy trnh cht ch 268ngi dng thuc, loi t gp l ADR xy ra
211cung cp cho cc bc s, dc s v cn b y 269di 1 phn trm v ln hn 1 phn nghn
212t cc thng tin v thuc nhm hng ti s 270s ngi dng thuc, loi him gp l ADR
213dng thuc hp l, an ton, hiu qu. 271xy ra di 1 phn nghn s ngi dng
214Trn 600 dc cht trong s 900 dc cht c 272thuc.
215trong hn 10.000 dc phm lu hnh trn 27313. Hng dn cch x tr ADR.
216th trng Vit Nam c trnh by trong 27414. Liu lng v cch dng:
217cun Dc th quc gia, bao gm: Thuc thit 275Liu lng ghi trong Dc th nhm hng dn
218yu v mt s thuc chuyn khoa. 276chung v liu lng thng thng, dng cho
219Dc th quc gia Vit Nam c chia thnh ba 277ngi ln v tr em theo ng ung, tr tr-
220phn: 278ng hp c ghi r ng dng khc. Thy
221Phn mt: Cc chuyn lun chung nh s 279thuc c th cho cao hn hoc thp hn
222dng hp l thuc khng sinh, thuc chng 280liu thng thng t c tc dng
223ng kinh, nguyn tc s dng thuc tr 281iu tr ti u tng ngi bnh c th.
224em... 282mt s chuyn lun thuc c ghi c liu gii
225Phn hai: Cc chuyn lun ca 600 dc 283hn khi k n ( ngi ln hoc tr em) ch
226cht c trnh by theo th t bng ch 284yu hng dn dc s yu cu thy
227ci v theo tn gc (tn chung quc t). Mi 285thuc xc nhn liu k cao hn liu
228chuyn lun u c trnh by theo b 286bnh thng.
229cc thng nht nh sau: 28715. Tng tc thuc: Khi s dng cng mt
2301. Tn chuyn lun thuc: L tn vit theo 288lc hai hoc nhiu thuc thng d xy ra
231tn thuc gc c Vit Nam ha theo 289tng tc thuc dn n hin tng i
232nguyn tc ca B Y t. Tn thng mi ca 290khng hoc hip ng. Tc dng i
233thuc c a vo mc lc theo vn ch 291khng l hin tng mt thuc c th lm
234ci v quy v tn gc tin tra cu. Vi 292gim (hoc mt) tc dng ca thuc khc
235nhng thuc c qu nhiu tn thng mi 293khi dng ng thi; ngc li l tc dng hip
236ch gii thiu mt s tn ph bin. Cc tn 294ng (c khi tc dng tng cng n mc
237thng mi ca thuc trong nc c gii 295gy c cho ngi bnh). V vy cn thn
238thiu u tin cho nhng sn phm ca cc 296trng v khi tht cn thit mi dng chung
239x nghip dc phm t tiu chun thc
297cc thuc vi nhau.
240hnh tt sn xut thuc.
29816. n nh v bo qun.
2412. Tn thuc vit theo INN (International
29917. Tng k: Thuc khng c trn ln vi
242Nonproprie-
300thuc khc v xy ra phn ng ngoi c
243tary Name) vit theo ting Anh.
301th.
2443. M ATC (The Anatomical Therapeutic
245Chemical Code). 30218. Qu liu v x tr.
2464. Loi thuc: Phn loi theo nhm tc 30319. Thng tin quy ch: i vi cc thuc v
247dng. 304dng thuc c trong DTQGVN.
2485. Dng thuc v hm lng: Dng bo ch 305Trong mt s chuyn lun thuc, nu mt
249hin c trn th trng v hm lng. 306mc cha c y thng tin cn thit
2506. Dc l v c ch tc dng: Trnh by tc 307th s c b qua.
251dng dc hc, dc ng hc v c ch tc 308Phn ba: Cc ph lc bao gm: Bng xc
252dng. 309nh din tch b mt thn th ngi t
2537. Ch nh: Cung cp thng tin la 310chiu cao v cn nng; phn loi cc
254chn hp l v thuc.

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311thuc trong Dc th quc gia theo m phn 364th thuc m mnh bit c th iu tr
312loi iu tr - gii phu - ha hc (ATC). 365ph hp cho tng ngi bnh. Nn s dng
313Cc thng tin trong Dc th quc gia Vit 366cc thuc quen dng. Cn hi ngi bnh
314Nam c tham kho t cc sch gio khoa 367v cc phn ng xy ra khi dng thuc
315v dc l, cc ti liu hng dn dng thuc 368trong qu kh.
316v phc iu tr chun ca B Y t v 369Sng lc ln lt cc thuc da trn cc
317T chc y t th gii, cc sch hng dn s 370tiu ch sau:
318dng v iu tr c uy tn trn th gii nh: 371Thuc c hiu qu nht, an ton nht v
319Goodman & Gilmans The Pharmacological 372ph hp vi hon cnh ca ngi bnh nht.
320Basis of Therapeutics; Martindale, British 373Trong nhng trng hp bnh nng th
321National Formulary (BNF); Drug information 374hiu qu l yu cu trc tin. Trong nhng
322(AHFS); Drug information For The Health 375trng hp bnh mn tnh v th trng ngi
323Care Professional (USPDI); Physi- 376bnh yu th tiu chun an ton phi c
324cians Desk Reference (PDR)... nhm m 377t ln hng u.
325bo tnh khoa hc chnh xc, cp nht v 3783/ K n thuc khi c ch nh r
326thc tin. 379rng:
327Trong bi cnh nn y hc v dc hc ang 380Khi k n, tt nht l dng tn gc hay tn
328pht trin nhanh chng, ln u tin 381chung quc t km theo tn bit dc t
329Vit Nam t chc bin son Cun Dc th 382trong ngoc, nu thy cn thit. Phi
330quc gia Vit Nam, v vy kh trnh khi 383trnh vit tt. Khi k hai thuc hoc nhiu
331thiu st. Ban bin son mong nhn c 384thuc hn trong cng mt n thuc,
332kin ng gp ca cc ng nghip 385thuc chnh ghi u tin. Nn trnh k qu
42 K n thuc
333cc ln xut bn tip theo, Dc th quc gia 386nhiu thuc trong mt n thuc. K n
DTQGVN
334Vit Nam c cht lng cao hn. 387cng t thuc cng tt trnh tng tc
388thuc.
389n thuc phi vit r rng bng mc, ghi
390r ngy, thng, nm, h v tn, tui, a
335 K N thuc 391ch, s th bo him y t ca ngi bnh
392(nu c). Ngi k n phi k vo n
336Thuc ch c k n khi cn thit. Khi k
393bng mc v ghi r h tn.
337n thuc, thy thuc cn phi cn nhc 394Cc thuc c, thuc hng tm thn v
338gia li ch v nguy c i vi ngi bnh.
395thuc gy nghin phi vit ring trong
339iu ny c bit quan trng khi k n 396mt n khc, theo quy ch v qun l
340cho ngi mang thai, ngi cho con b, ngi
397thuc c, thuc hng thn v thuc gy
341cao tui, ngi c bnh thn, bnh gan 398nghin do B Y t ban hnh. Tn thuc,
342hoc c c a d ng.
399hm lng, s ln dng trong ngy, liu dng
343Mt n thuc tt phi th hin c cc 400mi ln phi ghi r bng ch v s. Ngi k
344yu cu: Hiu qu cha bnh cao, an ton
401n phi k, ngy, thng, nm v phi
345trong dng thuc v tit kim. Mun k 402vit r tn, a ch.
346n thuc tt phi tun theo quy trnh 4034/ Hng dn dng thuc cho ngi bnh:
347sau y: 404Thy thuc cn gii thch r rng v ngn
3481/ Chn on, xc nh ng bnh: 405gn bng ngn ng thng thng ngi
349Thy thuc cn tm hiu hon cnh ca 406bnh hiu c cch dng cc thuc k
350ngi bnh, pht hin cc du hiu lm 407(s lng phi dng, thi gian, s ln dng v
351sng v xt nghim phi lm sng. Cn 408cc iu khc nh cch pha, cch dng).
352tm hiu lch s dng thuc ca ngi 409Nu phi dng n mt dng c a
353bnh, dng nhng thuc g, kt qu ra 410thuc vo c th, thy thuc phi hng
354sao ghi vo bnh n. Nh vy thy 411dn c th hoc cng lm vi ngi bnh.
355thuc xc nh c cc vn ca ng- 412Thy thuc phi lun lun cnh gic
356i bnh. Trn c s , xc nh cc mc 413pht hin qu liu i vi cc thuc tc
357tiu iu tr chnh, ph, trc, sau; tp 414dng mnh k trong n.
358trung gii quyt mc tiu chnh. 415Cn dn d nhng iu king c i vi
3592/ La chn thuc ph hp vi ngi bnh: 416ngi bnh. Nn ht sc thn trng khi k
360Thy thuc phi t hi xem nhng thuc 417n cho nhng ngi ang mang thai,
361quen dng theo kinh nghim bn thn trc 418ang cho con b, ngi c tin s bnh
362y liu c hiu qu v an ton i vi 419gan, thn, c a d ng.
363tng ngi bnh c th. ng thi lit k cc

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4205/ Thng tin v phn ng khng mong 476Nhng thuc nhiu tc dng ph nh khng
421mun ca thuc: 477sinh, corticoid, thuc chng ung th, trong
422Bt c thuc no cng c th gy tc dng 478n hoc bnh n nn nh s ghi r
423khng mong mun. Cn ch theo di, 479ngy dng thuc th my.
424pht hin, ghi chp cc tc dng khng 480 tng tnh chnh xc khi s dng thuc,
425mong mun. 481nn s dng m ATC.
426Hng dn ngi bnh pht hin nhng du
427hiu ca phn ng khng mong mun, h-
428ng dn cch x tr v bo co. 482 Thuc dng trong thi k
429Thy thuc phi hn ngy khm li i vi483 mang thai v cho con b
430ngi bnh.
4316/ Theo di hiu qu iu tr: 484Thi k mang thai
432Nu ngi bnh khng quay li th c th 485Cho ti gia th k trc, a s thy thuc
433n thuc c hiu qu, bnh 486vn ngh t cung l mt mi trng bo v
434hn hoc khi. Nu n thuc khng c 487thai v l mt l chn i vi mi trng
435hiu qu th ngi bnh c th s quay li. 488bn ngoi. Ngy nay, quan nim hng ro
436Cn tm hiu l do: Thuc khng hiu 489nhau thai cn loi b.
437qu; khng an ton, ngi bnh khng chu 490Thuc c th gy hi thai vo bt c thi
438ng c cc phn ng ph; khng thun 491im no trong thi k mang thai. Bao gi
439tin do cch ung, mi v... 492cng phi nh iu ny mi khi k n
440Trong trng hp ny ty tng l do, thy 493cho ph n tui mang thai.
494Thuc c th gy nhiu tc hi ti thai
441thuc li bt u quy trnh khm li.
495ang ln, ph thuc vo thi gian tip xc.
442Ch : 496Trong hai tun u k t khi th thai n
443Khng nn k nhiu thuc trong mt n. 497giai on u cha bit c thai, phi c
444Nn k nhng thuc mt thnh phn. 498coi l khng vi tc dng gy qui thai ca
445Khng nn k nhng thuc hn hp nhiu 499thuc. Giai on ti quan trng ca pht
446thnh phn. 500trin phi, khi cc h thng c quan pht
447Nn k n thuc theo tn gc ca thuc. 501trin, bt u khong 17 ngy sau th
448Tn thng mi ghi bn cnh, trong du 502thai v hon thnh vo ngy th 60 n
449ngoc. 50370. Tip xc vi mt s thuc trong giai
450Nn tranh th s gip ca dc s c 504on ny (ngy th 17-70) c th gy
451cc thng tin v thuc. 505khuyt tt bm sinh ln.
452Nn theo di nhng tin tc cp nht v 506Trong 3 thng th nh v th ba ca thai
507k, thuc c th tc ng n pht trin
453thuc n v thng tin thuc.
508tng trng v chc nng ca thai v gy
454Nn s dng Dc th quc gia Vit Nam 509c cho m thai; thuc cho ngay trc thai
455nhm khai thc cc thng tin s dng thuc 510k n hn hoc trong lc chuyn d
456hiu qu, hp l, an ton, tit kim. 511c th c tc dng xu n chuyn d
457Nn a ni dung iu tr bng thuc 512hoc cho tr s sinh sau khi . Thuc
458thnh ch trong cc cuc hp ca Hi 513chuyn ha chm hn nhiu ngi mang
459ng thuc v iu tr ca bnh vin. 514thai so vi khi khng mang thai.
460Nn ht sc thn trng s dng cc thng 515Thc nghim trn ng vt cung cp rt
461tin v thuc t nhng ngun thng tin th- 516nhiu thng tin lin quan n tc dng
462ng mi. 517gy qui thai ca thuc. Nhng khng may
463Nn phi hp vi dc s sp xp cc thuc 518l cc kt qu trn thc nghim khng th
464iu tr cng nhm, nh gi theo 4 tiu 519suy t ng vt sang ngi c. Kinh
465chun: Hiu qu, an ton, thch hp v gi 520nghim dng thuc trong thi k mang thai
521cn hn ch. Do thuc ch c k n
466c. Bng ny cn lun c cp nht.
522trong thi k mang thai khi li ch i vi
467Trc khi chp thun nhn xt v hiu qu 523b m ln hn nguy c i vi thai, v phi
468 ca nhng thuc mi, cn c nhng s liu 524trnh dng tt c cc thuc, nu c th c
DTQGVN T-
469 thng
ng tc k dch t
thuc 43 hc v cc phn ng 525trong ba thng u thai k. Khng c mt
470khng mong mun. 526thuc no c coi l an ton 100% cho thai
471Trc khi s dng thuc mi, cn c nhng 527ang pht trin. Khi k n, nn chn cc
472th nghim lm sng ngay ti c s 528thuc c dng rng ri trong thi k
473thu thp nhng kinh nghim thc t. 529mang thai v thng t ra an ton hn l k
474i vi ngi bnh ni tr, tt nht l k n 530n dng thuc mi hoc cha c th
475thuc hng ngy. 531thch, v phi dng liu thp nht c hiu
532qu.

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533Mt vi thuc c kt lun gy qui 587ng thi mt thuc li tiu vi mt thuc

534thai ngi nhng khng c mt thuc no 588gin mch v/hoc mt glycosid tr tim th-
535c th coi l an ton tuyt i trong thi 589ng cn thit t c hiu sut tim
536k u mang thai. 590tha ng v gi cho ngi bnh khng b
537Thi k cho con b 591ph. Vic s dng nhiu thuc (a ha tr
538Tr nh c th b nhim c khi mt lng 592liu) l chun mc trong ha tr liu ung
539 ln thuc vo sa c tc dng dc l. 593th v trong mt s bnh nhim khun.
540Hu ht cc thuc b m dng u qua 594Trong nhng trng hp ny, mc ch th-
541sa mt mc no . 595ng l ci thin hiu qu iu tr v
542Mt vi thuc (th d ergotamin) dng cho 596lm chm xut hin t bo c tnh hoc
543b m cho con b c th gy c cho tr 597vi khun khng vi cc khng sinh hin c.
544nh, trong khi cc thuc khc (th d 598Khi dng ng thi nhiu thuc, ngi thy
545digoxin) li t tc ng n tr s sinh. 599thuc ng trc vn khng bit cch
546ngha ca nhiu bng nng thuc 600phi hp thuc no mt ngi bnh c
547trong sa m ch c ngha l thuc c 601th c th dn n tng tc hay khng.
548vo trong sa nhng khng a ra c li 602Nu c, th lm th no tn dng li
549khuyn no cho thy thuc. Thy thuc 603th ca tng tc nhm c kt qu iu
550cn bit cc kt qu nghin cu trn ng 604tr tt hn hoc lm th no trnh
551vt trong lnh vc ny v nguy c tim 605cc hu qu ca tng tc c hi.
552tng i vi tr b m khi m dng thuc. 606Khi nim tng tc thuc tim nng l kh
553Nhng i vi nhiu thuc, hin nay cha c 607nng ca mt thuc c th lm thay i
554sn
44 s liutc
Tng hng dn. Quyt nh 608cng tc dng dc l ca mt thuc
thuc
555cui cng
DTQGVN phi ty tng trng hp, ty theo 609khc khi s dng ng thi. Kt qu cui
556c im bnh v phng thc iu tr. 610cng c th l mt hoc c hai thuc tng
557Thy thuc bao gi cng phi cn nhc t 611hoc gim tc dng hoc xut hin mt
558l nguy c trn li ch khi k n bt c 612tc dng mi khng thy c khi dng ring
559mt thuc no cho ngi m cho con b. 613tng thuc.
560Nu sau khi cn nhc nguy c trn li ch, 614c tnh tn sut tng tc thuc trong lm
561m thy thuc quyt nh phi dng 615sng khong 3 - 5% s ngi bnh dng
562thuc cho m, th lc phi lm cho tr 616vi thuc v ti 20% ngi bnh ang
563nh tip xc t nht vi thuc bng cch 617dng 10 - 20 thuc. V a s ngi bnh
564cho m dng thuc mi ln ngay sau khi 618nm vin dng t nht 6 thuc, nn vn
565cho con b. Mt quy tc tt l: Nu dng 619tng tc thuc l kh quan trng. Cn c
566thuc trc tip cho tr m an ton th 620s hiu bit k lng v cc tc dng ca
567thuc cng thng an ton khi dng cho 621thuc khi k n pht huy cc tng tc
568ngi m cho con b. 622c li v hn ch cc tng tc c hi.
569Cng nh khi mang thai, thuc thng c k 623Ngi thy thuc phi c nhng hiu bit
570cho b m cho con b cha cc triu 624v c ch tng tc thuc phn tch
571chng m khng cn thit phi iu tr. 625cc tng tc thuc mt cch h thng.
572Nu cc b m c thy thuc cho bit v 626Nhim v ca ngi thy thuc l phi hiu
573cc nguy c c th xy ra vi a tr th 627nhng nguyn l c bn ca tng tc
574hu ht h th chu ng cc triu chng 628thuc trong vic xy dng phc iu
575 hn l dng thuc v ngng cho con b. 629tr. Nhng tng tc c cp tng
630chuyn lun thuc ring bit trong quyn
631sch ny.
632Cc tng tc c th l tng tc dc ng
576 Tng tc thuc 633hc (thay i hp thu, phn b hoc
634o thi ca thuc ny hay thuc khc)
577Thng thng vic s dng nhiu thuc trn 635hoc tng tc dc lc hc (th d tng tc
578mt ngi bnh trong cng mt thi gian l 636gia duy tr v i khng cc th th
579cn thit t mc tiu iu tr mong 637thuc). Cc tng tc c hi quan trng nht
580mun hoc cha nhiu bnh cng mt 638thng xy ra nhng thuc c c tnh
581lc. Tuy nhin trong nhiu trng hp, thuc 639cao hoc c ch s iu tr thp, v
582c phi hp qu nhiu khng cn thit. 640nng thuc ch thay i tng i
583Trong iu tr tng huyt p, nn s dng 641nh c th dn n nhng hu qu c
584ng mt thuc li tiu hoc thuc chn 642hi r rt. Ngoi ra, cc tng tc thuc c
585beta, c th t hiu qu trn 30 - 50% s 643th nh hng ln v mt lm sng trn ng-
586ngi bnh. Trong iu tr suy tim, dng

16
17

644i bnh nng hoc c th dn n t 703thuc. Kt qu l, tc dng ca tng tc

645vong nu iu tr khng liu. 704kiu nh vy thng thp, nht thi v khng
705thy r.
646Tng tc thuc - thuc theo c ch dc
706Mt vi thuc chuyn vn tch cc n
647ng hc
707v tr hot ng. Th d, cc thuc chng
648Thuc c th tng tc bt c thi im
708tng huyt p guane-
649no trong sut qu trnh hp thu, phn 709thidin v guanadrel, gy c ch chc
650b, chuyn ha hoc bi xut; kt qu l 710nng h thng thn kinh giao cm sau khi
651tng hoc gim nng ca thuc c 711chuyn vo nron adrenergic bng c
652quan tc dng. 712ch thu nhp norepinephrin. c ch h
653Thuc c th b thay i bi cc tng tc 713thng thu nhp ny ca nron bi cc
654l ha xy ra trc hp thu trong trng hp 714thuc chng trm cm ba vng v mt s
655thuc tim v tim truyn. Th d, cc 715amin tc dng ging thn kinh giao cm s
656thuc c th tng tc trong mt dung dch 716c ch s phong b giao cm v gim tc
657tim tnh mch to ta khng tan c 717dng chng tng huyt p ca guanethidin
658th thy c hoc khng thy c r rng. 718v guanadrel.
659Trong rut, cc thuc c th to phc vi ion 719Tng tc lin quan n chuyn ha thuc
660kim loi hoc hp ph trn cc cht nha 720c th lm tng hoc gim lng thuc sn
661cao phn t lm thuc. Ca2+ v cc cation 721c tc dng ty theo tng ng c ch
662kim loi cha trong cc antacid to phc hp 722hoc cm ng chuyn ha. Tng tc c
663vi tetracyclin, khng hp thu qua rut. 723th xy ra gia cc thuc hoc gia thuc
664Choles- 724vi cc cht dinh dng (th d naringenin
665tyramin hp ph v c ch s hp thu ca 725trong nc p bi (mt cht gy c ch
666thyroxin, glycosid tr tim, warfarin, 726CYP3A4); hoc vi ha cht khc (th d ru
667corticosteroid, v c mt s thuc khc. Tc 727hoc dung mi hu c vi cc cht cm
668 v i khi c mc hp thu c th 728ng CYP2EI); khi thuc l, biphenyl
669b nh hng bi nhng thuc lm thay 729polyclorinat (cc cht gy c ch CYP1A2).
670i nhu ng ca d dy, nhng iu ny 730Cc tc dng cm ng hoc c ch enzym
671thng t c hu qu lm sng. Cc tng 731thng thy r nht i vi thuc ung, v
672tc trong rut c th gin tip v phc tp. 732ton b hp cht hp thu phi qua gan trc
673Cc khng sinh lm thay i vi khun ch 733khi vo h tun hon. V vy, ngay c
674 rut c th lm gim tc tng hp 734nhng thuc c thanh thi ton thn
675vitamin K ca vi khun, lm tng cng tc 735ph thuc ch yu vo lu lng mu gan
676dng ca cc thuc ung chng ng (l 736(th d propranolol), lng thuc thot khng
677nhng cht cnh tranh vi vitamin K). Vi 737b chuyn ha ln u qua gan s chu
678mt thuc c chuyn ha bi vi sinh vt 738nh hng ca cm ng hoc c ch
679ng tiu ho, iu tr khng sinh c th 739enzym. Cc v d v thuc chu nh hng
680dn n tng hp thu thuc, nh chng 740ca cc cht gy cm ng enzym l cc
681minh mt s ngi bnh ung digoxin. 741thuc ung chng ng, quinidin,
682Nhiu thuc lin kt mnh vi albumin 742corticosteroid, thuc trnh thai estrogen
683huyt tng (cc thuc acid) hoc vi 743liu thp, theophylin, mexiletin, methadon
684glycoprotein acid-alpha1 (cc thuc kim). 744v mt s thuc chn bta adrenergic.
685Ni chung, ch c cc phn t dc cht t 745Hiu bit v cch chuyn ha c trng
686do khng lin kt mi c tc dng hoc c 746ca mt thuc v cc c ch phn t ca
687phn b vo cc m. S y mt thuc ra 747cm ng enzym c th gip ch trong vic
688khi v tr lin kt bi mt thuc khc c 748hoch nh cc nghin cu v tng tc
689th dn n thay i tc dng ca 749thuc c th xy ra. Nh vy, nu mt hp
690thuc. Mc d c nhng tng tc lin 750cht thy b CYP 3A4 chuyn ha in vitro,
691kt/chuyn dch nh vy, nhng t khi cc t- 751nn nh hng nghin cu cc thuc thng
692ng tc ny c ngha lm sng. l do 752dng c th c ch (th d ketoconazol)
693thuc chuyn dch c phn b nhanh 753hoc cm ng (th d rifampicin) enzym
694vo cc m, th tch phn b biu kin 754ny, do c tim nng gy ra tng tc c
695ca thuc cng ln th cc phn t nng 755ngha lm sng. V d gn y v lon
696 thuc t do trong huyt tng cng 756nhp do phi hp terfenadin v ketoconazol
697thp. Hn na, sau khi chuyn dch, li c 757gy ra, nhn mnh nhu cu phi c
698thm thuc t do chuyn ha v bi 758nhng nghin cu nh vy. Trong tng tc
699xut. Nh vy, ni chung cc qu trnh 759ny, ketoconazol c ch chuyn ha ca
700thanh thi ca c th lm gim nng 760terfenadin (bi CYP3A4) thnh sn phm
701cc phn t thuc t do xung ti nng 761hot tnh, dn n tng cao nng ca
702c t trc khi xy ra tng tc chuyn dch

18
19
DTQGVN Phng nga v x tr phn ng thuc c hi v
tc dng ph 45

721terfenadin khng chuyn ha c tc dng 781ca digoxin do kt qu h kali - mu do

722c. 782thuc li tiu gy ra.
723Kh nng mt thuc c ch s bi xut qua 783Tm tt
724thn ca mt thuc khc ph thuc vo t- 784Tng tc thuc - thuc ch l mt trong
725ng tc cc v tr chuyn vn tch cc. 785nhiu yu t c th nh hng n p
726Nhiu tng tc c thng bo xy ra v 786ng ca ngi bnh vi iu tr. Nhim v
727tr chuyn vn anion, th d ti probe- 787ch yu ca ngi thy thuc l xc nh t-
728necid c ch bi xut penicilin gy tc 788ng tc c xy ra hay khng v mc
729dng mong mun l tng cao nng ca 789tc dng ca n. Khi thy c nhng tc
730khng sinh trong huyt tng v ko di 790dng khng mong mun, phi ngh l t-
731na i ca thuc . Tng t nh vy, s 791ng tc thuc. nh gi cn thn ton b
732o thi ca methotrexat b c ch bi 792tin s dng thuc ca ngi bnh l quan
733probenecid, salicylat, v phenylbutazon, 793trng, v h c th dng cc thuc khng
734nhng trong trng hp ny c tnh ca 794n, hoc c th dng thuc do nhiu
735methotrexat c th xy ra t tng tc ny. 795thy thuc k n, hoc c th dng
736V tng tc v tr chuyn vn i vi 796thuc ang c k n cho ngi bnh
737cc thuc kim c th nu s c ch bi 797khc. Phi cn thn khi c s thay i
738xut procainamid bi cimetidin v 798ng k trong phc iu tr bng
739amiodaron. Tng tc mt v tr ng thn 799thuc v phi ngng cc thuc khng cn
740cha bit r gy c ch bi xut digoxin 800thit.
741bi quinidin, verapamil v amiodaron. S
742bi xut ca Li+ c th b nh hng bi cc
743thuc lm thay i kh nng ti hp thu
744Na+ ca ng thn gn. Do vy, thanh thi801 Phng nga v x tr phn ng
745Li+ gim v nng Li+ trong huyt tng802 thuc c hi v tc dng ph (ADR)
746tng bi cc thuc li tiu gy gim th
747tch v bi cc thuc chng vim khng 803Cc thuc trong Dc th quc gia Vit Nam
748steroid gy tng ti hp thu Na+ ng thn 804c trnh by km vi nhng tc dng c
749gn. 805hi quan trng nht nhng mi ch mc
750Tng tc thuc - thuc theo c ch dc 806 nht nh, v bo co v tc dng c
751lc hc 807hi (ADR) cng khng d kin c ht cc
752C nhiu v d v thuc tng tc mt v 808nguy c c th gp. Vic bo co cc
753tr th th chung hoc c tc dng cng 809phn ng c hi l bt buc trong cc th
754lc hay c ch do tc ng trn cc v tr 810nghim lm sng. Nhng trong cc th
755khc nhau mt c quan. Nhng tng tc 811nghim lm sng ch c rt t ngi bnh
756ny c m t trong ti liu ny. Th d 812tip xc vi nhng phn ng , do
757cc phenothiazin l cc cht i khng 813hn ch kh nng pht hin nhng phn
758mnh alpha-adrenergic; nhiu thuc khng 814ng him gp nghim trng c th xy ra.
759histamin v chng trm cm ba vng l 815V vy vic bo co t nguyn v tc
760nhng cht i khng mnh th th 816dng khng mong mun l rt quan trng
761muscarinic. Nhng tc ng "nh" ny ca 817sau khi thuc c bn rng ri trn th tr-
762thuc c th l nguyn nhn tng tc 818ng, c bit iu ny tr thnh
763thuc. 819nguyn tc i vi cc thuc mi. Phi bo
764Cc tng tc khc thuc bn cht c v l d- 820co tt c nhng triu chng v phn ng
765c lc hc cn t hiu bit hoc tc dng 821khng mong mun khi pht hin c v
766gin tip. Cc hydrocarbon halogen ha, 822nghi ng l tc dng c hi hoc tc dng
767bao gm nhiu thuc m, lm c tim nhy 823ph. iu quan trng cn nhn r l tt c
768cm vi tc ng gy lon nhp ca 824mi thuc u c tc dng c hi v ph.
769catecholamin. Tc dng ny c th do tc 825Vn chnh khng phi l phn chia
770ng trn ng dn t th th adrenergic 826mt cch l thuyt xem mt triu chng
771n b phn tc ng, nhng chi tit cha 827hoc phn ng no l tc dng ph hay l
772r. Tng tc ni bt gia pethidin v cc 828tc dng c hi. C hai loi u cn c
773cht c ch monoamin oxidase gy co git 829bo co v lm r. Vn chnh l nhng
774v st cao c th lin quan n lng qu 830phn ng khng mong mun ny thc s l
775mc ca cht dn truyn thn kinh kch 831khng mong mun v i khi rt nghim
776thch, nhng c ch cha c sng t. Mt 832trng. Cng c khi cn c nguy c l cc
777thuc c th lm thay i ni mi bnh 833tc dng c hi v tc dng ph c th gy
778thng, do lm tng hoc gim tc dng 834cho ngi bnh nhng bnh mi, c th rt
779ca mt thuc khc. Mt v d bit r 835nng, gy tn tt ko di thm ch t
780v kiu tng tc ny l s tng c tnh 836vong. Do iu quan trng l phi tm

20
21

837cch hn ch cng nhiu cng tt nguy c 895v triu chng khng mong mun pht
838gp phi nhng phn ng ny. Nguyn 896hin c.
839tc chung hn ch cc tc dng ph l
840s dng ng liu cho tng ngi bnh. 897Trch nhim theo di ADR:
841Nguy c v nhng phn ng thuc c hi 898Mi bc s, cn b y t hoc dc s c
842khng ph thuc vo liu c th hn ch 899trch nhim ngh nghip vi bnh nhn
843bng cch cng t ngi cng tt phi 900ca mnh, gio dc v cho li khuyn
844tip cn vi nguy him ca dng thuc. 901nhm mc ch hn ch nguy c. Mi cn
845Trong thc hnh, iu c ngha l ch 902b y t sau c trch nhim phi bo
846nhng ngi c bnh mi dng thuc, v 903co v nghi vn tc dng khng mong
847bnh nng ti mc li ch ca vic dng 904mun nu triu chng xy ra c th ch
848thuc vt tri so vi nguy c c th gp 905ra rng l mt tc dng khng mong
849phi. Vai tr ca ngi thy thuc rt quan 906mun c hi.
850trng trong qu trnh ny, chn on
851ng v k n ph hp cn c vo nhng 907Phng nga ADR
852hng dn iu tr hp l v an ton. 908Nhiu phn ng c hi ca thuc, tng tc
853Do bo co ADR cng phi bao gm c 909thuc v tc dng ph c th phng nga,
854nhng iu m theo l thuyt c th c 910nu tun th nhng nguyn tc sau
855coi l tc dng ph. Mc ch chnh l 911y:
856nhn ra c cc vn ang gy au 9121. Khng bao gi k n bt k thuc no
857n v kh chu khng cn thit cho ngi 913m khng c ch nh r rng bin minh
858bnh. Khi thay i cch s dng mt 914cho vic k n thuc .
859thuc c, khi phi hp vi mt thuc khc 9152. Nu ngi bnh mang thai, rt hn ch
860theo cch mi, hoc khi s dng cho mc 916dng thuc.
861ch mi, u c th gy nhng phn 9173. Hi ngi bnh v d ng. D ng mc
862ng khng mong mun mi hoc hay gp 918trc l mt yu t d on tin cy v
863hn.
919nguy c d ng vi thuc.
864V vy, bo co ADR phi nu nhng mi
9204. Hi ngi bnh xem trc dng bt
865lin quan nghi ng gia thuc v triu
866chng khng mong mun. Ch bng cch
921k thuc no cha, k c nhng thuc t
ny,Phng
th mi c th pht 922dng. S dng thuc trc cng c th
867
46 nga v x trhin c
phn nhng
ng thuc c hi v tc dng ph
868 vn mi. Ch khi tm ra vn mi, 923gy tng tc thuc nghim trng v bt
DTQGVN
869th mi x tr c chng. 924ng.
870Cch bo co ADR: Phi da trn c s 9255. Trnh nhng phi hp thuc khng cn
871nhng tc dng c hi v tc dng ph nghi 926thit. Hy dng cng t thuc nu c th.
872vn. Khng cn thit phi xc nhn nhng 9276. Tui tc, cc bnh gan hoc thn c
873triu chng nhn xt thy c tht s l tc 928th nh hng n chuyn ha v kh
874dng c hi hay ph khng. tng tng 929nng o thi thuc. nhng ngi bnh
875qut ca vic bo co l thu thp du hiu, 930ny, cn phi dng liu thp hn bnh th-
876da trn nhng quan st ngh nghip t 931ng.
877nhng tnh hung m ngi bnh dng 9327. Cung cp nhng ch dn tht r rng
878thuc, thy c phn ng v triu chng 933v gio dc bnh nhn, c v bnh v v
879khng mong mun. 934cch s dng ng thuc k n.
880Khi nhng phn ng ny xy ra, iu 9358. Khi c nguy c l cc thuc c k n
881quan trng l phi m t k cc triu 936c th gy phn ng c hi, phi gio dc
882chng, thi gian triu chng xut hin, kt 937ngi bnh v cch nhn bit cc triu
883thc v ghi chp tt c nhng thuc m 938chng sm, nh vy vn phn ng c hi
884ngi bnh dng. Cng cn hi ngi bnh 939c th c iu tr sm mc c th.
885v t dng thuc v thuc c truyn. Cn 940Nhn bit v x tr cc triu chng da
886thng tin v tnh hnh bnh ca ngi 941quan trng ca ADR
887bnh, v thng tin v thi gian ca tt c 942Cc phn ng da vi thuc rt quan trng
888cc thuc m ngi bnh c cho dng hoc 943cn nhn bit, mt mt v tnh cht
889 t dng. Theo nguyn tc, mi phn ng 944nghim trng ca chng, mt khc l
890nghim trng v c bit tt c nhng 945s cnh bo v nhng phn ng thuc
891phn ng c hi gy cht ngi hoc e 946nghim trng hn thm ch e da tnh
892da tnh mng phi c bo co. Trong khi 947mng.
893iu tr vi thuc mi, c mt nguyn tc 948Ban dt sn: Phn ng nga v trc
894quc t l phi bo co ngay mi phn ng 949vy, c th t ht nu ngng thuc,

22
 23

950chim mt t l ln trong tt c nhng1005Hng ban a dng v hi chng Stevens-

951phn ng da do thuc. 1006Johnson: Phn ng ny tng i thng
952My ay/ph mch: My ay l mt cnh1007gp nhng khng phi lun lun l do thuc
953bo quan trng v c mi lin quan rt1008gy nn. Cc triu chng gm: Xut hin
954cht ch vi phn ng phn v y v1009t ngt, thng tn ban c da v nim
955hen nng. My ay xut hin t ngt,1010mc; cc v tr u tin hay b v cc thng
956cng vi ban nga phn tn. Thng du1011tn tch bit c th pht trin dng v hoi
957i trong vng 24 gi. Ban da bng nc c1012t hoc dng "bia bn".
DTQGVN Phntc
Nguyn ngsny
dng
958to thnh l
thuc tr em do hu
47 qu gii phng 1013 cng phi hp vi st, kh chu v vim
959histamin, c th do nhiu qu trnh gy1014hng do lin quan n nim mc (hi
960ra. iu quan trng cn nh: Phn ng phn1015chng Stevens - Johnson). y l mt th
961v l do s hot ha ca cc cht trung1016bnh nng gy hoi t biu b hi lu. Cc
962gian rt ging nhau. Ph mch khc v mt1017thuc c bit c th gy phn ng ny l
963ha sinh, tuy nhin cng c th rt nng1018salicylat, sulphonamid, penicilin, sulpho-
964khi lin can n cc nim mc ng h1019nylur v barbiturat. iu tr: Ngng cc
965hp trn. N c th e da tnh mng1020thuc nghi vn, iu tr glucocorticoid v
966bng cch trc tip gy tc nghn ng1021adrenalin v nu cn kim ch ph
967th. Ph mch c th do cc thuc c ch1022hy m, dng cc thuc c ch min dch
968enzym chuyn angiotensin. Cc peni-1023khc.
969cilin v aspirin cng c th gy ra ph1024Vim da trc: Phn ng ny th hin ban
970mch thng qua s hot ha b th qua1025, v c t liu chng minh r rng l do
971trung gian IgE hoc IgG. Phn ng my1026barbiturat, salicylat, penicilin, sulphonamid
972ay cng c th pht trin do kt qu ca1027v sulphonylur.
973ci c gi l bnh huyt thanh. Trong tr-
974ng hp ny, my ay tn ti lu hn1028Hoi t biu b c (TEN): Xut hin
975bnh thng v phi hp vi cc triu chng1029nhanh vi ban dng si hoc hi lu km vi
976ton thn. iu tr bng adrenalin,1030hoi t mn nc rng khp, v nhy cm
977glucocorticoid v khng histamin. Ngng1031au da "kiu vt thng bng". Cn
978cc thuc nghi vn, v cn thn trnh dng1032phn bit vi cc mn nc nguyn vn ring
979li nhng thuc . Hen c iu tr theo1033r do bng nc t min. C s chng ln ln
980nhng hng dn chun. 1034nhau gia TEN, hng ban a dng v hi
1035chng Stevens - Johnson. Cng c hai dng
981Ban c nh do thuc: Phn ng ny c1036khc nhau cn ch xem xt: ngi ln
982nhng ranh gii r rt, tn thng ban 1037dng gy do qu mn vi thuc, tr nh
983au bn tay, mt, cng tay v b phn1038dng gy do tc dng hoi t trc tip ca
984sinh dc. Tng sc t cc b thng tn ti1039c t t cu. Loi ny c th do penicilin,
985sau khi hi phc. Tip xc li vi thuc nghi1040sulphonamid, cc khng sinh khc, sn
986vn li gy cc ban mi cng ni. Cc1041phm mu, thuc chng vim khng steroid
987thuc gy phn ng ny bao gm1042hoc thuc chng co git (khng c bo
988sulphonamid, tetracyclin, barbiturat,1043co vi acid valproic). iu tr: H tr cn
989salicylat, dapson. 1044bng dch v in gii. Dng khng sinh
990Phn ng thuc nhy cm nh sng: Phn1045chng nguy c nhim khun. H tr chng
991ng ny gii hn nhng v tr tip xc vi1046tc dng ca chy mu, bao gm chy mu
992nh sng mt tri v c th do mt phn1047ng tiu ha. Quan st nguy c ph phi
993ng d ng nh sng qua trung gian min1048v hi chng suy h hp cp ngi ln.
994dch th d sau khi dng clorpromazin,1049iu tr chng ng d phng vi heparin
995sulphanilamid, amiodaron. Phn ng cng1050tim di da 5000 vqt, 3 ln/24 gi. Gim
996c th trc tip c vi nh sng v khng1051au v thuc an thn. iu tr st cao.
997lin quan n min dch, th d sau khi1052Cc phn ng penicilin thng thng:
998dng tetracyclin, sulphonamid, griseofulvin,1053Cc phn ng vi penicilin gp 1-10% s
999naproxen v furosemid liu cao. Vim da1054bnh nhn iu tr, nhng ch c 0,04%
1000nh sng cng c th pht trin sau liu1055ca s ny, ngha l khong 1/50.000 ngi
1001php tia X, c th tng ln nhiu do mt s1056iu tr b phn ng d ng nng. 10%
1002thuc. Hn ch tip xc vi nh sng mt1057d ng vi penicilin cng d ng cho vi
1003tri, nu vn phi tip tc iu tr vi1058cephalosporin. Cc phn ng d ng e
1004thuc. 1059da tnh mng (typ I) thng qua trung gian
1060IgE, hoc trong mt s trng hp him

24
 25

1055gp qua trung gian IgG c lin quan n1107ring tng thuc, theo tui (yu t quyt
1056bnh huyt thanh. Nhng phn ng ny1108nh chnh), tnh trng bnh, gii tnh
1057dn ti cc phn ng phn v, my ay v1109(trong thi k sau dy th) v theo nhu
1058nguy c sc. Hay gp nht l phn v vi1110cu ca tng bnh nhi. Nu khng, c th
1059penicilin tim tnh mch. Yu t di truyn1111dn n iu tr khng kt qu hoc c
1060d ng bm sinh, d ng khc, atopi l1112nguy c nhim c.
1061nhng yu t nguy c d on phn1113Trong mi trng hp nn trnh tim bp
1062ng. 1114tht v gy au cho tr.
1063Ngoi ban km hoc khng km theo nga1115Phi c bit coi trng vic ghi n
1064nh: Tip tc iu tr, nhng phi theo di1116thuc tht r rng, hm lng thuc. Mc d
1065ngi bnh. Nu ngi bnh c phn ng1117cc loi thuc nc ch sn ph hp vi cc tr
1066ngoi ban khng km nga trong ln iu1118nh nhng thuc pha c cha nhiu ng
1067tr trc vi penicilin: iu tr liu u tin1119c kh nng gy su rng. V vy khi
1068phi tin hnh ti bnh vin, gi ngi1120dng thuc di ngy, tt hn l nn dng
1069bnh theo di v chun b tt x1121cc thuc khng c ng.
1070tr nu c phn ng d ng. 1122i vi cc n thuc ch nh dng thuc
1071My ay va phi hoc ngoi ban km1123nc vi liu lng di 5 ml, cn mt bm ht
1072nga: Ngng iu tr, tim adrenalin, dng1124chia th tch, khi cho ung thuc cn
1073thuc khng histamin, dng glucocorticoid.
1125thng bo b m khng cho bt k loi
1074Khng bao gi c iu tr li vi penicilin,
1126thuc no vo trong bnh sa v thuc c
1075tr khi c gii mn cm.
1127th tng tc vi sa hoc cc thc n. Hn
1076My ay nng hoc my ay km vi sng
1128na, lm nh vy c th s lng thuc a
1077khp v mt: Ngng iu tr. iu tr vi
1129vo c th b thiu ht nu bnh nhi
1078adrenalin, glucoco-
1130khng dng ht sa hoc thc n cha
1079rticoid v khng histamin. Khng bao gi
1131trong bnh.
1080iu tr li vi penicilin.
1132Cui cng cn lu khng thuc tm
1081Phn ng da nim mc hoc cc phn ng
1133vi ca tr em.
1082da nng khc: Ngng v khng bao gi
1083iu tr li bng penicilin. 1134Liu lng thuc cho tr em
48 Nguyn tc s dng thuc tr em 1135Liu lng thuc tr em trong Dc th quc
DTQGVN 1136gia Vit Nam trong a s trng hp c
1137ghi trong chuyn lun ca ring tng thuc,
1084 Nguyn tc s dng thuc 1138tr khi thuc c khuyn co khng dng
1085 tr em 1139cho tr em.
1140Liu lng thuc thng cn c vo cn
1086Tr em, c bit tr s sinh, p ng vi1141nng c th (th trng tnh bng
1087thuc khc ngi ln. Cn c bit thn1142kilogam) hoc theo tui: Mi (thng
1088trng giai on s sinh (30 ngy u1143u), cho n 1 tui (tr nh), 1 - 5 tui,
1089sau khi ), liu lng cn phi tnh ton11446 - 12 tui.
1090tht chnh xc. thi k s sinh, nguy c1145Cch tnh liu lng thuc cho tr em c th
1091ng c thuc tng ln nhiu do thn lc1146da trn liu lng ca ngi ln bng cch cn
1092km hiu qu, cc enzym tng i thiu1147c tui, th trng hay din tch b mt
1093ht, tnh nhy cm vi thuc ca cc c1148c th hoc phi hp cc yu t trn. Ph-
1094quan ch rt khc nhau v c bit h1149ng php tt nht l da trn din tch b
1095thng kh c cha hon chnh gy thi1150mt c th.
1096tr chm. 1151Th trng c th c dng tnh liu
1097Liu php dng thuc an ton v hiu qu1152biu th bng mg/kg; tr em c th phi
1098 tr s sinh, tr nh v tr em i hi phi1153cn mt liu lng cho mi kg th trng cao
1154hn ngi ln v tc chuyn ha tr
1099c s hiu bit v nhng thay i trong
1155em cao hn. Nhiu yu t khc cng cn
1100qu trnh trng thnh tc ng n1156phi tnh n. V nh tnh liu theo th
1101tc dng, chuyn ha v thanh thi1157trng cho cc chu bo ph cn phi dng
1102hon ton ca thuc. 1158liu cao hn nhiu. Trong nhng trng hp
1103Hu nh tt c cc thng s dc ng hc1159ny, liu phi c tnh theo cn nng l
1104thay i theo la tui. Liu lng thuc 1160tng lin quan n chiu cao v tui.
1105tr em tnh theo mg/kg, cn phi c iu1161
1106chnh theo c im dc ng hc ca

26
 27

1162S dng yu t din tch b mt c th1171

1163lm cho vic tnh liu lng thuc tr em1172Liu lng c lng cho bnh nhi =
1164chnh xc hn so vi th trng. V rt1173 Din tch b mt c th (m 2) x
1165nhiu hin tng sinh l c tng quan vi1174liu ngi ln/1,8.
1166nhau tt hn trong din tch b mt c1175Bng tnh sn theo t l phn trm di
1167th. Din tch b mt trung bnh ca1176y c th dng tnh liu lng thuc
1168mt nam gii nng 70 kg vo khong 1,81177cho tr em i vi cc thuc thng thng c
1169m2. Nh vy c th dng cng thc sau y1178s cch xa gia liu iu tr v liu c.
1170 tnh liu lng thuc cho tr em: 1179
Tui Cn nng l Chiu Din tch b mt Phn trm liu
tng (kg) cao c th ngi ln
(cm) (m2)
S sinh 3,4 50 0,23 12,5
1 thng 4,2 55 0,26 14,5
3 thng 5,6 59 0,32 18
6 thng 7,7 67 0,40 22
1 nm 10 76 0,47 25
3 nm 14 94 0,62 33
5 nm 18 108 0,73 40
7 nm 23 120 0,88 50
12 nm 37 148 1,25 75
Ngi ln
Nam 68 173 1,80 100
N 56 163 1,50 100
1180 1208
1181Bng s liu ny p dng cho tr thng.
1182Cc tr thiu thng cn gim liu ty
1183theo bnh cnh lm sng. 1209 Ng c v thuc gii c
1184Liu lng thuc tnh ton theo din tch b
1185mt c th chnh xc hn v din tch1210Tnh hnh ng c ang
1186ny c th tnh t chiu cao v cn nng1211c chiu hng gia tng v
1187(xem ph lc 1). 1212ngy cng c nhiu ha
1188S ln dng thuc trong ngy 1213cht v thuc trn th tr-
1189Cc khng sinh thng dng cch 6 gi mt1214ng. iu quan trng khng
1190ln. Cn linh hot khi dng thuc cho tr em1215phi ch coi ngi bnh nh
1191 trnh nh thc tr v m, th d1216l mt cp cu ni khoa tc
1192thuc dng trong m c th cho tr ung1217thi, m cn phi tm xem
1193lc b m i ng. 1218nguyn nhn dn n ng
1194Khi s dng mt thuc mi hay thuc c1219c. Ngi t u c v
1195kh nng gy ng c, liu lng thuc do1220 t t cn c nng
1196nh sn xut khuyn co cn c thc1221 v tm thn v gip
1197hin nghim tc. 1222v nhng vng mc ng
1198 1223sau t t . Bnh
1199 1224tm thn v d nh chng
1200 1225trm cm phi c xem xt
1201 1226v iu tr thch ng.
1202 1227Ngi b ng c do tip
1203 1228xc vi cht c trong lao
1204 1229ng cn c s ch dn;
1205 1230cn b y t c vai tr quan
1206 1231trng gip loi tr v gim
1207 1232bt nguy c cho sc khe
1233do tip xc vi ha cht.
1234Trong iu tr ng c,
1235ngi thy thuc ng trc
1236nhiu ngun nguy c khc

28
 29

1237nhau, i khi rt kh xc1244ng hp, nh tr em ung

1238nh. Trc khi iu tr,1245phi cc sn phm du ha
1239cn ra sch cht c ng-1246v nguy c nh hng n
1240i bnh, thay qun o, v1247sc cng b mt trong
1241 thng phi ra d dy. Quan1248phi. Gy nn nh Ng
DTQGVN vyccv
1242 st nc
thuc ra d
gii c 49 dy. Nn trnh1249nguy c cao gy try h
1243gy nn, trong mt s tr-1250hp cp.
Thuc gii c, hoc thuc dng Ch nh chnh v/hoc tnh trng
trong iu tr ng c v cc tnh sinh l ch yu c iu tr vi thuc
trng lin quan lit k
Acetylcystein Ng c paracetamol, nhng cng c ng
Ch phm m c truyn 200 g/l c cc cht clofibrat hu c, hoc ng
Liu: Bt u vi 150 mg/kg th trng c amanitin.
trong 300 ml glucose 5%, truyn trong 15
pht. Sau cho 50 mg/kg trong 500 ml
glucose 5% truyn trong 4 gi. Sau
cho 100 mg/kg trong 1000 ml glucose 5%
truyn trong 16 gi; ri nhc li.
Xem xt nguy c phn v.
Than hot phng nga hp thu, sau khi nut
cht c.
Amoni clorid thay i pH nc tiu.
Amyl nitrit Ng c cyanid.
Angiotensinamid Qu liu cc cht c ch enzym chuyn
(angiotensin).
Acid ascorbic Peroxid hu c v osmi.
Atropin n c hoc phi hp vi Hi chng c ch cholinesterase, th d
obidoxim. sau tip xc vi phosphat hu c.
Acid aurin tricarboxylic (ATA) Ng c beryli.
Benztropin Lon trng lc do ng c.
Biperiden iu tr lon trng lc, trong iu tr
Dung dch tim 5 mg/ml. ng c phenothiazin, tioxanthen v
Liu: 5 mg tim tnh mch chm hoc butyrophenon, ng c metoclopramid
tim bp, c th nhc li. v.v..
Tr em: 60 microgam/kg.
Calci clorid dung dch tim 0,5 mmol/ml. Ng c thuc chn calci, ng c acid
Trong trng hp gim kali mu hoc qu hydrofluor (HF), cc fluorid khc v oxalat.
liu thuc chn calci: 5 ml vi nng 0,5
mmol /ml tim tnh mch chm.
Calci glubionat Ng c acid oxalic hoc acid sulfuric,
Dung dch tim 9 mg/ml tng ng vi 0,22 fluorid v cc thuc khng calci v gim
mmol calci cho 1 ml. calci mu do kt qu ca bi niu cng
Liu ngi ln: 10 ml tim tnh mch. bc.
Carbamid Ng c formaldehyd.
Liu: 20 - 30 g ung, ha vo nc. Vi tr
em, 400 mg/kg.
Clorpromazin iu tr cc tnh trng o gic v lon
Xem chuyn lun: Clorpromazin. tm thn.
Corticosteroid Chng cc phn ng d ng cp, ph thanh
Xem chuyn lun ca tng thuc. qun v.v..
Dantrolen St cao c tnh, nhng c hi chng an
Xem chuyn lun: Dantrolen. thn kinh c tnh.
Deferoxamin Ng c st, nhm v Paraquat.
Xem chuyn lun: Deferoxamin.

30
31

Diazepam Ng c cloroquin, v iu tr co git,

Xem chuyn lun: Diazepam. kch thch, tng trng lc c.
Dicobalt EDTA Ng c cyanid.
Khng th c hiu digoxin. Digoxin, digitoxin, glycosid digitalis.
Dimercaprol Arsen (As), Cu, Au, Hg (v c), bnh no
do ch.
4 Dimethylaminophenol Ng c cyanid, ng c hydro sulfid.
(4 - DMAP)
Diphenhydramin Lon trng lc do ng c.
Dobutamin iu tr suy c tim.
Dopamin iu tr suy c tim, v gy gin
mch.
50 Ethanol
Ng c v thuc gii c Methanol, ethylenglycol, ether glycol v
DTQGVN alkoxysilan.
Epinephrin (adrenalin) iu tr sc phn v, ngng tim.
Flumazenil Benzodiazepin
Acid folinic Cc cht i khng acid folic.
Fomepizol Thuc gii c ethylenglycol v methanol.
(4 - methylpyrazol) Fomepizol l cht c ch
alcoldehydrogenase, do ngn chn
chuyn ha ca methanol v ethylenglycol.
iu tr c bn hin nay vn phi cho ngi
bnh ethanol lm thuc gii c u tin.
Glucagon Ng c thuc chn beta. Glucagon tc
dng bng cch kch thch adenylcyclase
c tim.
Glucose Qu liu insulin, v iu tr h ng
huyt ni chung.
Guanidin Ng c Clostridium botulinum.
Haloperidol o gic v trng thi lon tm thn.
Heparin Tnh trng tng ng mu.
Hydroxycobalamin Cyanid
Isoprenalin Cc thuc chn beta.
Lidocain Lon nhp tht.
Mannitol tim tnh mch Ph no, gi nc.
Methionin Cch la chn th hai chng qu liu v
ng c paracetamol, dng trong trng
hp ngi bnh d ng vi acetylcystein l
thuc gii c c la chn u tin.
Methylthionin clorid Methemoglobin mu.
(xanh methylen)
N - acetylpenicilamin Thy ngn.
Naloxon Cc opiat.
Natri bicarbonat iu tr nhim acid, mt s ri lon tim
(ng c thuc chng trm cm ba vng)
v thay i pH nc tiu.
Natri nitrit Cyanid v hydrosulfid
Natri nitroprussid Ng c ergotin.
Natri salicylat Beryli
Natri thiosulfat Cyanid, bromat, clorat, iod v tip xc vi
khi. Hydroxocobalamin l thuc la chn
u tin dng cho ng c cyanid.
Neostigmin Ng c cc thuc chn thn kinh - c tip
curar, v thuc khng cholinergic ngoi vi.

32
 33

Sulphonylurea Sulphonureid
Oxim Cc phosphat hu c.
Oxygen Cyanid, carbon monoxid, hydrosulfid.
Oxy tng p Carbon monoxid, cyanid, hydro sulfid,
carbon tetrac-lorid.
Pancuronium Cng c, co git.
Penicilamin ng, vng, ch, thy ngn.
Acid pentetic (DTPA) Kim loi phng x.
Phentolamin Ng c thuc alpha adrenergic.
Physostigmin Hi chng khng cholinergic trung ng do
atropin v dn xut, v chng tc dng
ph khng cholinergic trung ng ca cc
thuc khc.
Phytomenadion Thuc chng ng coumarin.
(vitamin K)
Kali hexacyano ferrat Ng c thali, phc hp lin kt thali trong
(Prussian blue C 177520)
DTQGVN rut. Ng c v
250 gii
thuc mg/kg/24
c gi 51 chia lm 4 liu ung,
pha trong nc.
Kali permanganat bt dng ra sch d Phosphor vng, trng v nitrit
dy
Kali permanganat cng natri bicarbonat. Phosphor vng v trng.
Pralidoxim B sung cho atropin trong iu tr ng
c phosphat hu c.
Prenalterol Ng c thuc chn beta. thay th,
dng dobu-
tamin. C th cn liu rt cao.
Promethazin Phn ng d ng.
Propranolol Ng c thuc beta adrenergic.
Protamin sulfat Qu liu heparin.
Pyridoxin Qu liu isoniazid do thiu ht vitamin B 6,
ethylengly-
col, gyrometrin, hydrazin.
Salbutamol Co tht ph qun.
Silibinin Amanitin
Tocopherol Ng c carbon monoxid v oxy.
Toloni clorid Methemoglobin mu.
(xanh toluidin)
Trientin Ng c ng.
(triethylen tetramin)
Unithiol (DMPS) As, Cu, Ni, Pb, Cd, Hg (c methyl v v
c).
1251
1252 Bng tm tt v triu chng ng c km theo danh sch cc cht c ha hc
1253 v dc phm
1254 c kh nng lin quan nht.
1255
1256Biu ny khng phi l mt hng dn tuyt i v cch x tr ngi bnh. Ty theo
1257tnh hnh a phng, v cc loi ng c thng gp nht, phng cp cu phi lp phc
1258 triu chng hc v ng c cho ring mnh. y ch l hng dn cch xy dng mt
1259phc n gin gip cc bc s v y t nh nhng ng c quan trng nht, hay
1260gp nht v cc triu chng ca chng.
1261
Triu chng Nguyn nhn nghi ng ng c/qu liu thuc.
Hn m Nghi ng c barbiturat, benzodiazepin, ru, ethylenglycol,
methanol, opiat, triclo-

34
 35

roethanol thuc chng trm cm ba vng.

Co git Nghi ng c amphetamin, ecstasy (methylen
dioxymethamphetamin), phenothiazin, theophylin, thuc chng trm
cm ba vng.
Co ng t Nghi ng c clonidin, opiat, phenothiazin, tetrahydrozolin, acid
valproic. Cng nghi cc thuc dit cn trng carbamat, nicotin,
phosphat hu c, physostigmin v pilocarpin.
Gin ng t Nghi ng c cc thuc tc dng ging thn kinh giao cm, th d
amphetamin, cocain, dopamin, LSD, cc cht c ch monoamin
oxidase v nicotin.
Cng c th do cc thuc khng cholinergic th d thuc khng
histamin, atropin v cc thuc khng cholinergic khc, glutethimid v
thuc chng trm cm ba vng.
Cng xem xt tricloroethanol.
Trong s dc phm, c bit nghi phenothiazin, quinin, thuc tc
dng ging thn kinh giao cm v thuc chng trm cm ba vng.
Lon nhp tim Nghi ng c v/hoc qu liu cc thuc chng lon nhp, cc khng
cholinergic, phenothiazin, quinin, thuc tc dng ging thn kinh giao
cm, v thuc chng trm cm ba vng.
Ph phi Nghi ng c aspirin, ethylenglycol, cc kh gy kch ng, cc
opiat, phosphat hu c, thuc chng trm cm ba vng v
paraquat.
Nhim acid Nghi ng c aspirin, ethanol, ethylenglycol, methanol, thuc chng
chuyn ha trm cm ba vng.
St cao Nghi qu liu hoc ng c cc thuc khng cholinergic, ecstasy v
cht c ch MAO.
Suy gan Nghi ng c paracetamol.
Suy thn khng Nghi ng c ethylenglycol, methanol, paracetamol, aspirin.
lin quan n
h huyt p
52 hoc globulin
D ng thuc v cch x tr
c niu kch
DTQGVN
pht
1262 D ng thuc v cch x tr 1285lin quan p ng - liu thng khng r
1286rng gy phn ng d ng.
1263Phn ng d ng 1287Cc p ng d ng c chia thnh 4 typ,
1264D ng ha cht l mt phn ng c hi do1288da trn c ch min dch tham gia
1265mn cm trc vi mt ha cht ring bit1289(Coombs v Gell, 1975).
1266hoc vi mt cht c cu trc tng t nh1290Typ I, hoc phn v, l nhng phn ng
1267cht dng trc. Nhng phn ng d ng1291ngi qua trung gian khng th IgE. on Fc
1268nh th u qua trung gian h thng min1292ca IgE c th gn vi th th trn cc dng
1269dch. Cc thut ng qu mn v d ng1293bo (mast cell) v bch cu a baz. Nu
1270thuc thng c dng m t nhng1294on gn khng nguyn (Fab) ca phn t
1271phn ng v triu chng d ng khc nhau1295khng th sau gn vi khng nguyn,
1272. 1296nhiu cht trung gian khc nhau c phng
1273Vi mt ha cht c trng lng phn t thp1297thch (histamin, leukotrien, prostaglandin).
1274th d nh mt thuc gy phn ng d ng,1298Chng gy gin mch, ph v p ng
1275thuc ny hoc cht chuyn ha ca n1299vim.
1276thng ng vai tr nh mt hapten, phi1300Cc ch ch yu ca typ phn ng ny l
1277kt hp vi mt protein ln hn to1301ng tiu ha (d ng thc phm), da
1278thnh mt phc hp khng nguyn. Nhng1302(my ay v vim da atopi), h thng h
1279khng nguyn ny gy tng hp khng1303hp (vim mi v hen) v h mch (sc
1280th, thng sau mt thi k tim n t nht1304phn v). Nhng p ng ny c chiu h-
12811 hoc 2 tun. S tip xc sau ca c1305ng xy ra nhanh sau khi c s tip xc vi
1282th vi ha cht dn n mt tng tc1306mt khng nguyn m c nhn c mn
1283khng nguyn - khng th, gy ra nhng1307cm, v c gi l phn ng qu mn tc
1284biu hin in hnh ca d ng. Cc mi1308th.

36
 37

1309Typ II, hoc tiu t bo, l nhng phn1366mt s ha cht, khi, mt s thuc thng
1310ng qua trung gian c vi khng th IgG v1367gy phn v (sn phm mu, vaccin,
1311IgM, thng c cho l do chng c kh1368khng sinh, aspirin v cc thuc chng vim
1312nng hot ha h thng b th. Cc m1369khng steroid khc, ch phm st tim,
1313ch ch yu i vi cc phn ng tiu t1370heparin v cc thuc chn thn kinh c).
1314bo l cc t bo trong h tun hon. Th1371Ngi c tng d ng c bit d c nguy
1315d v p ng d ng typ II bao gm thiu1372c phn ng phn v.
1316mu tan mu do penicilin, thiu mu tan1373Phn v c th xut hin rt nhanh trong
1317mu t min do methyldopa, xut huyt1374vi pht (sc phn v cn phi iu tr
1318gim tiu cu do quinidin, gim bch cu1375cp cu) nhng cng c th xy ra mun,
1319ht do sulfonamid, luput ban ton thn1376i khi 1 ngy sau iu tr. Ngi bnh
1320do hydralazin hoc procainamid. Rt may1377cm thy kh chu, lng ngc nh b "p",
1321mn l nhng phn ng t min vi thuc1378c th nga, hoc ph n, nguy him nht
1322ny thng du i trong vng nhiu thng1379nu ph thanh qun gy cn tr h hp
1323sau khi loi b tc nhn gy bnh. 1380e da tnh mng, co tht ph qun gy
1324Typ III, l nhng phn ng ch yu qua1381cn hen.
1325trung gian IgG; c ch bao gm s sinh1382Sc phn v
1326phc hp khng nguyn khng th, sau 1383X tr: Trc ht tim adrenalin, tim bp
1327gn vi b th. Cc phc hp lng ng1384 dung dch 1/1000 hoc tim tnh
1328trn ni m mch, ti xy ra mt p1385 mch dung dch 1/10 000 theo liu ni
1329ng vim gy ph hy, c gi l bnh1386 mc thuc cp cu. Nu ngi bnh
1330huyt thanh. Hin tng ny tng phn vi1387 ang dng thuc chn beta, thay
1331phn ng typ II, trong p ng vim -1388 adrenalin bng salbutamol 0,25 mg
1332c gy ra bi khng th hng vo chng li1389 tnh mch. ng thi phi bo m
1333khng nguyn ca m. Cc triu chng1390 thng kh.
1334lm sng ca bnh huyt thanh bao gm1391 u thp v k cao chn. Th oxygen.
1335ban da, my ay, au khp hoc vim1392Hi sc tim mch nu ngng tim. Xoa bp
1336khp, bnh hch bch huyt v st. Nhng1393tim ngoi lng ngc. Tim tnh mch natri
1337phn ng ny thng ko di 6 n 121394bicarbonat.
1338ngy sau gim bt sau khi tc nhn1395Hydrocortison 200 mg tim tnh mch.
1339gy bnh b loi b. Nhiu thuc, th d1396Thuc khng histamin (clorpheniramin tnh
1340sulfonamid, penicilin, mt s thuc chng1397mch chm, hoc promethazin tnh mch
1341co git, v cc iodid, c th gy bnh1398chm). iu tr khc: truyn dch tnh
1342huyt thanh. Hi chng Stevens - Johnson,1399mch chng gim th tch mu.
1343nh do sulfonamid gy ra, l mt th rt1400Aminophylin tnh mch chm (nu trc
1344nng ca vim mch min dch. Cc triu1401cha dng theophylin ung).
1345chng ca phn ng ny gm ban a1402Nu c ph n ng th, c th xt
1346dng, vim khp, vim thn, bt thng ca1403adrenalin thng vo ch sng phng.
1347h thn kinh trung ng v vim c tim.
phn ng typ IV cng c gi l phn1404Cch dng mt s thuc cp cuiu
DTQGVN
1348Cc trong
tr hp
l bnh
1349ng qu mnhenchm,53 qua trung gian t bo1405 sc phn v
1350lympho T mn cm v i thc bo. Khi1406Adrenalin (epinephrin).
1351cc t bo mn cm tip xc vi khng1407Ch nh: Sc phn v, ph mch, hi sc
1352nguyn, mt phn ng vim c to ra do1408tim mch.
1353c s sn xut cytokin/lymphokin dn n1409Thn trng: Tng nng gip, i tho ng,
1354s dn ti ca bch cu trung tnh v i1410thiu mu cc b c tim, tng huyt p,
1355thc bo tip sau . Mt th d ca qu1411ngi cao tui.
1356mn chm typ IV l vim da tip xc. 1412Tng tc: Ngi b phn v nng ang
1413dng thuc chn beta khng chn lc i
1357X tr sc phn v
1414vi tim c th khng p ng vi adrenalin,
1358Phn ng phn v 1415lc cn tim tnh mch salbu-
1359Phn v l mt phn ng d ng nng, rt1416tamol 0,25 mg.
1360d gy t vong, cn phi iu tr ng1417Ngi ang dng thuc chng trm cm 3
1361v nhanh. Cn tp hun thu o, thng1418vng d b tc dng khng mong mun
1362xuyn, cho mi cn b y t lm sng 1419lon nhp tim, do phi dng adrenalin
1363bit x l ng. 1420liu thp hn nhiu liu thng thng.
1364Phn v c th do cn trng t, ng vt1421Cc tng tc khc: Xem cc thuc ging
1365cn, mt s thc n (trng, c, sa b, lc),1422giao cm.

38
 39

1423Tc dng khng mong mun: Lo hi, run,1471adrenalin hoc prome-

1424nhp nhanh, lon nhp, lnh u chi, tng1472thazin tnh mch liu 15 mg.
1425huyt p (nguy c xut huyt no) ph1473Glucocorticoid: C gi tr va phi trong
1426phi (qu liu hoc nhy cm), bun nn,1474iu tr cp phn v (tc dng chm) nh-
1427nn, v m hi, yu c, chong vng. 1475ng bao gi cng phi tim, cng sm cng
1428Liu lng v cch dng 1476tt ngay sau khi tim adrenalin ngn
1429Cch dng: Adrenalin tim bp hp thu1477chn tnh trng xu hn.
1430nhanh hn tim di da trong sc phn v.1478Hydrocortison natri succinat tim tnh
1431Tim tnh mch ch dnh cho trng hp ti1479mch liu 100-300 mg.
1432cp. 1480Trong hen: hydrocortison tnh mch 100 -
1433Liu dng: Adrenalin 1 mg/ml (dung dch1481200 mg hoc betametazon 4 - 8 mg tnh
14341/1000). 1482mch hoc tim bp, hoc betametazon
1483vin 0,5 mg, 12 vin pha vo 1 cc nc,
Tui Th tch adrenalin
1484ung 1 ln.
1mg/ml.
1485Aminophylin (theophylamin) (23 mg/ml):
Di 1 tui 0,05 ml
1486Liu np 0, 25 mg/kg >liu u tin thch
1 tui 0,1 ml 1487hp 10 mg tnh mch chm (1 mg/pht)
2 tui 0,2 ml 1488chia lm 2 ln, tim cch nhau vi pht
3 - 4 tui 0,3 ml 1489(tim 5 mg u, sau ch khong 5 - 10
5 tui 0,4 ml 1490pht v kim tra nhp tim, sau cho
6 - 12 tui 0,5 ml 1491tip 5 mg sau). Nu bit bnh nhn
ngi ln 0,5-1 ml 1492ung theophylin, liu np phi di mt na
1435Liu adrenalin tim bp lp li cch nhau1493liu np ni trn.
143610 pht, ty theo huyt p v mch cho ti1494Salbutamol tim tnh mch 0,25 mg.
1437khi . Ch tim tnh mch khi bnh rt
1438nng, hoc nghi ng hp thu chm khi
1439tim bp. Tim tnh mch chm vi liu 1495 iu tr hp l bnh hen
1440500 microgam (5 ml dung dch 1/10.000)
1441vi tc 100 microgam (1 ml dung dch1496Khi nim v hen
14421/10.000) mi pht, ngng khi t kt1497Y hc hin i cho thy co tht ng
1443qu mong mun. Tr em c th cho liu 101498th do hen, ngoi cn cng nh lc ln cn
1444microgam/kg (0,1 ml dung dch 1/10 000)1499hen nng, u do vim. ng th ngi hen
1445tim tnh mch trong vi pht. Cn ch 1500thm nhim nhiu t bo vim, bao gm
1446dng ng nng . Trong b cp cu, 21501bch cu a eosin, i thc bo v lympho
1447loi dung dch ny phi ring r, ghi r1502bo. Ngay c ngi hen c chc nng phi
1448 trnh nhm ln. 1503bnh thng lc ngoi cn v khng c cn
1449Thuc khng histamin 1504hen no mi xy ra, cng c mt lng ln
1450Ch nh: d ng mi (vim mi d ng1505bch cu a eosin v cc t bo vim khc
1451theo ma), vim mi vn mch, gim chy1506ng th. iu ny ng vi c hen d ng
1452nc mi v ht hi, ngn nga my ay,1507v khng do d ng. Sau tip xc vi d
1453nga, d ng thuc. Tim clorphe-1508nguyn, s lng t bo vim gia tng thm
1454niramin hoc promethazin ph thm vi1509ngi hen d ng.
1455adrenalin trong iu tr cp cu phn v1510So snh vi ngi bnh thng, ngi hen cng
1456v ph mch. 1511c thnh ng th dy hn v t bo vim
1457Cc thuc khc nhau v thi gian tc dng1512tng hn m phi. C ch vim ni trn
1458v t l tc dng khng mong mun (bun1513cn cha hon ton sng t. khong 50%
1459ng v tc dng khng muscarin). Phn ln1514tr em v mt t l nh hn nhiu ngi
1460tc dng ngn, tr promethazin (ti 121515ln, c th xc nh c d nguyn tip
1461gi).Tt c u gy bun ng1516xc gy ra hen. nhng ngi bnh ny,
1462(promethazin, alimemazin, dimenhydrinat)1517tip xc vi d nguyn t nhiu gy
1463nhng clorpheniramin, cyclizin v1518vim trong hen, thng qua phn ng loi
1464mequitazin t gy bun ng hn. Thuc1519qu mn tc th (tp I). i a s ngi ln
1465mi (acrivastin, astemizol, cetirizin,1520hen, v khong 50% tr em b hen, khng
1466loratadin v terfenadin) t gy bun ng1521xc nh c ngay cc thnh phn d ng
1467v tn thng tm thn vn ng hn do1522i vi hen. Tuy nhin, nghin cu dch t
1468t qua hng ro mu - no. 1523hc cho thy c tng quan gia mc IgE
1469Trong cp cu, clorpheniramin tim tnh1524tng v t l mc bnh hen, v i a s
1470mch liu 10-20 mg, tim sau khi tim1525cc trng hp hen thc s c th do mt

40
 41

1526thnh phn d ng tuy khng d xc nh1584vi ngi dng salbutamol hoc terbutalin
1527c bng cc test da thng thng. 1585khng tc dng, khi ngi khng th
1528Hen d ng c dng lm m hnh 1586dung np salbutamol hoc terbutalin liu
1529nghin cu chung bnh hen, mt phn v1587cao hn. nhng trng hp , phi hp
1530c th gy c cc cn hen bng tip xc1588salbutamol v ipratropium thng l cch
1531vi d nguyn thch hp. Nghin cu k c1589iu tr c ch. Trong y hc hin i,
1532ch hen d ng cho php hiu thu o1590theophylin khng phi l thuc u tin -
1533cch tip cn iu tr hp l i vi hen.1591c chn. Thuc ny ch dnh dng cho
1534IgE c hiu i vi d nguyn gn vo1592cc trng hp rt nng, v thuc c nguy
1535dng bo thng qua th th Fc. Khi d1593c gy lon nhp tim nng.
1536nguyn tip xc vi IgE, dng bo c hot
1537haiu
54 v gii
tr phng
hp l mt
bnh lng
henln cht trung1594X tr hen cp nng trong thc hnh
1538gian gy vim. C ch bao gm gii1595chung
DTQGVN
1539phng cc cht cha trong cc ht ca dng1596Hen cp ngi ln
1540bo sn xut cytokin. Nhiu cht trung1597Ni bnh thng.
1541gian c gii phng, mi hp cht u c1598Mch < 110/pht.
1542mt s tc dng n vim ng th. 1599Th < 25 ln/pht.
1543Tc dng bao gm gin mch v tng tnh1600Lu lng nh > 50% d on hoc trong
1544thm mch, v tng nhiu t bo vim hn1601gii hn tt nht.
1545vo cc m phi, ch yu lympho bo,1602iu tr ti nh nhng phi nh gi p
1546bch cu a eosin v i thc bo. Mt khi1603ng vi iu tr trc khi thy thuc ra v.
1547cc t bo mi b sung thm ny vo ti1604iu tr:
1548phi, cc t bo ny cng li gii phng1605Salbutamol phun sng 5 mg hoc
1549cc cht trung gian ca bn thn mnh,1606terbutalin phun sng 10 mg.
1550lm tng thm tc dng vim. Vim trong1607Theo di p ng sau phun sng 15 - 30
1551hen c c tnh l tng tnh phn ng1608pht.
1552ca ph qun, v vy khc vi vim trong1609Nu lu lng nh 50 - 75% d on hoc
1553cc bnh khc, nh trong vim phi. Kt1610trong gii hn tt nht, cho:
1554qu lu di l ph n ng th, ph i1611Prednisolon ung 30 - 60 mg v cho iu
1555c trn, t bo biu m bong rng, v1612tr thng thng.
1556tng tnh phn ng ca ph qun i vi1613Cch khc: Nu lu lng nh >75% d
1557nhng tc nhn kch thch khng c1614kin hoc trong gii hn tt nht,
1558hiu nh mi nng, khng kh lnh, nhim1615Cho iu tr thng thng.
1559v histamin. Vim ng th do hen cng1616Theo di:
1560thng gy tng hp ph qun do i giao1617Gim st cc triu chng v lu lng nh.
1561cm. 1618Thit lp mt k hoch t x tr.
1562C ch hen ni trn cho thy trc rng mt1619Duyt li ti khoa ngoi trong vng 48 gi.
1563thuc ch tc ng n mt cht trung1620Thay i iu tr lc duyt li theo hng
1564gian, khng chc c li ch nhiu, n1621dn i vi hen mn.
1565gin l v c nhiu cht trung gian tham1622Quan trng: Hy coi mi ln khm cp cu
1566gia. Th d, r rng histamin c gii1623nh l mt hen nng cp cho ti khi biu
1567phng trong phn ng hen d ng, nhng1624hin khc.
1568thuc khng histamin li khng c ch li
1625Hen cp nng ngi ln
1569trong hen d ng. Thc t, thuc khng
1626 Khng th ni thnh cu.
1570histamin c kh nng gy suy h hp, nn
1627 Mch 110/pht.
1571khng thch hp dng iu tr hen.
1628 Th 25 ln/pht.
1572iu tr hen, theo m t bnh trn y,
1629 Lu lng nh 50% d kin hoc
1573cn s dng glucocorticoid chng li s
1630trong gii hn tt nht.
1574huy ng cc t bo vim. Liu php
1631Hy cn nhc nghim tc cho nhp vin,
1575glucocorticoid c coi nh mt iu tr d
1632nu c trn mt du hiu k trn.
1576phng cn thit ngn nga bnh nng
1633iu tr:
1577hn. Tuy nhin i vi hen cp,
1634Oxygen 40 - 60%, nu sn c.
1578glucocorticoid c tc dng rt hn ch, v
1635Salbutamol phun sng 5 mg hoc
1579vy, thuc u tin c chn l cc thuc
1636terbutalin phun sng 10 mg.
1580ch vn th th beta 2, nh salbutamol.1637Prednisolon ung 30 - 60 mg hoc tim
1581Ngoi ra i vi thnh phn cholinergic ca1638tnh mch hydrocortison 200 mg.
1582co tht ph qun, ipratropium thng l
1583thuc iu tr thm c ch, c bit i

42
 43

1639Gim st p ng sau phun sng 15 - 30 1694Kh th n mc khng n c.

1640pht. 1695Th 50/pht.
1641Nu cn bt c mt du hiu hen cp no:1696Mch 140/pht.
1642Thu xp cho nhp vin. 1697Lu lng nh 50% lu lng nh d kin
1643Khi ch i xe cu thng, lp li1698hoc trong gii hn tt nht.
1644ipratropium phun sng 500 microgam. 1699Du hiu e da tnh mng:
1645Hoc cho tim di da terbutalin. 1700Lu lng nh <33% d kin hoc trong
1646Hoc cho tim tnh mch chm
1701gii hn tt nht.
1647aminophylin 250 mg (quan trng: khng
1702Xanh tm, lng ngc im lng, hoc th
1648tim nu ang ung theophylin).
1703yu khi phi gng sc.
1649Cch khc: Nu triu chng ci thin, h1704Mt mi, kit sc.
1650hp v mch n nh, v lu lng nh >1705Vt v, hoc thc gim.
165150% d kin hoc trong gii hn tt nht: 1706Quan trng: Khng p ng tha ng vi
1652Cho iu tr thng thng v tip tc1707iu tr bt c thi im no cng cn
1653prednisolon.
1708phi chuyn ngay n bnh vin.
1654Theo di:
1655Gim st triu chng v lu lng nh. 1709Nt c trng iu tr hen cp tr
1656Thit lp k hoch t x tr. 1710 em
1657Duyt li ti khoa ngoi trong vng 24 gi. 1711Dng bnh kh dung thuc kch thch
1658Thay i iu tr lc duyt li. 1712beta2 tc dng ngn c liu nh lng km
1659Hen e da tnh mng ngi ln 1713theo, bnh ht th tch ln c th cng
1660Lng ngc im lng. 1714hiu qu nh dng my phun m; liu: 1 xt
1661Xanh tm. 1715cch nhau vi giy cho ti khi c ci thin
1662Tim chm hoc kit sc. 1716(ti a 20 xt) dng mt n tr nh.
1663Lu lng nh < 33% d kin hoc trong1717C th tim di da terbutalin trong t
1664gii hn tt nht. 1718nng
1665Cn cho nhp vin ngay. 1719Cho th oxygen: C ch.
1666iu tr: 1720Tr em no cn thuc ht gin ph qun
1667Prednisolon ung 30 - 60 mg hoc tim1721liu cao cng phi ung vin prednisolon
1668tnh mch hydrocortison 200 mg (ngay lp1722tan 1- 2 mg/kg (ti a 40 mg) 1 ln/ngy
1669tc). 1723cho ti 5 ngy nu cn ; tr cn phi gi i
1670My phun m chy bng oxygen trong xe1724bnh vin ngay nu khng p ng vi
1671 cu thng.
DTQGVN iu tr hp
1725iu tr.
lDng
1672 bnh thuc
hen phun55 m kch thch beta 2 cng1726Aminophylin khng cn c dng cho tr em
1673vi ipratropium;
1727ti nh na.
1674hoc tim di da terbutalin;
1728iu tr thm cho nhng ngi bnh ny
1675hoc tim tnh mch chm aminophylin
1729bnh vin l an ton hn, v sn c cc
1676250 mg (quan trng: Khng tim nu ang
1730phng tin hi sc. Khng bao gi c tr
1677ung theophylin).
1731hon iu tr lm xt nghim, khng
1678Nu khng c sn my phun m, cho xt 2
1732bao gi c dng thuc an thn cho ngi
1679ln thuc kch thch beta2, dng bnh ht
1733bnh, v cng phi nh c kh nng b trn
1680th tch ln v lp li 10-20 ln.
1734kh mng phi.
1681Quan trng: Khng tim c liu
1735Nu bnh xu i mc d c iu tr
1682aminophylin mt lc cho ngi bnh dng
1736thuc thch hp, c th tng lc phi cho
1683theophylin ung.
1737thng kh p lc dng cch qung.
1684Quan trng: Ngi bnh c cn hen nng
1685hoc e da tnh mng khng c qu lo1738X tr hen mn ngi ln
1686lng cng thng vt v kit sc; c bt c1739Bt u bc thch hp nht i vi mc
1687mt bt thng no cng phi bo cho thy1740 nng ban u ; liu php"cu nguy"
1688thuc. 1741dng prednisolon bt c thi im no
1742v bt c bc no.
1689Hy li vi ngi bnh ti khi xe cp cu
1690 n. 1743Bc 1: i khi mi phi dng thuc gin ph
1744 qun.
1691Hen cp tr em 1745Dng thuc ht kch thch beta2 tc dng
1692Hen cp nng 1746ngn, khi cn (khng nhiu qu 1
1693Kh th n mc khng ni c. 1747ln/ngy).

44
 45

1748Ghi ch: Chuyn sang bc 2 nu cn ht1805Cromoglycat hoc nedocromil.

1749trn 1 ln/ngy (hoc triu chng hen v1806Ghi ch: Ch xt n thuc ht gin ph
1750m). 1807qun liu cao nu ngi bnh khng p
1751Bc 2: Dng liu php d phng thng1808ng vi liu thng thng; c th cho thuc
1752 xuyn bng ht. 1809kch thch beta2 v ipratropium bng my
1753Dng thuc ht kch thch beta2 tc dng1810phun m (hoc xt nhiu ln bng bnh
56 iu
1754ngn, tr hp l bnh hen
khi cn. 1811kh dung c liu nh lng km mt bnh
DTQGVN
1755Cng thm corticosteroid ht u n, 1812ht th tch ln); cho theo nhu cu trc v
1756 liu thng thng. 1813khi k n dng my phun m.
1757Hoc th dng cromoglycat hoc1814Bc 5: Corticosteroid ung thng xuyn.
1758 nedocromil ht u n (nhng1815Dng thuc ht kch thch beta2 tc dng
1759 chuyn sang ht corticosteroid, nu1816ngn, khi cn.
1760 khng kim sot c). 1817Vi corticosteroid ht u n liu cao
1761Ghi ch: Liu ht corticosteroid c th phi1818 (bnh ht th tch ln) v vi mt
1762cao hn t kim sot ban u; mt1819 hoc vi thuc gin ph qun tc
1763s ngi ln phi dng liu gp i trong1820 dng ko di (xem bc 4).
1764mt thi gian ngn khng ch hen
1821Cng
1765trm trng.
1822Prednisolon ung u n (ung liu
1766Bc 3: Corticoteroid ht liu cao hoc liu1823n hng ngy).
1767 thng thng + thuc kch thch beta18242 Ghi ch: Ngoi vin prednisolon ung u
1768 ht, tc dng ko di. 1825n, tip tc ht corticosteroid liu cao
1769Dng thuc ht kch thch beta2 tc dng1826(trong trng hp ngoi l, c th dng liu
1770ngn, khi cn. 1827vt qu liu quy nh); thng phi a
1771Cng thm corticosteroid ht u n1828nhng ngi bnh i khoa hen bnh vin.
1772 liu cao (bnh ht th tch ln).
1773Ghi ch: Mt s t ngi c vn khi ht1829Gim iu tr tng bc
1774corticos- 1830Cch 3-6 thng duyt li cch iu tr;
1775teroid liu cao, c th tip tc ht1831nu kim ch c bnh, c th li bc;
1776corticosteroid liu thng thng km thm1832 ngi bnh mi bt u iu tr bc 4
1777ht u n thuc kch thch beta 2 tc1833hoc 5 (hoc dng vin corticosteroid),
1778dng di hoc ung u n theophylin1834th c th gim sau mt thi gian ngn;
1779gii phng thay i hoc c th th dng1835hen mn, phi c thi gian n nh t 3
1780u n cromog-1836n 6 thng trc khi thc hin li bc.
1781lycat hoc nedocromil.
1782 mt s t ngi c triu chng nng khc1837Tr em di 5 tui:
1783thng v m (mc d, cc thi gian khc,1838Bc 1: i khi mi phi dng thuc gin ph
1784 kim sot tt vi ht corticosteroid liu1839 qun.
1785thng thng hay liu cao) c th cn1840Dng thuc kch thch beta2 tc dng
1786nhc dng theophylin ung (gii phng1841ngn, khi cn (khng nhiu hn 1 ln mi
1787thay i) hoc mt thuc ht kch thch1842ngy).
1788beta2 tc dng ko di hoc mt thuc1843Ghi ch: Ht nu c th (ung km hiu
1789kch thch beta2 gii phng t t vo ban1844qu v nhiu tc dng ph hn).
1790m.
1845Bc 2: Liu php d phng thng xuyn
1791Bc 4: Corticosteroid ht liu cao + thuc
1846 bng kh dung.
1792 gin ph qun thng xuyn.
1847Dng thuc ht kch thch beta2 tc dng
1793Dng thuc ht kch thch beta2 tc dng
1848ngn, khi cn
1794ngn, khi cn cng vi corticosteroid liu
1795cao ht u n (bnh ht th tch ln).1849Cng
1850Cromoglycat ht u n (ng ht bt
1796Cng, th iu tr ln lt vi mt hoc vi1851hoc bnh ht th tch ln).
1797thuc sau: 1852Ghi ch: Th dng cromoglycat trong 4 - 6
1798Thuc ht kch thch beta 2 tc dng ko1853tun trc khi sang bc 3 (cung cp lu lng
1799di.
1854nh - k ni thch hp).
1800Theophylin ung (gii phng thay i).
1801Ipratropium hoc oxitropium ht. 1855Bc 3: Corticosteroid ht phi tng liu.
1802Thuc ung kch thch beta2 gii phng1856Dng thuc ht kch thch beta2 tc dng
1803thay i. 1857ngn, khi cn.
1804Thuc ht gin ph qun liu cao.

46
 47

1858Cng 1911Cng
1859Corticosteroid ht u n, liu thng1912Prednisolon 5 - 10 mg, ung cch 1 ngy.
1860thng tr em (bnh ht th tch ln). 1913Cn nhc
1861 n nh, cn nhc dng: 1914Ht u n ipratropium hoc tim di
1862Vin prednisolon tan, 1 - 2 mg/kg mi ngy,1915da thuc kch thch beta2 tc dng ngn.
1863trong 1 - 5 ngy (ti a 40 mg/ngy) hoc
1916Gim iu tr theo tng bc tr em
1864tm thi tng gp i liu ht
1917u n duyt li nhu cu iu tr ;
1865corticosteroid.
1918tr ln dng cch ghi lu lng nh nh
1866Ghi ch; Sau 1 thng, nh gi tc dng
1919gi tc ngng thuc; ngng
1867da trn lu lng nh v/hoc triu chng
1920cromoglycat hoc corticosteroid sau 6 -
1868v iu chnh liu; nu cha kim sot -
192112 thng nu cn t hoc khng cn
1869c, cn nhc tng liu corticosteroid ht
1922triu chng (nu triu chng theo ma,
1870gp i trong 1 thng (cch khc, cho ung
1923cn nhc ngng thuc vo cui ma).
1871vin prednisolon tan mt t ngn ngy
1872hoc cn nhc dng cch iu tr khc). 1924Thuc dng trong hen
1873Bc 4: Corticosteroid ht liu cao + thuc1925Cc thuc di y thng c dng trong
1874gin ph qun thng xuyn 1926hen:
1875Dng thuc ht kch thch beta2 tc dng1927Thuc kch thch th th adrenalin
1876ngn, khi cn. 1928(Thuc ging giao cm)
1877Cng 1929Thuc kch thch chn lc beta 2
1878Corticosteroid ht u n vi liu cao tr1930adrenergic (thuc kch thch chn lc
1879em (bnh ht th tch ln hoc ng ht1931beta2, thuc ch vn chn lc beta 2) nh
1880bt kh). 1932salbutamol hoc terbutalin (c a dng di
1881Cn nhc 1933dng ht kh dung) l cc thuc kch thch
1882Ung vin prednisolon tan, 1 - 21934beta an ton v hiu qu nht i vi hen.
1883mg/kg/ngy, trong 1935Cc thuc ny c khuyn co nn dng
18841 - 5 ngy (ti a 40 mg/ngy). 1936hn l cc thuc kch thch beta km
1885Dng u n thuc ht kch thch beta1937 chn lc nh isoprenalin hoc orciprenalin,
2
1886tc dng ko di. 1938 l thuc nn trnh dng nu c th c.
1887Ghi ch: Thuc kch thch beta 2 tc dng 1939 Adrenalin (thuc c c hai tnh cht kch
1888ko di c l phi dnh b sung iu1940thch alpha v beta adrenergic) c dng
1889tr cho tr dng cromo-1941trong iu tr cp cu cc phn ng d
1890glycat hoc mt corticosteroid. 1942ng v phn v.
1943Phn ln cc cn hen t nh n va p
1891Bc 5a: 1944ng nhanh vi kh dung thuc kch thch
DTQGVN
1892Dng thuc ht kch thch beta2 tc dng1945chn iu tr hp
l bnh hen 57 lc beta 2 adre-
1893 ngn, khi cn. 1946nergic nh salbutamol hoc terbutalin.
1894Cng vi: Corticosteroid ht u n vi1947Ngi vim ph qun mn v kh ph thng
1895liu cao tr em (bnh ht th tch ln hoc1948thng c m t l tc ng th khng
1896ng ht bt kh). 1949hi phc, nhng thng p ng mt phn vi
1897Nh trong bc 4, cn nhc dng vin1950cc thuc kch thch beta 2 adrenergic
1898prednisolon ha tan cng vi dng u n1951hoc vi thuc ipratropium hoc
1899thuc ht beta2 tc dng ko di. 1952oxitropium khng muscarin.
1900Cng 1953C mt s chng c ngi bnh dng thuc
1901Ung u n theophylin gii phng1954kch thch beta2 adrenergic khi cn, bnh
1902thay i c th c ch (c bit i vi1955hen c ci thin tt hn ngi dng thuc
1903triu chng ban m) nhng c tc dng1956ny u n. i vi ngi hen cn thuc
1904ph ng k ti 1/3 s tr em (khuyn1957kch thch beta2 adrenergic trn 1
1958ln/ngy, nn th iu tr d phng bng
1905co gim st nng huyt tng hoc nc
1959ht corticosteroid, cromoglycat hoc
1906bt); ung salbutamol gii phng thay i1960nedocromil.
1907cho kt qu lm sng tng t, nhng t tc1961C vi im khc bit gia cc thuc kch
1908dng ph hn. 1962thch chn lc beta2 adrenergic.
1909Bc 5b 1963Isoprenalin sulfat
1910Nh bc 5a. 1964Ch nh: Tc ng th hi phc c,
1965nhng xem ghi ch trn.

48
 49

1966Thn trng, tc dng khng mong mun:2024iu tr tc ng th t nh n va.

1967Xem salbu-2025Thi gian tc dng ca kh dung ph thuc
1968tamol v ghi ch trn. 2026vo thuc cha trong bnh v liu lng. Vi
1969Tng tc: Thuc ging giao cm. 2027liu khuyn co, rimiterol thng tc dng
1970T vn: Khuyn ngi bnh khng vt qu liu2028t 1 n 2 gi, salbutamol, terbutalin v
1971k n v theo hng dn ca nh sn xut;2029fenoterol t 3 n 5 gi, v salmeterol
1972nu 1 liu ht isoprenalin trc y c tc2030trong khong 12 gi. Ht kh dung c a
1973dng m khng lm bnh t nht 3 gi,2031thch v bnh nhanh hn v t tc
1974nn khm li cng sm cng tt. 2032dng ph (nh run v cng thng thn
1975PoW Medihaler - iso (3M).
2033kinh) hn thuc vin ung, v thuc c
1976Kh dung, isoprenalin sulfat 80
2034a trc tip ti ph qun v do c hiu
1977microgam/liu ht, l 400 liu.
2035qu vi liu nh hn.
1978T dc: Bao gm cht y CFC.
1979Ghi ch: khng khuyn co, nn khng ni
2036Ngi bnh phi c hng dn cn thn cch
1980liu lng. 2037dng bnh kh dung di p lc v iu
1981PoW Medihaler - iso Forte (3M). 2038quan trng phi kim tra xem h c tip
1982Kh dung, isoprenalin sulfat 4002039tc dng ng khng, v k thut khng
1983microgam/liu ht, l 400 liu. 2040ng c th lm l thuc khng tc dng.
1984T dc: Bao gm cht dy CFC. 2041c bit, phi nhn mnh l h phi ht
1985Ghi ch: Khng khuyn co, nn khng ni2042vo chm v nhn th trong 10 giy sau
1986liu lng. 2043khi ht. Phn ln ngi bnh c hng dn s
1987Salbutamol v terbutalin c dng rng ri2044dng thnh cng. Nhng mt s ngi, c
1988nht trong cng thc iu tr. 2045bit ngi cao tui, ngi bnh khp, v tr
1989Rimiterol c thi gian tc dng ngn hn2046nh khng th dng c bnh kh dung;
1990salbutamol, terbutalin v fenoterol. 2047mt s ngi bnh khng th th ng
1991Fenoterol c th l thuc kch thch chn2048nhp vi lc lm kh dung. i vi nhng
1992lc beta2 km hn salbutamol. 2049ngi bnh , hin nay c nhiu loi
1993Salmeterol l thuc kch thch beta2050 2 bnh kh dung khi ng do th v phu
1994adrenergic tc dng ko di, dng 22051 th. Cch khc, bnh ht bt kh c
1995ln/ngy; thuc khng phi ct cn2052khi ng khi ngi bnh ht vo cng c
1996hen (nn dng mt thuc kch thch beta2053 2 gi tr; mt s bnh i khi gy ho.
1997tc dng ngn nh salbutamol). Salmeterol2054Liu lng phi c ni r rng bng s lng
1998nn thm vo liu php corticosteroid2055ht mi ln, tn s, v s ln ti a c
1999ang dng v khng thay th c liu
2056php ht trong 24 gi. Liu cao thuc kch
2000php ny.
2057thch beta2 c th nguy him i vi mt
2001Eformoterol l thuc kch thch beta 2
2058s ngi bnh. Dng qu mc thng chng t
2002adrenergic tc dng ko di c a vo
2003s dng gn y. Thuc c bo co c
2059iu tr hen khng tha ng v phi
2004tc dng tng t nh salmeterol nhng bt2060dng thuc d phng nh corticosteroid ht.
2005u tc dng nhanh hn. 2061Ngi bnh c khuyn i khm thy thuc
2062khi khng t c mc triu chng
2006Thuc gin ph qun khng muscarin 2063thng l, v iu ny thng chng t hen
2007Cc thuc ny theo truyn thng c2064nng ln v c th i hi phi dng thuc
2008coi c hiu qu hn trong lm gim co
2065khc. Khi ngi b hen khng c kim sot
2009tht ph qun do vim ph qun mn.
2066tho ng bng ht thuc kch thch
2010Ipratropium c th lm gin ph qun phn
2067beta2 1 hoc 2 ln mi ngy, cn phi xem
2011no trong vim ph qun mn khi m cc
2012thuc kch thch chn lc beta 2 adrenergic2068xt dng thm thuc d phng nh
2013 tht bi. Khng ging cc thuc khng2069corticosteroid ht (xem bng Hen mn);
2014muscarin c, t gp tc dng ph ca2070iu ny thun li i vi ngi bnh hn
2015thuc. Kh dung c tc dng ti a 30 - 602071l dng liu thuc kch thch beta 2 cao
2016pht sau khi dng.Thi gian tc dng lu t2072hn v thng cho php kim sot ton b
20173 n 6 gi v thng c th duy tr gin2073tt hn.
2018ph qun vi iu tr 3 ln/ngy. 2074Dung dch salbutamol v terbutalin cho
2019Oxitropium c tc dng tng t nh2075my th (hoc my phun m) c dng
2020ipratropium. 2076iu tr hen cp c bnh vin v trong
2077thc hnh chung. bnh vin dng my
2021Cch dng thuc iu tr bnh hen 2078phun m hot ng bng oxygen trong thi
2022Ht: Ht di p lc (kh dung) l mt phng2079gian khong 15 pht. My nn kh chy
2023php s dng hiu qu v thun tin 2080in l ph hp nht dng ti nh nhng

50
 51

2081my t tin. Ngi c cn hen nng phi2137prednisolon v thuc qua nhau thai chm
2082th oxygen, nu c th, trong khi phun m2138hn so vi mt vi thuc khc.
2083v thuc kch thch beta2 c th gy tng2139Tuy theophylin c dng, ni chung
2084tnh trng gim oxygen huyt ng mch.2140khng gy tc dng ph no trong thai k
2085Tuy vy, i vi ngi b vim ph qun mn2141hoc trong thi gian cho con b, nhng i
2086v tng carbon dioxid huyt, oxygen c th2142khi cng c thng bo v c tnh vi thai
2087
58nguy
nhhim v my
hng phun m
ca bnh phi
i vihot
liung
dng vnhi
2143 v tr mi
nguyn tcsinh.
iu chnh liu ca thuc
2088 bng
DTQGVN khng kh. Liu k n cho my
2089phun m cao hn nhiu so vi liu k n
2090cho bnh kh dung c liu nh lng. Th
2091d, mt ng phun m Ventolin 2,5 ml cha
2144 nh hng ca bnh i vi liu
20922,5 mg salbutamol l tng ng vi 25 xt 2145 dng v nguyn tc iu chnh
2093ca bnh kh dung. Do , ngi bnh cn 2146 liu ca thuc
2094phi c cnh bo s nguy him nu vt 2147 (Bnh ng tiu ha - Bnh thn -
2095liu quy nh v nu h khng p ng 2148 Bnh gan)
2096vi liu thng thng dung dch dng cho
2097my th, h phi i khm. 2149 Cc bnh ng tiu ha
2098Ung: c ch phm ung cho ngi2150
2099khng th s dng bng ng ht. Thuc2151Chng v toan (achlorhydia) gp ngi
2100ung i khi dng cho tr em, tuy dng -2152cao tui, pH ca dch v d dy tng cao
2101ng ht tt hn v a s tr em c th
2153v mc tit acid ca d dy c th gim
2102dng c loi bnh ht hin c. Thuc
2154n 25 - 30% so vi mt thanh nin 25
2103ung c thi gian bt u c tc dng
2155tui. iu ny c th nh hng n s
2104chm hn, nhng tc dng hi di hn so
2156hp thu ca thuc c ha tan ph thuc
2105vi bnh kh dung. Ch phm gii phng
2106thuc thay i c th c gi tr i vi2157vo pH. S hp thu thuc rut non khng
2107ngi hen ban m v l thuc thay th cho2158b nh hng.
2108ch phm theophylin gii phng thay i.2159Bnh ng rut gy nhiu bin i v
2160sinh l bnh hc nh hng n hp
2109Tim: Tim tnh mch, salbutamol v2161thu ca thuc. Din tch bnh thng ca
2110terbutalin i khi tim di da trong co tht2162rut gim i lm gim hp thu, nhu ng
2111ph qun nng. 2163d dy tng ln, pH ng tiu ha thay
2112Tr em: Thuc kch thch chn lc beta2164 2 i, tun hon rut - gan gim, tnh thm
2113adrenergic c ch ngay c tr em di 182165ca thnh rut tng, chuyn ha thuc
2114thng. Thuc hiu qu nht bng ng2166trong rut gim v hot tnh ca cc enzym
2115ht, nhng cn phi c mt bnh ht (vi k2167khc nhau bao gm cc esterase cng b
2116thut c kim tra cn thn).Thuc cng2168gim. Hu qu phc tp. Mt s thuc b
2117hiu qu qua ng ung. Trong cn hen2169gim hp thu nh amoxicilin, pivampicilin,
2118nng, nn cho phun m mt thuc kch2170nhng hp thu mt s thuc khc nh
2119thch chn lc beta2 adre-2171cephalexin li tng. Hp thu acid folic trong
2120nergic hoc ipratropium. 2172thc n b gim n mc ngi bnh c
2121Mang thai v cho con b: iu c bit2173th b thiu acid folic, hoc c nguy c
2122quan trng l hen phi c kim sot tt2174nhim c ty xng nng nu iu tr
2123khi mang thai; nu t c th hen khng2175ngi bnh bng trimethoprim - sulfame-
2124gy tc hi quan trng n thai k, lc2176thoxazol.
2125chuyn d hoc thai nhi.
2177Bnh Crohn gy nhiu bin i khc
2126Cho thuc bng ng ht trong khi mang
2178nhau c th nh hng n hp thu thuc.
2127thai c li c bit v c th t c tc
2179Din tch hp thu ca rut gim, thnh
2128dng iu tr m khng cn c nng
2129thuc trong huyt tng kh d c tc dng2180rut dy ln v vi khun ch ng rut b
2130dc l n thai nhi. 2181ri lon. Hp thu cotrimoxazol
2131Cn hen trm trng c th tc hi n 2182 (trimethoprim - sulfa-
2132thai k, phi c iu tr nhanh bng liu2183methoxazol) b nh hng theo hai chiu
2133php thng thng, bao gm corticosteroid2184ngc nhau: Hp thu trimethoprim gim, ng-
2134ung hoc tim v phun m thuc kch2185c li hp thu sulfa-
2135thch chn lc beta2 adrenergic;2186methoxazol li tng.
2136corticosteroid ung c a thch l2187Hi chng km hp thu khng nht thit
2188l km hp thu thuc. Thc t c mt s

52
 53

2189thuc li c hp thu nhiu ln mc d ngi2242Tng liu duy tr hng ngy ca mi

2190bnh ang b hi chng km hp thu (c2243thuc c th gim xung bng cch h thp
2191ngha l qu trnh hp thu thc n b2244liu dng hng ngy hoc ko di khong
2192gim). 2245cch gia cc liu. i vi mt s thuc cn
2193Trong lm sng, thay i hp thu thuc2246phi gim liu duy tr nhng li mun c tc
2194ni tri nht l do nn v a chy, do 2247dng ngay th tt nht l cho mt liu
2195cn c bit quan tm khi cho ngi2248"np" ln hn liu u duy tr. Bi v
2196bnh dng thuc. 2249nu cho u n liu duy tr gim
2250th phi mt hn 5 ln na i thi tr
2251nng thuc trong huyt tng mi t
2197 Bnh thn 2252c trng thi n nh. Do na i thi
2253tr ca thuc ko di ngi suy thn cho
2198Ri lon chc nng thn c th nh hng2254nn mun t nng thuc trng thi
2199n tr liu bng thuc v nhng l do2255n nh trong huyt tng th phi mt
2200sau: 2256nhiu thi gian hn. i vi nhiu loi
22011. Dc ng hc ca thuc c th b thay2257thuc, sau khi gim liu phi mt nhiu
2202i do gim o thi cc thuc m bnh2258ngy mi t c nng iu tr trong
2203thng c thi tr hon ton hoc ch2259huyt tng. Theo thng l th liu "np"
2204yu qua thn. Bnh thn cng c th lm2260 ngi suy thn c th cho ngang liu ban
2205gim gn kt thuc vi protein v lm thay2261u ca ngi bnh c chc nng thn
2206i hoc gim chuyn ha thuc gan. 2262bnh thng, cc liu tip theo phi gim.
22072. Hiu qu ca thuc c th b thay i.2263 nh gi tc ng ca ri lon chc
22083. Hin trng lm sng ca ngi bnh c2264nng thn i vi vic s dng thuc,
2209th xu i. 2265chng ta c th tnh thanh thi
22104. Tc dng c hi ca thuc c th tng2266(clearance) ca thuc. Thut ng thanh
2211ln. 2267thi c th biu th bng phng trnh
2268n gin l clearance = K x Vd, trong
2212Thay i dc ng hc
2269K l hng s thi tr, Vd l th tch phn
2213Thn l mt trong nhng ng thi tr ch
2270b. Hng s thi tr K c tnh theo phng
2214yu ca thuc, do khi chc nng thn
2271trnh ln2 chia cho thi gian na i thi
2215b gim th vic thi tr thuc c th b
2272tr ca thuc (ln2 = 0,693), na i ca
2216nh hng. V nguyn tc, iu chnh2273thuc c ghi trong cc chuyn lun thuc
2217liu ca thuc cho ngi b bnh thn, trc2274ca Dc th quc gia Vit Nam. Nh vy K =
2218ht cn xem loi thuc c thi tr hon22750,693/t (K l hng s thi tr ca thuc
1/2
2219ton qua thn hay khng v thuc c c2276tc l bng tng ca nhiu hng s thi
2220hi nh th no. 2277tr tng phn bao gm thi tr qua thn,
2221i vi nhiu loi thuc m tc dng ph2278qua gan, qua cc con ng khc: K = k
2222ch lin quan rt t hoc khng lin quan2279thn + k gan + k khc).
2223n liu dng th thng khng phi tnh2280Th tch phn b Vd l mt thng s biu
2224 liu iu chnh mt nh
DTQGVN cchhng
tht chnh xc2281
ca bnh ithvi
tliu
l thuc
dng hin din tc
v nguyn trong khoang
iu
2225 m ch cn mt phc
chnh liu ca thuc 59 gim liu n 2282trung tm tc l trong huyt tng so vi
2226gin. 2283tng lng thuc trong c th v c gii
2227i vi cc thuc c hi hn, c khong an2284thiu trong mi chuyn lun thuc ca Dc
2228ton hp th khi thn suy phi iu2285th quc gia Vit Nam. Trong mi chuyn
2229chnh liu da vo mc lc cu thn. 2286lun thuc cng c ghi t l phn trm
2230i vi cc thuc m hiu lc v c tnh2287(%) ca tng thi tr c thi tr qua thn
2231c lin quan cht ch vi nng thuc2288v t l c thi tr qua gan trong iu
2232trong huyt tng th phc iu tr2289kin bnh thng. Do ngi ta c th d
2233khuyn co ch nn coi l mt hng dn2290dng tnh c tc dng ca suy gim hon
2234ban u. Trong qu trnh iu tr phi2291ton hoc suy gim mt phn chc nng
2235thm d liu cn thn, da trn p ng2292thn. V d nu bnh thng thuc c thi
2236lm sng v nh lng nng thuc2293tr 50% qua thn v 50% chuyn ha
2237trong huyt tng. Nh vy i vi ngi b2294gan th k thn = 0,5 x K, k gan = 0,5 x K.
2238bnh thn m phi dng nhng thuc loi2295Trong trng hp nu chc nng thn b
2239ny th cn c iu tr v theo di 2296gim hon ton th c ngha l b mt
2240cc bnh vin chuyn khoa m khng nn2297i 50% phn ng gp bnh thng i
2241iu tr cc tuyn khc. 2298vi tng liu thi tr K v thuc phi chu
2299mt na i thi tr chm hn: t1/2 =

54
 55

23000,693/(0,5 x K). Hng s K bnh thng c2358nng thuc trng thi n nh trong
2301th tnh d dng t t1/2 bnh thng c gii2359huyt tng sau liu lp i lp li s tng
2302thiu trong mi chuyn lun thuc ca Dc2360ln theo t l tng ng.
2303th quc gia Vit Nam (K = 0,693/t1/2). 2361Cn nm vng iu quan trng c bit
2304 thanh thi (clearance) l mt thng s2362ny phng cc tc dng ph, nht
2305biu th v thi tr bao gm c thuc 2363l vi nhng thuc c thang iu tr hp.
2306c phn b trong cc m. Ngi ta c th2364Nng trung bnh ca thuc trng thi
2307s dng thng s ny phn tch xem2365n nh trong huyt tng (k hiu Css)
2308trong suy thn th vic thi tr thuc xy2366sau khi ung nhiu liu lin tip c th
2309ra nh th no. 2367tnh nh sau:
2310Nu do bnh thn m chc nng thn2368Css = (Fx liu): (Vd x K x T)
2311(mc lc cu thn) b gim i 50% th2369Trong T l khong cch thi gian gia
2312phi cho gim liu i vi mt thuc no2370cc liu , F l kh dng sinh hc tc l t l
2313 bnh thng c thi tr 100% qua2371% ca liu c hp thu. Nh thy qua
2314thn. C mt s khc bit rt ln gia vic2372phng trnh trn, nu khong thi gian
2315thuc c thi
60 nh hng tr ca
honbnh
ton i
quavi
thn hay
liu 2373gia
dng cc liutc
v nguyn l ngn
iu th nng
chnh ca
liu thuc
thuc
2316khng
DTQGVNcho nn phi tnh ton. Mt khc2374trung bnh trong mu s cao. V nu hng
2317 xc nh mc iu chnh liu2375s thi tr K gim i ch cn 50% so vi
2318cn phi xem xt s khc bit v phn b2376mc bnh thng th nng Css ca
2319thuc trong c th. Nu ta n gin ha2377thuc trong mu cng s tng ln theo t l.
2320v gi s thuc ch c phn b trong2378Trong phng trnh trn Vd x K l bng
2321huyt tng th th tch phn b Vd = 32379thanh thi ca thuc, do phng trnh
2322lt, nhng th tch phn b c th cao hn2380c th vit li nh sau:
2323nhiu vi cc thuc c phn b vo cc m.2381Css = (F x liu) : ( thanh thi x T)
2324Ly mt v d trong thuc ch phn2382 thanh thi tng cng = thanh thi thn
2325b trong huyt tng. Trong trng hp ny2383+ thanh thi chuyn ha + thanh thi
2326th tch phn b ca thuc bng th2384khc.
2327tch huyt tng ngha l bng 3 lt. Nu2385Qua ta c th thy c chc nng thn
2328tng mc thi tr i vi thuc ph thuc2386gim s nh hng n nng thuc
2329hon ton vo mc lc cu thn (bnh th-2387trng thi n nh trong huyt tng n
2330ng l 125 - 130 ml/pht) th thanh2388mt mc no vi mt thuc bnh th-
2331thi tng s ca thuc l bng thanh2389ng c thi tr 100% qua thn so vi
2332lc ca thn tc l mc lc cu thn (1302390thuc ch c thi tr 50% qua thn, phn
2333ml/ph) tnh theo thanh lc creatinin. 2391cn li c thi tr qua chuyn ho.
2334ngi bnh khng c tn thng thn, ta c2392Phng trnh Css = (F x liu): ( thanh
2335th tnh d dng na i thi tr ca2393thi x T), ch cho ta thy c hai bin php
2336thuc nh sau: 2394khc nhau iu chnh liu thuc khi
2337 thanh thi thuc = K x Vd = K x 3 lt2395thn suy:
2338=130 ml/ph. Nh vy hng s thi tr K =23961. iu chnh bng gim liu.
2339130 ml/ph: 3000 ml -> K = 0,043 pht -12397 . 2. iu chnh bng tng khong cch gia
2340T ta tnh c na i thi tr t 1/2 =2398cc liu, cho cc liu tha hn.
23410,693/K = 0,693/0,043 pht -1. Nh vy vi2399Nu nh gi c thanh thi ca mt
2342thuc ny th t1/2 = 16 pht nu chc nng2400thuc ngi bnh th c th tnh liu
2343thn l bnh thng. Khi chc nng thn2401duy tr t nng trng thi n
2344(mc lc cu thn) gim i 50% so vi2402nh trong huyt tng (Css) nh sau :
2345bnh thng, na i thi tr s phi tng2403i vi cc liu ung lin tip: Liu duy tr
2346ln 50% v nh th na i thi tr trng2404= { liu Css cn t x thanh thi x T} :
2347hp ny l t1/2 (mi) = 0,693/0,5x 0,043 pht2405F (kh dng sinh hc).
2348-1 ngha l t1/2 (mi) = 32 pht. Tuy nhin2406i vi liu tim truyn: Tc truyn =
2349nu thuc cng c thi tr mt lng ln2407Css trung bnh cn t x thanh thi.
2350qua chuyn ha gan th s gim chc2408Trong vic iu chnh liu cn phi ch
2351nng thn cng t nh hng v na i2409 c bit n c tnh ca thuc. V
2352thi tr mi tnh c s khng n ni2410d cc trng hp s dng cc khng sinh
2353chm nhiu nh vy. 2411nhm aminoglycosid th d chc nng thn
2354Nh din gii trn, nu mt thuc2412gim rt t cng cn iu chnh liu. Vi
2355bnh thng c lc thi qua thn th na2413penicilin th khi thn suy nng, thanh
2356i thi tr s b ko di khi chc nng2414lc creatinin tc mc lc cu thn < 10
2357thn b suy gim. Cng c ngha rng2415ml/pht mi phi iu chnh liu. Trong

56
 57

2416mi chuyn lun thuc u c khuyn co2472khc thay th c. V d nh cc

2417cch s dng thuc khi thn suy. 2473aminoglycozid, ampho-
2418Gim gn kt protein: S gim gn kt 2474tericin, cisplatin, vng, mesalazin, cc
2419protein s tng lng thuc t do, gy tng 2475khng vim khng steroid, penicilamin v
2420tc dng ca thuc v cng tng c tc2476vancomycin. Cng c mt s thuc trc
2421dng ph. Hu qu ca s gn kt vi2477tip gy gi nc v do c th gy
2422albumin tng quan vi mc suy thn,2478nng hn cc bin chng v tim mch
2423cc thuc c tnh acid t gn vi albumin2479ngi b suy thn. Nh vy nn trnh dng cc
2424huyt thanh. S gn kt ca cc thuc2480thuc gy gi nc nh carbenoxolon v cc
2425kim tnh vi protein (vi alpha 1 - acid2481thuc khng vim khng steroid nh
2482indomethacin. iu quan trng cn phi
2426glycoprotein) khng hoc t thay i khi
2483ni l ngi bnh suy tim sung huyt,
2427chc nng thn gim. Ngoi ra cn c
2484vic ti mu thn ph thuc vo lng
2428thm mt nguy c lm gim gn kt
2485prostaglandin c sn xut ti thn. iu
2429protein l cc sn phm ni sinh cnh tranh
2486tr bng thuc khng vim khng steroid s
2430gn kt albumin vi thuc. Thm tch mu
2487c ch tc dng ti ch ca prostaglandin
2431khng a c kh nng gn kt protein
2488i vi thn gy gim dng mu qua thn
2432tr v bnh thng cho nhng ngi suy
2489lm xu thm chc nng thn suy v
2433thn nng. Trong phn ln cc trng hp
2490gi nc. Do nn tuyt i trnh dng
2434th s thay i gn kt vi protein ca
2491thuc khng vim khng steroid cho ngi
2435thuc t tc ng n tnh trng lm
2492bnh suy thn. Mt s thuc cng gy
2436sng v khng cn iu chnh liu. Tuy
2493tng thm ur huyt. Tetracyclin (tr
2437nhin cng c trng hp s gn kt protein
2494doxycyclin) c tc dng chng ng ha
2438li rt quan trng nh trong iu tr ng
2495nn khng dng.
2439kinh bng phenytoin. Thang iu tr ca
2440phenytoin thng thng l t 10 - 20 mg/lt2496Tng tc dng c hi ca thuc: Nh vi
2441(40 - 80 micromol/lt) bao gm c lng2497digoxin chng hn, ngi suy thn nng,
2442thuc t do hoc c gn kt protein. ng-2498km thm gim o thi, c th gy tc
2443i suy thn phn thuc c gn kt gim,2499dng c hi nhiu hn do nguy c ri lon
2444phn t do ca phenytoin tng. Do phn t2500cn bng cc cht in gii. c bit l
2445do ca thuc c tc dng dc l nn nng2501tng calci huyt v/hoc gim kali huyt
2446 ton phn thuc c tc dng phi2502s tng nguy c tc dng ph ca digoxin
2447gim, ni mt cch c th th c ngha l2503 ngi bnh c gim chc nng thn. Do
+
2448 ngi suy thn nng thang iu tr ca2504o thi kali (K ) b gim ngi suy thn,
2449phenytoin c th gim i 1/2 tc l cn t2505nn cc thuc li tiu gi kali (amilorid,
24505 - 10 mg/lt (tc l 20 - 40 micromol/lt). 2506spirono-
2507lacton) c th gy tng kali huyt nng
2451Chuyn ha gan: C th b gim mt
2508hn.
2452s ngi suy thn i vi mt s thuc nh
2509
2453nicardipin, propranolol.
2510Thuc gy tc dng c hi thn
2454Tng tnh nhy cm vi thuc: Thng2511
2455gp ngi bnh suy thn. Cc thuc nh Tn, nhm Tc dng c hi
2456thuc phin, thuc an thn nhm thuc
2457benzodiazepin, thuc ng barbiturat, phe- Anticholinergic - Gy ri lon chc
2458nothiazin u tng tc dng i vi h Disopyramid nng bng quang v
2459thn kinh trung ng ngi b suy thn so Monoamine i khng t ch.
2460vi ngi chc nng thn bnh thng. oxidase inhibitor - Phi theo di vic
DTQGVNnhn cha r nhng
2461Nguyn nhcng
hngcca
thbnh
do i vi liu dng v nguyn tc iu chnh
(IMAO) dng thuc gim
liu tnh
2462tng ca thuc
thm ca61 hng ro mu - no. Cc Prazosin liu hoc ngng dng
2463thuc h huyt p cng thng gy h thuc.
Terazosin
2464huyt p t th nhiu hn ngi suy thn,
Thuc trm cm
2465c th l do thay i cn bng natri
3 vng
2466trong mu.
Acetazolamid D gy ng si
2467Bnh thn nng ln do thuc: C th Vitamin D thn - tit niu
2468gp ngi bnh thn nu thuc gy Khng dng qu liu
2469ri lon chc nng thn. Ngi bnh c Demeclocyclin - Gy i nhiu do
2470tin s suy thn th khng nht thit phi Lithium gim kh nng c
2471dng cc thuc c cho thn khi c thuc Methoxyfluran c.

58
59

Vitamin D - Cn dng thn trng.2512 Bnh gan

- Chng ch nh
trong i tho nht 2513Ri lon chc nng gan c th nh hng
Cyclophosphami - Gy vim bng 2514n p ng ca thuc v s dng thuc,
d quang xut huyt 2515bng nhiu ng:
- Nu dng phi ung 25161. Thng qua ri lon dc ng hc vi tng
nhiu nc 2517kh dng sinh hc do gim chuyn ha
Thuc c ch - C th gy ri lon 2518qua gan bc u: hoc do gim hot ha
enzym chuyn chc nng thn 2519bc u ca cc thuc tin thn.
Ciclosporin - Khng dng khi c 25202. C th do gim kh nng gn kt
Thuc khng thn suy cp hoc 2521protein v gim thi tr thuc.
vim khng mn 25223. C nguy c lm thay i tc dng ca
steroid - Dng cho ngi bnh 2523thuc.
Pentamidin thng nu xut hin 25244. C nguy c lm tnh trng chuyn ha
Triamteren protein niu phi 2525ca ngi bnh xu i.
gim liu hoc ngng
2526Ri lon dc ng hc ca thuc c th
thuc.
2527l hu qu ca bnh gan, v gan l c
Acyclovir - C th gy tng ur
2528quan quan trng nht loi thi chuyn
Thuc c t huyt tm thi do c
2529ha thuc. Suy gim chc nng t bo gan
bo c cho thn.
2530s lm gim kh nng thc hin qu trnh
Methotrexat - Khng dng khi c
Metirosin thn suy cp hoc 2531chuyn ha bnh thng ca gan. Cc
mn. 2532bnh c tc ng xu n tun hon h
- Dng cho ngi bnh 2533tnh mch ca cng c th nh hng n
cha c suy thn phi 2534chuyn ha thuc do hp thu thuc qua
theo di ur huyt v 2535ng tnh mch tt, khng cho thuc
protein niu. 2536n v tr chuyn ho. C hai tc ng
Cephalosporin - Dng liu cao ko 2537 u nh hng mnh ti chuyn ha
Ciprofloxacin di c th gy vim 2538ca thuc ngi bnh b x gan nng.
k thn. 2539Hiu r c thuc no chuyn ha qua gan
Allopurinol
Furosemid Khng dng khi b 2540bc u l rt quan trng v bnh l
Thuc khng vim thn b thn 2541hoc phi hp thuc khng chun c th
cp v mn. 2542lm gim chuyn ha lc u gy nn t-
vim khng
steroid - Cn gim liu khi 2543ng tc chuyn ha.
thn suy. 2544Kh dng sinh hc (F) l thut ng dng
Methicilin
- Vim mch mu thn, 2545 ch t l phn trm ca mt liu
Phenindion
vim thn k d ng, 2546thuc c hp thu vo h tun hon mu.
Rifampycin 2547Trong phng trnh trn ca chng ti k
i tho ng.
Sulfonamid 2548hiu l F v biu th t l % ca liu
Thiazid 2549thuc cho. F c th l t 0% - 100%.
Captopril - C th gy hi 2550Sau tim tnh mch kh dng sinh hc c
Mui vng chng thn h. 2551coi l hon ton. Sau nhng liu ung
Ketoprofen - Chng ch nh 2552chc nng gan quyt nh mc kh
Penicillamin trong vim cu thn 2553dng sinh hc ca nhiu thuc thng qua
Phenindion c hi chng thn h. 2554hiu qu ca chuyn ha qua gan bc
Probenecid 2555u. Hiu qu bc u hay chuyn ha b-
Aminoglycosid - C th gy hoi t 2556c u l chuyn ha ca thuc c hp
Amphotericin B ng thn cp. 2557thu trn ng i sau khi thuc ha tan
Cephaloridin - Chng ch nh 2558trong lng rut qua gan vo h tun
Colistin trong suy thn cp, 2559hon. Phn ln thuc ung u c hp
suy thn mn. 2560thu t on ng tiu ha c dn lu theo
Ciclosporin
Polymyxin - Dng cho ngi bnh 2561h thng tnh mch ca - gan. Do ngay
Sulfamid khng suy thn, nu 2562mt thuc c hp thu tt cng phi i
Tetracyclin c thiu niu phi 2563qua v thot khi gan trc khi vo h thng
gim liu hoc ngng 2564tun hon. i vi cc thuc nhy cm vi
Thuc cn quang 2565chuyn ha gan mt phn ln liu ung c
thuc.
iod phng x. 2566th b chuyn ha v bin mt ngay trc
2567khi n v tr tc dng. V d mt s
2568thuc c thi tr cao bc u bao gm

60
 61

2569cc thuc gim au: acid acetylsalicylic,2626ca cc thuc ny thp v thanh thi
2570morphin, paracetamol, pentazocin,2627ph thuc ch yu vo mc thuc c
2571pethidin, cc thuc tim mch: glyceryl2628ti n cc enzym gan. Do thanh
2572trinitrat, isoprenalin, isosorbid dinitrat,2629thi cc thuc ny tng i nhy cm vi
2573labetalol, lignocain, metoprolol, nifedipin,2630cc yu t nh hng n dng mu qua
2574prazosin, propranolol, verapamil, cc thuc2631gan, v d trong suy tim sung huyt. Tuy
2575trn h thn kinh trung ng: clomethiazol,2632nhin cc thuc ny li tng i t nhy
2576clorpromazin, imipramin, levodopa,2633cm vi lng enzym, hot tnh ca enzym
2577nortriptylin, cc thuc v h hp:2634hoc kh nng gn kt protein. V d v
2578salbutamol, terbutalin. 2635cc thuc c chuyn ha cao gan bao
2579Tm quan trng ca chuyn ha bc u2636gm alprenolol, desipramin, labetalol,
2580gm 2 mt: 2637lidocain, metoprolol, morphin, glyceryl
25811. Chuyn ha bc u l l do quan trng2638trinitrat, pentazocin, propoxyphen,
2582
62nhtnh
hng
gii ca
thch s khc
bnh i nhau v dng
vi liu hp2639
vpropranolol, pethidin,
nguyn tc iu chnhnortriptylin v
liu ca thuc
2583 thu thuc gia cc c th. Ngay nhng ng-2640verapamil.
DTQGVN
2584i khe mnh cng c mc kh nng2641Cc thuc c mc chit xut thp
2585chuyn ha ca gan v chuyn ha bc2642gan: Trong trng hp ny, mc chuyn
2586u rt khc nhau. 2643ha thuc thp thanh thi
25872. ngi b bnh gan nng chuyn ha b-2644gan tng i t nhy cm vi dng mu
2588c u c th b gim mnh, thng dn2645qua gan m ch yu ph thuc vo cc
2589n hp thu mt lng thuc cao hn2646enzym ca gan. V d v loi ny bao gm
2590bnh thng, hu qu l b nhim c v2647cloramphenicol, paracetamol v
2591chu cc tc dng c hi ngay c vi nhng2648theophylin. Cc thuc trong nhm ny,
2592liu bnh thng. 2649nhm c gn kt nhiu vi protein, nh
2593Nu chuyn ha bc u b c ch hoc2650carbamazin, diazepam, indomethacin,
2594gim st, v d do bnh gan, th hu qu2651naproxen, nitrazepam, phe-
2595r nt l thuc thot khi chuyn ha ca2652nobarbital, tolbutamid, phenytoin,
2596gan nhiu hn vo h tun hon v t 2653procainamid, acid salicylic, theophylin, acid
2597i n v tr tc dng. Cc v d v hiu2654valproic, v warfarin, c thanh thi
2598qu ca thuc do nh hng ca s tng qu2655chuyn ha ph thuc c vo kh nng ca
2599mc kh dng sinh hc do x gan bao2656cc enzym gan v c vo gn kt protein
2600gm cc thuc clomethiazol (kh dng sinh2657v phn t do ca thuc. Do bnh gan th-
2601hc tng 1000%), labetalol (kh dng sinh2658ng kt hp vi gim nng albumin
2602hc tng 90%), metoprolol (kh dng sinh2659huyt thanh nn thng cng c tng phn
2603hc tng 65%), nicardipin (kh dng sinh2660t do ca cc thuc thnh th kh m
2604hc tng 500%), paracetamol (kh dng2661d on c nh hng ca bnh gan trn
2605snh hc tng 50%), propra-2662nng ton phn ca thuc. Do phi
2606nolol (kh dng sinh hc tng 42%),2663thn trng trong vic l gii mi tng
2607verapamil (kh dng sinh hc tng 140%).2664quan gia nng v hiu qu ca liu
2608S tng kh dng sinh hc ny l trc tip2665thuc i vi cc thuc c lin kt protein
2609do x gan gy gim s phn hy thuc2666cao nh phenytoin.
2610qua chuyn ha gan xy ra bnh thng khi2667nh hng ca bnh gan i vi thi tr
2611thuc i qua gan. Nh vy x gan lm tng2668thuc cng phc tp. Loi bnh gan c tnh
2612mc hp thu v do nng thuc2669quyt nh. Trong vim gan virus cp,
2613trong mu c t l cao hn ngi khe2670thay i ch yu l chc nng t bo
2614mnh. 2671gan nhng kh nng chuyn ha thuc ca
2615Ngc li hot ha chuyn ha bc u ca2672gan thng cn gi c nguyn vn v
2616thuc tin thn thnh dng hot ng2673dng mu qua gan c th cn tng ln. X
2617cng b c ch. iu ny nh hng n2674gan nh v va c khuynh hng gy gim
2618nhiu thuc c ch enzym chuyn nh2675dng mu qua gan v c mch tt ca -
2619enalapril, do hiu qu ca thuc s b2676ch, cn trong x gan nng th thng c
2620gim. 2677chc nng t bo gan v dng mu qua
2621Bnh gan v s gim chuyn ha 2678gan u gim.
2622gan. 2679Khc vi o thanh thi creatinin trong
2680bnh thn, ngi bnh gan khng c test
2623Cc thuc c mc chit xut cao gan:2681no c th d on c mc chuyn
2624Gan chuyn ha nhng thuc ny vi mt2682ha thuc. Tuy nhin s gim albumin
2625mc rt cao. Do kh dng sinh hc2683huyt thanh, tng bilirubin mu v ko di

62
 DTQGVN S dng hp l cc thuc khng virus v iu tr
63 nhim khun 63

2684thi gian prothrombin c th cho php2742khng nh bnh thng, do thiu

2685nh gi s b mc bnh ca gan.2743antithrombin III. Do phi xem xt rt
2686Trong thc t, mt thuc c chuyn ha2744cn thn ngi b bnh gan v c nguy
2687do gan khng nht thit c ngha l dc2745c bin chng xut huyt do thuc c kh
2688ng hc ca thuc b ri lon bi bnh2746nng gy chy mu.
2689gan, do khng d suy on t kt qu2747Ri lon tnh trng chuyn ha do
2690ca mt thuc ny p dng cho mt2748thuc
2691thuc khc. iu mt phn cng l do
2692chuyn ha ca thuc c th c xc tc2749Nhim kim do thuc c th xy ra do
2693bi nhiu enzym cytochrom P450 khc nhau2750dng qu nhiu thuc li tiu. T thc
2694v nhng h thng enzym lin hp khc2751y gy bnh no. C ch l tnh trng
2695nhau. Nu trong lm sng cn s dng2752nhim kim +
gim kali, hu qu l chuyn
2696mt thuc c thi loi qua chuyn ha2753ion NH4 thnh NH3 d dng i qua hng
2697gan cho ngi bnh x gan th liu lng2754ro mu - no thc y hoc lm cho
2698ban u phi rt thp ri tng dn tng b-2755bnh no nng thm.
2699c v phi theo di cn thn, cht ch hiu2756Gi nc qu mc ngi b bnh gan giai
2700qu v tc dng ph. 2757on nng thng gy ph v c trng do
2701Cng c mt s thuc nh hng n cc2758gim albumin huyt tng v tng p lc
2702enzym gan. Vic hiu r loi thuc no c2759tnh mch ca. Tnh trng ny c th xu
2703th c ch cc enzym chuyn ha thuc2760i do dng thuc gy gi nc nh carbeno-
2704ca gan l rt quan trng. V d nh2761xolon, antacid c cha nhiu natri v thuc
2705allopurinol, azapropazon, cloramphenicol,2762gim au khng steroid. Cn nh nn trnh
2706cimetidin, ciprofloxacin, disulfiram,2763dng thuc gim au khng steroid cho ng-
2707erythromycin, v isoniazid u l nhng2764i b bnh gan v ngoi nguy c gi nc
2708thuc c ch mnh enzym gan: Cimetidin2765qu mc cn c nguy c gy xut huyt
2709c th minh chng iu ny v mt lm2766tiu ha.
2710sng. Cime-2767Thuc c cho gan
2711tidin c ch chuyn ha ca theophylin,2768Khi c thuc thay th chp nhn c th
2712dn n cc tc dng ph rt nguy him,2769lun lun nn trnh dng cc thuc c th
2713bao gm lon nhp tim e da mng sng2770gy hy hoi gan nh cc sulphonamid,
2714ca ngi bnh. 2771rifampicin v dng nhiu ln thuc m h
2715Ri lon tc dng ca thuc: Bnh gan 2772halogen. Cc thuc gy c kiu vim gan
2716giai on nng thng km theo nhng ri2773bao gm halothan, isoniazid, methyldopa,
2717lon chc nng ca no v cui cng c th2774phenelzin v paracetamol. Cc thuc c
2718dn n hi chng bnh no do gan. Ngay2775th gy mt bao gm phenothiazin,
2719trc khi xut hin bnh no th no b cng2776thuc chng trm cm 3 vng, thuc gim
2720 rt nhy cm vi tc dng ca cc thuc2777au khng steroid (c bit l
2721c tc dng trung ng. ngi c bnh gan2778phenylbutazon), rifampicin, ethambutol,
2722nng s dng liu bnh thng cc thuc2779pyrazinamid, sulfonylurea, sulfonamid,
2723ng barbiturat, thuc phin cng c th2780ampicilin, nitrofurantoin, erythromycin
2724dn n hn m. 2781estolat. Ring methotrexat c th gy x
2725Gim cc yu t ng mu cng l mt2782gan. i vi cc thuc c c tnh cao vi
2726vn ngi b bnh gan. Nhng ngi2783gan cn xem danh mc thuc trong Dc th
2727bnh ny t ra tng nhy cm vi thuc2784quc gia Vit Nam. Cc thng tin quc t
2728chng ng loi ung. Tc dng ca cc2785tp hp c v nguy c cc tc dng ph
2729thuc ny l lm gim tng hp cc yu t2786khc nhau bao gm nhim c gan c
2730ng mu (II, VII, IX, v X) ph thuc2787trnh by mt cch c h thng cho tng
2731vitamin K. Khi vic sn xut cc yu t2788thuc. Cng cn xem c bin php iu
2732ny b gim do bnh gan th mt liu2789tr c hiu nhim c gan do nhim
2733thuc chng ng ung c hiu qu2790c paracetamol v do qu liu.
2734nhiu hn l ngi c chc nng gan
2735bnh thng. Cng cn nh rng nhng
2736ngi bnh ny nu dng qu liu thuc
2737chng ng coumarin th c khi khng
2738th cha tr c bng vitamin K v gan
2739trng thi ny khng p ng vi vitamin K
2740 tng tng hp cc yu t ng mu.
2741Cng ging nh th, hiu qu ca heparin

64
 65

2791 S dng hp l cc thuc khng 2848Lamivudin (3TC)

2792 virus v iu tr nhim khun c2849Stavudin (d4T)
2850Thuc c ch enzym sao chp ngc khng
2793 hi ngi bnh b HIV/AIDS 2851phi nucleosid:
2852Nevirapin
2794S dng thuc khng retrovirus 2853Delaviridin
2795Cc thuc hng u iu tr retrovirus l2854Thuc c ch protease:
2796cc thuc loi tng t nucleosid. Hin nay,2855Saquinavir
2797ngi ta cha bit lc no l lc tt nht 2856Ritonavir
2798bt u iu tr bng cc thuc khng2857Indinavir
2799retrovirus. Tuy nhin, vi ngi mang thai2858Nelfinavir
2800vic dng thuc thch hp c th ngn2859Cc chng ch nh quan trng:
2801chn truyn bnh t m sang con. Ngi2860Zidovudin: Thiu mu v gim bch cu
2802ta thy nh iu tr bng thuc khng2861trung tnh l cc bin chng tim tng; do
2803retrovirus c th ko di cuc sng ca ng-2862 cn phi xem xt thn trng khi dng
2804i bnh c lng t bo CD4 di 500 t2863cho ngi bnh m kh nng tng hot
2805bo/mm3 hoc c s lng virus ln hn2864ng ca ty xng b hn ch.
280610.000 virus/ml. 2865Didanosin: Khng dng cho ngi bnh c
2807Cng nn iu tr bng thuc khng2866tin s vim ty hay ngi mc bnh
2808retrovirus i vi nhng ngi nhim HIV c2867thn kinh.
2809s lng virus trn 30.000/ml huyt tng m2868Zalcitabin: Khng nn dng cho ngi b
2810khng cn xt n s lng t bo CD4 v2869bnh thn kinh ngoi bin t trc.
2811s lng virus l mt ch bo c lp 2870Lamivudin: Xem chuyn lun.
2812tin
64 lng
Stin trin
dng hpca bnh.
l cc S khng
thuc lng virus
2871Stavudin:
virus v iuCn tr coi cc bnh
nhim khunv thn kinh l
2813cng
DTQGVNnhiu lm cho s lng t bo CD2872 4 chng ch nh tng i ging nh i vi
2814gim cng nhanh. Cn bt u iu tr2873zalcitabin.
2815nhm mc ch lm gim s lng virus ti2874Navirapin: Xem chuyn lun.
2816mc khng pht hin c. iu tr chun2875Delaviridin: Tc dng khng mong mun th-
2817hin nay gm hai thuc khng retrovirus,2876ng gp nht l ni mn, nhim c gan,
2818loi tng t nucleosid, kt hp vi mt thuc2877nhc u, bun nn v mt mi. Ngoi ra
2819c ch protease. Cn kt hp t nht hai2878cn c tng lipid huyt, ri lon phn b
2820thuc tng t nucleosid nhm ngn nga2879m, khng dung np glucose. Do , cn
2821s pht trin nhanh chng ca cc virus2880nh gi cn thn cc yu t trc v
2822khng thuc. c hiu qu lu bn,2881trong khi dng thuc cc ngi bnh b ri
2823iu tr mt cch linh hot l iu quyt2882lon cc thng s trn.
2824nh. Nu ngi bnh khng p ng vi2883Saquinavir: Tng t nh delaviridin v xem
2825iu tr (lng virus tng ln 3 ln hoc s
2884thm chuyn lun v thuc ny.
2826lng CD4 gim hoc bnh chuyn sang
2885Ritonavir: Tng t nh delaviridin v xem
2827AIDS) th phi chuyn sang kt hp cc
2886thm chuyn lun v thuc ny.
2828thuc nucleosid khng retrovirus khc. Cn
2887Indinavir: Tc dng khng mong mun hay
2829phi la chn kt hp mi sao cho nguy c
2830khng cho vi iu tr trc y l ti
2888gp nht l si thn bao gm c au, km
2831thiu. Trong trng hp ny, ging nh2889theo hoc khng km theo i ra mu. Cn
2832nguyn tc iu tr lao, khng c dng2890dn ngi bnh ung nhiu nc, t nht 2
2833ch mt th thuc v virus s nhanh chng2891lt mi ngy gim thiu nguy c ny.
2834khng li thuc khng virus. 2892Khng dng thuc ny iu tr cho ng-
2835Nu iu tr khng c hiu qu v cn2893i bnh b suy gim chc nng thn v b
2836phi thm mt thuc mi th nguyn tc2894suy tim do khng iu chnh c lng nc
2837cng l khng thm ch mt th thuc m2895phi ung gng sc.
2838l b sung kt hp hai th thuc mi. Cn2896Nelfinavir: Xem chuyn lun v thuc ny.
2839xem xt nguy c do tng tc thuc khi2897A. iu tr nhim HIV/AIDS
2840iu tr bng cc thuc khng retrovirus.2898Hin nay, chng ta cha c iu kin
2841Xem tng thuc trong cc chuyn lun2899o nng virus trong huyt thanh, do
2842thuc. 2900 mi quyt nh iu tr da vo cc
2843Thuc nucleosid c ch enzym sao chp2901biu hin lm sng v s lng t bo CD4
2844ngc v cc tn vit tt: 2902trong mu.
2845Zidovudin (AZT)
2903Bnh vin (c s iu tr) thc hin
2846Didanosin (ddI)
2904iu tr ngi bnh nhim HIV/AIDS theo
2847Zalcitabin (ddC)

66
 67

2905hng dn, ng thi phi hp vi cc c2959Zidovudin 600 mg/ ngy, chia 3 ln ung
2906quan lin quan t chc theo di v2960(cch 6 gi ung mt ln).
2907qun l tt ngi bnh nhim HIV/AIDS ti2961Lamivudin 300 mg/ ngy, chia 2 ln ung.
2908cng ng. 2962Hin nay thuc kt hp 2 loi ny l
2909Phng hng iu tr: 2963Combivir (1 vin gm c lamivudin 150 mg
2910iu tr khng retrovirus (khng HIV). 2964v zidovudin 300 mg; ngy ung 2 vin).
2911iu tr chng nhim khun c hi. 2965Didanosin + Stavudin
2912Chm sc, dinh dng, nng cao th trng. 2966Didanosin 250 mg/ ngy, chia 2 ln ung
2913I. iu tr khng retrovirus 29671/2 gi trc khi n.
2914Cc nhm thuc iu tr khng retrovirus2968Stavudin 80 mg/ ngy, chia 2 ln.
2915hin nay bao gm: 2969Zidovudin + Didanosin
2916Nhm nucleosid c ch cc enzym sao2970Zidovudin 600 mg/ngy, chia 3 ln ung.
2917chp ngc (nucleoside reverse2971Didanosin 250 mg/ngy, chia 2 ln ung
2918transcriptase inhibitors - NRTIs), cc thuc29721/2 gi trc khi n.
2919thuc nhm ny gm: Zidovudin (ZDV,2973Kt hp 3 loi thuc
2920AZT), Didanosin (ddI), Lamivudin (3TC),2974p dng cho nhng ngi nhim HIV m c
2921Zalcitabin (ddC), Stavudin (Zerit, d4T)... 2975cc bnh ch im (lm sng loi C theo
2922Nhm khng phi nucleosid c ch cc2976phn loi ca CDC) hoc t bo CD4 di
2923enzym sao chp ngc (nonnucleoside2977200 t bo/mm3 hoc RNA ca HIV trn
2924reverse transcriptase inhi-297810.000 sao chp/ mm3. C th p dng
2925bitors- NNRTIs), cc thuc thuc nhm ny2979mt trong nhng cch kt hp sau:
2926gm: Nevirapin (Viramun), Delaviridin2980Combivir + Indinavir
2927Lovirid... 2981Combivir ngy ung 2 vin
2928Nhm c ch protease (protease inhibitors2982Indinavir 2400 mg/ ngy, chia 3 ln, 8 gi
2929- PIs), cc thuc thuc nhm ny gm:2983ung mt ln; ung 1 gi trc khi n hoc 2
2930Indinavir (Crixivan), Nelfinavir, Ritonavir,2984gi sau khi n; ung nhiu nc.
2931Saquinavir... 2985Zidovudin + Didanosin + Indinavir
29321. Tiu chun bt u iu tr2986Zidovudin 600 mg/ ngy
2933nhng ngi nhim HIV 2987Didanosin 250 mg/ ngy
2934Vic iu tr c tin hnh khi: 2988Indinavir 2400 mg/ ngy
2935Nhim HIV c triu chng lm sng, bao2989Zidovudin +Zalcitabin + Indinavir
2936gm: Nhim nm Candida ti pht nim2990Zidovudin 600 mg/ ngy
2937mc, bch sn dng lng li, st ko di2991Zalcitabin vin 0,75 mg, ngy ung 3 vin
2938trn 1 thng, tiu chy ko di, gy st2992cch nhau 8 gi, trnh dng cng vi thuc
2939cn.v.v... 2993khng acid hoc thuc c albumin.
2940Nhim HIV khng c triu chng lm sng2994Indinavir 2400 mg/ngy.
2941nhng s lng t bo CD4 < 500/ mm3 mu.2995Stavudin + Lamivudin + Indinavir
2942Nhim HIV khng c triu chng lm sng2996Stavudin + Didanosin + Indinavir
2943v s lng t bo CD4 > 500 mm3 mu.2997Ghi ch: Liu dng cc thuc c ch
2944Nu c iu kin o c nng virus2998protease: Indinavir: 2400 mg/ngy,
DTQGVN
2945HIV trong mu th tin hnh iu tr i S2999 saquinavir:
dng 800thuc
hp l cc mg/ngy, chia
khng 3 ln
virus v ung
iu tr
nhim
2946vi: khun
Ngi bnh 65
c 30.000 - 50.000 RNA sao 3000 trong ngy; ritonavir: 1200 mg/ngy, chia 2
2947chp/mm3 (bDNA) hoc ngi bnh c CD43001ln ung trong ngy.
2948gim nhanh mc d ch c 5.000 - 10.00030023. Tng tc thuc
2949RNA sao chp/ mm3 (bDNA).
3003Trong khi iu tr khng dng kt hp
29502. iu tr: 3004cc thuc nh:
2951Kt hp dng 2 loi thuc 3005Zidovudin + Stavudin
2952Dng cho nhng ngi nhim HIV c cc3006Didanosin + Zalcitabin
2953biu hin lm sng, nhng ngi m s l-3007Stavudin + Zalcitabin
2954ng t bo CD4 t 200 - 499 t bo/mm 3; l-3008Zalcitabin + Lamivudin
2955ng RNA t 5.000 - 10.000 sao chp/ mm3009 3 Kt hp thuc theo cc cng thc trn s
2956(bDNA), dng mt trong nhng cch kt hp3010lm tng c tnh ca thuc.
2957sau: 3011Tng tc gia thuc chng retrovirus
2958Zidovudin + Lamivudin 3012v thuc iu tr nhim khun c
3013hi.

68
 69

3014Zidovudin 3070clorazepat, midazolam (Versed) trizolam

3015Tng c tnh khi dng chung vi co-3071(Halcion); thuc chng Mycobacterium nh
3016trimoxazol, acy-3072rifabutin.
3017clovir, ganciclovir, interferon alpha,3073Saquinavir
3018fluconazol, am-3074Cc thuc kt hp s lm gim nng
3019photericin B, flucytosin, vincristin,3075saquinavir nh rifampin, rifabutin,
3020probenecid. Nu cn thit kt hp vi cc3076phenobarbital, dexamethason, car-
3021thuc trn th phi theo di chc nng3077bamazepin, phenytoin.
3022thn, cng thc mu, v nu cn th gim3078Cc thuc lm tng nng saquinavir nh
3023liu thuc. 3079fluconazol (tng mc saquinavir ti 150%),
3024Nhng thuc lm gim nng zidovudin3080itraconazol, ritonavir, indinavir.
3025l rifampin, trimethoprim, ribavirin,30814. Phn ng c hi ca thuc:
3026indomethacin. 3082Khi dng thuc khng virus, cn phi ch
3027Didanosin 3083n phn ng c hi ca thuc v khi c
3028Lm gim hp th ca ketoconazol,3084phn ng ny cn phi thay th bng
3029itraconazol, dapson, tetracyclin,3085thuc khc hoc tm thi ngng thuc
3030fluoroquinolon, do nn dng didanosin 6
3086Phn ng c hi ca zidovudin
3031gi trc hoc 2 gi sau khi dng cc thuc
3087(azidothymidin)
3032trn. 3088Ph bin : H bch cu, thiu mu, nn,
3033Khi dng vi cc thuc li tiu thiazid,3089mt mi, mt ng, tng sc t da.
3034furosemid, vi cc thuc azathioprin,3090t ph bin: Bnh v c ( yu c, teo
3035methyldopa, pentamidin, oestro-3091c), bnh l v thn kinh ngoi bin, lot
3036gen, s tng nguy c vim ty. 3092thc qun, st, co git.
3037Khi dng vi cc thuc dapson, ethambutol,3093Khi iu tr bng zidovudin cn phi xt
3038ethiona- 3094nghim cng thc mu mt thng 1 ln.
3039mid, INH, metronidazol, nitrofurantoin,3095Nu bch cu ht h di 1000/mm3 th phi
3040vincristin, zalcitabin c th tng nguy c3096ngng thuc cho n khi s lng bch cu
3041bnh l thn kinh ngoi bin. Khng dng3097tr li bnh thng th tip tc dng thuc.
3042didanosin khi ang iu tr rifampicin. 3098H bch cu ht trung tnh do zidovudin c
3043Zalcitabin 3099ch ty xng, lm gim t bo ty xng.
3044Dng vi cc thuc dapson, ethambutol, INH,3100Nu thiu mu, gim hemoglobin di 8
3045metro- 3101g/100 ml th ngng iu tr zidovudin.
3046nidazol, nitrofurantoin, vincristin, phenytoin3102Hng tun theo di s lng hemoglobin
3047c th tng c tnh gy bnh l thn3103trong mu, khi no hemoglobin tr v
3048kinh ngoi bin. 3104bnh thng th tip tc iu tr bng
3049Dng vi cc thuc pentamidin, ru,3105zidovudin.
3050didanosin, c th lm tng nguy c vim3106Nu xut hin bnh v c, teo c, yu
3051ty. 3107c lm i li kh khn th tm thi ngng
3052Lamivudin 3108thuc hoc thay bng thuc khc.
3053Tng tc dng lamivudin khi dng co-3109Nu nn nng th tm thi ngng thuc
3054trimoxazol 3110cho n khi ht nn, sau dng thuc li
3055Indinavir 3111hoc thay bng thuc khc.
3056Cc thuc rifampicin lm gim nng 3112Phn ng c hi ca didanosin
3057indinavir, nn khng dng kt hp. 3113Ph bin: Tiu chy, tng amylase, bn
3058Thuc ketoconazol lm tng tc dng3114chn, nhc u, mt ng.
3059indinavir, do khi dng kt hp phi gim3115t ph bin: Vim ty, nn, tng
3060liu indinavir (600 mg/ ln, 3 ln, cch 83116transaminase mu, gim bch cu ht,
3061gi mt ln). 3117thiu mu, pht ban.
3062Ritonavir 3118Vim ty: Khi dng thuc didanosin m thy
3063Chng ch nh dng cng vi cc thuc3119au bng, nn, th cn phi xt nghim
3064gim au: mephidin, piroxicam (Feldene),3120amylase huyt thanh, nu amylase tng
3065propoxyphen (Dar-3121cao th tm thi ngng thuc hoc thay
3066von); thuc an thn clozapin; cc thuc3122bng thuc khc.
3067chng lon nhp nh: quinidin, amiodaron,3123Bnh l thn kinh ngoi bin nh au, t b
3068encainid; cc thuc chng trm cm nh3124 chn, mt phn x, nu nng c th
3069bupropion; cc thuc an thn nh diazepam,3125tn thng vn ng. Khi c du hiu t

70
 71
66 S dng hp l cc thuc khng virus v iu tr nhim khun
DTQGVN

3125b, au th tm thi ngng thuc hoc

3126thay bng thuc khc.
3127Nu dng ko di c th lm tng acid uric
3128mu, do cn xt nghim acid uric.
3129Phn ng c hi ca zalcitabin
3130Ph bin: Bnh l thn kinh ngoi bin,
3131vim ming, pht ban, thiu mu, gim
3132bch cu trung tnh, mt mi, nhc u,
3133vim ty.
3134t ph bin: Nn, tiu chy, tng
3135transaminase mu.
3136Phn ng c hi ca lamivudin
3137Nhc u, mt mi, bun nn, au bng,
3138tiu chy, bnh l thn kinh ngoi bin,
3139bch cu trung tnh h, transaminase tng,
3140vim ty.
3141Phn ng c hi ca stavudin
3142Bnh l thn kinh ngoi bin khi iu tr
3143ko di, thiu mu, bch cu gim, vim
3144ty, nhc u, transaminase tng.
3145Phn ng c hi ca indinavir
3146Ph bin: Tng bilirubin gin tip, si thn,
3147i ra mu (do hng ngy khi ung
3148thuc cn ung nhiu nc).
3149t ph bin: Tng transaminase, nhc
3150u, bun nn, mt mi, mt ng, tai,
3151nhn m, tiu chy, pht ban,
3152h tiu cu.
3153Phn ng c hi ca saquinavir
3154au bng, tiu chy, nhc u, vng da,
3155transaminase tng, pht ban, i khi co
3156git hoc l ln.
3157Phn ng c hi ca ritonavir
3158Nn, tiu chy, nhc u, chng mt, dn
3159mch, vim hng, tng transaminase, tng
3160cholesterol mu, tng triglycerid.

72
 73

3161
3162II. iu tr nhim khun c hi:
1. Vi khun
Tc nhn Phc thuc u tin Phc thuc thay th
Campylobac Erythromycin 2 g/ngy, chia Ciprofloxacin 1 g/ngy, chia 2 ln, ung
ter lm 4 ln, ung trong 5 trong 5 ngy hoc norfloxacin 800
jejuni ngy. mg/ngy, chia 2 ln, ung trong 5 ngy.
Chlamydia Erythromycin 2 g/ngy, chia Doxycyclin 200 mg/ngy, chia 2 ln, dng
tracho lm 4 ln, dng trong 7 ngy trong 7 ngy.
matis hoc ofloxacin 300 mg,
ung 2 ln 1 ngy, dng
trong 7 ngy.
Vi khun lao INH 5 mg/kg
(Mycobacteri Rifampicin 10 mg/kg
um Ethambutol 15 - 20 mg/kg
tuberculosis Pyrazinamid 20 - 30 mg/kg
Mycobacteri Clarithromycin 1 g/ngy, Rifabutin 300 mg/ngy, kt hp vi
um avium chia 2 ln, kt hp vi ethambutol
complex ethambutol 15 mg/kg/ngy 15 mg/ ngy.
(MAC)
Salmonella Ciprofloxacin 1 g/ngy, chia Nu phn lp chng nhy cm vi
2 ln, ung trong 7 n 14 ampicilin hoc Cotrimoxazol th dng
ngy. ampicilin 2 g/ngy, chia 2 ln hoc
Cotrimoxazol (vin 480 mg) ngy ung 4
vin.
2. Nhim nm
Tc nhn Phc thuc u tin Phc thuc thay th
Aspergillus Amphotericin B 0,8 Itraconazol 200 mg/ngy, chia 2 ln
(Nhim mg/kg/ngy, tim tnh mch ung.
nm phi) cho n khi p ng.
Candida Fluconazol 100 mg/ngy, dng Itraconazol 200 mg/ ngy, chia 2 ln,
albicans trong 10 - 14 ngy. ung dng 10 - 14 ngy.
hng
CryptococcAmphotericin B 0,7 Fluconazol 400 mg/ngy, ung trong 10 -
us mg/kg/ngy, tim tnh mch 14 tun ri iu tr duy tr 200
neoftrong 10 - 14 ngy, ri sau mg/ngy hoc fluconazol 400 mg/ngy
orm dng fluconazol 400 mg, ung kt hp vi flucytocin 100 mg/kg/ ngy.
ans 2 ln 1 ngy, trong 2 ngy,
(Vim sau gim xung 400
mng no) mg/ngy, dng trong 10 - 14
tun.
Histoplasm Amphotericin B 0,8 Itraconazol 300 mg ung 2 ln/ngy,
a mg/kg/ngy, tim tnh mch dng trong 3 ngy sau gim xung
capsulatu trong 10 -14 ngy, ri sau 100 mg/ngy.
m dng itraconazol 400 mg/ngy,
dng trong 3 ngy ri gim
xung 200 mg/ngy.
Penicillium Amphotericin B 0,7 - 1 Itraconazol 300 mg ung 2 ln/ngy,
marneffei mg/kg/ngy, tim tnh mch dng trong 3 ngy, sau 400 mg/ngy,
trong 10 - 14 ngy, ri dng dng trong 12 tun.
itraconazol 400 mg/ngy,
DTQGVN S dng hp l cc thuc khng virus v iu tr
ung trong 4 tun, sau
nhim khun 67
duy tr 200 mg/ngy.
3. Nhim k sinh trng

74
 75

Tc nhn Phc thuc u tin Phc thuc thay th

Trichomon Metronidazol 2 g ung mt Metronidazol 0,5 g, ung 2 ln/ngy,
as liu duy nht. trong 7 ngy.
vaginalis
Pneumocys Sulfamethoxazol 75 Trimethoprim 5 mg/kg/ngy, kt hp vi
tis carinii mg/kg/ngy, kt hp vi dapson 100 mg/ngy, dng trong 21 ngy.
(PCP) trimethoprim 15 mg/kg/ngy, Hoc pentamidin 4 mg/kg/ngy, tim
chia 3 ln, ung trong 3 - 4 tnh mch trong 21 ngy hoc
tun. clindamycin 600 mg tim tnh mch hoc
300 mg ung cch nhau 8 gi 1 ln, kt
hp vi ung primaquin 15 mg/ngy, dng
trong 21 ngy.
Izopora Cotrimoxazol (vin 480 mg) Pyrimethamin 75 mg/ngy, kt hp vi
belli ngy ung 4 vin, chia lm 4 acid folinic 5 - 10 mg/ngy, ung trong 3
ln. Ung trong 10 ngy sau tun.
ung 2 vin/ngy, ung
trong 3 tun.
Toxoplasm Pyrimethamin 50mg/ngy kt Pyrimethamin 50 mg/ngy, kt hp vi
a hp vi sulfadiazin 1g/ngy, acid folinic
gond chia 2 ln v acid folinic 10 - 10 - 20 mg/ngy v clindamycin 2
ii 20 mg/ngy, dng trong 8 g/ngy, dng trong 8 tun. Hoc
tun. sulfamethoxazol 800 mg v trimethoprim
160 mg (vin cotrimoxazol 960 mg) ngy
4 vin, ung trong 8 tun, sau duy
tr mi ngy 1 vin.
4. Nhim virus
Tc nhn Phc thuc u tin Phc thuc thay th
Zona Aciclovir 30 mg/kg/ngy, tim tnh Foscarnet 40 mg/kg truyn tnh
mch hoc 800 mg ung 5 ln /ngy, mch, cch nhau 8 gi/ln, trong
trong 10 ngy hoc famciclovir 500 2 - 3 tun.
mg ung 3 ln/ngy, hoc valaciclovir
1 g ung 3 ln/ngy, trong 7 - 10 ngy.
Herpes Aciclovir 400 mg ung 3 ln/ ngy, Famciclovir 250 mg ung 3
trong 7 - 10 ngy hoc acyclovir 5 ln/ngy, trong 7-10 ngy hoc
mg/kg truyn tnh mch cch 8 gi 1 foscarnet 40 mg/kg truyn tnh
ln, dng trong 10 ngy. mch cch nhau 8 gi, trong 21
ngy.
Cytomegalovi Foscarnet 60 mg/kg truyn tnh
rus mch, cch nhau 8 gi 1 ln, dng
(CMV) trong 14 - 21 ngy hoc ganciclovir 5
mg/kg truyn 2 ln/ngy, dng trong
14 - 21 ngy.
3163B. iu tr d phng cho ngi b phi3183Nhn thy chy mu khi b kim m.
3164nhim vi HIV trong ngh nghip 3184Vt thng do dao m, do ng nghim
3185ng mu, cht dch ca bnh nhn
3165I. Nguyn tc chung
3186nhim HIV b v m vo da, cn xc
3166T vn cho ngi b phi nhim vi mu,
3187nh su v kch thc ca vt thng.
3167dch c th c nguy c ly nhim ca
3188Da b tn thng t trc v nim mc.
3168ngi HIV(+).
3189Da c cc tn thng do: Chm, bng hoc
3169Cn ly mu th ngay HIV v iu tr
3190b vim lot t trc.
3170ngay khng cn ch kt qu xt nghim.
3191Nim mc mt hoc mi hng.
3171Th li HIV sau khi dng thuc 1 thng; 3
3172thng v 6 thng. 31922. X tr ngay ti ch
3173Khng iu tr tn thng khng lm xy3193Da: Ra k bng x phng v nc sch, sau
3174xt da m ch cn ra sch da. 3194 st trng bng dung dch Dakin hoc n-
3195c Javel pha long 1/10 hoc cn 70 o,
3175II. nh gi mc phi nhim v x
3196tip xc ni b tn thng t nht 5 pht.
3176tr vt thng ti ch
3197Mt: Ra mt vi nc ct hoc dung dch
31771. nh gi tnh cht phi nhim 3198natri clorid ng trng (0,9%), sau
3178Kim m 3199nh mt bng nc ct lin tc trong 5 pht.
3179Cn xc nh v tr tn thng. 3200Ming, mi: Ra mi bng nc ct, sc
3180Xem kch thc kim m (nu kim to v3201ming bng dung dch natri clorid ng
3181rng th nguy c ly nhim cao). 3202trng (0,9%).
3182Xem su ca vt kim m

76
 77

3203III. iu tr d phng 3261T vn cho ngi m v li ch ca vic nui

3204Thi gian iu tr tt nht l ngay t3262tr bng sa thay th nu c iu kin,
3205nhng gi u tin (2- 3 gi sau khi xy ra3263 gim bt nguy c ly truyn bnh.
3206tai nn), mun nht khng qu 7 ngy.
3207Nu tn thng ch xy xc da khng
3264i vi tr mi sinh
3208chy mu hoc mu, dch ca bnh nhn3265Khng t in cc vo u thai nhi.
3209bn vo mi hng th phi hp 2 loi3266Khng ly mu da u thai nhi lm pH.
3210thuc trong thi gian 1 thng theo hng dn3267Tm cho tr ngay sau khi sinh.
3211 phn trn. 3268Ngay sau khi tr c sinh ra, cn b y t
3212Nu tn thng su, chy mu nhiu th3269bung phi thng bo cho cho khoa Nhi
3213phi hp 3 loi thuc trong thi gian 1 thng3270 tr c chm sc c bit ti khoa Sn
3214theo hng dn phn trn.
3271v khoa Nhi ca bnh vin.
3215C. iu tr d phng ly nhim HIV t
3216m sang con 32723. iu tr sau khi sinh
3273iu tr cho con
3217I. iu tr ph n mang thai nhim3274Nu ngi m ung nevirapin th cho con
3218HIV phng ly nhim t m sang3275ung duy nht mt ln siro nevirapin 2
3219con
3276mg/kg cn nng, trong vng 72 gi sau
3220iu tr ngi mang thai nhim HIV vi mc
ch sang3277khi sinh.
3221
68 S lm
dnggim ly
hp l ccnhim
thuc t m virus
khng vNu
3278 iu trm
ngi nhim
ung khun
zidovudin th cho con
3222con,
DTQGVN nu ngi m v gia nh sau khi c
3223t vn vn mun gi thai. 3279ung siro zidovudin 2 mg/kg/6 gi, bt
3280u khong 8 - 10 gi sau khi sinh, ko
32241. iu tr trc khi v trong khi : 3281di trong 6 tun. Trng hp khng c siro
3225Ty iu kin c th chn mt trong hai
3282zidovudin th s dng siro nevirapin nh
3226phc sau:
3227Phc s dng nevirapin
3283trn.
3228Ch nh: Khi bt u chuyn d thc s3284iu tr cho m
3229hoc trc khi m ly thai. 3285Nu cn thit v c iu kin, s p dng
3230iu tr: Ung mt ln duy nht 1 vin3286iu tr c hiu theo mt trong cc
3231nevirapin 200 mg. 3287phc gii thiu phn "iu tr d
3232Theo di cuc chuyn d v tip tc 3288phng cho ngi b phi nhim vi HIV
3233nh bnh thng. 3289trong ngh nghip"
3234Phc s dng zidovudin 3290II. Cc ch nh nh ch thai nghn
3235Zidovudin 600 mg/ngy, chia 2 ln, ung3291Vi nhng thai cn nh (di 3 thng), sau
3236bt u t tun thai th 36 n khi3292khi c t vn, nu thai ph v gia nh
3237chuyn d. Trong trng hp thai ph n3293ng ph thai th gii quyt ht hay no
3238mun (sau tun th 36), cng cho ung vi3294thai ty theo tui thai. Nhng trng hp
3239liu trn cho n khi chuyn d. 3295ny s c thc hin ni c c s phu
3240Trong khi chuyn d , tip tc dng3296thut (c bc s chuyn khoa sn, phng
3241zidovudin 300 mg/ln, c 3 gi cho ung 13297m).
3242ln n lc cp v ct dy rn th3298Sau khi ph thai, tip tc iu tr nh cc
3243ngng ung thuc. 3299trng hp bnh nhn nhim HIV khc.
3244Cn cho thm thuc chng thiu mu bng3300Nu thai ph mun gi thai th y t c s
3245cch b sung vin st hoc acid folic. 3301nn gi n khoa sn bnh vin tnh
3246Nu ngi m c nhim khun c hi km3302hoc tuyn k thut cao hn c
3247theo th iu tr nh nhng ngi bnh3303qun l.
3248nhim khun c hi khc hoc gi i3304D. iu tr cho tr em nhim hiv/aids
3249khm chuyn khoa c ch nh dng
3250thuc ng v hp l. 3305I. iu tr khng retrovirus
33061. Ch nh
32512. Cc im cn thc hin ng khi3307Tr nhim HIV c triu chng lm sng
3252 3308theo phn loi A, B, C.
3253i vi sn ph 3309Tr nhim HIV c suy gim min dch theo
3254m bo v khun tuyt i khi . 3310phn loi 2, 3 (phn loi da vo lympho
3255Lau m o nhiu ln bng bng tm3311CD4).
3256dung dch ben-3312Tr sinh ra ngi m HIV (+) trong 6 tun
3257zalkonium clorid hay clorhexidin 0,2%. 3313sau sinh, trong khi ch lm xt nghim
3258Khng co lng vng v. 3314chn on xc nh.
3259Ch m ly thai khi c ch nh sn33152. Ch iu tr
3260khoa. 3316iu tr bng 1 loi thuc: Zidovudin
3317Tr t 0 - 6 tun tui

78
 79

3318Siro zidovudin 2 mg/kg/6 gi, bt u3373E. iu tr cc bnh khc

3319khong 8 - 10 gi sau khi sinh. 33741. iu tr ngi bnh lao/HIV/AIDS
3320iu tr bng kt hp thuc cho tr di 133375iu tr nhim HIV/AIDS theo hng dn ny
3321tui. 3376kt hp vi iu tr lao.
3322Phng php kt hp thuc nh hng dn
3323phn trn, liu lng thuc dng nh sau: 3377Hng dn iu tr cho nhng ngi
3324Zidovudin: 5 mg/kg ung 3 - 4 ln/ngy. 3378bnh lao nhim HIV theo cng thc:
3325Didanosin: 5 mg/ kg dng 3 - 4 ln/ ngy. 33792HRZE/6HE
3380Hai thng iu tr tn cng hng ngy vi
3326Zalcitabin: 0,01 mg/ kg 3 ln/ ngy.
33814 thuc: Isoniazid (H), rifampicin (R),
3327Lamivudin: 4 mg/ kg 2 ln/ ngy.
3382pyrazinamid (Z), v ethambutol (E). Su
3328II. iu tr nhim khun c hi thng3383thng iu tr cng c bng 2 thuc
3329gp 3384isoniazid v ethambutol hng ngy. Liu
33301. Nhim khun ng h hp 3385nh sau:
3386Isoniazid (H): 5 mg/kg
3331Vim phi do Pneumocystis carinii:
3332Trimethoprim 20 mg/kg/ngy +3387Rifampicin (R): 10 mg/kg
3388Pyrazinamid (Z): 25 mg/kg
3333sulfamethoxazol 100 mg/kg/ngy, 14 - 21
3389Ethambutol (E): 15 mg/kg
3334ngy.
3390Nu m bo tt cc quy trnh chng ly
3335Vim phi do Cryptococcus:
3391nhim, c th s dng cc phc ging
3336Amphotericin B: 0,25 mg/kg/ngy, tim3392nh nhng ngi bnh lao khng nhim HIV,
3337tnh mch, sau tng ln 0,5 mg/kg/ngy,3393 l:
3338trong 6 tun. 33942 SHRZ/ 6HE, ch nh cho nhng trng
3339Lao phi hoc lao ton th: Theo hng3395hp mi pht hin:
3340dn ti phn E. 3396Hai thng u dng 4 loi thuc:
3341Vim phi do Cytomegalovirus. 3397Streptomycin (S) 15 mg/kg, isoniazid,
3342Ganciclovir 5 mg/kg/ln, 2 ln/ngy, 14 -3398rifampicin, pyrazinamid hng ngy, liu nh
334321 ngy. 3399trn.
3344Vim phi do cc vi khun thng gp nh3400Su thng sau dng 2 loi thuc isoniazid v
3345Hemo- 3401etham-
3346philus influenzae, S. pneumoniae,3402butol hng ngy, liu nh trn.
3347Klebsiella: Chn khng sinh thch hp. 34032 SHRZE/1 HRZE/5 H3R3E3, ch nh cho
33482. Nhim khun ng tiu ha 3404nhng trng hp ti pht sau iu tr theo
3349Nm Candida ming- hu: 3405cc cng thc:
3350Nystatin (Myconistine) ti ch. 3406Hai thng u dng 5 loi thuc:
3351Herpes simplex gy lot ming, hu mn.3407Streptomycin, isoniazid, rifampicin,
3352Aciclovir: 5 mg/kg/ln, 3 ln/ngy, 5 - 143408pyrazinamid, ethambutol hng ngy, liu
3353ngy, ung hoc tim tnh mch. 3409nh trn.
3354Vim rut do Salmonella, Shigella,3410Thng th ba dng 4 loi thuc: Isoniazid,
3355Campylobacter: 3411rifampicin, pyrazinamid, ethambutol hng
3356Hi phc nc, in gii; 3412ngy, liu nh trn.
3357Dinh dng; 3413Tip theo iu tr bng 3 loi thuc:
3358Khng sinh thch hp. 3414Isoniazid, rifam-
33593. Nhim khun da 3415picin, ethambutol 3 ln trong mt tun lin
3360Herpes zoster: Aciclovir 5 - 10 mg/kg/ln, 33416tc trong 5 thng. Liu nh sau:
3361ln/ngy, dng trong 7 ngy, ung hoc3417Isoniazid (H) : Liu cch qung 3
3362 tim tnh mch. 3418ln/tun:10 mg/kg
DTQGVN 3419Rifampicin (R): 10S dng hp
mg/kg/24 gi l thuc
3363 Do vi sinh
khng khun, nm: 69Chn khng sinh thch3420Ethambutol (E): Liu cch qung 3
3364hp.
33654. Nhim khun thn kinh 3421ln/tun: 30 mg/kg
3366Vim mng no do Cryptococcus. 3422Nhng im cn ch :
3367Amphotericin B: 0,25 - 0,5 mg/kg/ngy,3423Cn b y t phi gim st trc tip iu
3368dng trong 6 tun. 3424tr trong 2 thng u.
3369Toxoplasma no:
3370Pyrimethamin 25 - 50 mg/ngy kt hp vi3425Khng ch nh streptomycin iu
3371sulfadiazin 150 mg/kg/ngy, thi gian 3 - 63426tr bnh lao cho ngi nhim HIV trnh
3372tun. 3427ly nhim HIV qua ng tim. Tuy nhin
3428nu c iu kin dng bm kim tim 1
3429ln, th c th s dng streptomycin v

80
 81

3427streptomycin l thuc dit khun rt tt3433Nhng cng thc c streptomycin hay

3428cho iu tr giai on u. 3434thiacetazon c thay bng ethambutol.
3429Khng ch nh thiacetazon (T) iu34352. iu tr cc bnh ly truyn qua
3430tr bnh lao cho ngi nhim HIV v c3436ng tnh dc: iu tr nhim
3431nguy c gy nhiu phn ng ph, thm3437HIV/AIDS theo hng dn ny kt hp vi
3432ch c th gy t vong. 3438iu tr cc bnh ly truyn qua -
3439ng tnh dc.

3440 S dng hp l thuc khng sinh

3441Thuc khng sinh cn c s dng hn ch3461c t vong bi nhng nhim khun n
3442v ch khi tht cn thit. Lm dng thuc3462gin s tng, thi gian b bnh ko di v
3443khng sinh hin nay ph bin l dng3463bnh nhim khun d dng ly lan hn.
3444thuc khi khng cn thit (v d nhim3464Danh sch di y gii thiu cc thuc hp
3445virus) v trong thi gian qu ngn. iu3465l c chn u tin hng u cho nhng
3446ny dn ti tnh trng rt nguy him l3466bnh nhim khun thng thng v c cc
3447ngy cng c nhiu bnh nhim khun3467thuc c la chn tip theo cho cc trng
3448khng li cc thuc sn c. Do , vn 3468hp nng hn. Hin nay, cc Hi ng
3449l phi dng khng sinh mt cch thn3469thuc v iu tr cn xem xt cn thn
3450trng v dnh cc thuc c hiu lc nht3470vic s dng thuc khng sinh trong c s
3451cho cc bnh nhim khun nng nht.3471ca mnh v S y t cn nh gi vic s
3452y l nguyn tc c T chc y t th3472dng thuc khng sinh trong vic chm sc
3453gii (WHO) khuyn co. Nu khng bt3473sc khe cng ng, trong cc phng mch
3454u s dng thuc khng sinh cn thn3474t, cc bc s t. iu quan trng l phi bt
3455nh vy, chng bao lu na s din ra3475u hot ng tch cc v vn cn thi
3456tnh trng tt c cc bnh nhim khun s3476gian duy tr tc dng ca thuc sn
3457khng th iu tr c vi bt k thuc3477c, nhm m bo c cc thuc khng sinh
3458khng sinh no, iu ny s a chng ta3478cng hiu iu tr cc bnh trong t-
3459tr li tnh trng ging nh khi cha pht3479ng lai.
3460minh ra cc thuc khng sinh. Nh vy nguy
3480
3481 Bng cc bnh nhim khun chnh, cc vi khun c nhiu kh nng gy bnh
3482 nht
3483 v khuyn co s dng thuc
Vim mng trong tim nhim khun
70 Bnh
S dng nhim
hp l Vi khun
thuc khngcsinh
nhiu Cch iu tr c khuyn co
khun
DTQGVN kh nng gy bnh
nht
iu tr theo Streptococcus spp. Benzylpenicilin 1,2 n 1,8 g, tim tnh
kinh nghim. hoc Staphylococcus mch, 4 gi mt ln, phi hp vi gentamicin
spp. 5 mg/kg th trng tim tnh mch, 8 gi
mt ln, phi hp vi flucloxacilin hoc
dicloxacilin 3 g tim tnh mch. Cng c th
dng oxacilin. Cn cy mu tm vi khun tr-
c khi iu tr.
Vim mng Streptococcus. iu tr nh trn.
trong tim.
Vim mng Enterococcus v Benzylpenicilin 1,8 g - 2,4 g, tim tnh mch
trong tim. Streptococcus khng 4 gi mt ln, dng trong 6 tun; hoc
tng i benzyl amoxycilin 2 g, tim tnh mch 4 gi mt
penicilin. ln, trong 6 tun, phi hp vi gentamicin 1
mg/kg tim tnh mch trong 6 tun hoc
lu hn, hoc vancomycin 15 mg/kg, tim
tnh mch cch 12 gi/1 ln cng
gentamicin nh trn, cho c 2 thuc trong 4 -
6 tun.

82
83

Vim mng Staphylococcus. Fluo/dicloxacilin hoc oxacilin phi hp vi

trong tim. gentamicin hoc nu nghi ng do
Staphylococci spp. khng methicilin
(oxacilin) th dng vancomycin 1 g tim
tnh mch chm trong 2 gi, 12 gi mt ln,
trong 6 tun.
Nhim khun ng h hp
Bnh nhim Vi khun c nhiu Cch iu tr c khuyn co
khun kh nng gy bnh
nht.
Vim hng cp. Thng do nhim virus. Vim amian do Streptococcus nn iu
Vim amian thng tr bng phe-
do Streptococcus noxymethylpenicilin, hoc amoxycilin bi
pyogenes. nguy c c bnh thp khp sau nhim
khun.
Vit Nam Streptococcus nhy cm vi cc
penicilin, nhng thng khng li cc
tetracyclin v cc macrolid.
iu tr vi phenoxymethylpenicilin 500 mg
(tr em 10 mg/kg, ti a 500 mg) bng -
ng ung, 12 gi mt ln trong 10 ngy,
hoc dng liu duy nht 900 mg
benzathinpenicilin tim bp.
Vim amian Streptococcus iu tr phng bnh trong thi gian di vi
ti pht. viridans. penicilin V, nu ngi bnh c vim amidan
ba ln hay nhiu hn trong mt nm.
Vim xoang cp Streptococcus Ung amoxycilin 500 mg, 8 gi mt ln,
do vi khun. pneumoniae trong 10 ngy, hoc liu cao
Haemophilus phenoxymethylpenicilin (xem trong chuyn
influenzae. lun phenoxymethylpenicilin).
Khng histamin, thuc tiu m v
corticosteroid khng c li trong iu tr
vim xoang do vi khun.
Croup (vim Virus Parainfluenza. Khng c ch nh dng thuc khng sinh.
thanh kh ph Nhng trng hp nh v va khng gy
qun cp). tc nhiu ng th, iu tr u tin
bng dexamethason 0,15 n 0,25 mg/kg.
Nhng trng hp va v nng c triu
chng tc nghn ng th r, tim tnh
mch dexamethason vi liu 0,5 n 1
mg/kg (ti a l 10 mg), cng thm kh
dung adrenalin vi liu 0,05 ml/kg/ln (ti
a l 0,5 ml) dng dung dch 1/100 pha
long thnh 3 ml v kh dung budesonid
hoc beclomethason.
Vim tai ngoi. Pseudomonas Dng glucocorticoid bi ti ch v thuc nh
aeruginosa v i khi tai khng sinh nh thuc nh tai
Staphylococcus dexamethason, framycetin, gra-
aureus. micidin

84
85

Vim tai gia Streptococcus Ung amoxycilin 500 mg mi ln, 8 gi mt

nhim khun pneumoniae hoc ln, dng t nht 5 n 10 ngy.
mng m cp Haemophilus influen- p ng km vi thuc chn hng u
tnh. zae. chng t Streptococcus pneumoniae
gim nhy cm vi penicilin, hoc
Haemophilus influenzae sinh beta-
lactamase. Khi ch nh dng
amoxycilin kt hp vi acid clavulanic: Mi
ln ung 500 mg amoxycilin v 125 mg acid
DTQGVN clavulanic (tr em 15 mg/kg, ti hp
S dng a l500
thuc
khng sinh 71 mg), 8 gi mt ln, thi gian iu tr t
nht 10 ngy.
Vim np thanh Haemophilus Cefotaxim 2 g tim tnh mch, 8 gi mt ln
qun cp. influenzae hoc ceftriaxon 2 g tim tnh mch mi
typ b. ngy mt ln. Trc y, c th dng
cloramphenicol trong trng hp d ng nng
vi penicilin. Do Haemophilus influenzae
khng thuc rng, nn cloramphenicol
khng cn l thuc thay th c hiu qu
na.
iu tr ti thiu 5 ngy.
Trnh khm hu-ming, c th gy t vong
do tc ng th. Cn chun b t ni
kh qun.
Ho g. Bordetella pertussis. iu tr khng sinh trong giai on vim
long v giai on u ho r tng cn s ci
thin bnh tt hn.
iu tr: Ung erythromycin 250 mg (tr em
10 mg/kg ti a 250 mg), 6 gi ung mt
ln, dng trong 10 ngy, hoc vi
trimethoprim/sulfamethoxazol 160/ 800 mg
(tr em 4/20 mg/kg ti a 160/800 mg), 12
gi ung mt ln, dng t 1 n 2 tun.
Vim ph qun Thng do virus, Khng iu tr bnh bng thuc khng
cp. khng do vi khun. sinh, bi v bnh vim ph qun cp ny
do virus. i vi tr nh, thuc xng ht
adrenalin c th rt cn thit iu tr
vim tiu ph qun do virus hp bo ng
h hp.
t cp ca vim Streptococcus Amoxycilin hoc cotrimoxazol (hoc dng
ph qun mn pneumoniae hoc ring trimethoprim) s dng nh trong iu
tnh. Haemophilus influen- tr vim phi mc phi trong cng ng.
zae, Moraxella
catarrhalis.
Bnh vim phi
Bnh nhim Vi khun c nhiu Cch iu tr c khuyn co
khun kh nng gy bnh
nht
Vim phi (ph Streptococcus iu tr ban u bng ung amoxycilin 500
qun ph vim) pneumoniae hoc mg, 8 gi mt ln hoc ampicilin 1 g
mc phi trong Haemophilus influen- (ampicilin ung hp thu km hn, nu phi
cng ng, th- zae. dng vin, 8 gi mt ln cho tc dng ging
ng t c triu amoxicilin).
chng ng h Nu cn thit tim tnh mch 600 mg
hp trn. benzylpenicilin, 4 gi tim mt ln.
Nu d ng penicilin, dng erythromycin 10
mg/kg, ung 6 gi mt ln i vi vim
phi thy.

86
87

Bnh vim phi Cefotaxim 1 g, tim tnh mch, 8 gi mt

nng, tn th- ln.
ng phi rng Ceftriaxon 1 g tim tnh mch mi ngy,
mc phi t phi hp vi erythromycin 500 mg tim tnh
cng ng. mch chm, 6 gi tim mt ln.
Vim phi Mycoplasma i vi tr em t 2 tun n 3 thng tui:
khng in pneumoniae, Erythromycin 10 mg/kg, dng vin nn, 6 gi
hnh, bnh th- Legionella ung mt ln, dng t nht t 7 n 10 ngy.
ng nng ln pneumophilia, i vi ngi ln v tr em trn 3 thng tui c
dn vi ho v Chlamydia th dng roxithromycin 300 mg dng vin nn,
cc triu chng pneumoniae. ngy mt ln (tr em 4 mg/kg, ti a 150 mg,
ng h hp 12 gi ung mt ln).
trn khc.
Vim phi do Nhiu loi vi khun Amoxicilin 1 g tim tnh mch, 6 gi mt
ht. bao gm c vi khun ln, phi hp vi metronidazol 500 mg, tim
k kh. tnh mch, 12 gi mt ln chng li
nguy c do vi khun k kh.
Nhim khun ng tiu ho
Bnh nhim Vi khun c nhiu Cch iu tr c khuyn co
khun kh nng gy bnh
nht
Vim ti mt E. coli, Klebsiella spp., Thuc la chn hng u: Ampicilin 1 g
cp. Enterococcus faecalis, tim tnh mch, 6 gi tim mt ln, phi hp
Bacteroides spp.. vi gentamicin 5 mg/kg tim tnh mch ngy
mt ln.
Nu ngi bnh c chng ch nh dng
gentamicin hoc ampicilin, hy dng thuc
la chn th hai cefotaxim 1 g, tim tnh
mch, 4 ln mt ngy hoc ceftriaxon 1 g
72 S dng hp l thuc khng sinh tim tnh mch, mt liu duy nht trong 24
DTQGVN gi. Ch cc cephalosporin khng c hiu
lc chng li Enterococcus faecalis.
Vim ng mt Cc trc khun Gram Dng gentamicin 5 mg/kg, tim tnh mch
trn. m mt ln mt ngy; phi hp vi metronidazol
Enterobacter spp, 500 mg, 12 gi mt ln, v ampicilin 2 g
Enterococcus faecalis. tim tnh mch, 6 gi tim mt ln.
Nu ngi bnh c chng ch nh dng
gentamicin th dng cefotaxim hoc
ceftriaxon. Ch cc cepha-
losporin khng c hiu lc chng li
Enterococcus faecalis.
Vim mng Nhiu loi vi khun Nn dng ampicilin 2 g tim tnh mch 6 gi
bng do thng hiu kh v k kh. mt ln, phi hp vi gentamicin 5 mg/kg
ph tng. tim tnh mch ngy mt ln, v
metronidazol 500 mg tim tnh mch, 12 gi
mt ln.
Vim mng Trc khun Gram Thuc la chn hng u: Ampicilin phi
bng tin pht m, E. coli, hp vi gentamicin ging nh trn.
do vi khun. Strep. pneumoniae, Thuc la chn th hai: Dng cefotaxim 1 g
Enterococcus. tim tnh mch, 4 ln mt ngy hoc
ceftriaxon 1 g tim tnh mch, liu duy nht
trong 24 gi. Ch cephalosporin khng c
hiu lc chng li Enterococcus faecalis.

88
89

Vim mng Staph. epidermidis, Dng vancomycin 2 g tim trong mng bng
bng bin Trc khun Gram m mt liu duy nht, gi mng bng
chng do thm (E. coli, Klebsiella trong 6 n 8 gi, phi hp vi gentamicin
tch mng spp., Peudomonas 80 mg tim trong mng bng (cn trnh
bng. spp.), hoc nhim iu tr gentamicin trong thi gian di
nm, khng ph bin ngi bnh thm tch mng bng bi nguy
nhng rt kh tr dit. c nhim c nng dy thn kinh VIII).
Vim nh ti Trc khun Gram m, Ung 500 mg amoxicilin kt hp vi 125 mg
tha. vi khun k kh. acid clavulanic (bit dc Augmentin), 8 gi
ung mt ln hoc metronidazol 400 mg,
ung 8 gi mt ln, phi hp vi cephalexin
500 mg, ung 6 gi mt ln. Trng hp
nhim khun nng iu tr ging nh vim
mng bng.
Vim i trng Clostridium difficile. Dng 200 - 400 mg metronidazol, ung 8 gi
mng gi. mt ln, trong 7 - 10 ngy. Trnh ung
vancomycin.
Vim ty cp. Cc thuc khng sinh khng c ch nh
trong iu tr ban u. Nu pht trin
thnh p xe ty th iu tr bng khng
sinh ging nh vi vim mng bng.
Nhim khun ng tit niu sinh dc
Bnh nhim Vi khun c nhiu Cch iu tr c khuyn co
khun kh nng gy bnh
nht
Vim bng E.coli, Proteus Ung trimethoprim 300 mg/ngy, trong 3
quang cp. mirabilis, Klebsiella ngy hoc ung cephalexin 500 mg, 12 gi
spp. coliforms. mt ln, trong 5 ngy, hoc 500 mg
amoxicilin kt hp vi 125 mg acid
clavulanic, 8 gi ung 1 ln, hoc
nitrofurantoin 50 mg, 6 gi ung mt ln,
trong 5 ngy.
Vim thn b E. coli. Dng ampicilin 2 g tim tnh mch 6 gi mt
thn cp. ln, kt hp vi gentamicin 5 mg/kg th
trng mt ln mi ngy, ti khi c kt qu
khng sinh .
Nhim khun Candida albicans, Dng clotrimazol 500 mg t m o mi
m o/vim Trichomonas ngy hoc dng kem nystatin 100.000 n
m o. vaginalis, v bi trong m o hng ngy trong 7
Gardenerella ngy.
vaginalis. Ung trinidazol hoc metronidazol 2 g mt
liu duy nht v iu tr c ngi bn tnh.
DTQGVN Ung metronidazol 400 mg Sln,
dng12hp
gi l
ung
thuc
khng sinh 73 mt ln, hoc tinidazol 2 g ln, ung mt
liu duy nht.
Vim mng Chlamydia Doxycyclin 100 mg ung 12 gi 1 ln trong
mch nho/vim trachomatis, 10 ngy hoc azithromycin 1 g, ung ngy
c t cung. Neisseria gonorrhoea. mt liu duy nht. Ciprofloxacin 500 mg
ln, ung ngy mt liu duy nht, hoc
ceftriaxon 250 mg tim bp mt liu duy
nht.

90
91

Bnh vim cc Mc bnh qua ng Nhim khun nh: Ceftriaxon 250 mg tim
c quan trong tnh dc: bp mt liu duy nht phi hp vi
khung chu. Chlamydia metronidazol 400 mg,12 gi ung mt ln
trachomatis, trong 14 ngy, v doxycyclin 100 mg, 12 gi
Neisseria gonorrhoea. ung mt ln trong 14 ngy.
Mc bnh khng qua Nhim khun nng: Ceftriaxon 1 g tim
ng tnh dc : tnh mch mi ngy, hoc cefotaxim 1 g
Vi khun ch hn hp tim tnh mch 8 gi mt ln phi hp vi
(Mycoplasma spp, vi metronidazol 500 mg tim tnh mch 12 gi
khun k kh). mt ln v doxycyclin 100 mg/ln, 12 gi
ung 1 ln. Vi ph n c thai, khng dng
doxycyclin, thay th bng erythromycin 500
mg tim tnh mch hoc ung, 6 gi mt
ln.
Nhim khun da, c, xng
Bnh nhim Vi khun c nhiu Cch iu tr c khuyn co
khun kh nng gy bnh
nht
Vim m t bo Cephalexin 500 mg, cch 6 gi ung mt ln
v vim qung. hoc flucloxacilin/dicloxacilin 500 mg, cch
6 gi ung mt ln, c th dng oxacilin
thay cc thuc trn cng rt tt.
i vi nhim khun nng: Dng
benzylpenicilin 600 mg ti 1000 mg, tim
tnh mch 6 gi mt ln, phi hp vi
flucloxacilin/dicloxacilin 2 g tim tnh mch,
6 gi mt ln, hoc thay
flucloxacilin/dicloxacilin bng oxacilin.
Chn thng c, Staphylococcus Flucloxacilin/dicloxacilin 1 - 2 g tim tnh
m mm, tn aureus, Strep. mch 6 gi mt ln, hoc thay bng
thng dp nt pyogenes, Clostridium oxaciclin, phi hp vi gentamicin, 5 mg/kg
v vt m perfringens, trc th trng trong 24 gi, dng t 5 n 10
chm. khun Gram m. ngy v metronidazol 500 mg tim tnh
mch 12 gi mt ln.
Vt thng do Vt cn do ngi: Bt u dng procain penicilin 1 g tim
cn, t, m Staph. aureus, bp, tip theo dng Augmentin (500 mg
nn . Eikenella corro- amoxicilin kt hp 125 mg acid clavulanic),
dens, Streptococcus 8 gi mt ln trong 5 n 10 ngy, thm
spp., vi khun k kh tim chng nga un vn.
to beta lactamase. Vi ngi d ng penicilin, dng metronidazol
Vt cn do ng vt: phi hp vi doxycyclin hoc trimethoprim-
Pasteurella multocida, sulfamethoxazol.
Staph. aureus,
Streptococ-
cus spp., vi khun k
kh.
Vim xng ty Staph. aureus. Flucloxacilin/dicloxacilin 2 g tim tnh mch
v vim khp 6 gi mt ln, hoc thay bng oxacilin.
nhim khun. Trong tt c cc trng hp: Dng t nht 2 - 4
tun vi ngi vim xng ty v vim khp
nhim khun cp, hoc 2 - 6 tun trong
nhim khun mn tnh. Sau dng:
flucloxacilin/dicloxacilin 1 g/ln, ung 6 gi
mt ln (hoc oxacilin) trong t nht 6 tun
i vi bnh nhim khun cp v vi thng
trong trng hp nhim khun mn tnh.

92
93

Vim xng - ty. Staphylococcus Vancomycin 1 g tim truyn tnh mach

khng methicilin. chm, 12 gi mt ln. Tip theo dng:
Rifampicin 600 mg ung hng ngy, phi
hp vi mui natri ca acid fusidic (hoc
74 S dng hp l thuc khng sinh natri fusidat) 500 mg, 12 gi ung mt ln.
DTQGVN Thi gian iu tr c quyt nh theo
p ng iu tr.
Nhim khun h thn kinh trung ng
Bnh nhim Vi khun c nhiu Cch iu tr c khuyn co
khun kh nng gy bnh
nht
Vim mng no N. meningitidis, iu tr phi nhm chng li 3 vi khun gy
iu tr theo Streptococcus bnh ph bin nht. Cy mu tm vi
kinh nghim. pneumoniae, khun gy bnh v lm khng sinh .
Listeria iu tr theo kinh nghim: Cefotaxim 100
monocytogenes, v mg/kg/ ngy, liu ti a 6 g/ngy, tim
Haemophilus tnh mch, chia 3 ln, hoc ceftriaxon 50
influenzae tr em. mg/kg/ngy, liu ti a 4 g/ngy, chia 1-2
ln. Cng vi: Benzylpenicilin 180
mg/kg/ngy, liu ti a 12 g/ngy, tim
tnh mch, chia 6 ln.
Thi gian iu tr cn ko di v cng cn
tim tnh mch dexamethason chng li
nh hng nguy him ca vim h thn kinh
trung ng.
nhng ni c nguy c lan truyn thnh
dch vim mng no do Neisseria
meningitidis, nn iu tr d phng cho tt
c mi ngi trong nh c tip xc, nhn
vin y t, bn ca ngi bnh v nhng ngi
khc sng gn ngi m. iu tr d phng
bng rifampicin 600 mg ung 12 gi mt
ln trong t nht 2 ngy, hoc
ciprofloxacin 500 mg ung mt liu duy
nht.
Ch ciprofloxacin mc du c gii thiu
l thuc d phng nhng khng dng
iu tr nhim khun.
Vim mng no Cc chng c kh nng khng khng sinh, do
mc phi th nhy cm khng sinh rt quan
bnh vin. trng.
iu tr theo kinh nghim bng vancomycin
1 g tim tnh mch, 12 gi mt ln (tr em
50 mg/kg, ti a 2 g, 6 gi mt ln).
Phi hp vi cefotaxim 2 g tim tnh mch, 6
gi mt ln hoc ceftriaxon 2 g, 12 gi mt
ln hoc meropenem 1 g (tr em 40 mg/kg
ti ti a 1 g) tim tnh mch, 8 gi mt ln.
(meropenem c a chn trc imipenem do
nguy c gy co git thp hn.).

94
95

p xe no hoc Nhiu loi vi khun, Ht m v xc nh vi khun l rt quan

tch m di bao gm: trng, kt hp vi khng sinh tm
mng cng. Streptococcus milleri nhy cm ca vi khun.
v vi khun k kh. iu tr c bn: Benzylpenicilin 1,8 g (tr
Nhim Nocardia v em 60 mg/kg, ti a ti 1,8 g) tim tnh
Actinomyces cng c mch 4 gi mt ln phi hp vi metronidazol
th xy ra. 500 mg(tr em 12,5 mg/kg, ti a ti 500
Sau nhim khun tai, mg) tim tnh mch 8 gi mt ln v
nhiu kh nng nht cefotaxim 2 g (tr em 50 mg/kg, ti a ti 2
do nhim trc khun g) tim tnh mch 6 gi mt ln hoc
Gram m ng rut. ceftriaxon 2 g (tr em 50 mg/kg, ti a ti 2
Sau chn thng hoc g) tim tnh mch 12 gi mt ln. Trong tr-
phu thut c th ng hp p xe no sau phu thut thn kinh:
nhim Staph. aureus. dng vancomycin 1 g tim tnh mch 12 gi
mt ln (tr em 15 mg /kg, ti a ti 500
mg, tim tnh mch 6 gi mt ln).
p xe ngoi Staph. aureus. p xe ngoi mng cng thng do vim xng
mng cng. ty gn hoc nhim khun a. Phu
thut khn cp l rt quan trng v iu
tr cn da trn nhum Gram v nui cy t
phu thut. Trc phu thut, iu tr theo
kinh nghim, nn bt u bng
flucloxacilin/ dicloxacilin 2 g (tr em 50
mg/kg, ti a ti 2 g) tim tnh mch 6 gi
mt ln (c th thay bng oxacilin), phi hp
DTQGVN vi gentamicin 5 mg/kgS tim tnh
dng hp mch
l thuc
khng sinh 75 ngy mt ln (tr em 7,5 mg/kg/ngy, tim
tnh mch, chia t 1 n 3 ln).
Vim no Herpes simplex virus. Aciclovir 10 mg/kg tim tnh mch, 8 gi
Herpes simplex. mt ln, trong 14 ngy.

Vim no hoc Toxoplasma gondii. Ung sulfadiazin 1 g, phi hp vi

p xe do pyrimethamin 25 mg, 8 gi ung mt ln v
Toxoplasma. acid folinic 7,5 mg ung mi ngy, thi gian
iu tr t 3 n 6 tun. Tuy nhin bnh
thng ti pht, nn cn thit phi iu tr
duy tr bng mt na liu nu trn i
vi ngi suy gim min dch.
Ngi d ng vi sulfonamid c iu tr vi
clinda-
mycin 600 mg, ung 6 gi mt ln.
Nhim khun mt
Bnh nhim Vi khun c nhiu Cch iu tr c khuyn co
khun kh nng gy bnh
nht
Bnh vim m Staphylococcus spp. Dng flucloxacilin/dicloxacilin 500 mg, ung
mt/nhim 6 gi mt ln (hoc thay bng oxacilin).
khun m mt. Nu vim m mt kt hp vi bnh trng c
: Ung doxycyclin 100 mg/ln; ung 12
gi mt ln, trong 2 tun.
Vim tuyn l. Staphylococcus spp. Nhim khun tuyn l do tc nghn, trong
trng hp nh, c th nh thuc nh mt
lm sn cha km sulfat 0,25%,
phenylephrin 0,12%, 1 - 2 git/ln, 3
ln/ngy. Vim tuyn l cp nng thng
do S. aureus hoc S. pyogenes, iu tr
bng flucloxacilin/dicloxaci-

96
97

lin, ung 500 mg/ln, cch nhau 6 gi. C

th dng oxacilin thay th.

Vim m t bo Streptococcus Tr em di 5 tui m khng c chn thng

hc mt. pneumoniae hoc hoc vt thng, nguyn nhn c nhiu
Haemophilus influen- kh nng nht l S. pneumonia hoc Hib,
zae typ b (Hib). iu tr bng cefotaxim 50 mg/kg c th
tng liu n 2 g/ngy, tim tnh mch
cch 8 gi 1 ln, hoc ceftriaxon 50 mg/kg,
ti a 2 g tim tnh mch, v amoxicilin
phi hp vi acid clavulanic 15 mg/kg, ti a
500 mg ung, c 8 gi 1 ln trong t nht 1
tun, n khi khi.
i vi tr ln hn 5 tui v ngi ln, nhiu
kh nng do Staphylococcus hoc
Streptococcus hn, v vy khi iu tr,
thm flucloxacilin/dicloxacilin 500 mg, ti
a 2 g/ln, 6 gi 1 ln. C th dng oxacilin
thay th.
Vim kt mc. Adenovirus Hu ht cc trng hp l do d ng hoc do
Haemophilus kch ng. Ph bin do nhim adenovirus.
influenzae (c bit Khuyn co iu tr triu chng, chm gc
tr nh), lnh v nh thuc co mch ti ch nh
Streptococcus phenylephrin 0,12%.
pneumoniae, Trng hp nh: Dng thuc nh mt
Streptococcus propamidin 0,1%, 1 - 2 git/ln, 3 - 4
pyogenes, Staph. ln/ngy.
aureus, i khi l Nng: Polymyxin B 5000 v/ml v
Neisseria neomycin 2,5 mg/ml v thuc nh mt
gonorrhoeae. Herpes gramicidin 25 microgam/ml, nh mt 1 - 2
simplex virus nu l git mi gi.
vim nang kt mc.
Vim kt mc N. gonorrhoeae. iu tr khng sinh ti ch khng . Ch
do lu cu. lu cu khun c t l khng penicilin ph
bin gia tng. Dng cefotaxim 50 mg/kg tim
tnh mch 8 gi 1 ln, hoc ceftriaxon 50
mg/kg tim tnh mch hng ngy trong 1
tun. ng nhim Chlamydia trachomatis
thng thy mt s vng. V vy cn ung
thm erythromycin.
Bnh mt ht. Chlamydia Nhim cp tng t nh nhim vi khun, v
trachomatis. vim kt mc ti din c th gy m. i vi
tr s sinh v tr em di 6 kg dng
erythromycin 10 mg/kg ung 6 gi mt ln
76 nh hng s dng cc cephalosporin trong 3 tun, i vi ngi ln v tr em trn 6
DTQGVN kg dng azithromycin 1 g (tr em 20 mg/kg,
ti a 1 g) ung 1 liu duy nht.
Tn thng Nhim a khun. Vancomycin 1 g (tr em: 15 mg/kg, ti a 1
xuyn mt. g) tim tnh mch, phi hp vi ciprofloxacin
750 mg. Hoc c th dng phi hp mt liu
duy nht gentamicin 5 mg/kg (cho mi la
tui). Tim tnh mch cefotaxim 1 g (tr em
50 mg/kg, ti a 1 g) hoc tim tnh mch
ceftriaxon 1 g (tr em 50 mg/kg, ti a 1 g).
Vim vng mc Gp ngi bnh AIDS, suy gim min dch
do virus c bo. do nguyn nhn khc v ngi b ung th.
iu tr bng ganciclovir 5 mg/kg cho mi
la tui, tim tnh mch 12 gi/ln, lin tc
trong 2-3 tun.

98
 99

Herpes zoster Aciclovir 800 mg (tr em 20 mg/kg, ti a

mt 800 mg) mt ln, ung 5 ln/ngy (cch 4
(Zona mt). gi khi thc/1 ln) ko di t nht 10 ngy,
hoc famciclovir 250 mg hoc valaciclovir
1 g/ln, cch 8 gi ung 1 ln, dng trong
10 ngy, hoc aciclovir 10 mg/kg (cho mi
la tui) tim tnh mch cch 8 gi mt ln,
dng trong 10 ngy.

3484 nh hng s dng cc 3529dng chng Pseudomonas aeruginosa

3485 cephalosporin 3530phi c
3531cn nhc rt thn trng v c s khc
3486S pht trin mnh m ca cc3532nhau ln v t l khng thuc, ty thuc
3487cephalosporin trong thp k qua rt ng3533vo vic s dng khng sinh cc bnh
3488c ghi nhn, v to ra mt nhm thuc rt3534vin, cc cng ng v cc thnh ph.
3489c quan tm. 3535Cephalosporin th h 4, nh cefepim, c
3490Mc d cc cephalosporin c phn loi3536ph khng khun rng so vi thuc th h
3491da vo cu trc ha hc, dc l lm sng,35373 v c bn vng cao i vi s thy
3492khng beta - lactamase, hoc ph khng3538phn bi cc beta - lactamase qua trung
3493khun, nhng phn loi theo th h c3539gian th nhim sc v plasmid. Khng
3494chp nhn l rt hu ch, tuy cha y3540sinh th h 4 c dng iu tr c
3495. 3541hiu nhim trc khun Gram m a kh
3496Phn loi cephalosporin theo th h da3542khng vi cephalosporin th h 3.
3497vo nhng c trng tc dng khng
3543C ch khng cephalosporin ca vi
3498khun ca thuc.
3544khun
3499Cephalosporin th h 1, nh cefalotin v
3545Kh nng khng cephalosporin ca vi khun
3500cefazolin c tc dng tt chng vi khun
3546c th do khng sinh khng ti c cc v
3501Gram dng, nhng t c tc dng chng vi
3547tr tc dng, do bin i cc protein gn
3502khun Gram m. Phn ln cu khun Gram
3548penicilin (PBP), ch ca cephalos-porin,
3503dng (tr Enterococcus, Staph. aureus
3549hoc do cc enzym beta - lactamase ca vi
3504khng methicilin v Staph. epidermidis)
3550khun ph hy vng beta - lactam lm mt
3505nhy cm vi thuc. Tuy vy, Vit Nam cc
3551tc dng ca cephalosporin.
3506chng vi khun thng c mc khng khng
3552S bin i ca 2 PBP (1A v 2X) lm cho
3507sinh cao. a s vi khun k kh ming th-
3553cephalospo-
3508ng nhy cm, nhng nhm vi khun
3554rin gn vi i lc thp hn, lm cho
3509Bacteroides fragilis thng khng thuc. Tc
3555Strepto-
3510dng chng Moraxella catarrhalis, E. coli, K.
3556coccus pneumoniae khng li cephalosporin
3511pneumoniae v Pr. mirabilis thng l tt,
3557th h 3. Ba PBP c trng lng phn t ln
3512nhng hin nay c hin tng khng thuc
3558vn c i lc thp vi cephalosporin.
3513 nhiu ni ti Vit Nam.
3559Tuy nhin, c ch khng cephalosporin
3514Cephalosporin th h 2 c tc dng chng
3560ph bin nht l ph hy cephalosporin
3515vi khun Gram m tt hn i cht nhng
3561bng cch thy phn vng beta - lactam.
3516km hn nhiu so vi cephalosporin th
3562Nhiu vi khun Gram dng tit mt lng ln
3517h 3. Mt nhm ph th h 2 (cefoxitin,
3563beta - lactamase ra xung quanh, vi khun
3518cefotetan, cefmetazol) cng c coi l c
3564Gram m cng sn xut beta - lactamase
3519tc dng chng Bacteroides fragilis.
3565nhng t hn.
3520Cephalosporin th h 3 ni chung t c tc
3566Cc cephalosporin nhy cm vi beta -
3521dng chng cu khun Gram dng hn
3567lactamase mc khc nhau. V d,
3522th h 1, nhng c tc dng tt hn nhiu
3568trong cc cephalosporin th h 1,
3523i vi h Enterobacteriaceae k c cc
3569cefazolin nhy cm vi s thy phn bi
3524chng tit beta - lactamase. Mt nhm ph
3570beta - lactamase, do Staph. aureus tit ra,
3525th h 3 ceftazidim, cefoperazon cng c
3571nhiu hn so vi cefalotin.
3526tc dng chng Pseudomonas aeruginosa,
3572Cefoxitin, cefuroxim v cephalosporin th
3527nhng t c tc dng chng cu khun Gram3573h 3 khng li s thy phn bi beta -
3528dng hn cc thuc th h 3 khc. Tc3574lactamase ca vi khun Gram m hn

100
 101

3575cephalosporin th h 1. Cephalosporin th3633- ty vi nng iu tr vim

3576h 3 nhy cm vi s thy phn bi beta-3634mng no. Cephalosporin cng qua c
3577lactamase (typ I) cm ng c th nhim3635nhau thai, v t nng cao trong hot
3578sc m ha. 3636dch v dch mng ngoi tim. S thm ca
3579S cm ng cc beta - lactamase typ I ny3637cc cephalosporin th h 3 vo trong thy
3580xy ra khi iu tr nhim cc trc khun3638dch mt kh tt nu dng ng ton
3581Gram m i kh (c bit l Enterobacter3639thn, nhng thuc thm km vo dch thy
3582spp., Citrobacter freundii, Morganella,3640tinh th. Thuc t nng iu
3583Serratia, Providencia, v Pseudomonas3641tr nhim khun mt do vi khun Gram d-
3584 aeruginosa) bng cc cephalosporin th h3642ng v Gram m
DTQGVN nhkhi dng
hng s ng ton
dng cc
3585 3 hoc
cephalosporin 2
77 v/hoc imi-3643 thn.
3586penem. Vic dng thuc ny c th dn3644Nng thuc trong mt thng cao v cao
3587n vic khng tt c cc cephalosporin3645nht khi dng cefoperazon v cefpiramid.
3588th h 3. Tuy nhin, cephalosporin th3646Cephalosporin th h 1
3589h 4, nh cefepim, l nhng cht cm ng3647Cephalotin hp thu km khi ung nn ch
3590yu ca beta - lactamase typ I v t b3648s dng dng tim. Do gy au ni tim
3591thy phn bi beta lactamase typ I hn3649bp nn thuc thng c tim tnh mch.
3592so vi thuc th h 3. 3650Nng ti a ca thuc trong huyt t-
3593Mt iu quan trng cn nh l khng mt3651ng khong 20 microgam/ml sau khi tim
3594cephalosporin no c tc dng ng tin3652bp liu 1 g. Na i ca cephalotin
3595cy i vi cc vi khun sau: Streptococcus3653ngn (30 - 40 pht) v c chuyn ha v
3596pneumoniae khng penicilin,3654thi tr qua thn. Khong 20 - 30% thuc
3597Staphylococcus aureus khng methicilin,3655thi tr di dng kh acetyl.
3598Staphylococcus epidermidis khng3656Cephalotin khng vo dch no - ty vi
3599methicilin v Staphylococcus coagulase -3657mc ng k nn thuc ny khng
3600m tnh khc, Enterococ-3658dng iu tr vim mng no.
3601cus, Listeria monocytogenes, Legionella3659Trong s cc cefalosporin th cefalotin t
3602pneumo- 3660chu tc dng ph hy nht ca beta -
3603phila, Legionella micdadei, C. difficile,3661lactamase do t cu khun tit ra nn rt
3604Pseudomonas maltophilia, P. putida,3662c hiu lc i vi nhim t cu khun
3605Campylobacter jejuni, cc loi3663nng, nh vim mng trong tim.
3606Acinetobacter, v tt nhin khng c tc3664Ph khng khun ca cefazolin ging vi
3607dng chng nm nh Candida albicans. 3665cefalotin, mc d cefazolin c tc dng tt
3608c tnh chung ca cephalosporin 3666hn i vi E. coli v cc chng Klebsiella,
3609Cephalexin, cephradin, cefaclor, cefadroxil,3667nhy cm hn cefalotin i cht vi beta -
3610loracarbef, cefprozil, cefixim, cefpodoxim3668lactamase ca t cu khun. Cefazolin
3611proxetil, ceftibuten, v cefuroxim axetil -3669dung np tng i tt sau khi tim bp v
3612c hp thu tt sau khi ung, nn c th dng3670tim tnh mch. Nng ca thuc trong
3613theo ng ny. Cefalotin v cefapirin gy3671huyt tng cao hn cefalotin sau khi tim
3614au khi tim bp nn ch dng tim tnh3672bp (64 microgam/ml sau khi tim 1 g)
3615mch. Cc thuc khc c th dng tim bp3673hoc tim tnh mch. Na i thi tr ca
3616hoc tim tnh mch. 3674thuc di hn, khong 1,8 gi. thanh
3617Cc cephalosporin thi tr ch yu qua3675thi thn ca cefazolin thp hn
3618thn, v vy phi thay i liu cc thuc3676cefalotin, iu ny c l do cefazolin thi
3619ny i vi ngi suy thn. Probenecid lm3677tr qua lc cu thn, cn cefalotin thi tr
3620chm s tit qua ng thn ca phn ln cc3678qua ng thn.
3621cephalosporin tr latamoxef (Moxa-3679Cefazolin lin kt vi protein huyt tng
3622lactam). Ring cefoperazon v cefpiramid3680mc cao (khong 85%). Trong cc
3623thi tr ch yu qua mt. Cefalotin,3681cephalosporin th h 1 th cefazolin thng
3624cefapirin, v cefotaxim chuyn ha di dng3682c a dng hn v na i thuc di hn,
3625kh acetyl, cc cht chuyn ha ny t c3683nn thuc c th s dng t ln hn trong
3626tc dng khng khun hn. Cc cht3684ngy.
3627chuyn ha kh acetyl cng o thi qua3685Cefalexin dng ng ung. Ph khng
3628thn. Cc cephalosporin khc khng3686khun ca thuc ging cc cephalosporin
3629chuyn ha. 3687th h 1, tuy nhin thuc t c tc dng
3630Nhiu cephalosporin nh cefuroxim,3688khng t cu khun tit ra beta-lactamase.
3631moxalactam, cefotaxim, ceftriaxon,3689Nng ti a trong huyt tng ca
3632cefepim, ceftizoxim thm c vo dch no3690cephalexin l 16 microgam/ml sau khi ung

102
103

36910,5g, lng ny c ch nhiu vi3749th h 3 khc. Nng trong huyt t-

3692khun Gram m v Gram dng gy bnh3750ng khong 22 microgam/ml sau khi tim
3693nhy cm vi cefalotin. Thuc khng3751bp 1g. Na i thi tr ca thuc khong
3694chuyn ha, v khong 70% n 100%375240 pht. Vai tr c bit ca cefoxitin l
3695thuc thi tr qua nc tiu. 3753iu tr nhim vi khun k kh v nhim
3696Cephradin c cu trc ging cephalexin, v3754hn hp c vi khun k kh v hiu kh,
3697tc dng in vitro hu nh ging cephalexin.3755nh vim tiu khung, p xe phi. Thuc c
3698Cephradin khng b chuyn ha, sau khi3756hiu qu vi bnh lu, ngay c khi bnh do
3699hp thu nhanh qua ng tiu ho, thuc3757Neisseria tit peni-
3700thi tr di dng khng bin i qua nc3758cillinase.
3701tiu. Cephradin c th dng ng ung,3759Cefaclor dng ng ung. Nng thuc
3702tim bp, hoc tim tnh mch. Sau khi3760trong huyt tng sau khi ung bng
3703ung thuc, kh c th phn bit c3761khong 50% nng t c sau khi ung
3704cephradin v cephalexin. Mt s chuyn gia3762mt liu tng ng cephalexin. Tuy nhin
3705cho rng hai thuc ny c th dng thay3763cefaclor c tc dng chng H. influenzae v
3706th nhau. Cephradin c hp thu tt, n3764M. catarrhalis tt hn, mc d mt vi
3707mc nng thuc trong huyt tng khi3765chng trn tit ra beta - lactamase c th
3708ung gn bng khi tim bp (khong 103766khng thuc.
3709n 18 microgam/ml sau khi ung hoc3767Loracarbef l mt carbacephin dng ng
3710tim bp 0,5 g). 3768ung, tc dng ging cefaclor, ngha l
3711Cefadroxil l cht tng t parahydroxy ca3769bn vng hn i vi mt vi beta -
3712cepha- 3770lactamase. Na i thi tr trong huyt
3713lexin. Nng ca cefadroxil trong huyt
3771thanh l 1,1 gi, liu ung thay i t
3714tng v nc tiu cao hn i cht so vi
3772200 mg n 400 mg, 12 gi 1 ln.
3715nng cephalexin. Thuc c th dng -
3773Cefuroxim rt ging cefamandol v cu
3716ng ung 1 hoc 2 ln trong mt ngy
3774trc ha hc v tc dng khng khun in
3717iu tr nhim khun ng tit niu. Tc
3775vitro, mc d c phn bn vng hn vi
3718dng ca thuc in vitro ging cephalexin.
3776beta - lactamase. Na i thi tr di hn
3719Cephalosporin th h 2 3777cefamandol (1,7 gi so vi 0,8 gi). Thuc
3720Cefamandol c tc dng khng khun tt3778c th dng 8 gi 1 ln. Nng thuc
3721hn cc cephalosporin th h 1 i vi3779trong dch no ty bng khong 10% nng
3722mt s vi khun Gram m. iu ny c3780 trong huyt tng. Cefuroxim c hiu
3723bit r vi cc chng Enterobacter, Proteus3781qu (nhng km hn ceftriaxon) khi iu
3724indol dng tnh, Klebsiella. Cc chng H.3782tr vim mng no do H. influenzae (k c
3725influenzae cha beta - lactamase TEM - 13783vi cc chng khng ampicilin), N.
3726ca plasmid khng cefamandol. Phn ln3784meningitidis, v Strep. pneumoniae.
3727cc cu khun Gram dng nhy cm vi3785Cefuroxim acetil l 1- acetyloxyethyl ester
3728cefamandol. Na i ca thuc l 45 pht,3786ca cefuroxim. Khong 30 - 50% liu ung
3729thuc thi tr di dng khng bin i qua3787c hp thu sau khi ung. Sau khi thy
3730
78nc tiu.
nh Nng
hng ca thuc
s dng trong huyt t-3788phn thnh cefuroxim, nng trong
cc cephalosporin
3731 ng l 20 - 36 microgam/ml sau khi tim3789huyt tng thay i.
DTQGVN
3732bp 1 g.
3790Cefonicid c tc dng khng khun in vitro
3733Cefoxitin l mt cephamycin do3791ging cefamandol. Na i thi tr ca
3734Streptomyces lactam-
3792thuc khong 4 gi. Dng mi ngy 1 ln,
3735durans sn sinh. Thuc ny khng beta -
3793thuc c tc dng i vi cc bnh do vi
3736lactamase do mt s trc khun Gram m
3794khun nhy cm vi thuc.
3737tit ra. Thuc c tc dng khng khun tt
3795Cefotetan l mt cephamycin, v ging
3738hn cefalotin vi cc vi khun Gram m,
3796cefoxitin, c tc dng tt chng B. fragilis.
3739mc d tc dng km hn so vi
3797Thuc cng c tc dng chng mt vi loi
3740cefamandol i vi cc loi Enterobacter,
3798Bacteroides khc, v tc dng hi km
3741H. influenzae. Tc dng ca cefoxitin vi cc
3799hn cefoxitin i vi cc vi khun hiu kh
3742vi khun Gram dng km hn so vi c
3800Gram m. Sau khi tim bp liu 1g, nng
3743cefamandol v cc cephalosporin th h 1.
3801 nh trong huyt tng ca cefotetan
3744Cefoxitin c tc dng tt hn cc
3802trung bnh l 70 microgam/ml. Na i
3745cephalosporin th h 1 v 2 khc (tr
3803thi tr khong 3,3 gi. Gim prothrombin
3746cefotetan) i vi vi khun k kh, c
3804huyt km theo xut huyt xy ra ng-
3747bit l B. fragilis. Tc dng ny ging vi
3805i bnh suy dinh dng khi dng cefotetan v
3748moxalactam v tt hn cc cephalosporin

104
 105

3806c th phng c nu cng cho dng3863ha, 90% lng thuc c thy trong nc
3807vitamin K. 3864tiu.
3808Ceforanid c cu trc v tc dng khng3865In vitro, ceftriaxon c hot tnh khng
3809khun ging cefamandol, tuy nhin thuc3866khun rt ging cefotaxim v ceftizoxim.
3810t tc dng hn vi H. influenzae. Na i3867Na i khong 8 gi l mt c im
3811thi tr ca thuc khong 2,6 gi v c3868khc bit ni bt. Dng thuc 1 - 2 ln
3812tim 12 gi 1 ln. 3869trong ngy c tc dng tt i vi ngi b
3813Cefprozil l thuc dng ng ung c tc3870vim mng no, trong khi liu dng mt
3814dng tt hn cc cephalosporin th h 13871ln trong ngy c tc dng tt i vi cc
3815i vi cc Streptococ-3872nhim khun khc. Mt na lng thuc c
3816cus nhy cm vi penicilin, E. coli, P.3873thy trong nc tiu; phn cn li thi tr
3817mirabilis, Klebsiella spp., v Citrobacter3874qua mt. Dng mt liu duy nht ceftriaxon
3818spp.. Na i thi tr ca thuc trong3875(125 mg) c hiu qu trong iu tr bnh
3819huyt thanh l 1,2 n 1,4 gi. Liu dng3876lu niu o, trc trng, c t cung,
3820l 250 mg n 500 mg, 12 n 24 gi 13877hoc hng, bao gm bnh do vi khun tit
3821ln. 3878penicilinase.
3822Cephalosporin th h 3 3879Cefixim dng ng ung, so vi cc
3823Cefotaxim rt bn vng i vi nhiu beta 3880cephalosporin th h 2 ung, th km tc
DTQGVN
3824 lactamase do vi khun tit ra, c tc 3881dng trn cu khun Gram
nh dng
hng s hn,
dng nh-
cc
cephalosporin
3825dng khun Gram dng v3882ng c tc dng tt hn trn
tt trn cc vi 79 Entero-
3826Gram m hiu kh. Tuy nhin, tc dng3883bacteriaceae, H. influenzae v N-
3827i vi B. fragilis thp hn so vi3884gonorrhoeae tit beta lactamase. Thuc
3828clindamycin v metronidazol. Na i ca3885ny c t tc dng trn Staph. aureus. Na
3829cefotaxim trong huyt tng vo khong 13886i trong huyt thanh khong 3 gi. Liu
3830gi, nn dng thuc cch 4 - 8 gi 1 ln i3887dng 200 mg cch 12 gi mt ln, hoc
3831vi nhng nhim khun nng. Trong c3888400 mg cch 24 gi mt ln.
3832th, thuc c chuyn ha thnh3889Cefpodoxim proxetil l mt cephalosporin
3833desacetyl cefotaxim, cht ny c hot tnh3890th h 3 ung, c tc dng rt ging
3834i vi a s cc vi khun km hn so vi3891cefixim, nhng c tc dng tt hn mt t
3835cefotaxim. Tuy nhin n c hot tnh hip3892trn Staph. aureus. Na i trong huyt
3836ng vi cefotaxim chng mt s vi khun.3893thanh l 2,2 gi. Liu dng t 200 mg n
3837Cefotaxim rt c hiu qu i vi trng3894400 mg, mt ln trong 12 gi.
3838hp vim mng no do H. influenzae, Strep.3895Cephalosporin th h 3 c tc dng
3839pneumoniae nhy cm vi penicilin v N.3896tt trn Pseu-
3840meningitidis. 3897domonas
3841Latamoxef (Tn khc: Moxalactam) c cu3898Cefoperazon t tc dng trn vi khun
3842trc c o (cu trc oxa - beta lactam).3899Gram dng hn so vi cefotaxim v t tc
3843Cu trc ny c to ra do c s thay th3900dng trn nhiu loi Gram m hn so vi
3844nguyn t lu hunh trong nhn cephem3901cefotaxim hay moxalactam. Thuc tc
3845bng mt oxygen. 3902dng mnh hn trn P. aeruginosa so vi hai
3846Moxalactam c hot tnh khng khun3903thuc trn, nhng km hn so vi ceftazidim.
3847rng, c trng cho cephalosporin th h3904Mt iu bt li l cc vi khun khng
38483. nhn thy c du hiu xut huyt3905thuc xut hin trong khi iu tr.
3849nhiu trn lm sng (i khi t vong) sau3906Cefoperazon tc dng trn B. fragilis ging
3850khi dng moxalactam, v thuc ny c th3907nh cefotaxim. Cefoperazon t bn vng vi
3851gy chy mu do lm gim prothrombin3908beta lactamase hn mt t so vi cefotaxim
3852huyt (d phng c bng cch dng 10 mg3909hoc cc thuc nhm 7-methoxycephem.
3853vitamin K mi tun), ri lon chc nng
3910Ch 25% lng cefoperazon tm li c
3854tiu cu, hoc him hn lm gim tiu
3911trong nc tiu v phn ln thuc c thi
3855cu thng qua c ch min dch. Do c
3912tr qua mt. Na i thi tr khong 2 gi.
3856tnh nn cc cephalosporin th h 3
3913Nng cefoperazon trong mt cao hn
3857khc c a dng hn trn lm sng.
3914so vi cc cepha-
3858In vitro, ceftizoxim c ph khng khun t-
3915losporin khc. Nng thuc trong mu
3859ng t cefotaxim. Na i di hn i
3916cao hn 2 - 3 ln so vi cefotaxim. Liu
3860cht, bng 1,8 gi, v vy thuc c dng
3917dng cefoperazon khng thay i ngi
3861cch 8 - 12 gi mt ln, trong nhim
3918suy thn, nhng ri lon chc nng gan hoc
3862khun nng. Ceftizoxim khng chuyn
3919tc mt nh hng n s thanh thi

106
107

3920thuc. Cefoperazon c th gy chy mu3977Tc dng khng mong mun ca cc

3921do gim proth-3978khng sinh nhm beta lactam
3922rombin huyt, tc dng ny c th khc3979Phn ng qu mn i vi cc
3923phc bng cch dng vitamin K. Phn ng3980cephalosporin l phn ng khng mong
3924ging disulfiram ngi ung ru khi ang3981mun thng gp nht v khng c chng
3925dng cefoperazon c thng bo. 3982c no cho thy cephalosporin ny li gy
3926Ceftazidim c tc dng trn vi khun Gram3983mn cm t hoc nhiu hn so vi
3927dng ch bng 1/4 n 1/2 hot tnh ca3984cephalosporin khc. Cc phn ng xy ra
3928cefotaxim cng lng thuc dng. Tc dng3985ging nh phn ng do penicilin, iu ny
3929trn Enterobacteriaceae rt ging3986c th lin quan n cu trc beta lactam
3930cefotaxim v c c im chnh l tc3987ca c hai nhm khng sinh ny.
3931dng tt trn Pseudomonas. Ceftazidim c3988Phn ng tc thi nh phn v, co tht ph
3932hot tnh thp trn B. fragilis. Na i3989qun, my ay. Thng gp hn l pht
3933trong huyt tng khong 1,5 gi v thuc3990ban dt sn, thng xy ra sau vi ngy
3934khng b chuyn ha. In vitro, ceftazidim3991iu tr. C th km hoc khng km st,
3935c tc dng i vi Pseudomonas mnh3992tng bch cu i toan.
3936hn cefoperazon v piperacilin. 3993Do cu trc tng t gia penicilin v
3994cephalosporin, ngi bnh b d ng vi
3937Cephalosporin th h 4 3995mt nhm thuc ny c th b phn ng
3938Cefepim l cephalosporin th h 4, bn3996cho vi mt trong nhm thuc kia khi dng.
3939vng i vi s thy phn do beta3997Cc nghin cu v min dch cho thy
3940lactamase m ha trn plasmid c xc3998phn ng cho vo khong 20% s bnh
3941nh t trc (gi l TEM -1, TEM -2, v SHV3999nhn b d ng vi penicilin, nhng nghin
3942- 1), l mt cht gy cm ng yu v tng4000cu trn lm sng cho thy cc phn ng
3943i bn vng i vi beta lactamase m4001ny thp hn nhiu (khong 1%). Khng
3944ha trn th nhim sc typ I. V vy4002c test no trn da c th d on mt
3945thuc c tc dng trn mt s4003cch tin cy ngi bnh s c d ng vi
3946Enterobacteriaceae khng cc4004cephalosporin hay khng.
3947cephalosporin khc thng qua cm ng4005Ngi bnh c tin s d ng nh hoc
3948beta lactamase typ I, nhng vn nhy cm4006phn ng t lu vi penicilin th t c
3949i vi mt s chng vi khun tit beta4007nguy c pht ban hoc phn ng d ng
3950lactamase thng qua plasmid ph rng4008khc i vi cephalosporin. Tuy nhin, ngi
3951(nh TEM - 3, TEM - 10). In vitro, cefepim c4009bnh c phn ng gn y nng v tc
3952tc dng hn cefotaxim i vi cc chng4010thi vi penicilin th khi dng cephalosporin
3953Gram m (H. influenzae, N. gonorrhoeae,4011phi ht sc thn trng hoc khng dng.
3954v N. meningitidis). Cefepim c tc dng t-4012Phn ng Coombs dng tnh thng gp
3955ng t ceftazidim trn P. aeruginosa, mc4013 ngi dng liu cao cephalosporin. Tan
3956d tc dng ca n thp hn ceftazidim4014mu thng khng kt hp vi phn ng
3957i vi cc chng Pseudomonas khc v4015Coombs, mc d c trng hp c thng
3958Xanthomonas maltophi- 4016bo. Cephalosporin him gy c ch ty
3959lia. Cefepim tc dng mnh hn ceftazidim4017xng, c trng l gim bch cu ht.
3960v ngang cefotaxim i vi Streptococcus4018Cephalosporin c coi l c tim nng c
3961v cc chng Staph. aureus nhy cm4019vi thn, mc d khng c nh
3962methicilin. Cefepim khng tc dng trn cc4020aminoglycosid hoc polymyxin. Hoi t ng
3963chng Staph. aureus khng methicilin,4021thn xy ra khi dng cephaloridin vi liu
3964Pneu- 4022trn 4 gam mi ngy. Nhng cephalosporin
3965mococcus khng penicilin, Enterococcus, B.4023khc t c hn nhiu v liu iu tr,
3966fragilis, L. monocytogenes, M. avium, M.4024him khi thy du hiu c vi thn khi
3967tuberculosis. Cefe-4025dng mt mnh. Dng liu cao cefalotin c
3968pim thi tr hu nh 100% qua thn, liu4026th gy hoi t ng thn cp trong mt s
3969dng phi c iu chnh ngi suy4027trng hp, liu thng dng
3970thn. Cefepim thm rt tt vo dch no4028(8 - 12 gam /ngy) gy c vi thn
3971ty trn ng vt thc nghim gy vim4029ngi mc bnh thn t trc. C bng
3972mng no. Khi dng liu tim tnh mch 2 g4030chng cho thy, khi s dng ng thi
3973 ngi ln cch 12 gi mt ln, nng 4031cefalotin v gentamycin hoc tobramycin,
3974nh trong huyt thanh l 126 - 1934032xut hin tc dng hip ng gy c vi
3975microgam/ml. Na i trong huyt thanh4033thn, c bit r ngi trn 60 tui. a
3976khong 2 gi. 4034chy c th xy ra khi dng cephalosporin

108
 80 S dng hp l thuc khng ng kinh
DTQGVN
109

4035v thng gp hn khi dng cefoperazon, III: Cn cc b, pht trin

4036c th do cefoperazon thi tr ch yu thnh cn ng kinh co
4037qua mt. Cn phi ch s khng dung git ton b:
4038np ru (phn ng ging disulfiram) khi dng - Cn cc b n thun,
4039cefamandol, cefotetan, moxalactam, v pht trin thnh cn co git
4040cefoperazon. Chy mu nng do gim ton b.
4041prothrombin huyt, gim tiu cu v/ - Cn cc b phc hp, pht
4042hoc ri lon chc nng tiu cu c trin thnh cn co git ton
4043thng bo nhiu khng sinh nhm beta b.
4044lactam. iu ny cn c ch mt s - Cn cc b n thun,
4045ngi bnh (ngi cao tui, suy dinh dng, pht trin thnh cn cc b
4046hoc suy thn) ang dng moxalactam. phc hp ri pht trin thnh
cn co git ton b.
Thut ng kinh cn ln, hin nay
ng gi l cn ng kinh co git
4047 S dng hp l quen ton b.
4048 thuc khng ng kinh dng trc Cn ng kinh tm thn
kia vn ng, hin nay nm
4049C th phn loi ng kinh da trn c loi trong nhm cc cn cc b
4050cn ln hnh thi tin trin, ngha l da phc hp c th xut pht t
4051vo "hi chng ng kinh". S la chn nhiu v tr khc nhau
4052cch iu tr bng thuc ty thuc vo loi no.
4053cn ng kinh. Do cn phi bit cch
4054phn loi quc t v cc loi cn ng4067Nguyn l chung i vi iu tr hp
4055kinh theo nh ngha ca Bng phn loi4068l bng thuc khng ng kinh:
4056quc t cc hi chng ng kinh (1989).4069Trc kia iu tr thng qui thng kt hp
4057Khi phn loi theo nguyn nhn, ngi ta4070nhiu thuc. Cc th nghim lm sng
4058phn bit gia ng kinh t pht ngha4071hin i cho thy tr liu ch dng mt
4059l loi bnh khng thy r nguyn nhn4072thuc cng c hiu lc tng ng trong
4060ngoi cc yu t di truyn v ng kinh4073phn ln cc trng hp v nu s dng mt
4061triu chng l khi thy c tn thng thc4074loi thuc n thun th s lng v mc
4062th no gy ra cn. Sau cng cn c4075 nng ca cc phn ng th pht gim
4063ng kinh cn nguyn n khi nghi ng c4076i rt nhiu. mi ni, t nhiu nm, -
4064th c c ch gy bnh nhng cha th4077ng li iu tr hin thi l chuyn t
4065pht hin hoc chng minh c. 4078iu tr bng nhiu thuc theo thng qui
4066 4079sang iu tr bng mt thuc. Vic ny
Cc loi 4080 lm gim mnh cc phn ng th pht
ng 4081v ng thi tn sut cc cn ng kinh
kinh 4082ngi bnh cng gim.
Cn I: Cn vng thc (in 4083Ci thin hiu lc v gim nguy c nh vy
ng no : phc hp nhn - 4084l h qu ca vic s dng m rng iu
kinh sng 3 Hz). 4085tr bng mt thuc. Ch cc ngi bnh
ton b II: Cn vng khng in 4086mc phn ln ng kinh trm trng, ti
hnh (in no : phc 4087a 10 - 15% mi t kt qu vi a tr
hp nhn sng, khng 4088liu.
u). 4089Khi iu tr vi cc thuc khng ng kinh
III: Cn git c ton khi. 4090cn phi theo di thn trng bng cch
IV: Cn ng kinh co git. 4091phn tch nng thuc trong mu
V: Cn mt trng lc. 4092(huyt thanh). V vy, cc ngi bnh ny
Cn I: Cn cc b n thun 4093cn c iu tr ti cc bnh vin c
ng khng b ri lon thc, vi: 4094trang b tt. C hai tc dng iu tr v
kinh cc - Cc triu chng vn ng. 4095tc dng ph c hi u lin quan mt
b, tng - Cc triu chng vn ng 4096thit vi nng thuc trong huyt thanh.
phn c th hoc cm gic c 4097Kh s dng liu lng chun v c s khc
bit nh d cm. 4098nhau ln gia cc c th v kh nng hp
- Cc triu chng t qun. 4099thu, chuyn ha v thi loi thuc. Cc
- Cc triu chng tm thn. 4100thuc khc c th cn tr chuyn ha
II: Cn cc b phc tp c ri
4101thuc cng s nh hng ti cc yu t ni
lon thc.

110
111

4102trn. V vy, nguyn l cng t thuc cng4159cch nh git tnh mch lin tc 200 mg
4103tt l tuyt i cn thit cho vic iu4160diazepam ha trong 500 ml glucose (nn
4104tr cc ngi bnh ny. Nguy c xy ra cc4161dng glucose ng trong chai thy tinh v
4105tc dng ph c hi phn ln thng lin quan4162khng dng glucose trong ti nha v ti
4106vi nng trong huyt thanh. 4163ny hp th ht diazepam). Nu khng a
4107Liu lng cng cao v cng dng nhiu4164diazepam vo tnh mch cng c th a
4108thuc th nguy c tc dng ph c hi4165vo hu mn 0,5 -1 mg i vi 1 kg th
4109cng cao. 4166trng. Ngi ta t tim bp v thuc hp
4110V vy, chuyn lun ny cp n vic4167thu rt chm. Diazepam cng ch c thi
4111xc nh loi ng kinh no l nghim4168gian tc ng ngn. V vy, i vi cc
4112trng, ngha l cn chp nhn nguy c4169cn ti pht ngi ta khuyn co cho tim
4113iu tr bng liu cao v/hoc nguy c4170tnh mch 0,5 - 1 mg clonazepam, hoc
4114iu tr bng nhiu thuc. 4171tim bp 100 - 200 mg phenobarbital. iu
4115i vi ng kinh tin trin lnh tnh c4172tr bng phenytoin ng tnh mch, cho
4116th iu tr d dng vi mt loi thuc4173liu bo ha khi u l 15 mg cho mi kg
4117th s dng iu tr bng nhiu loi thuc4174th trng, tip ni l liu duy tr 6mg cho
4118hoc s dng liu cao l khng hp l v4175mi kg th trng trong 24 gi.
4119khng an ton. 4176Phn loi cc hi chng ng kinh:
4120Khi thay i thuc iu tr, bao gi cng4177Trc kia cc loi cn ng kinh c phn
4121phi tin hnh t t. Thay i thuc4178loi theo nhm cc th bnh lin quan n
4122nhanh cng c th thc y xy ra ng4179la tui, gi l cc hi chng ng kinh.
4123kinh lin tc. Phi p dng nguyn l sau:4180Cc hi chng ny, hin nay c nh
4124Trc tin thm loi thuc mi vi liu khi4181ngha theo cc kiu c bit ca cn
4125u thp vo loi thuc ang iu tr.4182ng kinh, vi thi im khi pht c
4126Khi t c mc n nh trong huyt4183bit v/hoc cc hin tng c hiu i
4127thanh ca loi thuc mi th c th bt4184km v cc bin i in no c tr-
4128 u gim dn liu lng thuc c trong 1 4185
DTQGVN - ng. u im caS cch
dng phn loithuc
hp l ny, so
4129 2 thng. Tuy
khng ng kinhth vn81lun c nguy c xy4186 snh vi cch phn loi da trn loi cn, l
4130ra cc cn ng kinh. Cc cn khng4187do ngy nay ngi ta hiu bit nhiu hn
4131phi l du hiu thuc mi khng tc4188v cch tin trin d kin i vi cc loi
4132dng. ch l nhng triu chng cai4189ng kinh khc nhau v c cc loi thuc
4133thuc do ct gim loi thuc ban u, v4190no c tc dng tt nht i vi cc th
4134d phenobarbital. Hin tng xy ra cn cai4191tin trin/hi chng khc nhau. Do
4135thuc ny thng b gii thch sai lm v4192bng phn loi hin i ny c th lm
4136dn n sai lm t b k hoch iu tr4193cho ta hiu c rt sm thi gian cn thit
4137bng mt thuc. Cc cn ng kinh do b4194cho iu tr bng khng ng kinh l
4138thuc s t thoi bin dn. 4195iu rt quan trng khi ra cc bin
4139Gin on iu tr: Kinh nghim cho thy4196php gim cc nguy c i vi cc tc dng
4140xu hng xy ra cn ng kinh thng thoi4197ph c hi v bin chng.
4141bin theo tui nhiu ngi bnh. Sau mt
4198ng kinh s sinh:
4142giai on 2 - 5 nm khng c cn, ty theo
4199Triu chng: Cc cn ng kinh tr s
4143loi ng kinh, ngi ta c th th thi
4200sinh thng kh phn loi theo kiu cn.
4144khng iu tr thuc khng ng kinh.
4201Phn ln l cc cn cc b c hoc khng
4145Mun vy, phi tin hnh thn trng v t
4202km theo cn ton b th pht. Trong mt
4146t c theo di k. Trng hp c cn ti pht
4203s trng hp c th thy kiu cn cc b
4147phi bt u iu tr li.
4204kinh in, i khi c cn ngng th hoc
4148iu tr cn ng kinh cp tnh 4205cc biu hin tng t lm cho thy thuc
4149Phn ln cc cn ng kinh xy ra ngn4206khng hng ngay ti chn on ng kinh.
4150v c th kt thc trong vng vi pht, trc4207Nguyn nhn: C nhiu nguyn nhn: C
4151khi bt u iu tr. Trng hp cn ko4208th l hu qu ca bin chng sn khoa,
4152di, xy ra tng hi, hoc ng kinh lin4209c th l d dng bm sinh hoc bin
4153tc, lc c ch nh iu tr nh sau:4210chng chuyn ha. Ngay nhng bnh
4154Tc dng tt nht l dng diazepam ng4211vin c trang b rt tt cng c khong
4155tnh mch, vi liu 10 mg, c th nhc li421230% cc trng hp khng th xc nh c
4156nhiu ln. C mt nguy c nh nhng thc4213nguyn nhn c hiu.
4157t, l c th b suy h hp sau khi cho4214Tin trin: Tin trin in hnh ca hi
4158nhiu liu. Cng c th iu tr bng4215chng ny tng i xu vi t l trung

112
 82 S dng hp l thuc khng ng kinh
113 DTQGVN

4216bnh trn th gii khong 20 - 30% t4273no c cc bin i c trng di dng

4217vong, v khong 50% tr sng st c bin4274cc phng lc nhn - sng lan ta xen ln
4218chng thn kinh nng ko di. 4275vi cc tn s thng l 1 - 3 Hz, cho nn trc
4219iu tr: iu tr triu chng nu nguyn4276kia c m t l ng kinh cn nh.
4220nhn do chuyn ha. Mt khc, s dng4277Nguyn nhn: y cng thy cc s
4221diazepam iu tr cn cp tnh, cn4278kin nh i vi cn co tht ca tr th.
4222acid valproic, carbamazepin, clona-4279Tin trin: Cc cn thng khi pht trc khi
4223zepam v phenobarbital l cc thuc dnh4280tr ln 5 tui v phn ln thy tr trai. Cc
4224cho iu tr phng nga cn ng kinh. 4281cn ny thng rt kh cha tr v iu
4282, cng vi nguy c chm pht trin tm
4225Cn co tht ca tr th: 4283tr, khin cho loi ng kinh ny l mt
4226Triu chng: Cn in hnh ca loi ny4284th trm trng nht.
4227l cc cn co tht c t ngt, xy ra4285iu tr: iu tr thng kh v him khi
4228ngn, lm cho u b chi v pha trc,4286hon ton ht cn, mc d th mi cch
4229v cc khp hng, khp gi b gp li. ng4287iu tr nghim tc. i vi loi ng kinh
4230thi cc chi trn b ht ra pha trc khin4288ny c th phi cn phi hp nhiu thuc
4231cho loi cn ny cn c bit danh l "ng4289khng ng kinh khc nhau, thng l 2 - 3
4232kinh vi cho". Cc cn thng xy ra thnh4290loi thuc. Ngi ta chn cc thuc iu tr
4233t vo lc tr sp ng hoc sp tnh4291c hiu lc nht l acid valproic,
4234gic. Trn in no c th thy cc4292clonazepam, carbamazepin v phenytoin.
4235bin i c trng theo dng sng rt bt4293ng kinh cn nh dy cn:
4236thng, hu ht hn n, gm cc phng4294Triu chng: Biu hin thng l cc cn
4237lc bt bnh thng ton b xen k vi cc4295vng thc kinh in, giai on vng
4238b v bin thng cao. Ngi ta gi kiu4296ngn, xy ra khng c g bo trc, v kt
4239in no ny l lon nhp in th cao. 4297thc t ngt, thc bnh thng c phc
4240Nguyn nhn: 60 - 70% tr em, c th4298hi ngay.
4241thy nguyn nhn di dng ca tn thng4299Cc cn hay xy ra thnh t tp trung v
4242no bm sinh hoc mc phi do chn th-4300tn s xy ra nhiu cn mi ngy khng
4243ng, nhim khun, thiu oxy hoc h -4301phi l khng ph bin. cho tr th tng
4302ln trong vi pht thng c th thc y
4244ng huyt.
4303cn xut hin. Cc cn thng c mt kiu
4245Tin trin: Cn u tin xut hin lc 5 -4304in no kinh in l cc phng lc
42467 thng tui. Sau thng thy r chm4305nhn 3 Hz. Phn ln cc cn vng thc
4247pht trin tm tr tin trin v phn ln tr4306ch ko di trong vi giy hoc ngn
4248sng st c nguy c km kh nng tr tu.4307hn. C th gp cc cn ko di 15 - 20
4249Nguy c t vong cao nht nhm c cc4308giy v i khi cc cn c km theo mt
4250triu chng biu hin nng n. Cc cn4309trng lc c, nhy mt, ng tc mt a
4251in hnh thng thoi bin theo tui, nh-4310nhanh hoc cc tic mt.
4252ng thng b thay bng cc loi cn khc,4311Nguyn nhn: Loi ng kinh ny l mt
4253c bit l cn ng kinh ton b. Loi4312v d kinh in ca ng kinh ton b,
4254tin trin ny hay gp cc tr trai. 4313nguyn pht, di truyn ngha l ngi ta
4255iu tr: ACTH, ni tit t v thng thn t4314khng th pht hin hoc chng t l c
4256ra c hiu lc i vi cn ng kinh, nhng4315nguyn nhn cu trc gii phu no
4257khng phng nga c chm pht trin4316gii thch cn bnh. S pht trin tm l -
4258tm tr. Cc thuc khng ng kinh khc4317tr tu ca cc tr ny thng bnh thng.
4259cng khng c hiu lc chng nguy c4318Th vng thc ph bin nht cc tr
4260chm pht trin tm tr. iu tr v sau4319gi.
4320Tin trin: Tin trin thng lnh tnh nhng
4261ny ty thuc vo loi cn. Vigabatrin t ra
4321cn iu tr tt trnh pht trin cc
4262c hiu lc i vi cn co tht ca tr th.4322cn ng kinh ton b, c th xy ra i
4263ng kinh git c - mt trng lc: 4323vi khong 50% cc ngi bnh ny. ng
4264Triu chng: nh ngha theo tn gi,4324kinh cn nh, dy cn thng khi pht
4265bnh cnh ny bao gm nhiu loi cn4325la tui tr em, nhng cng c th xy ra
4266khc nhau nh cc cn vo m khuya km4326mun hn. Thng thng, cc cn ny t
4267theo mt trng lc t ngt lm cho tr b4327thoi bin trong phn ln cc trng hp vo
4268ng, cc cn git c v cc cn vng 4328lc 20 tui.
4269thc khng in hnh, khc hn cc cn4329iu tr: iu tr th bnh ny mang li
4330kt qu tt v 90 - 95% cc ngi bnh c
4270vng thc kinh in v xut hin ng
4331iu tr thuc thch hp c th hon ton
4271thi cc ng tc git c. ng kinh ton
4332ht cn. Trc kia ethosuximid c khuyn
4272b km theo cng kh ph bin. Trn in

114
 115

4333co dng iu tr u tin. Hin nay, ngi4388phenothiazin c ng biu din v liu l-

4334ta thng dng acid valproic nhiu hn i4389ng - p ng tng i dt v c th dng
4335vi cc ngi bnh ny. Cc thuc u cng4390trong mt phm vi liu lng rng. Mc du
4336c hiu lc i vi loi ng kinh ny, nh-4391i khi t vong do qu liu c thng
4337ng ch acid valproic c kh nng bo v4392bo nhng vic ny him gp nu ngi
4338chng nguy c xy ra cn ton b. 4393bnh c chm sc ni khoa tt v nu
4339ng kinh thy nh: 4394vic s dng qu liu khng b phc tp
4340Triu chng: Loi cn ny c c im l4395thm v dng km ru hoc cc thuc khc.
4341cc cn ng kinh cc b vi cc triu4396Ch s iu tr thp nht i vi
4342chng ming - hu, ngi bnh pht ra m4397thioridazin v clorpromazin v cao nht
4343thanh bng ming, cc m d k kiu nh4398i vi cc thuc c hiu lc hn. Ngi
4344ang c nut, nghin rng, kh nut, cm4399bnh chp nhn c vi liu
4345gic b bp c hoc cc triu chng cm4400clorpromazin ti 10 g v t vong do qu liu
4346gic t hu hng. Thng cng c cc triu4401haloperidol n c cha c ni ti. Tuy
4347chng c bit ca git c t ngt trc4402nhin, t vong do cc tc dng khng mong
4348ht u v chi trn ri qua giai on vi
4403mun ca thuc c ghi nhn trong
4349thng hoc vi nm s c xu hng pht
4404nhiu trng hp.
4350trin thnh nhiu cn ng kinh ton b.
4351Do ngi bnh hay c cn ng kinh4405Do cn phi hiu bit v cc tc dng
4352vo bui sng c th kh nghi mc loi4406khng mong mun v cc tc dng l
4353ng kinh ny k c khi h khng c biu4407s gia tng trc tip cc tc ng dc l
4354hin git b c t ngt. 4408ca thuc. iu c ngha l liu ng
4355Hn na, cc ngi bnh ny c th c cc4409cho tng c nhn thng c th hn ch -
4356giai on ngn vng thc, km theo mt4410c nguy c. Cc phn ng khng mong
4357trng
DTQGVN
lc c lm cho h b ng. l cn 4411mun
Thuc quan
chng trng
lon nhtx
thn, nh
trhng ti h
cc tc thnkhng
dng
4358ng
mongkinh
munmt trng
83 lc. Ung ru hoc4412kinh trung ng, tim mch, thn kinh t
4359cc thuc an thn thng c th gy ra cn4413qun v cc chc nng ni tit. Tc dng
4360ng kinh. Trn in no thy c cc4414ngoi thp c tm quan trng ln s c bn
4361phng lc nhiu nhn - sng ng th4415lun chi tit di y. Cc tc dng khng
4362ton b. 4416mong mun nguy him khc l cc cn co
4363Nguyn nhn: y l th ng kinh ton4417git, mt bch cu ht v thoi ha sc t
4364b nguyn pht, di truyn v nguyn nhn4418vng mc, tt c u him gp.
4365di truyn c xc nh r. Tr cc trng4419Tuy nhin cc liu iu tr ca cc
4366hp ng kinh khc trong gia nh, cc4420phenothiazin thng c th gy ngt, nh
4367ngi h hng thng c cc bin i in4421trng ngc v nhiu tc dng khng
4368no c trng d cho h khng c cn4422cholinergic khc bao gm ngt mi, kh
4369ng kinh lm sng no. 4423ming, nhn m, to bn v triu chng to
4370Tin trin: Tin trin ca th ng kinh4424tuyn tin lit, b tiu tin nam. Tc
4371ny lnh tnh vi nhng cn thng khi4425dng khng mong mun v tim mch
4372pht trong tui thiu nin, nhng vn phi4426phin phc nht l h huyt p t th ng
4373iu tr trong nhiu nm, mc du phn4427c th dn n ngt. Huyt p h c th
4374ln ngi bnh thy cn t thoi bin theo4428xy ra khi dng cc phenothiazin loi c
4375tui. Tuy nhin i vi mt s ngi bnh,4429chui bn aliphatic. Cc cht cng loi
4376thy c lin quan n s pht trin cc4430piperazin v c cc thuc an thn kinh
4377vn tm bnh. 4431mnh khc t gy h huyt p hn.
4378iu tr: Loi ng kinh ny thng d4432Tc dng khng mong mun v thn
4379iu tr v thuc c la chn l acid4433kinh :
4380valproic. i vi mt vi trng hp him, cn4434Hu ht cc thuc chng lon thn gy
4381s dng phenobarbital. Cng cn hn ch4435ra nhiu hi chng thn kinh lin quan
4382ngi bnh dng ru v cc thuc an thn. 4436c bit ti h vn ng ngoi thp. Cc
4437phn ng ny c bit ni bt khi iu
4438tr bng cc thuc c hiu lc mnh (cc
4383 Thuc chng lon thn, X tr cc 4439piperazin ba vng v cc butyrophenon).
4440Clozapin, thioridazin hoc liu thp
4384 tc dng khng mong mun
4441risperidon t c kh nng gy ra cc tc
4442dng khng mong mun ngoi thp cp
4385Thuc chng lon thn ni chung c ch s
4443tnh.
4386iu tr cao v l nhng thuc tng i
4387an ton. Trong cc thuc , phn ln cc

116
 117

4444C su hi chng thn kinh c trng ca4501tnh tin trin dn dn t vi ngy n

4445cc thuc chng lon thn. Trong s bn4502vi tun. Cc du hiu d thy nht l co
4446hi chng (lon trng lc c cp, khng4503cng v run khi ngh, c bit chi trn.
4447ngi yn, hi chng Parkin-4504C th thy cc ng tc nh "v thuc",
4448son v hi chng an thn kinh c tnh4505tuy nhin do thuc an thn kinh, chng
4449him gp) thng xut hin sm sau khi4506khng r rt nh trong hi chng Parkinson
4450cho dng thuc, v hai hi chng (run4507v cn. Cc tc dng khng mong mun
4451quanh ming him gp v lon vn ng4508kiu Parkinson c th b lm l trm cm
4452hoc lon trng lc mun) l cc hi chng4509v v mt t biu l v cc c ng chm
4453xut hin mun sau khi iu tr ko di. 4510chp c th ging nh cc du hiu ca
4454Phn ng lon trng lc cp thng thy4511trm cm. Phn ng ny c x tr bng
4455lc bt u iu tr bng thuc lon4512cc thuc chng Parkinson c tnh cht
4456thn, c bit i vi cc cht c hiu lc4513khng cholinergic hoc bng amantadin.
4457mnh v c th biu l nh nhn mt, vo4514S dng levodopa hoc bromocriptin em
4458c hoc cn xoay mt. Cc hi chng4515li nguy c gy vt v v lm cho bnh
4459 c th b nhm l cc phn ng tm4516tm thn nng ln.
4460cn hysteria hoc co git, nhng li p ng4517Hi chng c tnh thuc an thn kinh
4461iu tr tt vi cc thuc tim chng4518mt bnh l him gp ging nh mt th
4462Parkinson loi khng cholinergic. Cho ung4519rt nng ca hi chng Parkinson bao gm
4463cc thuc khng cholinergic cng c th4520cng , run mnh hoc nh, du hiu
4464phng nga lon trng lc, c bit ng-4521thc vt khng n nh (mch v huyt
4465i bnh nam tr tui c dng mt4522p khng n nh, st cao), sng s, tng
4466thuc an thn kinh c hiu lc mnh. Mc4523creatin kinase trong huyt tng v i khi
4467du c iu tr nhng cc phn ng4524c myoglobin-huyt. Trong th trm trng
4468lon trng lc c cp vn gy khip s4525nht, hi chng ny c th ko di hn
4469cho bnh nhn; t vong t ngt xy4526mt tun sau khi ngng thuc. V t vong
4470ra trong mt s him trng hp, c th do4527cao (trn 10%) nn cn phi iu tr ni
4471suy h hp v lon trng lc c hu hng,4528khoa ngay. Phn ng do nhiu loi
4472thanh qun v cc c khc. 4529thuc an thn kinh, nhng t l mc c th
4473Chng khng ngi yn (Akathisia) lin4530ln hn khi s dng cc liu tng i cao
4474quan ti cm gic ch quan bt rt hoc4531ca cc thuc c hiu lc mnh hn, c
4475kh chu hay thy chn, phi thng4532bit khi dng ng tim. Ngoi ngng
4476xuyn c ng hn l tun theo bt k4533iu tr tc thi v tin hnh iu tr h
4477mt khun mu vn ng c bit no.4534tr, iu tr c hiu cha c tha ng;
4478Ngi bnh cm thy h phi ng dy i4535s dng dantrolen hoc bromocriptin l
4479hoc lin tc di ng v khng th khng4536cht ch vn dopamin c th gip ch.
4480ch c xu hng . Chng khng ngi yn4537Mc du dantrolen cng c dng x
4481thng hay b lm l kch ng cc ngi4538tr hi chng st cao c tnh do cc thuc
4482bnh lon thn; phn bit triu chng 4539m gy ra, nhng th cng v st cao
4483rt quan trng v kch ng c th iu4540do thuc an thn kinh gy ra c th khng
++
4484tr bng cch tng liu lng. V p ng4541do khim khuyt ca chuyn ha Ca
4485ca chng khng ngi yn i vi cc thuc4542c xng.
4486chng Parkinson thng khng t yu cu4543Mt ng tc bt thng him gp c th
4487nn cn phi gim bt liu lng thuc chng4544xy ra mun trong qu trnh iu tr cc
4488lon thn. Thuc chng lo u hoc liu4545ngi bnh mn tnh bng cc thuc chng
4489propranolol va phi c th c li. Hi4546lon thn l run quanh ming, thng c
4490chng ph bin ny thng khng c chn4547gi l "hi chng mm th" v cc ng
4491on v thng cn tr dng thuc an thn4548tc c trng ca bnh cnh ny. Thut
4492kinh iu tr. 4549ng thng c dnh cho cc phn ng
4550ma git - ma vn hoc lon trng lc
4493Hi chng Parkinson c th khng phn
4551xy ra sau khi iu tr ko di, mc du
4494bit c vi hi chng Parkinson v cn th-
4495ng din ra dn dn trong khi iu tr cc4552i khi cng l c im ca cc lon
4496thuc chng lon thn. Tn sut bnh thay4553ng mun (tin trin sau ny hoc
4497i theo cc thuc khc nhau. Trn lm4554chm) thc t "hi chng mm th" cng
4498sng, ton b ng tc hu chm chp4555c nhiu c tnh nh hi chng Parkinson
4499li (mt vn ng) vi v mt nh eo mt4556v run c tn s khong t 5 - 7 Hz v p
4500n v gim c ng tay. Hi chng c c

118
119

84 Thuc chng lon thn, x tr cc tc dng khng mong mun

4557ng tt vi cc cht khng cholinergic cng4615rng c s lin quan v tng cng b tr
DTQGVN
4558nh vi vic loi b thuc gy phn ng. 4616chc nng ca dopamin l mt cht dn
4617truyn thn kinh cc nhn vng y no.
4559Lon ng mun l mt (hoc cc) hi
4618Quan nim ny cn c vo cc p ng
4560chng thn kinh xut hin chm, lin quan
4619iu tr khng ging nhau cc ngi
4561n s dng cc thuc an thn kinh. Bnh
4620bnh mc bnh Parkinson v cc ngi
4562cnh thng hay xy ra hn ngi cao tui
4621bnh b lon ng mun v s p ng
4563v nguy c cc ngi bnh c ri lon kh
4622ging nhau cc ngi bnh mc cc lon
4564sc c th ln hn cc ngi bnh b tm
4623ng ma git - ma vn khc nh trong
4565thn phn lit. T l trung bnh l 15 -
4624bnh Huntington. Do cc thuc chng
456625% ngi lon thn mn tnh, vi t l mi
4625dopamin c xu hng loi b cc biu hin
4567pht hin hng nm l 3 - 5% v mt t l
4626ca lon ng mun hoc bnh
4568thuyn gim t pht hng nm phn no
4627Huntington, cn cc cht ch vn dopamin
4569nh hn mc du vn tip tc iu tr
4628li lm cho cc bnh nng ln; tri vi
4570thuc an thn kinh. i vi clozapin, nguy
4629hi chng Parkinson, cc cht chng
4571c thp hn, cn i vi cc thuc
4630muscarin c xu hng lm cho lon ng
4572chng lon thn khng c hiu khc mi
4631mun nng ln, cn cc cht cholinergic
4573ra i th cha r. Lon ng mun c
4632thng khng c hiu qu. Do tnh qu nhy
4574c im l lp li iu b, ti din,
4633cm i vi cc cht ch vn dopamin c
4575khng au, khng hu , ng tc nhanh
4634xu hng khng ko di qu vi tun sau khi
4576kiu ma git (ging nh thi tt) mt, mi
4635tip xc vi cc cht i khng ca cht
4577mt (nhm hoc co tht), ming (nhn
4636dn truyn thn kinh, hin tng ny dng
4578ming) li, t chi hoc thn. C nhiu mc
4637nh ng mt vai tr trong cc bin th
4579 bin i ma vn chm (ng tc
4638ca lon ng mun v c gii quyt
4580xon) v tnh trng lon trng lc tn ti
4639nhanh; ngi ta thng coi cc th l cc
4581rt hay gp ngi tr tui v c th gy
4640lon ng xy ra khi ngng thuc. Cc
4582tn tt. S xut hin mun ca cc bnh
4641mt l thuyt v lm sng ca vn
4583cnh c th c lin quan ti c tnh ch
4642ny c cp chi tit on khc.
4584yu l ri lon trng lc hoc vn ng
4643Cn phng nga cc hi chng thn kinh l
4585khng ngh (trng thi lun ca quy) cng
4644bin chng khi s dng thuc chng lon
4586 xy ra. Tt c cc ng tc u
4587mt i khi ng (cng nh trong nhiu hi4645thn. Phi theo mt s ti liu hng dn
4588chng ngoi thp khc), bin i v cng4646iu tr. S dng thng quy cc thuc
4589 theo thi gian v ty thuc vo mc 4647chng Parkinson nhm mc ch trnh sm
4590tnh thc hoc ri lon cm xc. Mc du4648cc phn ng ngoi thp thng khng cn
4591cc ng tc lon ng mun c th phn4649thit, gy thm tc dng khng mong
4592no b loi tr do dng mt thuc an thn4650mun v tn km cho iu tr. Tt nht l
4593kinh mnh v c th do dng mt cht gim4651 dnh cc thuc chng Parkinson cho
4594dopamin nh reserpin hoc tetrabenazin,4652cc trng hp c phn ng ngoi thp r rt
4595nhng ngi ta dnh cc cch x tr cho4653v s c p ng thun li vi thuc. Nhu
4596lon ng nng, c bit khi ang c4654cu cc thuc cho iu tr cc phn
4597lon thn. Mt s ngi bnh lon ng,4655ng lon trng lc cp tnh thng gim
4598in hnh l nhng ngi bnh c c4656theo thi gian, nhng hi chng Parkinson
4599im ri lon trng lc, c th dng4657v vn ng khng ngh c khuynh hng
4600clozapin c hiu qu v vi thuc nguy4658ko di. S dng c suy tnh v thn trng
4601c b lon ng mun rt thp. Cc triu4659cc thuc chng lon thn cc ngi bnh
4602chng i khi ko di mi mi sau khi 4660c bnh lon thn mn tnh hoc hay ti
4603ngng iu tr; thng thy hn, cc triu4661pht hu nh chc chn c th gim bt
4604chng gim hoc ht dn qua theo di vi4662nguy c gy lon ng mun. Mc du
4605thng, c bit cc ngi bnh tr tui4663gim liu mt thuc chng lon thn l
4606hn. Cc thuc chng Parkinson t c nh4664cch tt nht gim thiu cc tc dng
4607hng mt cch in hnh hoc c th4665thn kinh khng mong mun nhng vic
4608lm nng thm lon ng mun v cc4666c th khng thc t i vi ngi bnh c
4609th khc ca ma git- ma vn nh trong4667bnh lon thn kh iu tr. Thc hin
4610bnh Huntington v ngi ta vn cha 4668phng nga tt nht l s dng liu ti
4611xut c cch iu tr ph hp. 4669thiu hiu lc ca mt thuc chng lon
4612Cha xc nh c thn kinh bnh hc4670thn cho iu tr lu di v ngng ngay
4613trong lon ng mun v c s sinh l4671khi thy c th ngng c hoc nu
4614bnh vn cha c r. Ngi ta gi nh4672khng t c p ng nh mong mun. S
4673dng clozapin v cc thuc chng lon thn

120
121

4674mi khc c nguy c gy tc dng ph4731clorpromazin. Nhiu loi bnh da c th

4675ngoi thp thp cng l mt gii php cho4732xy ra. Phn ng qu mn c th l my
4676mt s ngi bnh, c bit l cc ngi4733ay, dt sn, chm xut huyt hoc ph,
4677bnh c cc triu chng lon thn lin tc4734thng xy ra trong khong tun 1 - 8 ca
4678km thm lon ng. Nguy c cao mt bch4735iu tr. Da ht phn ng sau khi ngng
4679cu ht xy ra vi clozapin. Do cn4736thuc v c th vn nh vy ngay c khi
4680m bch cu hng tun gim thiu4737iu tr tr li vi thuc dng. Vim da
4681nguy c ny. 4738tip xc c th xy ra nhn vin ng
4739chm n clorpromazin v c th c mn
4682Vng da 4740cm cho vi cc phenothiazin khc. Mn
4683Vng da thy sau khi bt u dng4741cm vi nh sng xy ra ging nh b chy
4684clorpromazin thi gian ngn. Vng da ni4742nng nng. Mt ch phm chng nng
4685chung nh v t khi nga, thng xy ra khi4743hiu lc phi c k n cho cc ngi
4686iu tr vo tun th hai n th t. Phn4744bnh ngoi tr ang c iu tr bng
4687ng c l l mt biu hin qu mn v4745phe-
4688c thm nhim bch cu i toan gan v4746nothiazin trong ma h. Loi sc t xm-
4689c tng bch cu i toan trong mu v4747xanh do dng lu di cc phenothiazin hiu
4690khng c s tng quan vi liu. C th xy4748lc thp vi liu cao him gp trong thc
4691ra mt nhy cm i vi clorpromazin khi4749hnh thng thng.
4692dng thuc tip v c th hoc khng xy4750Bnh sng ha biu b thng thy cc
4693ra vng da li nu li cho dng thuc an4751ngi bnh iu tr bng clorpromazin lu
4694thn kinh . i vi mt ngi bnh b4752di v cng thy c c gic mc v th
4695vng da do dng thuc an thn kinh, nu4753thy tinh mt. Trng hp c bit, cc
4696bnh tm thn cn phi c iu tr lin4754lng ng th thy tinh c th gy suy
4697tc th an ton nht l dng liu thp ca4755gim th gic. iu tr tch cc chng
4698mt thuc khc m c hiu lc hn. 4756bnh (v d bng penicilamin) khng
4757gip ch g c bit v cc th lng
4699Ri lon to mu
4758ng c khuynh hng t tan bin, tuy c
4700Tng nh bch cu, gim bch cu v tng
4759chm, sau khi ngng s dng thuc. Bnh
4701bch cu i toan i khi xy ra vi cc
4760sc t vng mc cng c thng bo,
4702thuc iu tr lon thn, c bit vi
4761c bit sau khi dng thioridazin qu 1000
4703clozapin v t hn i vi cc phenothiazin
4762mg mi ngy, cho nn ngi ta thng khuyn
4704hiu lc thp. Kh xc nh l gim bch
4763dng liu ti a hng ngy l 800 mg.
4705cu xy ra khi dng phenothiazin l s bo
4706trc e da mt bch cu ht. Bin chng
4707nng ny tuy him, xy ra khong di 1 tr-
4708ng hp cho 10.000 ngi bnh dng clor-4764 Gim au
4709promazin
DTQGVN hoc cc thuc hiu lc thp
4710khc au
Gim ngoi clozapin;
85 bin chng thng xy4765au l mt cm nhn kh chu v cm gic
4711ra trong vng 8 n 12 tun u iu4766v cm xc do m b e da v/hoc b
4712tr. c ch ty xng hoc t ph bin4767tn thng thc th gy nn, hoc do cc
4713hn, mt bch cu ht, c bit do s4768tnh trng c ngi bnh cm nhn l au
4714dng clozapin; t l khong 1% trong vng4769(nh ngha ca Hip hi quc t nghin
4715vi thng iu tr, khng lin quan n4770cu au).
4716liu v cn theo di st ngi bnh dng4771Ngay c tr b nht, k c tr non, cng
4717thuc c an ton. Ri lon mu c th bt4772 cm nhn c au v v vy cn c
4718u t ngt nn mt s ngi bnh4773gim au thch hp.
4719ang c iu tr bng thuc chng lon4774Trong iu tr t au nh n va, thuc
4720thn, khi xut hin st, kh th hoc4775c coi hng u l paracetamol v mt
4721nhim khun ng h hp trn phi theo4776vi thuc khng vim khng steroid nh
4722di ngay bng m s lng hng bch cu.4777ibuprofen, diclofenac v naproxen.
4723Nguy c mt bch cu ht gim i4778Trng hp cn gim au mnh hn, c th
4724nhiu tuy cha loi tr hn, bng cch th-4779dng ng thi acid acetylsalicylic hoc
4725ng quy hng tun m bch cu cc4780paracetamol vi codein hoc
4726ngi bnh ang iu tr bng clozapin. 4781 dextropropoxyphen. Nh vy, cng gim c
4782au cng c kh nng gp nhiu tc dng
4727Phn ng da 4783khng mong mun, c bit l bun nn,
4728Thng xy ra phn ng da i vi4784to bn v chng mt. Do c nguy c tc
4729phenothiazin. My ay hoc vim da xy4785dng khng mong mun nn cn phi hn
4730ra khong 5% ngi bnh dng4786ch dng acid acetylsalicylic tr em v

122
123

4787c bit khng dng cho tr di mt thng4845mt vn y hc quan trng i vi c

4788tui. 4846hai trng thi au cp v mn. au cng l
4789iu tr au cp trm trng bng thuc4847mt du hiu v triu chng quan trng
4790gim au loi opiat khi khng c chng4848ca bnh, phi c thy thuc xem xt
4791ch nh c hiu. Morphin l thuc la4849cn thn trc khi bt u iu tr chng
4792chn hng u. 4850au n thun. V vy, phi lun nh
4793Tr86emGim
cng au
phi cho thuc gim au loi4851rng nu ch ch vo gim au thi c
4794opiat trong trng hp au nng. Tuy nhin4852th s b qua mt bnh quan trng cn -
DTQGVN
4795iu quan trng cn bit l cc tr b rt4853c can thip iu tr.
4796nhy cm vi morphin v tr non d4854Ch lng gi cng au th khng ,
4797ngng h hp. 4855cn phi nh l cng phi lng gi kiu
4798Trong phn ln cc trng hp au nh sau4856au, thi gian, tnh cht, phn b au v
4799phu thut hoc sau chn thng, c th4857c gng xc nh nguyn nhn no gy
4800cho ngay thuc gim au morphin c liu4858au. Nn chun b sn mt b cu hi
4801m khng c nguy c gy nghin; cn4859chun lng gi au.
4802xem xt ring bit nhng ngi c nguy c4860Cn phi xem xt hai nguyn nhn gy
4803cao, trc b nghin ha cht. 4861au khc nhau, v s khc nhau l
4804au kiu do thn kinh hoc kiu bnh4862iu quan trng c bn cho vic la chn
4805dy thn kinh nh chng ha thng, au4863cch iu tr. Trong au theo kiu cm
4806dy thn kinh sau herpes, au r thn4864th au, au bt ngun t cc th th
4807kinh, au u thn kinh, hoc au chi ma,4865au ngoi vi b kch thch/hot ha, phn
4808thng cn ti nhng cch iu tr rt khc4866ng c hiu vi hot ha c hc, ha hc
4809nhau so vi iu tr au do cm th (tn4867hoc nhit . Cc th th au ny hot
4810thng m gy ra au). 4868ha cc si thn kinh dn truyn (si C v si
4811i khi thuc khng ng kinh hoc thuc4869delta A) bnh thng th ngh. Trong tr-
4812chng trm cm c th iu tr c hiu4870ng hp m b tn thng, nh vim, thiu
4813qu au do thn kinh hoc bnh thn4871mu cc b hoc xm nhim ung th
4814kinh. i vi au sau chy mu di mng4872mt m, s to thnh cc cht kch thch
4815nhn, loi au nng do thn kinh, i khi4873au (cc cht gy au) nh prostaglandin,
4816c th iu tr c bng mexiletin l loi4874leucotrien, cytokin, bradykinin, vv... C th
4817tng t nh lidocain, c tnh thm cao vo4875tin hnh c ch loi au ny bng cch
4818trong h thn kinh trung ng. Tuy nhin
4876c ch to thnh cc cht gy au , v
4819thuc ny c tc dng khng mong mun
4877d cc thuc gim au tc ng ngoi vi.
4820mnh i vi tim nn kh s dng.
4878Loi au do cm th au cng thng p
4821Khng c nh gi thp vai tr quan
4879ng tt vi iu tr bng cc thuc opiat
4822trng ca gim au thch ng. Nhiu tr-
4880tc ng trung ng.
4823ng hp bin chng hu phu c th phng
4881Trng thi au khc l au do thn kinh.
4824nga c nh gim au thch hp khin
4882y, ngun gc au hoc tn thng
4825cho ngi bnh bt u vn ng c v
4826ri khi ging, lm gim trit nguy c
4883khu tr ngay ti h thn kinh trung ng.
4827nhim khun hu phu (v d c th gim4884Kiu au ny yu cu mt chin lc iu
4828trit nguy c vim phi) v nguy c4885tr hon ton khc so vi au kiu cm th
4829bin chng nghn mch v tc mch sau4886au.
4830phu thut c gim i rt nhiu nu ngi4887V mt iu tr bng thuc, ta phi nh
4831bnh c th bt u c iu tr vt l4888rng cc opiat loi morphin thng t ra thc
4832tch cc sm nht sau phu thut. 4889t v hiu i vi kiu au nng do thn
4890kinh, nhng chnh cc thuc li tc ng
4833nh ngha v c ch 4891rt tt i vi au kiu cm th.
4834Theo Hip hi quc t nghin cu au4892au thn kinh nh chng ha thng, au
4835(IASP), au c nh ngha l mt cm4893dy thn kinh sau herpes, bnh r thn
4836nhn kh chu v cm gic v cm xc do4894kinh mn tnh, au do u thn kinh v au
4837m b e da v/hoc b tn thng thc4895do chi ma, thng hon ton khng c hiu
4838th gy nn, hoc do cc tnh trng c
4896qu vi cch iu tr thng thng. Do ,
4839ngi bnh cm nhn l au.
4897p ng m tnh vi iu tr bng
4840Nh vy, au l mt tri gic c th v ch
4898morphin l mt du hiu chn on quan
4841quan, bao gm cc tn hiu cm gic, cc
4899trng, bo cho ngi bc s cn phi xem
4842cm nhn xc cm v cc phn x ng x.
4900xt iu tr nh th no cho au do thn
4843Phi tha nhn rng i khi au khng c
4901kinh ch khng phi au do cm th. Mt
4844nguyn nhn thc th r rt. Gim au l

124
 125

4902s hnh thi au do thn kinh nh au4959c thi gian t c hiu qu hon
4903dy tam thoa, tuy vy, li p ng tt vi4960ton vi dextropropoxyphen. Nu cc phi
4904iu tr dc l c hiu bng thuc4961hp khng gim au tha ng, phi
4905khng ng kinh carbamazepin. Khng bao4962thm cc thuc opiat khc. i vi ngi bnh
4906gi c qun l c nhiu ngi bnh, nh ng-4963au trm trng, c tin lng cn sng tt,
4907i bnh ung th, thng au theo nhiu kiu4964ch c cho thuc opiat trong thi gian
4908khc nhau trong cng mt lc. 4965ngn (khng qu mt tun). Trng hp au
4966trm trng, i vi ngi bnh c tin lng
4909Gim au
4967cn sng thp, c th cho cc thuc opiat,
4910Trong iu tr au, phi xem xt qu
4968khng phi tnh ti nguy c gy nghin,
4911trnh t nhin ca au. V vy trong au4969nhm lm cho ngi bnh khng au v c
4912cp c th s dng rng ri cc thuc gim4970cht lng sng tt trong giai on cui i
4913au gm c cc opiat, v nguy c i vi4971ca h. iu tr thi gian di, methadon
4914tc dng khng mong mun v nguy c4972(dng ng ung) l mt opiat tc dng
4915nghin thuc rt thp trong thi gian iu4973lu bn rt hu hiu, chng t rt tin
4916tr ngn. 4974dng gim au giai on cui i ca
4917Trng hp au mn, hon cnh li rt khc.4975ngi bnh au trm trng do ung th.
4918Ngoi nguy c i vi tc dng khng4976Ngi ta thng dng ton b liu thuc gim
4919mong mun do dng thi gian di, cng cn4977au tc ng ngoi vi khi phi hp vi thuc
4920c nguy c nghin thuc v tm l cng4978opiat. Phi hp nh vy thng gim au tt
4921nh v sinh l. iu ny ch quan trng4979hn nhiu. Thuc tc ng ngoi vi c "tc
4922trong iu tr cc ngi bnh c tin lng4980dng gim liu opiat cn thit". Ngi bnh
4923sng st ln; cn i vi cc ngi bnh c4981au ko di thng cng cn iu tr
4924tin lng xu, th cht lng tt ca cuc4982bng cc thuc chng trm cm.
4925sng khng au n li quan trng nhiu
4983Thuc gim au tc ng ngoi vi
4926hn l trnh nguy c b mc nghin trong
4984Cc thuc ny c im tc ng chnh
4927on i ngn ngi cn li.
4985ngoi khu vc no v ty sng. Trong trng
4928Chin lc chng au mn tnh, ba4986hp chn thng m v vim, t m s gii
4929nhm dc l 4987phng ra cc cht ch yu: prostaglandin,
4930Thuc tc ng ngoi vi. 4988leucotrien, bradykinin, cytokin, sero-
4931Thuc tc ng trung ng. 4989tonin, cc gc oxy t do v histamin. Tt c
4932Phi hp thuc tc ng ngoi vi vi thuc4990cc cht u lm tng tnh nhy cm
4933tc ng trung ng. 4991ca th th au, gy ra mt trng thi gi
4934 gim au hu hiu, thy thuc phi4992l tng cm gic au. Mt tc dng chnh
4935rt quen vi mt s loi thuc trong mi4993ca cc thuc gim au tc ng ngoi vi
4936nhm v vi cc chin lc iu tr hu4994l c ch sn sinh ra prostaglandin, bng
4937hiu nht i vi cc trng thi au khc4995cch c ch cyclo-
4938nhau. 4996oxygenase. Nhm thuc c tc dng ny
4939i vi au do cm th t nh n va,4997tc ng nh acid acetylsalicylic v c xp
4940thuc u tin c chn l cc thuc gim4998vo mt nhm c tn l thuc khng vim
4941au tc ng ngoi vi nh salicylat hoc4999khng steroid (NSAID). Tt c cc thuc
4942paracetamol dng liu v khong cch5000ny u c mt dng tc ng tng t v
4943cho thuc ng. Mt sai lm ph bin l5001mt s tc dng khng mong mun tng
4944cho liu qu tha nn gy au tr li; iu5002t, do c ch prostaglandin ni cn thit.
4945ny c th trnh c nu c khong cch5003Thiu ht prostaglandin trong d dy dn
4946ph hp gia cc liu. 5004n c ch sn sinh ra cht mucin d
4947i vi cc ngi bnh b au sau chn th-5005dy s a n lot. Thiu ht
4948ng, nu c nguy c b chy mu tim5006prostaglandin thn lm gim ti mu cho
4949n, c bit i vi chn thng u,5007thn c th dn n suy thn cp v suy
4950chn thng tim n bng hoc vng5008tim cp ngi bnh trc vn c bnh thn,
4951chu, phi trnh dng aspirin v loi thuc5009gan v/hoc tim. Gim tng hp
4952khng vim khng steroid khc c nguy c5010prostaglandin trong cc tiu cu c ch
4953gy chy mu. Paracetamol khng lm5011s kt tp tiu cu lm tng nguy c chy
4954tng nguy c chy mu, do l thuc5012mu. Tt c cc thuc khng vim khng
4955c bit hu dng trong trng hp ny. 5013steroid u c mt nguy c chung l gy
4956Trong trng hp cc thuc ny khng 5014hen, ni my ay v phn v. ng thi
4957gim au, nn thm codein hoc5015ta lun phi nh rng mt ngi bnh
4958dextropropoxyphen liu. Tuy vy cn5016phn ng nh vy i vi mt thuc khng

126
 DTQGVN
Gim au
127 87

5017vim khng steroid, cng c nguy c cao5075khong 3 gi. Tuy vy, khi lp li vi liu
5018b phn ng nng nu dng mt thuc5076cao, na i thi tr l 15 - 30 gi. Nc tiu
5019khng vim khng steroid khc. Do , cn5077toan tnh c th lm chm thi tr hn
5020phi chng ch nh s dng tt c cc5078na.
5021thuc khng vim khng steroid i vi mt5079Nguy c lot d dy xy ra sau khi dng
5022ngi bnh nh vy. 5080lu di acid acetylsalicylic do c ch tng
5023Khi mang thai, c bit trong ba thng5081hp prostaglandin E2 l mt prostaglandin
5024cui, cn phi trnh thuc khng vim5082c tc dng bo v nim mc d dy do
5025khng steroid v nguy c i vi thai, e5083kch thch cht mucin bo v. nhng
5026da gy ng sm ng ng mch (ng5084ngi c bnh lot d dy - t trng cp
5027Botal) v nguy c gy chy mu trong t5085tnh v/hoc gin tnh mch thc qun,
5028cung, v niu s sinh v t nc i cng nh5086acid acetylsalicylic c th gy chy mu
5029nguy c c ch co bp t cung, do lm5087nhiu d dy-rut, e da tnh mng.
5030cho qu trnh sinh ko di. S dng5088Qu mn vi acid acetylsalicylic thng xy
5031thuc khng vim khng steroid khi mang5089ra di 1% qun th trung bnh, bnh th-
5032thai cng lm tng nguy c chy mu i5090ng, nhng li xy ra cao hn rt nhiu,
5033vi sn ph. 5091nhng ngi c mt vi kiu bnh d
5034Mt nhm nguy c c bit khc l5092ng (lc 2 - 3% b qu mn vi acid
5035nhng ngi b ph hoc c xu hng b ph5093acetylsalicylic).
5036nh suy tim, suy thn mn, suy gan l5094Trong s ngi c tin s hen, c ti 7 - 10%
5037nhng ngi c th phn ng vi tnh trng5095b qu mn nghim trng vi acid
5038gi nc nng nu iu tr bng thuc5096acetylsalicylic. nhng ngi bnh ny
5039khng vim khng steroid. Phn ln thuc5097xut hin hen, ni my ay, nght mi
5040khng vim khng steroid tc ng ngoi vi5098ph n v cc triu chng khc, i khi xy
5041cng c tc dng h st v khng vim. Tr5099ra phn v r rt.
5042paracetamol l c rt t tc dng ngoi vi,5100Cc vn khc lin quan ti s dng acid
5043paracetamol c tc dng gim au, h st,5101acetylsali-
5044qua tc ng trc tip ti h thn kinh5102cylic bao gm cc nguy c c bit nu
5045trung ng, cn tc dng khng vim ngoi5103cho dng thuc khi ang mc bnh virus
5046vi rt yu. 5104nh cm v thy u tr em, v acid
5105acetylsalicylic lm gia tng nguy c i vi
5047V tr trong iu tr 5106hi chng Reyes. Do phi trnh cho ng-
5048Acid acetylsalicylic: Trc y c s5107i di 18 tui dng acid acetylsalicylic.
5049dng rng ri, nhng c nhiu tc dng5108Paracetamol thng l thuc c la chn
5050khng mong mun nn ngy cng t c5109hng u i vi st v au. Thuc ny
5051coi l thuc hng u. Acid acetylsalicylic5110cng c tc dng gim au v h st mnh
5052c hiu lc tt i vi cc trng hp au5111nh acid acetylsalicylic. Tuy nhin tc dng
5053do chn thng mc va, au do c,5112gim vim km hn nhiu. C nhiu ti
5054khp v xng, au do vim, au rng v5113liu chng minh v tc dng gim au ca
5055au u. Tc dng ph thuc vo liu,5114thuc sau tiu phu thut nh ct amidan
5056gia 0,3 0,9 g. Liu cao 0,9 g, khng nn5115hoc nh rng, au sau , au mn
5057chia thnh liu nh. Liu ny c th lp5116tnh do ung th... Nu cn bnh c yu t
5058li cch 4 6 gi/1 ln, nu cn, cho ti ti5117vim, khuyn co dng cc thuc khc, c
5059a 5118th tham gia vo tc dng khng vim
50604 g/ngy. Ngi bnh b vim khp dng5119ngoi vi.
5061thp v cc trng thi vim khc cn dng5120Paracetamol c t nguy c liu bnh th-
5062liu cao, ti 3 - 4 g/ngy, chia thnh liu5121ng, 10 - 15 mg/kg th trng. Na i thi
5063nh. liu ny, acid acety-5122tr l 2 - 3 gi v phi dng paracetamol
5064lsalicylic c tc dng khng vim. Trong cc5123cch 4 gi mt ln t c tc dng
5065tc dng khc ca acid acetylsalicylic, ta5124gim au tt. Khng c nguy c chy mu
5066phi xem xt nguy c chy mu gia tng,5125gia tng, khng c tc dng khng mong
5067c ch khng hi phc qun th tiu cu5126mun v d dy-rut v rt t nguy c tc
5068hin c. V vy, s gia tng nguy c chy5127dng khng mong mun i vi thn.
5069mu vn cn cho ti khi hnh thnh qun5128Tuy nhin, vi liu cao, qu liu trn 8 - 10
5070th tiu cu mi, khong 4 - 7 ngy sau5129g, para-
5071mt liu acid acetylsalicylic duy nht. 5130cetamol c th gy ra tn thng gan rt
5072Cng vn phi ch l na i thi tr ca5131nng, e da sinh mng. Phn ng ny
5073acid acetylsalicylic ty thuc vo liu lng.5132xy ra chm, v vy iu rt quan trng
5074 liu gim au thp, na i thi tr5133l phi cho thuc gii c i vi nhng

128
 129

5134ngi nghi dng qu liu, k c khi khng5191au opiat l pethidin. Tim bp 75 mg

5135thy r du hiu hoc triu chng ng5192hoc t trc trng 50 - 100 mg c tc
5136c. Cc triu chng r rt ny c th5193dng chng au tt sau phu thut.
5137thy u tin sau 2 ngy, k c sau khi5194Diclofenac cng c tc dng nh
5138dng cc liu rt cao, liu ch t. Nguy c5195indomethacin ngi bnh b au cp
5139c i vi gan cng phi c xem xt5196tnh do si niu qun v au do si ng
5140nu cc liu thp hn c nhc li qu5197mt.
5141nhiu trong thi gian ngn. Nguy c ny
5142s cao hn i vi ngi bnh nghin ru v5198Naproxen: Cng c tnh cht khng vim
5143ngi bnh c iu tr bng cc thuc5199tc ng ngoi vi v h nhit. Thuc ny
5144nh hng ti chuyn ha ca gan, nh iu5200c s dng t lu chng cc bnh
5145tr bng phenytoin, carbamazepin,5201vim khp v c ch nh chng au c-
5146rifampicin. 5202ng va phi. Thuc c hp thu tt v
5147Nh vy l tn thng gan c th xy ra i5203na i thi tr huyt tng khong 10 -
5148vi liu paracetamol thp hn. Ngi bnh520417 gi, di hn nhiu so vi thuc khng
5149
88dngGim auparacetamol phi c iu5205vim khng steroid khc, t tc dng gim
qu liu
5150 tr tht sm vi acetylcy-stein hoc5206au ko di hn sau khi dng mt liu.
DTQGVN
5151methionin. 5207Trng hp au cp nh hoc va, liu
5152Ibuprofen: C tc dng gim au, khng5208khuyn co l 250 - 500 mg, ung 2 ln
5153vim v h st. Ibuprofen cng nh hng v5209trong 24 gi. Cc tc dng khng mong
5154c ch kt tp tiu cu, nhng tc dng ny5210mun cng ging nh acid acetylsa-
5155c th hi phc c v ngn hn so vi5211licylic.
5156acid acetylsalicylic. Tc dng gim au t
5212Diflunisal: L thuc gim au lin quan
5157c vi liu khong 200 - 400 mg v liu5213n acid acetylsalicylic. Vi liu 500 mg,
5158trn 400 mg cng khng lm tng thm tc
5214diflunisal cng c tc dng gim au bng
5159dng gim au. Ngi ta ch dng cc liu5215hoc c phn hn 1000 mg acid
5160cao hn trong trng hp vim khp dng
5216acetylsalicylic hoc 400 mg ibuprofen. Tc
5161thp v thoi khp. Thuc c na i thi5217dng chng au sau phu thut c th t-
5162tr trong huyt tng l 2 gi v cn phi
5218ng ng vi tc dng ca codein hoc
5163cho liu dng t nht 3 ln trong 24 gi.5219dextropropoxyphen t c liu bnh th-
5164Ibuprofen cng c dng tc dng khng
5220ng. Diflunisal c hp thu tt, khong
5165mong mun chung ging nh acid522185% liu ung. Na i thi tr huyt t-
5166acetylsalicylic, nhng t c tc dng khng
5222ng l
5167mong mun i vi d dy - rut, l522310 - 12 gi liu lng bnh thng, cn
5168mt thun li, c bit trong vai tr l
5224liu cao thi tr chm hn.
5169thuc t iu tr thay th cho acid
5225Cc tc dng khng mong mun bao gm
5170acetylsalicylic.
5226au bng, a chy, bun nn v nn.
5171Diclofenac: L dn cht ca acid acetic,5227Thuc ch c tc dng nh hoc va phi
5172c dng rng ri trong iu tr cc bnh5228i vi chng kt tp tiu cu v v vy
5173vim khp. Diclofenac cng c tc dng5229t c nguy c gia tng thi gian chy mu.
5174gim au v h st ging nh cc thuc5230So snh vi acid acetylsalicylic, diflunisal c
5175khng vim khng steroid khc. Dng thuc5231nhiu u im nh thi gian tc dng di
5176tim c ch nh iu tr au sau phu5232hn v t l tc dng khng mong mun
5177thut. Khi thay i gia loi tim v thuc5233thp hn.
5178vin nn, iu cn nh l cc vin nn ch
5234Indomethacin: Do tnh cht khng vim,
5179c 50% sinh kh dng so vi thuc tim, do
5235thuc c dng ch yu i vi cc bnh
5180c thi tr chuyn ha bc u trong khi
5236vim m lin kt. Thuc cng c dng tim
5181hp thu v khi qua gan ln u.
5237tnh mch vi liu 50 mg chng cc
5182Na i thi tr trong huyt tng l 1 - 2
5238cn au cp do si niu qun. iu tr vi
5183gi v iu thun li l c th cho liu
5239indomethacin lm gim p lc h thng
5184diclofenac bnh thng i vi ngi cao
5185tui v ngi b suy gim chc nng thn5240thn v gim au 70 - 80% ngi bnh.
5186hoc gan m khng cn iu chnh liu5241Tc dng l do lm gim bi niu v gin
5187lng. 5242cc c trn. Tc dng ny cng do c ch
5188 ngi bnh b au sau phu thut vi c-5243rt mnh tng hp prostaglandin thn. C
5189ng va phi, c kh nng diclofenac c5244th iu tr nhc li 20 pht sau liu
5190hiu lc gim au tng ng vi loi gim5245u tin. Nhng ngi bnh khng thy

130
 DTQGVN
131 Gim au 89

5246au sau khi iu tr nh trn, cn thay5301enkephalin v dynorphin. Cc thuc dng

5247bng thuc gim au opiat. Cc tc dng5302opi/opiat l nhng thuc gim au c ph
5248khng mong mun bao gm c ch mnh5303tc dng ch vn (ging morphin) v i
5249kt tp tiu cu, v nguy c cao b gi n-5304khng (ging naloxon) trn cc th th ny.
5250c nng hn nu dng thuc i vi ngi5305Morphin v methadon l cc cht ch vn
5251bnh b suy thn, gan hoc tim. Cc loi5306thun ty, cn pentazocin v buprenorphin
5252tc dng khng mong mun cng bao gm5307l cc cht ch vn/ i vn (i khng)
5253mt s tc dng trm trng i vi mu. 5308hn hp. liu thp, cc tc dng ch vn
5254Ketorolac: L mt dn cht ca acid5309chim u th, cn tc dng i vn tr nn
5255acetic, c ch nh trong cc trng thi5310r rt hn vi liu cao.
5256au sau phu thut mc va v5311Trong nalorphin, cc tnh cht i khng
5257nng. Na i thi tr huyt tng l 4 5312
- chim u th. Naloxon l mt cht i
52587 gi, tng ng vi tc dng gim au 5313 khng thun ty, hon ton khng c tc
5259sau mt liu duy nht. Trong cc nghin 5314 dng ch vn.
5260cu so snh, liu 30 mg ketorolac tim bp5315Morphin: B phn hy gan to cc cht
5261cng c tc dng mnh bng 12 mg5316chuyn ha thi loi theo ng thn. Na
5262morphin. Dng tc dng khng mong mun5317i thi tr huyt tng khong 2 - 4 gi.
5263rt ging nh cc thuc khng vim khng5318Hai cht chuyn ha chnh ca morphin l
5264steroid. 5319morphin - 6 - glucuronid (M6G) v mor-
5265Ketoprofen: L dn cht ca acid5320phin - 3 - glucuronid (M3G) xut hin vi
5266phenylpropionic, c tnh cht khng vim5321nng cao khi iu tr bng morphin.
5267v h nhit. Cc ch nh gm au cp t5322M6G tham gia vo tc dng ch vn chng
5268nh n va. Na i thi tr trong5323au ca morphin, cn cht chuyn ha
5269huyt tng khong 2 gi, ngha l c thi5324M3G l mt cht i khng mnh. Sau khi
5270gian tc dng gim au tng i ngn5325iu tr lu di, ngi bnh xy ra tch
5271sau khi cho dng mt vin nn hoc vin5326t M3G mc cao, khin cho tc dng
5272nang. Tuy vy, ngi ta cng sn xut5327gim au ca morphin t nhin mt i.
5273ch phm gii phng chm (thi gian tc5328Trong trng hp , nu thay morphin
5274dng 24 gi) sau mt liu dng cch 24 gi.5329bng mt opiat ch vn thun ty khc, cc
5275Vin nn gii phng chm c dng trong5330cht chuyn ha c to thnh b thi
5276cc bnh thp khp v au kt hp, cn5331tr.
5277vin thng thng c dng trong au cp5332 ngi ln bnh thng, nu tim bp hoc
5278tnh. Ketoprofen l thuc gim au snh5333di da, liu lng morphin bnh thng l 10 -
5279c vi cc thuc khng vim khng steroid533415 mg. Nu cho ung vin nn morphin
5280khc; xt v cc tc dng khng mong5335phi tng liu v sinh kh dng theo ng
5281mun v chng ch nh th cng tng5336ung trung bnh ch l 35%. Liu ung
5282t nh phn ln cc thuc khng vim khng5337thng thng cch 6 gi mi ln l 5 - 10
5283steroid khc. 5338mg trong 24 gi. Nh vy khng th t c
5284Azapropazon: Cng ging nh cc thuc5339thi gian tc dng di hn trung bnh l 4
5285khng vim khng steroid khc, thuc c5340gi i vi mt liu thuc. Tuy nhin, hin
5286tc dng khng vim, gim au v h st.5341nay c ch phm gii phng chm, thi
5287Cc ch nh l vim khp dng thp, thoi5342gian tc dng 8 - 12 gi mt ln.
5288khp v bnh Bechterev. Cc tc dng5343iu quan trng cn phi bit l ngi cao
5289khng mong mun v cc chng ch nh5344tui thng nhy cm vi morphin hn so vi
5290cng ging nh cc thuc khng vim khng5345ngi tr. Do , theo l thng h cn dng
5291steroid khc. 5346liu thp hn, nhng vn cn phi dng mt
5347liu mi cch nhau 4 - 5 gi.
5292Cc thuc gim au tc ng trung -
5348Nguy c xy ra nghin thuc l mt nguy
5293ng:
5349c cn c xem xt sau mt tun iu
5294Cc thuc gim au tc ng trung ng
5350tr nhc li nhiu ln. Tuy nhin nguy c
5295gm cc thuc c v tr tc ng ch yu
5351 thng b cng iu v iu ng
5296 no v/hoc ty sng. Tc dng gim
5352tic l cc thy thuc s gy nghin cho
5297au l do gn vo cc th th opiat c
5353ngi bnh, nn thng cho iu tr au di
5298hiu c hot ha v v th ngn tr vn
5354liu ti u i vi cc ngi bnh cn c h
5299chuyn xung au. Cc cht ni sinh gn
5355tr chng au trm trng.
5300vi cc th th ny l cc endorphin,

132
 133

5356Trong iu tr au do ung th, iu cn5412bp hoc tnh mch v tim di da thng

5357thit l thy thuc thc hin c mc tiu,5413gy cc tc dng khng mong mun ti
5358gim au tt nht, to c cht lng5414ch. Vi cng liu gim au, tc dng gy
5359cuc sng tt, v trong hon cnh m5415suy gim h hp v nguy c gy nghin
5360cn nhc v nguy c nghin thuc thng5416ca pethidin tuyt i ngang bng vi suy
5361l khng thch ng. 5417gim h hp v nguy c gy nghin do
5362Chng ch nh tng i i vi thuc5418morphin gy ra. S chuyn ha ca
5363gim au typ morphin: 5419pethidin to ra mt cht chuyn ha c kh
5364Bnh phi tc nghn mn tnh (hen, vim5420nng tch t li khi iu tr lu di. ngi
5365ph qun mn). 5421suy thn, cht chuyn ha ny c th t
5366Tng p lc ni s. 5422ti mc rt cao v gy ra cn ng
5367Gim nng tuyn gip. 5423kinh. V th ch c dng pethidin trong
5368Tm ph mn, chn thng lng ngc. 5424iu tr au cp tnh m khng c s
5369Trng thi ng li b (narcomania). 5425dng trong iu tr au mn tnh.
5370Ketobemidon: C lch s lu di dng kt5426Buprenorphin: L mt thuc gim au
5371hp vi mt thuc chng co tht. nhiu n-5427tc ng trung ng, ch c dng ng
5372c chu u, hin nay ketobemidon c5428tim do c sinh kh dng thp qua ng
5373dng n thun, khng km theo bt k5429ung. Thuc c c hai tnh cht ch vn v
5374loi thuc chng co tht no. Ketobemidon5430i vn opiat hn hp. i vi au sau phu
5375l mt cht dng opi mnh c th th , c5431thut, liu tim 0,3 mg buprenorphin cng
5376c hai hnh thi tc dng v dc ng hc5432gim au bng 10 mg morphin, nhng thi
5377rt ging morphin. Sinh kh dng khong5433gian tc dng c phn di hn. Cng c cc
537835%
90 v i thi tr khong 2 - 3 gi.5434tc dng khng mong mun l bun ng,
na au
Gim
5379Liu khuyn co l 5 - 7,5 mg tim bp. 5435bun nn v chng mt nh morphin. Cn
DTQGVN
5436nh l suy gim h hp do buprenorphin
5380Methadon: C sinh kh dng cao qua -5437gy ra rt kh ngn ct, khi s dng
5381ng ung (trung bnh 80%) v do liu5438naloxon.
5382tim v liu ung bng nhau trong thc
5383hnh y hc. liu tim, 10 mg methadon5439Pentazocin: Ging nh buprenorphin, l
5384mnh gn bng 10 mg morphin, nhng sau5440cht ch vn morphin mt phn v cht
5385khi dng liu ung, 10 mg methadon mnh5441ny c th kch thch ln c ch cc th
5386bng 20 - 30 mg morphin ung. Mc d5442th opiat. Tc dng ca 50 mg pentazocin
5387na i thi tr ca methadon chm trn5443ung bng 650 mg acid acetylsalicylic, nh-
538812 gi, nhng thi gian tc dng sau mt5444ng thi gian tc dng ngn hn nhiu. t
5389liu duy nht cng bng mt liu morphin5445gim au sau
5390duy nht (khong 4 gi). Hu qu ca na54461/2 - 1 gi, v t mc ti a sau 1 - 2 gi.
5391i thi tr chm ca methadon l cn5447Sau khi tim bp, t gim au sau 20
5392nhiu thi gian cho liu nhc li, trc khi5448pht. Thi gian tc dng ngn hn
5393ngi bnh t c mc n nh v khng5449morphin, v t tc dng ti a khong 1
5394th nh gi c tc dng gim au sm5450gi sau dng thuc. Khng nn cho ung
5395trc 5 - 6 ngy sau khi cho liu nhc li. 5451pentazocin, v cc tc dng khng mong
5396V vy, cc tnh cht dc ng hc lm5452mun c t l cao v ch gim au va
5397cho methadon khng thch hp iu5453phi. Pentazocin gi vai tr trong iu tr
5398tr au cp tnh. Tuy nhin thuc c u5454au trm trng cp tnh v sau phu
5399im ng k khi dng iu tr lu5455thut, c bit ngi bnh kh nghi lm
5400di au trm trng do ung th, nhng phi5456dng ru hoc benzodiazepin. Nguy c lm
5401cn nhc l kh "iu vn" hn morphin5457dng v nghin thuc t hn nhiu so vi
5402do na i thi tr di hn. 5458morphin.
5403Pethidin: L mt opiat gim au kiu5459Codein (methylmorphin): c nhiu ti liu
5404morphin, c lin quan ti atropin v ging5460chng minh l c tc dng chng nhiu
5405nh atropin nn c tc dng khng cholin,5461loi au do nhiu ngun gc. Tc dng
5406gm c kh ming. Tc dng gim au5462gim au ca codein do s chuyn ha
5407sau khi tim bng khong 1/10 tc dng5463thnh morphin v morphin - 6 - glucu-
5408ca morphin (100 mg pethidin gim au5464ronid. Liu ung codein thp nht mang li
5409bng 10 mg morphin). Thi gian tc dng5465tc dng gim au l 30 mg.
5410ca pethidin c phn ngn hn so vi
5411morphin v phi s dng bng ng tim

134
135

5466So snh liu dng duy nht th 30 mg5522carba-

5467codein c tc dng gim au bng 500 mg5523mazepin m khng thy gim au th
5468acid acetylsalicylic. 5524phi nghi ng v chn on au dy tam
5469Phi cn nhc dng liu thp hn i vi5525thoa.
5470ngi cao tui, v ngi trn 60 tui d5526Thuc chng trm cm gim au:
5471nhy cm hn i vi opiat. Codein c5527Clomipramin c ch nh cho iu tr
5472hp thu tt v thi gian tc dng ca mt
5528"hi chng au t pht c triu chng
5473liu duy nht l 3 - 5 gi. Na i thi tr
5529trm cm". Clomipramin l thuc chng
5474trong huyt tng khong 4 gi ngi
5530trm cm ba vng, cng c tc dng i
5475bnh trung bnh. Cc tc dng khng
5531vi cc chng lon thn kinh cng bch v lo
5476mong mun ca codein gm bun ng,
5532u trm trng. Thuc c nh hng ti s ti
5477bun nn, to bn v ri lon vn ng -
5533thu nhn cc cht truyn dn thn kinh
5478ng mt ngi d nhy cm. Phi hp 25 -
5534t bo thn kinh ging nh cc thuc chng
547950 mg codein vi acid acetylsalicylic hoc
5535trm cm khc. Tc dng gim au c lin
5480paracetamol iu tr trng hp au
5481va, khi dng thuc khng vim khng5536quan c bit n c ch ti thu nhn
5482steroid n thun khng tc dng. 5537serotonin t bo thn kinh khi s dng
5538clomipramin.
5483Dextropropoxyphen: Lin quan v mt5539Trong cc nghin cu lm sng c i
5484ha hc vi methadon, c hnh thi tc5540chng, clomipramin chng t c tc dng
5485dng yu ging dng opi. So vi codein,5541i vi hi chng au mn tnh t pht,
5486thuc c tc dng gim au yu hn, khi5542nh au lin quan ti bnh dy thn kinh
5487dng liu duy nht. Cn phi cn nhc s5543do i tho ng v au sau herpes. Tc
5488dng cc ch phm khc nhau, v liu 65
5544dng gim au ny khng phi l ph
5489mg dextropropoxyphen clorid mnh ngang
5545bin i vi mi loi thuc chng trm
5490100 mg dextropropoxyphen nap-
5546cm. Cn c mt thi gian clomipramin
5491sylat.
5492V na i thi tr chm nn tnh trng5547lm gim au va phi trc khi xc nh
5493n nh ch t c sau mt s liu5548l c p ng gim au lm sng. Tc
5494nhc li v tc dng gim au thng ch5549dng chng au khng nht thit lin h
5495c th nh gi c 3 - 4 ngy sau khi cho5550v thng khng lin quan vi tc dng
5496cc liu nhc li. Cc tc dng khng mong5551chng cc triu chng trm cm. Cc tc
5497mun cng ging nh i vi codein nhng5552dng khng mong mun ca loi iu tr
5498to bn v tc dng khng mong mun v5553ny gm cc tc dng khng cholin ph
5499ng mt cng t hn. Qu liu gy t5554thuc liu lng nh kh ming, kh iu
5500vong c bo co vi liu thp bng 6505555tit, to bn v kh tiu tin. An thn nh
5501- 1300 mg (10 - 20 vin nn) v thng th-5556v h huyt p t th l cc tc dng khng
5502ng nh vy nu ung cng vi ru s gy5557mong mun ph bin khc.
5503thm suy h hp. 5558Cc thuc an thn kinh gim au:
5504Cc thuc khng ng kinh chng5559Mt s thuc an thn kinh nh clorpromazin,
5505au: Tc dng ca cc thuc khng ng5560thioridazin, levome-promazin v
5506kinh c nghin cu trn cc ngi bnh5561cloprothixen c ch nh s dng trong
5507b au do thn kinh. au dy thn kinh5562mt s hi chng au. Cc thuc an thn
5508tam thoa l mt ch nh i vi cch5563kinh ny hu dng trong iu tr loi au
5509iu tr ny. Th au ny khi pht sau5564nng do thn kinh kh cha tr nh c th
551030 tui v c im l tng giai on5565gp ngi bnh b di cn ung th, au
5511ngn c cn kch pht, au xin vo khu5566dy thn kinh tam thoa v au dy thn
5512vc ca dy tam thoa. Khng c ri lon5567kinh do Herpes zoster. Tuy vy, tc dng
5513cm gic nhng in hnh l "khu vc kch5568gim au vn c cng nh tc dng tng c-
5514pht" v "ng x trnh n". i vi cc loi5569ng ca cc thuc an thn kinh cng c
5515au khc do thn kinh nh au thn kinh
5570cc thuc gim au khc, vn cha c
5516thit - hu, carbamazepin c tc dng d-
5571nh gi y trong cc nghin cu
5517ng tnh c chng minh. Thc t, c
5572lm sng hin i. V vy, vic s dng
5518tc dng hoc khng c tc dng ca
5573cn phi c coi nh c tnh cht thc
5519carbamazepin c coi l mt tiu chun
5520chn on lin quan n au dy thn5574nghim nhiu hn v ch dnh cho cc tr-
5521kinh tam thoa. Nu 24 - 48 gi sau khi cho5575ng hp kh. Cc tc dng khng mong

136
 137

5576mun ca iu tr bng thuc an thn

5577kinh gm an thn nh, cc tc dng khng
5578mong mun ngoi thp, h huyt p th
5579ng, kh ming...

138