{"id":10811,"date":"2023-08-02T23:30:49","date_gmt":"2023-08-02T15:30:49","guid":{"rendered":"https:\/\/docquity.com\/?post_type=articles&p=10811"},"modified":"2025-02-11T13:36:17","modified_gmt":"2025-02-11T05:36:17","slug":"phan-1-xu-tri-benh-nhan-soc-nhiem-khuan-nhung-vi-du-thuc-te","status":"publish","type":"articles","link":"https:\/\/docquity.com\/vi\/articles\/phan-1-xu-tri-benh-nhan-soc-nhiem-khuan-nhung-vi-du-thuc-te\/","title":{"rendered":"Ph\u1ea7n 1: X\u1eed tr\u00ed b\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec5m khu\u1ea9n? Nh\u1eefng v\u00ed d\u1ee5 th\u1ef1c t\u1ebf"},"content":{"rendered":"\n

M\u1ede \u0110\u1ea6U<\/strong><\/p>\n\n\n\n

B\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec5m khu\u1ea9n (septic shock) c\u1ea7n \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb b\u1eb1ng c\u00e1c t\u00e1c nh\u00e2n v\u1eadn m\u1ea1ch \u0111\u1ec3 \u0111i\u1ec1u ch\u1ec9nh huy\u1ebft \u00e1p v\u00e0 gi\u1ea3i quy\u1ebft t\u00ecnh tr\u1ea1ng nhi\u1ec5m toan lactic do nhi\u1ec5m tr\u00f9ng. C\u00f3 t\u1edbi 30 \u2013 40% tr\u01b0\u1eddng h\u1ee3p s\u1ed1c nhi\u1ec5m khu\u1ea9n b\u1ecb t\u1eed vong. B\u00e1c s\u0129 c\u1ea7n \u0111\u01b0a ra nhi\u1ec1u quy\u1ebft \u0111\u1ecbnh \u0111i\u1ec1u tr\u1ecb khi ki\u1ec3m so\u00e1t b\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec5m khu\u1ea9n, bao g\u1ed3m l\u1ef1a ch\u1ecdn thu\u1ed1c v\u1eadn m\u1ea1ch v\u00e0 c\u00e1c bi\u1ec7n ph\u00e1p \u0111i\u1ec1u tr\u1ecb b\u1ed5 tr\u1ee3.<\/p>\n\n\n\n

B\u00e0i vi\u1ebft n\u00e0y h\u1ed7 tr\u1ee3 \u0111\u1ed9c gi\u1ea3 tr\u1ea3 l\u1eddi cho c\u00e2u h\u1ecfi \u201cl\u00e0m th\u1ebf n\u00e0o\u201d b\u1eb1ng nh\u1eefng v\u00ed d\u1ee5 th\u1ef1c t\u1ebf trong vi\u1ec7c \u0111\u01b0a ra l\u1ef1a ch\u1ecdn thu\u1ed1c v\u1eadn m\u1ea1ch \u0111\u1ea7u tay, \u0111\u01b0a ra huy\u1ebft \u00e1p \u0111\u00edch, \u0111\u01b0\u1eddng d\u00f9ng c\u1ee7a thu\u1ed1c v\u1eadn m\u1ea1ch, l\u1ef1a ch\u1ecdn thu\u1ed1c v\u1eadn m\u1ea1ch h\u00e0ng 2 v\u00e0 c\u00e1c thu\u1ed1c \u0111i\u1ec1u tr\u1ecb b\u1ed5 tr\u1ee3. B\u00e0i vi\u1ebft \u0111\u01b0\u1ee3c chia l\u00e0m 2 ph\u1ea7n, ph\u1ea7n 1 gi\u1ea3i \u0111\u00e1p nh\u1eefng th\u1eafc m\u1eafc v\u1ec1 vi\u1ec7c l\u1ef1a ch\u1ecdn c\u00e1c thu\u1ed1c v\u1eadn m\u1ea1ch, corticosteroid v\u00e0 c\u00e1c bi\u1ec7n ph\u00e1p \u0111i\u1ec1u tr\u1ecb b\u1ed5 tr\u1ee3. Ph\u1ea7n 2 b\u00e0n lu\u1eadn v\u1ec1 th\u1eddi \u0111i\u1ec3m ng\u01b0ng l\u00ean thang thu\u1ed1c v\u1eadn m\u1ea1ch, c\u00e1ch xu\u1ed1ng thang thu\u1ed1c v\u1eadn m\u1ea1ch v\u00e0 x\u1eed tr\u00ed b\u1ec7nh nh\u00e2n s\u1ed1c dai d\u1eb3ng v\u00e0 kh\u00f3 tr\u1ecb.<\/p>\n\n\n\n

V\u00cd D\u1ee4 1<\/strong><\/p>\n\n\n\n

B\u1ec7nh nh\u00e2n n\u1eef, 65 tu\u1ed5i ti\u1ec1n c\u0103n rung nh\u0129 nh\u1eadp khoa c\u1ea5p c\u1ee9u do t\u00ecnh tr\u1ea1ng s\u1ed1t v\u00e0 b\u00ed ti\u1ec3u. Huy\u1ebft \u00e1p ban \u0111\u1ea7u c\u1ee7a b\u1ec7nh nh\u00e2n l\u00e0 75\/40 mmHg (huy\u1ebft \u00e1p trung b\u00ecnh 52 mmHg), t\u1ea7n s\u1ed1 tim 95 nh\u1ecbp\/ph\u00fat, \u0111\u1ed9 b\u00e3o h\u00f2a oxy m\u00e1u 92%. T\u1ee9 chi \u1ea5m v\u00e0 \u0111\u01b0\u1ee3c t\u01b0\u1edbi m\u00e1u t\u1ed1t. B\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c truy\u1ec1n d\u1ecbch Ringer\u2019s lactate cho \u0111\u1ebfn khi kh\u00f4ng c\u00f2n \u0111\u00e1p \u1ee9ng b\u00f9 d\u1ecbch. Huy\u1ebft \u00e1p c\u1ee7a b\u1ec7nh nh\u00e2n v\u1eabn \u1edf m\u1ee9c th\u1ea5p (82\/45 mmHg). Lactate huy\u1ebft thanh l\u00e0 2.5 g\/l. K\u1ebft qu\u1ea3 si\u00eau \u00e2m tim th\u1ea5y ch\u1ee9c n\u0103ng hai t\u00e2m th\u1ea5t gi\u1ea3m trung b\u00ecnh v\u00e0 ch\u1ee9c n\u0103ng t\u00e2m thu r\u1ed1i lo\u1ea1n m\u1ee9c \u0111\u1ed9 1 (kh\u00f4ng thay \u0111\u1ed5i so v\u1edbi \u0111\u00e1nh gi\u00e1 tr\u01b0\u1edbc \u0111\u00f3). Sau khi h\u1ed9i ch\u1ea9n v\u00e0 c\u00f3 s\u1ef1 \u0111\u1ed3ng \u00fd t\u1eeb b\u1ec7nh nh\u00e2n, norepinephrine qua catheter t\u0129nh m\u1ea1ch ngo\u1ea1i bi\u00ean \u0111\u01b0\u1ee3c l\u1ef1a ch\u1ecdn, \u0111\u1ed3ng th\u1eddi b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c chuy\u1ec3n \u0111\u1ebfn khoa ch\u0103m s\u00f3c t\u00edch c\u1ef1c.<\/p>\n\n\n\n

Li\u1ec7u c\u00f3 tr\u01b0\u1eddng h\u1ee3p ngo\u1ea1i l\u1ec7 cho l\u1ef1a ch\u1ecdn \u0111\u1ea7u tay norepinephrine?<\/em><\/strong><\/p>\n\n\n\n

Trong \u0111i\u1ec1u tr\u1ecb s\u1ed1c nhi\u1ec5m khu\u1ea9n, l\u1ef1a ch\u1ecdn \u0111\u1ea7u tay thay th\u1ebf cho norepinephrine hi\u1ebfm khi \u0111\u01b0\u1ee3c \u0111\u01b0a ra. \u0110\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n c\u00f3 nguy c\u01a1\/ho\u1eb7c \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ea9n \u0111o\u00e1n m\u1eafc rung nh\u0129 ho\u1eb7c c\u00e1c t\u00ecnh tr\u1ea1ng lo\u1ea1n nh\u1ecbp tr\u00ean th\u1ea5t v\u00e0 \u0111\u01b0\u1ee3c cho l\u00e0 k\u00e9m dung n\u1ea1p \u0111\u00e1p \u1ee9ng th\u1ea5t nhanh (ch\u1eb3ng h\u1ea1n nh\u01b0 b\u1ec7nh nh\u00e2n d\u1ef1 tr\u1eef tim k\u00e9m), vasopressin ho\u1eb7c phenylephrine \u0111\u01b0\u1ee3c c\u00e2n nh\u1eafc l\u1ef1a ch\u1ecdn l\u00e0m thu\u1ed1c v\u1eadn m\u1ea1ch kh\u1edfi \u0111\u1ea7u thay v\u00ec norepinephrine.<\/p>\n\n\n\n

Norepinephrine \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o l\u00e0 thu\u1ed1c v\u1eadn m\u1ea1ch \u0111\u1ea7u tay trong \u0111i\u1ec1u tr\u1ecb s\u1ed1c nhi\u1ec5m khu\u1ea9n trong h\u00e0ng th\u1eadp k\u1ef7. Khuy\u1ebfn c\u00e1o n\u00e0y \u0111\u01b0\u1ee3c \u0111\u01b0a ra d\u1ef1a tr\u00ean k\u1ebft qu\u1ea3 c\u1ee7a nh\u1eefng th\u1eed nghi\u1ec7m l\u00e2m s\u00e0ng ng\u1eabu nhi\u00ean, so s\u00e1nh gi\u1eefa norepinephrine (c\u01a1 ch\u1ebf ch\u1ee7 v\u1eadn ch\u1ee7 y\u1ebfu tr\u00ean \u03b11 <\/sub>v\u00e0 \u0111\u1ed3ng th\u1eddi tr\u00ean \u03b21<\/sub>) v\u00e0 c\u00e1c thu\u1ed1c v\u1eadn m\u1ea1ch kh\u00e1c v\u1edbi c\u01a1 ch\u1ebf ho\u1ea1t \u0111\u1ed9ng kh\u00e1c (vasopressin, phenylephrine, dopamine v\u00e0 epinephrine)1<\/sup>. C\u00f3 m\u1ed9t th\u1eed nghi\u1ec7m cho th\u1ea5y norepinephrine c\u00f3 nguy c\u01a1 g\u00e2y lo\u1ea1n nh\u1ecbp th\u1ea5p h\u01a1n so v\u1edbi dopamine2<\/sup>, c\u00e1c th\u1eed nghi\u1ec7m kh\u00e1c kh\u00f4ng cho th\u1ea5y c\u00f3 s\u1ef1 kh\u00e1c bi\u1ec7t v\u1ec1 t\u1ef7 l\u1ec7 t\u1eed vong ho\u1eb7c k\u1ebft c\u1ee5c l\u00e2m s\u00e0ng kh\u00e1c gi\u1eefa norepinephrine v\u00e0 c\u00e1c thu\u1ed1c v\u1ead m\u1ea1ch kh\u00e1c ngo\u00e0i dopamine1<\/sup>. K\u1ec3 t\u1eeb \u0111\u00f3, c\u00e1c h\u01b0\u1edbng d\u1eabn l\u00e2m s\u00e0ng cho r\u1eb1ng norepinephrine v\u01b0\u1ee3t tr\u1ed9i h\u01a1n dopamine. Nh\u00ecn chung, khuy\u1ebfn c\u00e1o thu\u1ed1c v\u1eadn m\u1ea1ch \u0111\u1ea7u tay l\u00e0 norepinephrine, tuy nhi\u00ean, c\u00e1c t\u00e1c nh\u00e2n kh\u00f4ng ch\u1ee7 v\u1eadn \u03b21<\/sub> (vasopressin ho\u1eb7c phenylephrine) \u0111\u01b0\u1ee3c c\u00e2n nh\u1eafc l\u1ef1a ch\u1ecdn thay v\u00ec norepinephrine khi nghi s\u1ebd x\u1ea3y ra c\u00e1c bi\u1ebfn b\u1ed1 c\u00f3 h\u1ea1i li\u00ean quan \u0111\u1ebfn t\u00e1c \u0111\u1ed9ng adrenergic c\u1ee7a norepinephrine ho\u1eb7c nghi s\u1ebd x\u1ea3y ra t\u00ecnh tr\u1ea1ng m\u1ea5t b\u00f9 l\u00e2m s\u00e0ng. C\u01a1 s\u1edf c\u1ee7a l\u1ef1a ch\u1ecdn n\u00e0y \u0111\u01b0\u1ee3c \u0111\u01b0a ra d\u1ef1a tr\u00ean k\u1ebft qu\u1ea3 c\u1ee7a m\u1ed9t s\u1ed1 nghi\u00ean c\u1ee9u cho th\u1ea5y kh\u1edfi \u0111\u1ea7u \u0111i\u1ec1u tr\u1ecb b\u1eb1ng phenylephrine c\u00f3 th\u1ec3 c\u1ea3i thi\u1ec7n nh\u1eb9 t\u1ea7n s\u1ed1 tim so v\u1edbi norepinephrine \u1edf b\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec3m khu\u1ea9n m\u1eafc k\u00e8m rung nh\u0129 3<\/sup>.<\/p>\n\n\n\n

Sau khi kh\u1edfi \u0111\u1ea7u \u0111i\u1ec1u tr\u1ecb b\u1eb1ng norepinephrine, n\u00ean \u0111\u01b0a ra huy\u1ebft \u00e1p trung b\u00ecnh m\u1ee5c ti\u00eau n\u00e0o?<\/em><\/strong><\/p>\n\n\n\n

Huy\u1ebft \u00e1p trung b\u00ecnh m\u1ee5c ti\u00eau th\u01b0\u1eddng \u0111\u01b0\u1ee3c l\u1ef1a ch\u1ecdn cho \u0111a s\u1ed1 b\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec5m khu\u1ea9n l\u00e0 60 \u2013 65 mmHg. M\u1ee9c huy\u1ebft \u00e1p n\u00e0y \u0111\u01b0\u1ee3c \u0111\u01b0a ra d\u1ef1a tr\u00ean d\u1eef li\u1ec7u cho th\u1ea5y s\u1ef1 t\u1ef1 \u0111i\u1ec1u h\u00f2a c\u1ee7a n\u00e3o b\u1ed9 gi\u1ea3m \u0111i nhanh ch\u00f3ng khi huy\u1ebft \u00e1p trung b\u00ecnh < 60 mmHg. Nh\u1eefng th\u1eed nghi\u1ec7m l\u00e2m s\u00e0ng g\u1ea7n \u0111\u00e2y cho th\u1ea5y m\u1ee5c ti\u00eau huy\u1ebft \u00e1p trung b\u00ecnh > 65 mmHg \u1edf b\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec5m khu\u1ea9n c\u00f3 th\u1ec3 g\u00e2y h\u1ea1i, l\u00e0m t\u0103ng nguy c\u01a1 nhanh nh\u1ecbp tr\u00ean th\u1ea5t v\u00e0 c\u00f3 th\u1ec3 g\u00e2y t\u1eed vong4, 5<\/sup>.<\/p>\n\n\n\n

Khi n\u00e0o n\u00ean \u0111\u1eb7t catheter t\u0129nh m\u1ea1ch trung t\u00e2m cho thu\u1ed1c v\u1eadn m\u1ea1ch?<\/em><\/strong><\/p>\n\n\n\n

\u0110\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c kh\u1edfi \u0111\u1ea7u \u0111i\u1ec1u tr\u1ecb b\u1eb1ng norepinephrine li\u1ec1u th\u1ea5p (< 15 \u00b5g\/ph\u00fat ho\u1eb7c < 0.3 15 \u00b5g\/kg\/ph\u00fat), norepinephrine b\u1eb1ng catheter t\u0129nh m\u1ea1ch ngo\u1ea1i bi\u00ean th\u01b0\u1eddng \u0111\u01b0\u1ee3c l\u1ef1a ch\u1ecdn, sau \u0111\u00f3 lo\u1ea1i catheter kh\u00e1c c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c c\u00e2n nh\u1eafc n\u1ebfu c\u1ea7n thi\u1ebft. \u1ede b\u1ec7nh nh\u00e2n c\u1ea7n \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb b\u1eb1ng epinephrine trong > 24 \u2013 48 gi\u1edd nh\u01b0ng v\u1edbi li\u1ec1u th\u1ea5p v\u00e0 c\u00f3 huy\u1ebft \u0111\u1ed9ng \u1ed5n \u0111\u1ecbnh, chuy\u1ec3n sang truy\u1ec1n b\u1eb1ng midline catheter th\u01b0\u1eddng \u0111\u01b0\u1ee3c c\u00e2n nh\u1eafc. \u1ede b\u1ec7nh nh\u00e2n kh\u00f4ng \u1ed5n \u0111\u1ecbnh dai d\u1eb3ng ho\u1eb7c c\u1ea7n \u0111i\u1ec1u tr\u1ecb b\u1eb1ng norepinephrine li\u1ec1u cao h\u01a1n, b\u1ed5 sung thu\u1ed1c v\u1eadn m\u1ea1ch kh\u00e1c ho\u1eb7c b\u1ed5 sung \u0111\u01b0\u1eddng truy\u1ec1n kh\u00e1c, n\u00ean chuy\u1ec3n qua catheter truy\u1ec1n t\u0129nh m\u1ea1ch trung t\u00e2m.<\/p>\n\n\n\n

Vi\u1ec7c truy\u1ec1n thu\u1ed1c v\u1eadn m\u1ea1ch qua t\u0129nh m\u1ea1ch ngo\u1ea1i bi\u00ean c\u00f3 < 5 % nguy c\u01a1 tho\u00e1t m\u1ea1ch n\u1ebfu truy\u1ec1n trong th\u1eddi gian < 72 gi\u1edd m\u00e0 kh\u00f4ng x\u1ea3y ra t\u00ecnh tr\u1ea1ng ho\u1ea1i t\u1eed m\u00f4 ho\u1eb7c thi\u1ebfu m\u00e1u c\u1ee5c b\u1ed9 \u1edf chi 6, 7<\/sup>. H\u01a1n n\u1eefa, truy\u1ec1n thu\u1ed1c t\u0129nh m\u1ea1ch qua \u0111\u01b0\u1eddng ngo\u1ea1i bi\u00ean c\u00f3 th\u1ec3 l\u00e0m gi\u1ea3m th\u1eddi gian s\u1eed d\u1ee5ng thu\u1ed1c v\u1eadn m\u1ea1ch so v\u1edbi catheter \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch trung t\u00e2m [8]. Nh\u1eefng d\u1eef li\u1ec7u n\u00e0y \u0111\u00e3 d\u1eabn \u0111\u1ebfn khuy\u1ebfn c\u00e1o y\u1ebfu trong h\u01b0\u1edbng d\u1eabn Surviving Sepsis Campaign v\u1ec1 vi\u1ec7c kh\u1edfi \u0111\u1ea7u thu\u1ed1c v\u1eadn m\u1ea1ch b\u1eb1ng \u0111\u01b0\u1eddng ngo\u1ea1i bi\u00ean \u0111\u1ec3 \u0111\u1ea1t huy\u1ebft \u00e1p m\u1ee5c ti\u00eau thay v\u00ec catheter t\u0129nh m\u1ea1ch trung t\u00e2m1<\/sup>.<\/p>\n\n\n\n

Khi n\u00e0o n\u00ean c\u00e2n nh\u1eafc b\u1ed5 sung thu\u1ed1c v\u1eadn m\u1ea1ch th\u1ee9 hai<\/em><\/strong><\/p>\n\n\n\n

Thu\u1ed1c v\u1eadn m\u1ea1ch th\u1ee9 2 \u0111\u01b0\u1ee3c c\u00e2n nh\u1eafc \u1edf b\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec5m khu\u1ea9n t\u0103ng nhu c\u1ea7u \u0111i\u1ec1u tr\u1ecb b\u1eb1ng thu\u1ed1c v\u1eadn m\u1ea1ch (th\u01b0\u1eddng v\u1edbi li\u1ec1u norepinephrine ti\u1ec7m c\u1eadn 15 \u00b5g\/ph\u00fat). N\u1ebfu m\u1ee5c ti\u00eau truy\u1ec1n kh\u00f4ng \u0111\u1ea1t v\u1edbi li\u1ec1u trung b\u00ecnh c\u1ee7a thu\u1ed1c v\u1eadn m\u1ea1ch kh\u1edfi \u0111\u1ea7u, vi\u1ec7c quy\u1ebft \u0111\u1ecbnh b\u1ed5 sung thu\u1ed1c v\u1eadn m\u1ea1ch kh\u00e1c ho\u1eb7c t\u0103ng li\u1ec1u thu\u1ed1c v\u1eadn m\u1ea1ch hi\u1ec7n d\u00f9ng c\u1ea7n \u0111\u01b0\u1ee3c c\u00e2n nh\u1eafc d\u1ef1a tr\u00ean vi\u1ec7c c\u00e2n b\u1eb1ng gi\u1eefa l\u1ee3i \u00edch\/nguy c\u01a1. Hi\u1ec7n ch\u01b0a c\u00f3 nhi\u1ec1u b\u1eb1ng ch\u1ee9ng tr\u1ef1c ti\u1ebfp h\u01b0\u1edbng d\u1eabn vi\u1ec7c b\u1ed5 sung thu\u1ed1c v\u1eadn m\u1ea1ch th\u1ee9 hai. \u1ede b\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec5m khu\u1ea9n, h\u01b0\u1edbng d\u1eabn hi\u1ec7n c\u00f3 \u0111\u01b0a ra khuy\u1ebfn c\u00e1o y\u1ebfu cho vi\u1ec7c b\u1ed5 sung vasopressin v\u00e0o ph\u00e1c \u0111\u1ed3 \u0111i\u1ec1u tr\u1ecb v\u1edbi norepinephrine khi li\u1ec1u norepinephrine \u0111\u1ea1t 0.25 \u2013 0.5 15 \u00b5g\/kg\/ph\u00fat1<\/sup>.<\/p>\n\n\n\n

Khi kh\u00f4ng th\u1ea5y \u0111\u01b0\u1ee3c \u0111\u00e1p \u1ee9ng \u2013 li\u1ec1u (s\u1ef1 thay \u0111\u1ed5i huy\u1ebft \u00e1p v\u00e0 c\u00e1c bi\u1ebfn ch\u1ee9ng li\u00ean quan \u0111\u1ebfn li\u1ec1u norepinephrine), quy\u1ebft \u0111\u1ecbnh v\u1ec1 vi\u1ec7c b\u1ed5 sung thu\u1ed1c v\u1eadn m\u1ea1ch th\u1ee9 2 n\u00ean \u0111\u01b0\u1ee3c \u0111\u01b0a ra d\u1ef1a tr\u00ean c\u00e1c c\u00e2n nh\u1eafc th\u1ef1c h\u00e0nh v\u00e0 c\u00e1c b\u1eb1ng ch\u1ee9ng gi\u00e1n ti\u1ebfp. M\u1ed9t s\u1ed1 c\u00e2n nh\u1eafc th\u1ef1c h\u00e0nh bao g\u1ed3m t\u1ed1c \u0111\u1ed9 c\u1ea7n ph\u1ea3i l\u00ean thang thu\u1ed1c v\u1eadn m\u1ea1ch v\u00e0 s\u1ef1 kh\u1ea3 d\u1ee5ng c\u1ee7a thu\u1ed1c v\u1ead m\u1ea1ch th\u1ee9 2; l\u00ean thang li\u1ec1u thu\u1ed1c v\u1eadn m\u1ea1ch kh\u1edfi \u0111\u1ea7u \u1edf b\u1ec7nh nh\u00e2n m\u1ea5t b\u00f9 nhanh ch\u00f3ng kh\u00f4ng n\u00ean b\u1ecb tr\u00ec ho\u00e3n do ch\u1edd thu\u1ed1c v\u1eadn m\u1ea1ch th\u1ee9 2. Tuy nhi\u00ean, b\u00e1c s\u0129 \u0111i\u1ec1u tr\u1ecb n\u00ean \u0111\u01b0a ra k\u1ebf ho\u1ea1ch cho vi\u1ec7c b\u1ed5 sung s\u1edbm thu\u1ed1c v\u1eadn m\u1ea1ch th\u1ee9 2 \u1edf b\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec5m khu\u1ea9n c\u00f3 nhu c\u1ea7u norepinephrine t\u0103ng.<\/p>\n\n\n\n

N\u00ean l\u1ef1a ch\u1ecdn thu\u1ed1c v\u1eadn m\u1ea1ch th\u1ee9 2 n\u00e0o?<\/em><\/strong><\/p>\n\n\n\n

Vasopressin th\u01b0\u1eddng l\u00e0 l\u1ef1a ch\u1ecdn \u0111\u1ea7u ti\u00ean cho b\u1ec7nh nh\u00e2n c\u1ea7n \u0111\u01b0\u1ee3c b\u1ed5 sung thu\u1ed1c v\u1eadn m\u1ea1ch th\u1ee9 2. Vi\u1ec7c \u0111\u01b0a ra l\u1ef1a ch\u1ecdn thu\u1ed1c v\u1eadn m\u1ea1ch th\u1ee9 2 n\u00ean d\u1ef1a tr\u00ean m\u1ee5c ti\u00eau \u0111i\u1ec1u tr\u1ecb. H\u01b0\u1edbng d\u1eabn \u0111i\u1ec1u tr\u1ecb hi\u1ec7n c\u00f3 khuy\u1ebfn ngh\u1ecb vasopressin nh\u01b0 l\u00e0 l\u1ef1a ch\u1ecdn n\u00ean \u0111\u01b0\u1ee3c \u01b0u ti\u00ean, v\u00ec c\u00f3 b\u1eb1ng ch\u1ee9ng cho r\u1eb1ng vasopressin l\u00e0m gi\u1ea3m nhu c\u1ea7u l\u1ecdc m\u00e1u v\u00e0 gi\u1ea3m nguy c\u01a1 lo\u1ea1n nh\u1ecbp9<\/sup>. Tuy nhi\u00ean, n\u1ebfu lo\u1ea1n nh\u1ecbp \u00edt c\u00f3 kh\u1ea3 n\u0103ng x\u1ea3y ra th\u00ec thi\u1ebfu m\u00e1u c\u1ee5c b\u1ed9 ng\u00f3n l\u00e0 v\u1ea5n \u0111\u1ec1 c\u1ea7n ph\u1ea3i quan t\u00e2m, ho\u1eb7c \u1edf b\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec5m khu\u1ea9n ngh\u0129 m\u1ed9t ph\u1ea7n do suy gi\u1ea3m cung l\u01b0\u1ee3ng tim, th\u00ec epinephrine l\u00e0 thu\u1ed1c v\u1eadn m\u1ea1ch th\u1ee9 2 n\u00ean \u0111\u01b0\u1ee3c l\u1ef1a ch\u1ecdn. Tuy nhi\u00ean, b\u1eb1ng ch\u1ee9ng h\u1ed7 tr\u01a1 epinephrine l\u1ea1i kh\u00f4ng c\u00f3 nhi\u1ec1u.<\/p>\n\n\n\n

Bi\u1ec7n ph\u00e1p \u0111i\u1ec1u tr\u1ecb b\u1ed5 tr\u1ee3 n\u00e0o n\u00ean \u0111\u01b0\u1ee3c c\u00e2n nh\u1eafc n\u1ebfu t\u00ecnh tr\u1ea1ng s\u1ed1c tr\u1edf n\u1eb7ng?<\/em><\/strong><\/p>\n\n\n\n

Corticosteroid (hydrocortisone \u0111\u01b0\u1eddng ti\u00eam t\u0129nh m\u1ea1ch 50 mg\/q6h ph\u1ed1i h\u1ee3p v\u1edbi fludrocortison \u0111\u01b0\u1eddng u\u1ed1ng 50 \u00b5g trong 7 ng\u00e0y m\u00e0 kh\u00f4ng xu\u1ed1ng thang) th\u01b0\u1eddng \u0111\u01b0\u01a1c l\u1ef1a ch\u1ecdn cho b\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec5m khu\u1ea9n c\u00f3 nhu c\u1ea7u l\u00ean thang thu\u1ed1c v\u1eadn m\u1ea1ch (th\u01b0\u1eddng \u0111\u00e3 \u0111\u01b0\u1ee3c b\u1ed5 sung thu\u1ed1c v\u1eadn m\u1ea1ch th\u1ee9 2). Ph\u00e1c \u0111\u1ed3 \u0111i\u1ec1u tr\u1ecb b\u1eb1ng nhi\u1ec1u t\u00e1c nh\u00e2n \u0111\u01b0\u1ee3c c\u00e2n nh\u1eafc \u0111\u1ec3 c\u1ea3i thi\u1ec7n huy\u1ebft \u0111\u1ed9ng \u1edf b\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec5m khu\u1ea9n. Nh\u1eefng t\u00e1c nh\u00e2n n\u00e0y bao g\u1ed3m corticosteroid, methylene xanh, vitamin (acid ascorbic ho\u1eb7c thiamine).<\/p>\n\n\n\n

Corticosteroid l\u00e0 t\u00e1c nh\u00e2n \u0111\u01b0\u1ee3c nghi\u00ean c\u1ee9u nhi\u1ec1u trong vai tr\u00f2 \u0111i\u1ec1u tr\u1ecb b\u1ed5 tr\u1ee3 \u1edf b\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec5m khu\u1ea9n. Corticosteroid li\u1ec1u trung b\u00ecnh (< li\u1ec1u t\u01b0\u01a1ng \u0111\u01b0\u01a1ng hydrocortisone 400 mg\/ng\u00e0y) c\u00f3 b\u1eb1ng ch\u1ee9ng m\u1ea1ch trong vi\u1ec7c l\u00e0m t\u0103ng huy\u1ebft \u00e1p v\u00e0 gi\u1ea3m th\u1eddi gian s\u1ed1c. Tuy nhi\u00ean, corticosteroid c\u00f3 th\u1ec3 l\u00e0m t\u0103ng nguy c\u01a1 x\u1ea3y ra bi\u1ebfn c\u1ed1 c\u00f3 h\u1ea1i ch\u1eb3ng h\u1ea1n nh\u01b0 t\u0103ng \u0111\u01b0\u1eddng huy\u1ebft, t\u0103ng natri m\u00e1u v\u00e0 y\u1ebfu c\u01a1. C\u00e1c h\u01b0\u1edbng d\u1eabn hi\u1ec7n c\u00f3 khuy\u1ebfn ngh\u1ecb s\u1eed d\u1ee5ng corticosteroid \u1edf b\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec5m khu\u1ea9n c\u00f3 nhu c\u1ea7u l\u00ean thang thu\u1ed1c v\u1eadn m\u1ea1ch. C\u01a1 s\u1edf c\u1ee7a vi\u1ec7c b\u1ed5 sung corticosteroid cho nh\u00f3m b\u1ec7nh nh\u00e2n n\u00e0y c\u00f3 th\u1ec3 l\u00e0 do corticosteroid c\u00f3 th\u1ec3 ho\u1ea1t \u0111\u1ed9ng nh\u01b0 m\u1ed9t t\u00e1c nh\u00e2n vasopressor-sparing \u0111\u1ec3 l\u00e0m gi\u1ea3m nh\u1eefng bi\u1ebfn c\u1ed1 c\u00f3 h\u1ea1i li\u00ean quan \u0111\u1ebfn thu\u1ed1c v\u1eadn m\u1ea1ch li\u1ec1u cao10<\/sup>.<\/p>\n\n\n\n

\u0110\u1ed1i v\u1edbi ph\u1ed1i h\u1ee3p fludrocortisone v\u00e0 hydrocortisone, 2 th\u1eed nghi\u1ec7m l\u00e2m s\u00e0ng cho th\u1ea5y l\u1ee3i \u00edch l\u00e2m s\u00e0ng c\u1ee7a ph\u1ed1i h\u1ee3p n\u00e0y, trong khi \u0111\u00f3 c\u00e1c th\u1eed nghi\u1ec7m hydrocortisone \u0111\u01a1n tr\u1ecb l\u1ea1i kh\u00f4ng cho th\u1ea5y l\u1ee3i \u00edch t\u01b0\u01a1ng t\u1ef1 11 \u2013 14<\/sup>. Th\u1eed nghi\u1ec7m so s\u00e1nh tr\u1ef1c ti\u1ebfp ph\u1ed1i h\u1ee3p hydrocortisone v\u1edbi fludrocortisone v\u00e0 hydrocortisone \u0111\u01a1n tr\u1ecb cho th\u1ea5y \u0111i\u1ec1u tr\u1ecb ph\u1ed1i h\u1ee3p l\u00e0m gi\u1ea3m 3% nguy c\u01a1 t\u1eed vong n\u1ed9i tr\u00fa15<\/sup>.<\/p>\n\n\n\n

Khuy\u1ebfn ngh\u1ecb b\u1ed5 sung ph\u1ed1i h\u1ee3p hydrocortisone v\u00e0 fludrocortisone trong v\u00f2ng 7 ng\u00e0y m\u00e0 kh\u00f4ng xu\u1ed1ng thang \u0111\u01b0\u1ee3c \u0111\u01b0a ra d\u1ef1a tr\u00ean k\u1ebft qu\u1ea3 c\u1ee7a th\u1eed nghi\u1ec7m APROCCHSS11<\/sup>. Tuy nhi\u00ean, kho\u1ea3ng th\u1eddi gian \u0111i\u1ec1u tr\u1ecb t\u1ed1i \u01b0u v\u1eabn ch\u01b0a \u0111\u01b0\u1ee3c ch\u1eafc ch\u1eafn v\u00e0 b\u1eb1ng ch\u1ee9ng cho v\u1ea5n \u0111\u1ec1 n\u00e0y v\u1eabn ch\u01b0a \u0111\u01b0\u1ee3c r\u00f5 r\u00e0ng. N\u1ebfu t\u00ecnh tr\u1ea1ng s\u1ed1c t\u00e1i di\u1ec5n sau khi ng\u01b0ng corticosteroid, th\u00ec corticosteroid c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c c\u00e2n nh\u1eafc t\u00e1i s\u1eed d\u1ee5ng, \u0111\u1ed3ng th\u1eddi ti\u1ebfn h\u00e0nh \u0111\u00e1nh gi\u00e1 nguy c\u01a1 g\u00e2y ra t\u00ecnh tr\u1ea1ng s\u1ed1c.<\/p>\n\n\n\n

B\u1eb1ng ch\u1ee9ng cho vi\u1ec7c s\u1eed d\u1ee5ng methylene xanh trong ph\u00e1c \u0111\u1ed3 \u0111i\u1ec1u tr\u1ecb s\u1ed1c nhi\u1ec5m khu\u1ea9n v\u1eabn ch\u01b0a c\u00f3 nhi\u1ec1u. M\u1ed9t th\u1eed nghi\u1ec7m pilot cho th\u1ea5y mehylene xanh c\u00f3 th\u1ec3 c\u1ea3i thi\u1ec7n huy\u1ebft \u00e1p trung b\u00ecnh v\u00e0 t\u1ea7n s\u1ed1 tim. Do v\u1eady, methylene xanh c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c c\u00e2n nh\u1eafc s\u1eed d\u1ee5ng \u1edf b\u1ec7nh nh\u00e2n s\u1ed1c kh\u00f3 tr\u1ecb \u0111\u00e3 \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb b\u1eb1ng nhi\u1ec1u thu\u1ed1c v\u1eadn m\u1ea1ch v\u00e0 corticosteroid.<\/p>\n\n\n\n

Nhi\u1ec1u th\u1eed nghi\u1ec7m l\u00e2m s\u00e0ng \u0111\u00e3 \u0111\u01b0\u1ee3c ti\u1ebfn h\u00e0nh \u0111\u1ec3 l\u00e0m r\u00f5 l\u1ee3i \u00edch c\u1ee7a acid ascorbic \u0111\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec5m khu\u1ea9n. C\u00e1c th\u1eed nghi\u1ec7m l\u00e2m s\u00e0ng ng\u1eabu nhi\u00ean \u0111\u1ec1u kh\u00f4ng cho th\u1ea5y \u0111\u01b0\u1ee3c l\u1ee3i \u00edch c\u1ee7a acid ascorbic. Do v\u1eady, acid ascorbic ho\u1eb7c thiamine kh\u00f4ng \u0111\u01b0\u1ee3c c\u00e2n nh\u1eafc s\u1eed d\u1ee5ng khi \u0111i\u1ec1u tr\u1ecb b\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec5m khu\u1ea9n.<\/p>\n\n\n\n

Ki\u1ec3m so\u00e1t b\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec5m khu\u1ea9n th\u01b0\u1eddng kh\u00e1 ph\u1ee9c t\u1ea1p. C\u00e1ch ti\u1ebfp c\u1eadn \u0111i\u1ec1u tr\u1ecb s\u1ed1c nhi\u1ec5m khu\u1ea9n nh\u00ecn chung \u0111\u01b0\u1ee3c m\u00f4 t\u1ea3 trong h\u00ecnh 1.<\/p>\n\n\n\n

\"\"
H\u00ecnh 1.<\/strong> T\u00f3m t\u1eaft chi\u1ebfn l\u01b0\u1ee3c ki\u1ec3m so\u00e1t b\u1ec7nh nh\u00e2n s\u1ed1c nhi\u1ec5m khu\u1ea9n<\/p>\n\n\n\n

C\u00e1c v\u00ed d\u1ee5 th\u1ef1c t\u1ebf kh\u00e1c c\u00f9ng nh\u1eefng c\u00e2u gi\u1ea3i \u0111\u00e1p t\u1eeb chuy\u00ean gia s\u1ebd ti\u1ebfp t\u1ee5c \u0111\u01b0\u1ee3c \u0111\u01b0a ra trong ph\u1ea7n 2 c\u1ee7a b\u00e0i vi\u1ebft. M\u1eddi qu\u00fd nh\u00e2n vi\u00ean y t\u1ebf \u0111\u00f3n \u0111\u1ecdc.<\/p>\n\n\n\n

B\u00e0i vi\u1ebft mang t\u00ednh ch\u1ea5t tham kh\u1ea3o. B\u00e0i vi\u1ebft \u0111\u01b0\u1ee3c l\u01b0\u1ee3c d\u1ecbch t\u1eeb ngu\u1ed3n Teja B, Bosch NA, Walkey AJ. How We Escalate Vasopressor and Corticosteroid Therapy in Patients With Septic Shock. Chest. 2023 Mar;163(3):567-574. doi: 10.1016\/j.chest.2022.09.019.<\/em><\/p>\n\n\n\n

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

    \n
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  14. Sprung CL, Annane D, Keh D, et al. Hydrocortisone therapy for patients with septic shock. N Engl J Med. 2008;358(2):111-124.<\/li>\n\n\n\n
  15. Annane D, Cariou A, Maxime V, et al. Corticosteroid treatment and intensive insulin therapy for septic shock in adults: a randomized controlled trial. JAMA. 2010;303(4):341-348.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

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