B Y T TRNG I HC DC H NI L TH HOI KHO ST TNG TC THUC TRN BNH NHN IU TR TI KHOA HI SC TCH CC BNH VIN E KHA LUN TT NGHIP DC S H NI 2014 B Y T TRNG I HC DC H NI L TH HOI KHO ST TNG TC THUC TRN BNH NHN IU TR TI KHOA HI SC TCH CC BNH VIN E KHA LUN TT NGHIP DC S Ngi hng dn: 1.TS. Nguyn Th Lin Hng 2. ThS. Nguyn Trung Ngha Ni thc hin: 1. B mn Dc Lm Sng 2. Bnh vin E trung ng

H NI 2014 Li cm n TixinbytlngbitnsusctihaingiThylTS.NguynTh LinHng-TrngbmnDcLmSng-trngihcDcHNiv Ths. Nguyn Trung Ngha -Trng khoa Dc Bnh vin E Trung ng tn tnh hng dn, ch bo v ng vin ti trong sut qu trnh hc tp v thc hin lun vn tt nghip ny. Ti xin chn thnh cm n bc s V c nh -Trng khoa Hi sc tch cc cng ton th cc bc s, dc s, cn b cng nhn vin ti khoa Dc, khoa Hi sc tch cc v phng K hoch tng hp bnh vin E Trung ng gip vtoiukinchotinghincuvhonthnh khalun.Xingilicmn dnh ring cho ch Nguyn Th H dc s lm sng ti bnh vin E trung ng v s nhit tnh ch bo v ng vin ti trong thi gian thc hin kha lun. Ti cng xin cm n s h tr nhit tnh ca cc thy c gio b mn Dc lm sng trng i hc Dc H Ni l nhng ngi chia s, gii p cc vng mc ca ti trong qu trnh lm kha lun. Cuicng,khalunttnghipcatiskhngthhonthnhnuthiu s ng vin, gip ca gia nh, bn b ti... c bit, ti mun by t s knh yu su sc n b m v ch gi ti, ngi lun bnh ng vin gip ti vt qua nhng lc kh khn nht trong sut qu trnh hc tp v hon thnh kha lun ny. Ti xin chn thnh cm n! Sinh vin L Th Hoi MC LC T VN ............................................................................................................. 1 CHNG 1. TNG QUAN ...................................................................................... 3 1.1. Tng quan chung v tng tc thuc ................................................................ 3 1.1.1. Khi nim tng tc thuc .......................................................................... 3 1.1.2. Phn loi tng tc thuc ........................................................................... 3 1.1.3. Dch t tng tc thuc ............................................................................... 4 1.2. c im bnh nhn khoa Hi sc tch cc v cc nghin cu trn th gii v tng tc trong khoa Hi sc tch cc ...................................................................... 6 1.2.1. c im bnh nhn khoa Hi sc tch cc ............................................... 6 1.2.2. Cc nghin cu c thc hin trn th gii v tng tc thuc trong khoa Hi sc tch cc ............................................................................................ 9 1.3. Pht hin tng tc thuc v phn mm tra cu Micromedex ....................... 11 1.3.1. Pht hin tng tc thuc trong thc hnh lm sng .............................. 11 1.3.2. Vi nt v phn mm tra cu Micromedex ............................................... 14 CHNG 2. I TNG V PHNG PHP NGHIN CU ................... 15 2.1.i tng nghin cu ................................................................................... 15 2.2.Phng php nghin cu .............................................................................. 15 2.2.1Mc tiu 1: Kho st tng tc thuc bt li tim n ti khoa Hi sc tch cc................................................................................................................ 15 2.2.2.Mc tiu 2: M t thc hnh lm sng lin quan n tng tc thuc vkinthc-thicaccbcsivitngtcthuctikhoaHisc tch cc................................................................................................................ 16 2.3.Ch tiu nghin cu ....................................................................................... 17 2.3.1.Mc tiu 1: Kho st tng tc thuc bt li tim n ti khoa Hi sc tch cc................................................................................................................ 17 2.3.2.Mc tiu 2: M t thc hnh lm sng lin quan n tng tc thuc vkinthc-thicaccbcsivitngtcthuctikhoaHisc tch cc................................................................................................................ 18 2.4.X l kt qu................................................................................................. 19 CHNG 3. KT QU NGHIN CU............................................................... 20 3.1.Kho st tng tc thuc bt li tim n ti khoa Hi sc tch cc ............ 20 3.1.1.Kt qu ly mu ..................................................................................... 20 3.1.2.c im lin quan n bnh nhn v lin quan n s dng thuc ... 20 3.1.3.M t tng tc thuc trong mu nghin cu ....................................... 24 3.1.4.Mt s yu t nh hng n s lng tng tc thuc....................... 31 3.2.M t thc hnh lm sng lin quan n tng tc thuc v kin thc-thi ca bc s i vi tng tc thuc ti khoa Hi sc tch cc ........................... 32 3.2.1.c im mu nghin cu ..................................................................... 32 3.2.2.Mtthchnhlmsngvkinthc-thicabcsivi tng tc thuc .................................................................................................... 32 CHNG 4. BN LUN ........................................................................................ 40 KT LUN V XUT ..................................................................................... 50 PH LC TI LIU THAM KHO

DANH MC CC K HIU VIT TT CADCoronary artery disease CMPCardiomyopathy COPDChronic obstructive pulmonary disease CYTcytochrome ICUIntensive care unit MMMicromedex 2.0 DRUG-REAX System NICENational Institute for Health and Care Excellence NSAIDNonsteroidal anti-inflammatory drug PPIProton pump inhibitor STT CMC S th t c ch men chuyn DANH MC CC BNG STTTn bngTrang 1Bng 1.1. Tnh trng mc km ph bin bnh nhn khoa Hi sc tch cc 7 2Bng 1.2. Mt s nghin cu trn th gii v tng tc trong khoa Hi sc tch cc 10 3Bng 3.1. c im tui, gii, thi gian nm vin, bnh mc km20 4Bng3.2.Slngnthuc,snthuctrungbnhtrongmt bnh n, s lng, t l n thuc theo s thuc s dng trong n 22 5Bng 3.3. Mi thuc/nhm thuc c k n nhiu nht22 6Bng3.4.Slngltvcptngtctheomcnngca tng tc 24 7Bng 3.5. S lng, t l n thuc, bnh n c tng tc thuc v n thuc, bnh n c tng tc thuc theo mc nng ca tng tc 24 8Bng 3.6. Trung bnh s lng tng tc trong n 25 9Bng3.7.Slng,tlnthuctheoslngtngtctrong n 26 10Bng3.8.Mitngtcthucphbinnhttrongmunghin cu 26 11Bng 3.9. S lng, t l tng tc theo thi gian khi pht27 12Bng3.10.Slng,tltngtctheokhuyncoqunllm sng ca Micromedex 2.0 28 13Bng 3.11. S lng, t l cc tng tc theo v tr nh hng29 14Bng3.12.Milinquangiatuibnhnhnvxuthintng tc thuc 31 15Bng 3.13. Mi lin quan gia bnh mc km v s lng tng tc thuc 32 16Bng 3.14. Quan st thc hnh lm sng i vi cc tng lin quan33 ti cc thuc nh hng ti nng kali 17Bng 3.15. Kin thc-thi bc s i vi cc tng tc lin quan n cc thuc nh hng ti nng kali34 18Bng 3.16. Quan st thc hnh lm sng i vi cc tng tc lin quan n digoxin 35 19Bng 3.17. Kin thc-thi bc s i vi cc tng tc lin quan n digoxin 36 20Bng 3.18. Quan st thc hnh lm sng i vi cc tng tc lin quan ti cc thuc c ch thn kinh trung ng (gy m, gim au) 37 21Bng3.19.Kinthc-thibcsiviivicctnglin quan n cc thuc c ch thn kinh trung ng 37 22Bng 3.20. Quan st thc hnh lm sng i vi cc tng tcnh hng ti chc nng thn 38 23Bng3.21.Kinthc-thibcsiviivicptnglin quan nh hng ti chc nng thn 38 24Bng 3.22. Quan st thc hnh lm sng i vi cc tng tc khc39 25Bng 3.23. Quan st thc hnh lm sng i vi cc tng tc khc39 DANH MC CC HNH STTTn bngTrang 1Hnh 1.1. S tm tt s thay i chc nng ca cc c quan/ h thng trong c th c th nh hng n dc ng hc ca thuc bnh nhn nng 8 2Hnh 2.1. S tm tt qu trnh thu thng tin giai on hi cu16 3 Hnh 2.2. Tm tt qu trnh thu thng tin tin cu17 4Hnh 3.1. Kt qu ly mu giai on hi cu20 5Hnh 3.2. th biu din mi quan h gia s lng thuc c k v s tng tc thuc tim n31 6Hnh 3.3. S tm tt qu kt qu quan st trc tip ti khoa Hi sc 33 1 T VN Tng tc thuc c th c li nu bit phi hp ng cch. Ngc li, tng tcthuccngcthlnguynnhngygimhiuquiutr,tngcngtc dngphcathuc,thayiktquxtnghimnghimtrnghn,tngtc thuccthdnncctaibinnguyhim,thmchdnntvong[7][52]. Khngchnhhngtihiuquiutr,tngtcthuccngcthgynh hng n kinh t.Tng tc thuc c xem nh l mt nguyn nhn ko di thi gian nm vin, tng chi ph iu tr [35][36]. Bnh nhn iu tr ti khoa hi sc tch cc (ICU) l i tng c nguy c cao.Tnhtrngbnhlnng,thngcbnhmckm,iutrnhiuthucl nhng yu t d dn n tng tc thuc tim n v biu hin tc dng c hi ca tngtcthuctrnbnhnhn.Hnna,mitrnglmvictiICUthngc nhp nhanh, din bin ca bnh nhn thng c nhiu bin i phc tp i hi s quyt nh nhanh ca bc s a ra bin php chm sc kp thi. Do , vic hiu r cc nguy c m thuc c th gy ra cho bnh nhn v bit cch gim st hp l ng vai tr quan trng trong vic m bo hiu qu iu tr, an ton ca ngi bnh, trong c vic pht hin, x tr v kim sot tng tc. Trn th gii c kh nhiu nghin cu v vn tng tc thuc trong ICU. Tuy nhin, cn t cc nghin cu kho st thc hnh lm sng ca bc s, cng nh kho st kin thc-thi ca bc s v vn tng tc thuc. Ti Vit Nam, cc nghin cu trn i tng bnh nhn ICU cn hn ch. Xutphttthct,chngtitinhnhtiKhosttngtc thuc trn bnh nhn iu tr ti khoa Hi sc tch cc - Bnh vin E, vi cc mc tiu: 1. Khosttngtcthuc bt li tim n trn bnhnhniu tr ti khoa Hi sc tch cc. 2. M t thc hnh lm sng lin quan n tng tc thuc v kin thc-thi ca cc bc s i vi tng tc thuc ti khoa Hi sc tch cc. 2 T , a ra nhng kin xut gp phn hn ch cc tng tc bt li trnitngbnhnhnICUnhmnngcaochtlngiutrvmboan ton cho bnh nhn. 3 CHNG 1. TNG QUAN 1.1. Tng quan chung v tng tc thuc 1.1.1. Khi nim tng tc thuc Tng tc thuc l hin tng thay i tc dng ca mt thuc bi s c mt ng thi ca mt thuc khc hoc thuc dc liu, thc n, ung hoc c th l mt tc nhn mi trng [5][52].Thng thng, cm t tng tc thuc dng ch tng tc thuc-thuc, c ngha l tng tc xy ra gia hai thuc. Tuynhin, tng tc thuc cn c th c nhiu dng khc nhau nh tng tc thuc-thc n, tng tc thuc- tnh trng bnh l, tng tc thuc-dc liu i khi thut ng tng tc thuc c s dng ch nhng phn ng vt l-ha hc xy ra khi cc thuc c trn ln trong dch truyn, gy rakt ta hoc smt hot tnh, gil tng k (pharmaceutical incompatibilitie) [7][52]. Trong phmvi nghin cu ti ny, khi nim tng tc thuc ch cp n tng tc thuc-thuc. Trn lm sng, cc bc s c th ch ng phi hp nhm tn dng tng tc thuc theo hng c li. Ngc li, tng tc thuc c th lm tng hoc gim tc dng ca thuc dn n tng cng qu mc tc dng dc l hoc gim hiu qu iu tr, i khi c th lm thay i kt qu xt nghim v gy c tnh, khi cc tngtcthucnytrthnhtngtcbtli[7].Vtrongthct,nhiutng tc nh vy vn xy ra v nh hng ti sc khe bnh nhn. Do , vic pht hin, kim sot v x l tng tc thuc c ngha quan trng i vi cng tc iu tr. 1.1.2. Phn loi tng tc thuc Cnhiucchphnloitngtcthuckhc nhau:theocch,theomc nng, theo thi gian khi pht, theo mc bng chng, theo ch tc dng hoc theo khuyn co qun l lm sng. Theo c ch, tng tc thuc chia thnh hai loi: tng tc dc ng hc v tng tc dc lc hc [2][5][7][52]. Tngtcdcnghclnhngtngtctcnglnccqutrnhhpthu, 4 phn b, chuyn ha, thi tr ca thuc. Hu qu ca tng tc dc ng hc l s thayinngcathuctronghuyttng,dnnthayitcdngdcl hoc c tnh.y l loi tng tc xy ra trong sut qu trnh tun hon ca thuc trongcth,khontrc,khnglinquanncchtcdngcathuc. Tng tc dc ng hc c th do: thay i hp thu ti v tr a thuc, thay i phnbcathuctrongcth,thayichuynhacathuc,thayibixut thuc [5][7][52]. Tngtcdclchcgpkhiphihpccthucctc dngdclhoctc dng ph tng t nhau hoc i khng ln nhau.y l loi tng tc c hiu, c th bit n trc nh kin thc ca thy thuc v tc dng dc l v tc dng ph ca thuc.Cc thuc c cng c ch tc dng s c cngmtkiu tng tc dc lchc. Tngtcdclchccthdo:cnhtranhtivtrtcdngtrnreceptor,tc dngtrncngmththngsinhl.ylloitngtcchimphnlncc tng tc gp phi trong iu tr [5] [7] [52]. Phnloitngtcthucdavomcnng,tytheocctiliukhc nhau s c s phn chia khc nhau. Tng tc thuc trong Micromedex 2.0 gm cc mc : chng ch nh, nghim trng, trung bnh, nh, khng r. Ti liu Tng tc thuc v ch khi ch nh chia nng thnh cc mc 1, 2, 3, 4. Trong khi trang web Drugs.com tng tc thuc ch c chia lm ba loi: nghim trng, trung bnh, nh. Mc bng chng cng ty theo cc ti liu khc nhau m c s phn chia khc nhau. Tngtcthuccthnhhnglnnhiu cquan:htun hon,htit niu, h h hp, h thn kinh, tiu haMi tng tc ty theomc , tnh cht m c cc khuyn co qun l khc nhau: cn nhc nguy c li ch, theo di, hiu chnh liu, trnh phi hp hoc chng ch nh. 1.1.3. Dch t tng tc thuc Tnsuttngtcthuccarabiccnghincuthngrtkhc nhau.iunyphthucvonhiuyut,vdnhitngnghincu,a 5 imtinhnh,khongthigiantinhnhnghincu,thitkhicuhaytin cu, tiu chun la chn, loi tr i tng,Pht hin tng tc bng cc cng c khc nhau cng dn n kt qu khc nhau [26]. Nm 2002, Sabin S. Egger v cng s tin hnh nghin cu hi cu ti bnh vin trng i hc Basel, Thy S trn bnhnca500bnhnhnxutvin,phthinrarng60%snthuccti thiumttngtcthuc[19].Mtnghincukhcdatrncsdliuca Italia vi tng s 185704 n thuc lin quan n 1020 thuc khc nhau, pht hin ra 119 cp tng tc mc nghim trng xy ra 1037 ln 758 bnh nhn (4,7%) [32]. Kim tra 19522 n thuc ca 6078 tr em ti bnh vin i hc Olomuc, t l tngtctimnl3,83%,trongtngtcmctrungbnhvnghim trngchchim0,47%[29].Tltngtcthuctrnitngbnhnhntim mch ti ICU l 287,5 tng tc trn 100 bnh nhn-ngy [51]. C s khc nhau gia t l tng tc tim n (potential drug interaction) v t ltng tc thc t (actually drug interaction)-l nhng tng tc m hu qu ca nbiuhinthcstrnbnhnhn.Kimtratngtcthuctrnbnhnca 2422 bnh nhn vi tng thi gian nm vin l 25005 ngy pht hin ra 113 (4,7%) bnhnhnctnhtmttngtctimn,nhngbngchngvhuquca tng tc ch c quan st thy 7 ngi (0,3%) [43]. Nghin cu tin cu i tng bnh nhn trn 65 tui trong vng 2 thng, t l tng tc tim nl85,6% (190/222 bnh nhn), tng tc thc t ch pht hin c 21 ngi (9,5%) [34]. Trong mt tng quan h thng, t l tng tc thuc tim n bo co thay i t 2,2 n 70,3%, t l tng tc thc t nh hn 11,1% [26]. Ti Vit Nam, gn y c kh nhiu nghin cu v vn tng tc thuc. Ktquchothytlbnhnhocnthuc(nitrhocngoitr)xuthin tng tc dao ng kh ln 17,8%-70,3% [1][3][4][6]. Nghin cu c thc hin tikhoanitiuhatitniubnhvinakhoaTrungngThiNguynnm 2013 ch ra rng trong 178 n thuc iu tr ni tr c 62 n thuc c tng tc, chim 34,83%, tuy nhin s lng tng tc c ngha lm sng ch chim 8,43% lin quan n 8 cp tng tc [1]. Trong khi , cng trong nm 2013, mt nghin cu khc r sot tng tc trn 165 bnh n ni tr ti khoa tim mch bnh vin a 6 khoa Bc Giang, kt qu t l bnh n c tng tc thuc ln ti 70,3% v s lng bnh n tng tc c ngha lm sng l 58,8% lin quan n 13 cp [4]. Khng mt nghin cu no c th a ra mt con s chnh xc v t l tng tc thuc xut hin trong thc hnh lm sng. Cho d mt s nghin cu c a ra nhng con s kh thp, slngbnh nhn c nguy c chu hu qu (thm chl nghim trng) do tng tc vn lkhng nh, c bit trong bi cnh hin nay s lng thuc c k n v s dng ngy cng nhiu [52]. 1.2. c im bnh nhn khoa Hi sc tch cc v cc nghin cu trn th gii v tng tc trong khoa Hi sc tch cc 1.2.1. c im bnh nhn khoa Hi sc tch cc Bnh nhn iu tr ti ICU c nhiu c im d dn n bin c bt li do thuc (ADE) ni chung v tng tc thuc ni ring [39]. T l bnh nhn b e da tnh mnglin quan n bin c bt li do thuc xy ra26% bnh nhn ICU so vi11%bnhnhnthuccckhoaphngkhc(non-ICU)(p65) i tho ng Bnh thn mn tnh X gan v cc bnh gan khc COPD, tng huyt p ng mch phi, v cc bnh phi khc Bnh tim mch (bnh ng mch vnh, bnh c tim, lon nhp) U c tnh Tng huyt p Bo ph c im s dng thuc Bnh nhn nng, ty theo mc v tnh cht m c nhng phc iu tr phctp,gmnhiuthuc.Bncnhiutrtnhtrngbnhcp,ccbnhmn tnh vn i hi phi s dng thuc lin tc.Khi , nhng bnh nhn nys phi tip xc vi s lng ln thuc v nhiu trong s l thuc c khong iu tr hp v tim n nguy c c tnh [40].Trung bnh s thuc s dng trn bnh nhn ICU xpxgpisovikhoakhngphiICU(non-ICU)[14].Cnhiucc nghin cu chng minh mi lin h gia s lng thuc bnh nhn s dng v s lng tng tc thuc tim n. Thm ch nhiu ti liu cho rng t l tng tc thuc tng theo cp s nhn vi s lng thuc phi hp, ngha l nguy c ri ro, tht bi cng tng theo [5]. ng a thuc ph bin trongICU l ng tnhmch [28], mt nghin cu ch ra bnh nhn dng thuc theo ng ny nguy c gp bin c bt li cao hn3%ivimithucsdngkhisovingdngkhc[27].ngtnh mchlngathucctcdngnhanhchngtuynhincngtimnnhiu nguyclinquannkthutphach,kthuttimtruyn,tngk,ctnh nhanhvcngnhhngnthigianvkhnngxuthinmttngtc thuc, v d, bnh nhn angdng thuc c ch thn kinh trung ng, dng thm 8 mtchtcngctcdngcchthnkinhtrungngtheongtnhmchth nhhngtrnbnhnhnxyranhanhhnnuthucthhaidngtheong ung [23]. Thay i dc ng hc ca thuc trn bnh nhn khoa Hi sc tch cc Xemxtthigianxyramttngtcthuc,ngitaquantmnthi gian khi phtca tng tc, thi gian c tc dng ti a, thi gian biu hin trn bnhnhn,thigiantngtcthucbloitr.Thigiannyngoichunh hng ca cc yu t nh tnh trng p ng ca c th, ng dng, liu dng th dcnghccathuccngctcngngk[23],vd,bnh nhnbsuy gim chc nng gan, chuyn ha theophylin gim, dng ng thi erythromycin l mt thuc gy c ch enzym gan th nguy c nng theophylin vt qu khong iu tr cao hn so vi bnh nhn c chc nng gan bnh thng [5]. MigiaiondcnghccathucubxotrnbnhnhnICU, baogmchpthu,phnb,chuynha,thitr.Cth,sinhkhdngng ungthnggim,thtchphnbcthtnghocgim,chuynhathucc bit l chuyn ha qua CYT P450 thng gim, thanh thi thuc cng thng b gim[12][40][42].Thayidcngcathuctrnbnhnhn nnglktqu ca nhiu nguyn nhn nh suy gim chc nng c quan, ng ch nht l s suy gimcaganvthn,huqucatbnhcp,canthipiutr(vd:lc mu) v cng c th l do tng tc thuc. S suy gim chc nng c quan nh hng n dc ng hc tm tt trong s 1.1. Nh vy, tnh trng bnh nng, bnh mc km, iu tr nhiu thuc, thay i dcnghccathuctrnbnhnhnlmtngnguycxuthintngtc thuc.Ngclitngtcthuclilmtnguynnhndnnthayidc ng hc, lm nng thm tnh trng bnh. Vi mi quan h hai chiu phc tp nh vy, hn na mi trng lm vic ti ICU thng c nhp nhanh, din bin bnh ca bnh nhn thng c nhiu s thay i i hi s quyt nh nhanh chng chm sc bnh nhn, do yu cu cc nh lm sng phi hiu r v cc c im ca bnh nhn hi sc v cc tng tc thuc tim n trn bnh nhn ti u ha vic s dng thuc trong iu tr [12][42]. 9 1.2.2. Cc nghin cu c thc hin trn th gii v tngtcthuc trong khoa Hi sc tch cc C kh nhiu nghin cu v t l, tn sut xut hin tng tc thuc v hu qucatngtcthuctrongICUtrnthgii[9][10][24][35][44][45][50][54] (Bng 1.2). Vit Nam nghin cu v tng tc thuc trn ICU cn hn ch. Trong mt nghin cu kho st tng tc trong cc n thuc c k n in t trongthigian6nm(2002-2008)tiICUcamtbnhvinHLan,ktqul 3892 bnh nhn trong s 9644 bnh nhn c n thuc cha tng tc, tng ng 40,35%. V nghin cu ny cng kho st mc ng thun ca bc s hi sc v dcsvmcnghacamtscptngtciviICU,ktqunghin cu a ra l sosnh vi dc s, cc bc s hisc t cho rng tng tcl c ngha lm sng hn (54,7% v 30,2%, p10 tng tc/ n) chim 1,0%. 3.1.3.3.Cc tng tc thng gp 10tngtcthnggpnhtv10tngtcmcchngchnhv nghim trng thng gp nht c trnh by trong bng Bng 3.8. Bng 3.8. Mi tng tc thuc ph bin nht trong mu nghin cu Tng tc ph bin nhtKt qu n (%) Tng tc mc nghim trng v chng ch nh ph bin nht Kt qu n (%) Perindopril-kali67 (10,7)Ceftriaxon-canxiclorid TM 5 (0,8) 27 Levofloxacin-methylprednisolon 47 (7,5)Perindopril-kali67 (10,7) Insulin-levofloxacin42 (6,7)Insulin-levofloxacin42 (6,7) Diazepam-esomeprazol40 (6,4)Perindopril-spironolacton 34 (5,4) Aspirin-perindopril, 37 (5,9)Kali-spironolacton 23 (3,7) Perindopril-spironolacton34 (5,4)Diazepam-morphin23 (3,7) Furosemid-perindopril29 (4,6)Furosemid-netilmicin,13 (2,1) Kali-spironolacton23 (3,7)Levofloxacin-theophylin12 (1,9) Diazepam-morphin23 (3,7)Ciprofloxacin-insulin11 (1,8) Diazepam-propofol, 23 (3,7)Levofloxacin-metformin9 (1,4) - Tng tc sp xp theo th t tn sut gim dn - Danhschcctngtcchngchnhvnghimtrngphbinspxpc theo mc nng- Cccpinnghingvaltngtcphbinnhtvathucdanhschcc tng tc mc nghim trng/chng ch nh ph bin Nhn xt: - Mitngtcphbinnhtlinquannccthuc:perindopril,kali, spironolacton,diazepam,morphin,propofol,furosemid,levofloxacin, methylprednisolon, aspirin, insulin. Trong c 5 thuc thuc danh sch 10 thuc s dng nhiu nht. - Danh sch 10 tng tc thuc ph bin nht c 5 cp cng thuc danh sch 10 tng tc mc nng v chng ch nh ph bin ph bin nht. - Tngtcgiaceftriaxon-calcicloridcmcchngchnh.Tnsut xut hin ca cp ny l 5 lt (0,8%). 3.1.3.6. T l tng tc trong mu theo ch nh hng, cch qun l lm sng,thi gian khi pht Phn loi theo thi gian khi pht, tng tc thuc c chia lm ba nhm: chm, nhanh, khng r. S lng, t l cc nhm trnh by trong bng 3.9. 28 Bng 3.9. T l tng tc thuc phn loi theo thi gian khi pht Thi gian khi pht Lt tng tcCp tng tc S lng% (n=627)S lng% (n=66) Chm Nhanh Khng r 254 217 156 40,5 34,6 24,9 17 18 30 25,8 27,3 45,5 Nhn xt: Tng tc khi pht chm c t l ln nht (40,5%) trong tng s lttngtcphthinclinquann17cp.Tngtccthigiankhi pht khng r c s lng ln nht trong danh sch cc cp tng tc thu c (30 cp) nhng tn sut ca cc cp ny khng cao (24,6%). C 217 lt tng tc khi pht nhanh lin quan n 18 cp. Phnnhmtheokhuyncoqunllmsng,tngtcthuccchia thnhbnnhmln:theodi,trnhkthp,hiuchnhliukhidngngthi, thc hin mt s bin php lm gim nguy c tng tc. C th s lng, t l cc nhm trnh by trong bng 3.10. Bng3.10.Tl tng tcthucphnloitheokhuyncoqunllmsng ca Micromedex 2.0 (Clinical management) STTKhuyn co qun l lm sng Lt tng tcCp tng tc S lng (%) (n=627) S lng (%) (n=66) Theo di56089,35583,3 Kali15124,157,5 Glucose6810,869,1 Chcnngthn(nng creatinin, theo di nc tiu) 62 9,946,1 Huyt p477,534,5 Nng thuc223,557,6 in gii 71,134,5 29 Theodilmsngvctnh hoc gim tc dng 265 42,33350,0 Trnh kt hp375,91015,1 Hiu chnh liu22135,33045,5 Gim nguy c tng tc629,946,1 Ungthuckhibanm,khi ngi hoc nm 46 7,323,0 Ch phm b sung kali142,211,5 Thiimdngthuccchxa nhau 2 0,311,5 Lu : tng cc t l phn trm c th ln hn 100 v mt cp tng tc c th c nhiu hn 1 khuyn co qun l Nhn xt: i vi vic qun l tng tc thuc, theo di l li khuyn quan trng nht chim (89,3%) lin quan n 55 tng tc, bao gm theo di cc thng sxtnghimnhnghuyt,kali,huytp,chcnngthnvtheodibiu hintrnlmsngphngnguycngchocgimtcdngcathuc.Cc khuyncokhcqunltngtcltrnhkthp(5,9%),hiuchnhliu (35,3%) hoc lm gim nguy c (9,9%). Tngtcthuccthnhhngtinhiucquan,bphn,qutrnh trong c th: qu trnh dc ng hc, h tun hon, h h hp, h tiu haC th s lng, t l cc tng tc trnh by trong bng 3.11. Bng 3.11: T l cc tng tc thuc phn loi theo v tr nh hng Loi tng tc c im chnh ca tng tc Lt tng tcCp tng tc S lng (%) (n=627) S lng (%) (n=66) Dc ng hcThayinnghuyt thanhcathuc,thayi hpthu,phnb,chuyn ha v/hoc thi tr 10116,11928,8 30 Nhnxt:CctngtctrongICUcthnhhngncquan,bphnkhc nhau trong c th nh tim, thn, h hp, tiu ha28,8% cp tng tc nh hng ti qu trnh dc ng hc. nh hng tim mch,huyt p c tnh trn tim mch, ko di QT,ngng tim, thay i huyt p 12119,31928,8 nh hng n h thn kinh ctnhtrnhthnkinh, cchhockchthch,an thn su 12219,51624,2 nh hng n thn ctnhtrnthn,tn thng thn, suy thn 9915,857,6 nh hng n gn , c Vim gn, t gn, yu c 7111,334,5 nh hng n chuyn ha Thayinngng huyt 6810,969,1 nh hng n h hp Nguy c c ch h hp 487,71116,7 nh hng n mu Tng nguy c chy mu 101,623,0 nh hng ti tiu ha Lot d dy 91,411,6 KhcTngkali,ctnhtrntai 19531,11725,8 Lu : tng t l cc loi tng tc c th ln hn 100% do mt tng tc c th c nhiu c ch, nh hng ln nhiu c quan 31 3.1.4.Mt s yu t nh hng n s lng tng tc thuc 3.1.4.1.S lng thuc trong n Sdnghiquytuyntnhnginphntchmilinhgiaslngthuc trong n v slng tng tc, kt qu nh sau: h s tng quan gia 2 bin l r=0.621vi mc ngha p0.5) gia s thuc c k v s tng tc xut hin.Phngtrnhhiquy:y=0,451x-2,358=>milntng1thuctrnnths lng tng tc tng thm 0,451 (CI 95%: 0,386-0,516) (Hnh 3.2). HsR2=0,383=>slngthucgiithch38,3%skhcbitvstngtc trn mi n.3.1.4.2.Tui ca bnh nhn Sdngkimnhkhi-bnhphngsosnhtlxuthintngtc thuc tim n gia hai nhm bnh nhn trn 65 tui v di 65 tui.Kt qu trong bng 3.12. Bng 3.12.Mi lin quan gia tui bnh nhn v xut hin tng tc thuc Tui bnh nhnC tng tcKhng c tng tcTngKim nh Chi-square 65 tui33336 Q=0,305 p=0,581 < 65 tui21122 Tng54458 32 Nhn xt:Gi tr Q=0,305, bc t do bng 1, mc ngha p=0,581>0,05. Tc l t l bnh nhn c tng tc thuc hai nhm tui trn l khng c s khc bit. 3.1.4.3.S lng bnh mc km S lng tng tc thuc trong n khng tun theo phn phi chun nn s dngkimnhMann-WhitneyUsosnhtrungvslngtngtcthucgia nhm c bnh mc km v khng c bnh mc km. Kt qu trong bng 3.13. Bng 3.13. Mi lin quan gia bnh mc km v s lng tng tc thuc S lngTrung bnh th t (mean rank) Kim nh Mann-Whitney U C bnh mc km223161,66 p 70 tui ), 1 bnh nhn c c 3 yu t nguy c km theo: tui cao, suy thn, i tho ng. kincabcsvcctngtclinquanticcthucnhhngti nng kali trnh by trong bng 3.15 Bng3.15.Kinthc-thibcsivicctngtclinquanncc thuc nh hng ti nng kali Cbitthngtinkhiphihpccchphmbsungkali,litiugikaliv Spironolacton-kali-furosemid 10000 Perindopril-kali-spironolaction 20020 Perindopril-kali-spironolaction-furosemid 20011 Theo di Kali v chc nng thn - a s cc trng hp u c lm xt nghim kali trc1 ngy hoc trong cng ngy s dng ng thi (13/15 trng hp). - a s bnh nhn c theo di kali, nhng khc nhau v tn sut theo di: 1 trng hp lm xt nghim 2 ln/ ngy trong lin tc 3 ngy, 1 trng xt nghim nng kali mu 3 ln trong 14 ngy. - 6/10 trng hp khng lm xt nghim kali no trong thi gian theo di. - 7 trng hp khng c xt nghim creatinin trong 3 ngy trc khi kt hp, 9 trng hp nng creatinin c o trong hoc trc khi dng ng thi 1 ngy. - Liu spironolacton ph bin l 50mg/ngy. - Khng ghi nhn trng hp tng kali no trong thi gian theo di. Lu : Bng kt qu chi tit theo di nng kai v creatinin trong ph lc 8. 35 thuc c ch men chuyn c nguy c lm tng kali mu; trong thc t c thy s tng kali, tuy nhin ch trong mc gii hn bnh thng. Qun l lm sng: - Theo di triu chng lm sng: chng bng, tc ngc khi loi tr cc nguyn nhn khc => nghi ng ri lon in gii - Theodiintm(Monitor)lintcbnhnhncyutnguyccaoXt nghim nng kali mu (kh mu ng mch) thng quy v theo biu hin lm sng - Khngbitthngtinkhimclccuthn khng tnh mc lc cu thn trc khi kt hp ( kin thng nht 5/5 bc s c hi) 3.2.2.2.Cp tng tc lin quan n digoxin Trong thi gian tin cu, c 3 tng tc lin quan n digoxin quan st c: digoxin-esomeprazol,digoxin-furosemid,digoxin-amiodaron.Quanstthchnh lm sng v kin ca bc s v cc cp tng tc ny trnh by trong bng 3.16v 3.17. Bng 3.16.Quanstthchnhlmsngivicctngtclinquann digoxin - Hai thuc digoxin, esomeprazol c dng ng thi trn 4 bnh nhn, tuy nhin 3 bnh nhn dng digoxintheo ng tnh mch (m c ch ca tng tc l tng hp thu digoxin ti rut), 1 bnh nhn dng digoxin theo dng ung. - 1bnhnhnsdngngthidigoxin0.5mg-TMC,furosemid80mg-TMC, amiodaron 150mg-TMC trong 2 ngy. Bnh nhn c theo di K+ lin tc trong 2 ngytrn.KhngcxtnghimK+ vongytiptheo.Trongnthuccch phm b sung kali. Bnh nhn khng c theo di in tm (monitor). - 1trnghpsdngngthidigoxin0.5mg-TMC,amiodaron150mg-TMC esomeprazol40mg-ungtrong1ngy.Bnhnhnctheodikalitrongngy hmv ngyhmsau.Trongn thuccchphmbsungkali.Bnhnhn khng c theo di in tm (monitor). 36 - 1 trng hp dng ng thi digoxin v furosemid t ngy 11/4 (15 ngy tnh n 25/4).Cxtnghimkalitrckhiphihp.CxtnghimK + voccngy 11/4;14/4;16/4;23/4. Trong n khng c ch phm b sung kali, bnh nhn c theo di in tm lin tc. - Khng c trng hp no c biu hin ng c digoxin trong thi gian theo di Bng 3.17. Kin thc-thi bc s i vi cc tng tc lin quan n digoxin - Khidngdigoxin,nngkalimuctheodithngxuyn(lmkhmu ng mch, xt nghim sinh ha mu). - Nhng thuc c khong iu tr hp nh digoxin, ty theo tnh trng bnh nhn s theo di in tm lin tc (monitor). Digoxin-furosemid - C bit n nguy c tng c tnh ca digoxin do digoxin rt nhy vi s thay i nng kali m furosemid l li tiu thi kali. - Trong n thuc c thm cc ch phm b sung kali. Digoxin-esomeprazol - Khng bit n thng tin tng tc, khng theo di khi dng ng thi. Digoxin-amiodaron - Dng ng thi hai thuc c th gy c tnh cho tim (v cng ch tc dng) - Khng bit n c ch amiodaron gy c ch bm tng thuc dn n c th lm tng liu digoxin nn khng h liu khi dng ng thi (liu c cho da trn tnh trng bnh ca bnh nhn) - Ti khoa khng lm xt nghim nng thuc trong mu. ( thng nht kin ca 5/5 bc s c hi) 3.2.2.3.Tng tc lin quan ti cc thuc c ch kinh trung ng (gy m, gim au) Cc tng tc ca nhm ny gm c: morphin-diazepam, morphin-fentanyl, morphin-fentanyl, diazepam-esomeprazol. Quan st thc hnh v kt qu phng vn bc s trnh by trong bng 3.18 v 3.19. Bng3.18.Quanstthchnhlmsngivicc tng tclinquanti 37 cc thuc c ch thn kinh trung ng (gy m, gim au) - 4 thuc morphin,fentanyl, diazepam, esomeprazol cng c dng ng thi trn 1 bnh nhn.- Tt c cc thuc dng theo ng tim tnh mch. - Morphinvfentanyl,diazepamcthmvonkhibnhnhnkchthch hoc chng my. - Bnh nhn b chn thng a tng nng ang trong tnh trnghn m, th my hon ton.Bng 3.19. Kin thc-thi bc s i vi i vi cc tng lin quan n cc thuc c ch thn kinh trung ng Morphin-fentanyl/ diazepam -fentanyl/ diazepam-morphin - Bitthngtinvnguychipngtcdnganthn,cchthnkinhtrung ng, c ch h hp khi phi hp cc thuc. - Morphinevfentanylkhngdngkoditrnbnhnhn,chsdngtrong trng hp cp cukhi bnh nhn au nhiu, kch thch, vt v, chngmy.( kin ca 1 bc s trn bnh nhn c th) Diazepam-esomeprazol:Khngbitthngtintngtc,khngtheodikhis dng ( thng nht 5 bc s c hi) 3.2.2.4.Tng tc nh hng ti chc nng thn Tngtcgiathuccchmenchuyn-litiuquaivgiacchmen chuyn -NSAID l 2 tng tc c th gy tn thng thn hoc suy thn cp. Quan st thc hnh v kin bc s v cc cp tng tc ny trnh by trong bng 3.20 v 3.21. Bng 3.20. Quan st thc hnh lm sng i vi cc tng tc nh hng ti chc nng thn - 1 trng hp dng ng thi perindopril, enalapril, furosemid. Huyt p ca bnh nhn c gim st nh k. Theo di nc tiu 24h hng ngy. Xt nghim sinh ha mu c thc hin 3ln trong thi gian dng thuc (10/4-25/4). Nng 38 creatinin, ure trong gii hn bnh thng. - 4trnghpdngngthiperindopril,furosemid.C4trnghpuc gim st huyt p cht ch, theo di nc tiu 24h.- 1 trng hp dng ng thi meloxicam v perindopril, furosemid c theo di huyt p cht ch v nc tiu 24h hng ngy. - Cc bnh nhn trn khng c bnh l v thn trc Bng3.21.Kinthc-thibcsiviivicptnglinquannh hng ti chc nng thn c ch men chuyn-li tiu quai - Tngtcctcdngcnghiuquhhuytp,khngbitnnguyctn thng thn khi dng phi hp - Bnh nhn ti khoa c theo di huyt p thng quy mi ngy vo 6h-14h-18h-21h -2h v theo biu hin lm sng ca bnh nhn - Bnh nhn nng th theo di Monitor NSAID (meloxicam)-perindopril - Khng bit n thng tin tng tc, khng c theo di c bit thm khi phi hp ( thng nht thng tin 5 bc s c hi) 3.2.2.5.Cc tng tc khc Quan st thc hnh lm sng v kt qu phng vn trc tip bc s trnh by trong bng 3.22 v 3.23. Bng 3.22. Quan st thc hnh lm sng i vi cc tng tc khc Ciprofloxacin-theophylinAspirin-methylprednisolon Levofloxacin-methylprednisolon - 2trnghpsdng ng thi, u t ngy 18/4 - Khngcshiuchnh liu n ngy 25/4.- Bnhnhnkhngcdu hiu nn, bun nn, co git. - 3 bnh nhn - Ccbnhnhnu c hi v tnh cht phn hng ngy. - 6 bnh nhn ny u trn 70 tui(itngcnguyc cao hn). - Khngtrnghpnoc triuchngaugtchn hay vim gn. 39 Bng 3.23. Kin thc-thi bc s i vi i vi cc tng tc khc Ciprofloxacin-theophylin - Khng bit n thng tin tng tc - Khng lm xt nghim nh lng nng thuc trong mu ( thng nht thng tin 5 bc s c hi) Aspirin-methylprednisolon - Tng tc ph bin=> theo di triu chng lm sng v cn nhc nguy c, li ch trc khi dng thuc ( tin s, tui tc) Levofloxacin-methylprednisolon - 5/6 bc s khng bit n thng tin ny - 1trongs6bcsbitnguycvimgnltcdngphcafluoroquinolon, nhng khng bit thng tin corticoid lm tng nguy c ny. 40 CHNG 4. BN LUN Tng tc thuc ti khoa hi sc tch cc trn th gii c nghin cu khnhiu.Phnlncc nghincu uara nhn nhkhoa hisctch ccl khoa tim n nhiu nguy c dn n tng tc thuc v biu hin tng tc thuc trnbnhnhn.Ktquccnghincuaratltngtcthuckhcao [9][10][35][44][45][50][54]. Tn sut tng tc thuc Duyt tng tc thuc hi cu trn bnh n ICU-Bnh vin E cho thytng tc thuc cn gp kh ph bin (627 tng tc/301 n/58 bnh nhn, trong c 5 lt tng tc chng ch nh, 180 lt tng tc mc nghim trng). S lng tngtcthuctrungbnhtrnmtnl2,1daongtrongkhong0n13 tng tc. S lng n thuc cha tng tc l 235 n chim 78,1%. T l ny so vi mt s nghin cu tng tc thuc ti cc khoa khc ca Vit Nam l cao hn. TrongnghincutikhoanitiuhatitniubnhvinakhoaThiNguyn nm2013,tltngtcthuc34,8%,trongtlnchatngtcmc chng ch nh v nghim trng l 8,43%[1]. Nghin cu ca Nguyn Thanh Sn vcngstrnnthuciutrngoitrtibnhvinakhoaHngnm 2011 a ra t l n thuc cha tng tc l 17,8% [6].Nghin cu do Rafiel v cng strn 371 bnh nhn ti mt ICU , kt qu r sot trn bnh n thu c 726 lt tng tc [45], trong khi tng s bnh nhn ca nghin cu hin ti ny ch l 58 nhngs lt tng tc quan st c ln ti 627 lt.Thtra,trongnghincuca Rafiel,tngtcthucchckimtratrn nthucsau24h utin.Nn 371 bnhnhnstngngvi371n thuc. Do,khngcskhcbitnhiuvktqugiaslngtngtctrns lng n gia hai nghin cu ny (627/301 n v 726/371 n ) . T l tng tc thuc tim n cao nh vy c th l do tnh cht c trng ca ICUlasccbnhnhnutrongtnhtrngnngthmchcnguyct vong, nhiu bnh mc km (trong nghin cu ny t l bnh nhn c bnh mc km cao74,1%)doslngthucsdngtrnbnhnhnln(trungbnh9.85 41 thuc/ n, s n c t 8 n 13 thuc chim 72,8%). Bnh nhn ICU c din bin phc tp, thng i hi quyt nh nhanh ca bc s c bit khi bnh nhn ln cn cphocedatnhmngdoviccnnhc,xemxt,tracutngtcthuc cng c th t c ch hn, c th l l do khin cho t l tng tc thuc ca ICU cao hn cc khoa phng khc. Mt s yu t nh hng n tng tc thuc Kt qu phn tch hi quy tuyn tnh gia s lng tng tc gp phi theo slng thuc s dng thy c milin hmnh (r=0,621). Kt qu nyph hp vi cc nghin cu khc v tng tc thuc. Xem xt mi lin quan gia tui bnh nhn v s xut hin tng tc thuc tim n, kim nh khi-bnh phng cho kt qu khng c s khc nhau v t l xut hin tng tc thuc gia hai nhm bnh nhn trn 65 tui v di 65 tui. Nhiu nghin cu a a ra kt lun tui lmtyu t nguy c ca tng tc thuc [18][13].TiVitNam,mtsnghincucngsosnhtlxuthintngtc gia hai nhm bnh nhn trn 65 v di 65 tui u thy c s khc bit gia hai nhm ny[1][4][6]. Tuy nhin, cc nghin cu ny c muln hn so vinghin cu hin ti. Nghin cu ca Dng Tun Anh trn 178 bnh nhn[1], c mu ca nghin cu ti bnh vin a khoa Bc Giang ca Nguyn Th Huy l 165 ngi[4], nghin cu ca Nguyn Thanh Sn trn 1502 bnh nhn iu tr ngoi tr[6], trong c mu ca nghin cu ny ch l 58 bnh nhn. C mu nh c th l mt nguyn nhn dn n s khc bit kt qu so vi cc nghin cu khc. Hn na, y ch l phn tch n bin, tnh trng bnh l, bnh mc km, s lng thuc c k trn ncng c th nh hng ti t l tng tc thuc tim n. Kim tra mi lin quan gia s lng bnh mc km v t l tng tc thuc timn,KimnhMann-WhitneyUsosnhtrungvcatngscptngtc trn n gia hai nhm c bnh mc km v khng c bnh mc km cho thy c s khc nhau c ngha thng k (p< 0.001). Kt qu ny ph hp vi l thuyt cho rng bnh mc km l mt nguy c lm xut hin tng tc thuc tim n. Tng tc thuc ph bin v phn loi tng tc 42 Danh sch 10 tng tc ph bin nht trong khoa ICU c s khc bit so vi khoaiutrkhc.Morphin,propofolthngcdngtikhoavimcch gim au, an thn. y l nhng thuc tc dng mnh, t tin,thng ch s dng trn i tng bnh nhn c ch nh c bit nh au nhiu, chng my, kch thch mnhDo,cptngtcgiamorphin,propofolvidiazepamctrongdanh sch 10 tng tc ph bin nht ti ICU nhng t gp cc khoa iu tr khc nh ni tiu ha tit niu, ni tim mch, iu tr ngoi tr[1][3][4][6].Trong mt nghin cu c cng b nm 2014, cng ch ra s khc bit gia tng tcphbintrongICUsosnhvikhoaiutrkhc.Nhmtcgithyrng tngtctimngiaMidazolam/alprazolamvccchtcchCYP3A4him gp khoa iu tr thng thng, nhng li l cp tng tc ph bin th 2 ti ICU mnghincuangtinhnhkhost.Ngclimtscptngtcgia NSAIDvcorticoidhocbiphosphonatvantacidnmtrongdanhsch10tng tcphbinnhttikhoaiutrthngthngthlirthimgptrongICU [54].Kt qu hi cu trong nghin cu hin ti, tn sut ca tng tc gia aspirin vmethylprednisolonl9,khngccptngtcnogiabiphosphonatv antacid. Micptngtcphbinnhtthuclinquannccthuc perindopril,kali,spironolacton,diazepam,morphin,propofol,furosemid, levofloxacin,methylprednisolon,aspirin,insulin.Trongc5thucthucdanh sch10thucsdngnhiunht.5cptngtcmcchngchinhhoc nghimtrngphbinnhtcngthucdanhschny,lperindopril-kali, insulin-levofloxacin, perindopril-spironolacton, diazepam-morphin. Ceftriaxon-calci l cp tng tc mc nghim trng duy nht trong mu hi cu, tn sut ca cp ny l 5/627 ln. Gii hn trong 20 cp tng tc c tn sut cao nht, thy rng 20 cp ny chutrchnhimchogn80%tngtcthucxuthintikhoa.iunycho phpkhoaxydngdanhschtngtccnchv hngdnxlph hp vi hon cnh ti khoa mnh. V d, tng tc gia perindopril v aspirin c th lm gim tc dng h p ca perindopril v nguy c tn thng thn nu dng liu cao. 43 y l cp phi hp rt quen thuc ti khoa v cc bc s cng chc chn v li ch khidngngthivtqunguyctimndotngtcgyra,hnnaiu kin gim st huyt p ti khoa rt cht ch. Do , trong danh sch khuyn co c thbcptngtcnyi.Vicxydngdanhschkhuyncotikhoaphi cthitkrtcnthnvcsnggpkincacbcsviudng. Dngnhmtdanhschtngtcstcnghanumicptngtcu c bit n mt cch r rng v cch qun l a ra l theo di nhng thng s bt buc phi theo di trn bnh nhn hi sc ngay c khi khng c tng tc. Phnloitngtcthucthuctrongmu,ktqul,vnng,cc tng tc mc trung bnh v nghim trng chim a s. V khi pht, gn mt na s tng tc (40,51%) l c khi pht chm. Gn 90% tng tc yu cu theo di.ivinhngtngtckhiphtchmnhvy,yucutheodicth khng ch dng li thi gian dng thuc, mt s sau khi dng thuc vn c nguy c, v d, bnh nhn dng ng thi levofloxacin v methylpredisolon, thm ch c trng hp bo co t gn xy ra vi thng sau khi dng thuc[11]. Do , vic nm c kin thc v tng tc thuc v bin php qun l l rt quan trng gim thiu nguy c gp bin c bt li do thuc trn bnh nhn. T l tng tc khuyn co nn theo di cao nh vylmtli th trong vic kim sot tng tc nhmgimnguy c gy hi chobnh nhn i vi khoa hi sc. Biv, ivikhoa iu tr c bit ny, a s bnh nhn u trong tnh trng nng v vic theo di cht ch cc biu hin lm sng, thng s xt nghim, i khi cn phi s dng c my mc c bit theo di lin tc nhp tim, huyt p, nhp thl quan trng m bo hiu qu iu tr v an ton cho bnh nhn. Mt s cp tng tc v kho st kin bc s - Cp tng tc gia ceftriaxon v calcium Ch xt ring v tng tc chng ch nh, nghin cu quan st c mt cp tngtcgiaceftriaxonvcalcingtnhmchxuthintrn5n.Theo Micromedex 2.0 th tng tc ny ch chng ch nh trn i tng tr em di 28 ngy tui, c rt nhiu bo co t vong trn i tng ny. cc la tui khc vn c th dng ln lt vi iu kin ng truyn phi c ra sch bng dung 44 dchthchhp.Trongc5nthuc,ceftriaxonulkhngsinhiutr nhim khun dng hng ngy. Calci clorid ng tnh mch ch l thuc thm vo iu tr t cp hoc theo biu hin lm sng. Khng c bnh nhn no l i tng tr em, tt c u dng theo ng tim trc tip, thi gian khc nhau. Do nguy c xy ra kt ta ceftriaxon-calci ti thn v phi gybin chng t vongl thp, tuynhintheotiliuAntibioticEssentials2010vnarakhuyncokhng dng ch phm cha calci trong vng 48h k t ln cui cng dng ceftriaxon [15]( y l ti liu v khng sinh ang c s dng ti khoa dc bnh vin E ). Theo bo co ca Trn Ngn H ti hi ngh Dc ng Dng thng 12/2013, s lngbocoADRtnguyncaVitNamt1/2008-12/2010clinquan ntng tc gia ceftriaxone v ringer lactac (dch pha truyn cha Canxi) lkh nhiu (20 bo co) [53]. Tuy nhin,trao i trc tip vi cc bc s ti khoa, th tt c cc bc s c hi u khng bit n thng tin tng tc ny. - Cc tng tc lm thay i nng kali Tng tc gia thuc c ch men chuyn, li tiu gi kali, ch phm b sung kali, li tiu thi kali u c quan st ph bin c giai on tin cu v hi cu. Khng ch c tng tc n c gia hai thuc, trn nhiu n cn quan st thy s phihpgiac3,thmch4thuccngnhhngtinngkali.Kimtra chc nng thn trc khi phi hp, theo di nng kali mu thng xuyn, thm ch c ti liu khuyn cao theo di c nng creatinin v kali trong 4 tun k t khi bt u s dng hoc tng liu c ch men chuyn [16] c bit trn bnh nhn cyutnguyccao(suythn,ithong,caotui,sdngchphmb sung kali, li tiu gi kali, c ch men chuyn) [25][47]. Trao i kinti khoa, cc bc s u cho rng y l nhng tng tc ph bin. Bnh nhn ti khoa khi dng thuc s thng xuyn c theo di triu chng lm sngvtheodinngkaliquaxtnghimkhmungmchhochasinh mu, i vibnh nhn nng s c theo di in tm lin tc, kalimu tng thtrnintmsngTnhnhn.Tuynhin,thngtintrnhphihp spironolacton v CMC khimclccu thn 25mg cng l mt yu t dn n nguy c tng kali mu [25][46]. Tuy c vi nghin cu cho rng liu spironolacton >25 mg lin quan n kh nng tng kalimu, nhng mt s tiliu nh AHFS hoc t hng dn s dng thuc cho php liu dng cho bnh nhn suy tim mn phi hp vi thuc CMC l t 25-50mg/ngy.Cnthmnhiunhincuvvnnyctharaktlun chnh xc, tuy nhin, trn i tng bnh nhn c nguy c cao cng nn c s cn nhc v nguy c tng kali mu la chn liu thch hp. - Tng tc gia digoxin-amiodaron Trongktquhicutrnbnhnkhnggptrnghpnocsdng ng thi hai thuc ny trn mt n. C ch ca tng tc c cho l thng qua vic c ch hot ng ca bm tng thuc P-glycoprotein rut v thn lm tng hpthudigoxinrutvgimbititthn,vvynngdigoxintrongmu tng[52][39].Mtnghincumtnngdigoxintngcnghasaukhi thmamiodaronvophciutrcabnhnhnangiutrdigoxinng ungvngtnhmchkodi.28bnhnhnangdngdigoxinngung, nng digoxin tng t 0,97 ln 1.98 ng/ml. Tc dng ph trn rut xy ra 9 bnh nhn, c tnh trn thn kinh trung ng quan st c 5 bnh nhn, phn ng tim mch4bnhnhn.Nngdigoxintngkodit1n3tunsaukhidng amiodaron [37]. Phng vn trc tip ti khoa, cc bc s c hi khng bit n c ch v nguy c tng nng digoxin khi dng ng thi hai thuc. Trongthigianquansttrctipti khoa,c2trnghpsdng digoxintheo ng tim tnh mch 0,5g iu tr triu trng trn bnh nhn, mt trng hp dng dingytheongung.Amiodaroncdngngthitrnhaibnhnhn dng ng tnh mch. C hai trng hp ny u khng c theo di in tm 46 lin tc v u khng quan st thy tc dng ph ca digoxin. Tuy nhin, s thiu kin thc c th dn n nguy c xy ra tng tc trong tng lai. Amidodaron v digoxin l mt tng tc i din cho c ch tng tc dc nghcthngquaP-glycoprotein.P-glycoproteinlbmtngthucphthin cmngmtstbo,ncthythucvchtchuynhacathucra khitbovdocthnh hngtinngtihpthu(ti rut),phnb (no, tinh hon, nhau thai), thi tr (thn v mt) ca thuc. V d, P-glycoprotein trongtbocanimmcrutcthtngmtsphntthuchpthuri quay tr li lng rut dn n gim tng khi lng thuc hp thu. Hot ng ca P-glycoprotein trong tbo nim ca hngro mu no cng c th ymts thuctno,hnchsxmnhpvtcngcathuclnthnkinhtrung ng.Bmtngthucnycthcmnghoccchbimtsthuc.Vd, Rifampicin c tc dng cm ng P-glycoprotein nn lm gim hp thu digoxin dn n gim nng digoxin trong huyt tng. c ch hot ng ca P-glycoprotein ngoiamiodaroncnmtsthuckhcnhclarithromycin,erythromycin, ketoconazol, tacrolimus, verapamil[52]. Cc thuc ny cng nm trong danh mc thuc dng ti khoa hi sc tch cc nm 2013. Digoxin l thuc c khong iu tr hp do vic tng nng lm tng nguy c ng c do khoa dc nn c k hochtphunbsungkinthcvtngtcthucnichungvtngtclin quan n digoxin qua c ch thng qua P-glycoprotein ni ring. - Tng tc gia methylprednisolon v levofloxacin Vim gn, t gn l mt trong cc tc dng ph ca levofloxacin.Thi gian xy ra c th l 48h sau khi dng thuc, thm ch c bo co xy ra sau vi thng s dng. Nguy c tng ln trn nn bnh nhn s dng corticoid v ngi cao tui, bnh nhn cy ghp tim,thn, phi. Nguy c cng tng ngi vn ng gng sc, ri lon gn nh trong bnh vim khp dng thp (rheumatoid arthritis) [8]. y l tng tc ph bin trong kt qu hi cu (47 cp), trong thi gian quan st trc tip ti khoa, c 6 bnh nhn gp tng tc thuc ny, tt c u cao tui (>70)-tui cao lmtyutnguyc.Trongccbcscphngvn,chduynhtmtngi bit n tc dng ph ny ca levofloxacin, tuy nhin cng khng bit n cc yu 47 t bnh nhn ang dng corticoid v tui cao lm tng nguy c xut hin tc dng ph trn. Chnh v l do khng bit n thng tin tng tc m c 6 bnh nhn u khng c t vn v nguy c c th xy ra. Mc d bnh nhn gp phi tc dng nylrthim,nhngtrn itngcnguyccaonhvynhnvinytvn nn nm r v c bin php x l kp thi nu c biu hin trn bnh nhn. - Tng tc nh hng ti chc nng thn Aspirin-perindopril,furosemid-perindoprill2cptngtctrongdanh sch 10 tng tc ph bin nht ti khoa trong thng 12.C hai cp ny u c nguy c gy tn thng thn.Bn thn thuc c ch men chuyn c nguy c gy suy thncp.Nhngrtmaymn,tcdngchinghimtrngnycathuclrt him, t hn 1% sbnh nhn gp phi. Bnh nhn c tin s bnh thn lm tng nguy c [16].Li tiu quai nh furosemid thng c phi hp iu tr tng huyt p cho bnh nhn, thng thng kt hp gia hai thuc kh an ton v hiu qu. Tn thngthnvsuythncpcbocokhidngphihp[52].Trongmt nghin cu phn tch 74 bnh nhn ang dng captopril vlisinopril, suy thn cp cthphchixyraphbinhnnhmdnglitiu(furosemidv/hoc hydrochlorthiazid) so vi nhm khng dng li tiu ( 11/ 33 so vi 1/41 bnh nhn) [33]. Aspirinhinnayhunhkhngcndngvichnhgimau,hst, chng vim.a s u c dng vi liu thp, ko di, c tc dng c ch kt tp tiucu.TheohngdniutrcaNICE2010,aspirin(75-150mg/ngy)nn csdngbnhnhncskthpcasuytimvbnhxvangmch (bao gm c ng mch vnh)[38]. Nguy c gim chc nng thn hoc suy thn cp dng nh him xy ra khi kt hp aspirin liu thp ko di v c ch men chuyn [52]. Quansttincu,cmttrnghptrnnthuccmtcbathuc perindopril,furosemidvmeloxicam.Thut ng Triple Whammy c dng 48 chcpphihpbba:NSAID,cchmenchuynhocikhngthth angiotesinvlitiu.Trongmtnghincuthuntphicusosnhtltn thng thn cp gia hai nhm s dng hai thuc (2 trong 3 cc thuc sau: c ch men chuyn, li tiu, NSAID) v b 3 thuc Triple Whammy ch ra rng s dng 3thucclinquan nvictngt ltnthngthncp,cns dng2thuc khngcmilinquanno(RR=1,13,CI95%:1,12-1,53)[30].Cchcacp phi hp b 3 cha r rng, cn thm cc nghin cu khng nh s tng cao hn nguy c khi phi hp. Tuy nhin, cc ti liu vn a ra khuyn co trnh phi hp khi c th, nu dng ng thi nn theo di cht ch bnh nhn, gio dc cho bnh nhnbitnguycvdnbnhnhnthngbochobcskhictriuchngbt thng (nn, ri lon, ph, nc tiu thp) [41]. Cpfurosemid-netilmicincngnhhngtichcnngthn,ngoira, tng tc ny cn c th gy tc dng ph trn tai. Khuyn co a ra l nn dng liu thp nht c tc dng, theo di cht ch bnh nhn khi phi hp, c bit kh nng nghe ca bnh nhn [52].- Tng tc thuc lin quan n c ch bm proton cchbmproton(PPI)lnhmthucdngnhiuthhaitikhoa(480 lt)saukhngsinhcephalosporin.Nhmnygmnhiuthuc:omeprazol, esomeprazol,lansoprazol,pantoprazol.Omeprazoltngtcvimtsthuc thng qua c ch enzym CYP2C19. Trong mt th nghim s dng liu omeprazol 40mg/1 ln/ngy trong lin tc 7 ngy lm gim thanh thi ca diazepam t 22,4 2,8 n 10,1 1,5 ml/gi/ kg th trng v ko di thi gian bn thi ca diazepam t 36,9 4,1 n 85,0 14,7 gi. Nng trong huyt tng ca cht chuyn ha chnh desmethyldiazepam cng gim sau khi iu tr bng omeprazol [21]. Xem xt kh nng c ch enzyme CYP2C19 ca cc thuc c ch bm proton , thy mc c ch khc nhau nhiu gia cc thuc trong nhm, thay i t 79% (esomeprazol) v46%(omeprazol)tinhhn1%(pantoprazol,rabeprazol)[57].Nuckin thcvvnnycthlachnthucmtcchhplgimthiunguyc xy ra tng tc trn bnh nhn, thay v s dng omepazol hoc esomeprazol c th lachnpantoprazolthaythkhiiutrdingytrnbnhangsdng 49 diazepam [31]. Tng tc thuc gia esomeprazol (hoc omeprazol) vi diazepam c quan st thy ti ICU bnh vin E.Phng vn trc tip cc bc s v vn ny nhn thy rng kin thc ca cc bc s v cc tng tc thuc thng qua c ch c ch hoc cm ngenzymegannichung,cptngtcgiaesomeprazol/omeprazolvi diazepam ni ring cn hn ch. Mt s cp tng tc khc quan st c trc tip trn lm sng v trao i kincvibcsl:ciprofloxacin-theophyllin,aspirin-methylprednisolon, morphine-propofol,morphin-diazepam,diazepam-propofol,digoxin-furosemid, digoxin-esomeprazol. Trong , cp tng tc gia cc cht c ch thn kinh trung ng aspirin-methylprednisolon, digoxin-furosemid c cc bc s nhn nh l ph bin ti khoa, v c cn nhc nguy c - li ch trc khi s dng. Thng tin v 2tngtcdcnghcciprofloxacin-theophyllinvdigoxin-esomeprazolth cha c cc bc s bit n. Tmli,tnsuttngtcthuctiICUbnhvinEcnkhcao.Tl tng tc mc chng ch nh v nghim trng chim mt phn khng nh. Cc tng tc thuc kh a dng thuc nhiu nhm thuc khc nhau, tc ng n nhiu c quan khc nhau theo nhng c ch khc nhau. Kho st kin bc s v mt s cp tng tc quan st trc tip c trn lm sng nhn thy rng tng tc thuc cn l mt vn t c cc bc s ti khoa quan tm, lng thng tin thuc bc s nm c cn hn ch, c bit l mt s tng tc theo c ch dc ng hc lin quannccenzymeganhocp-glycoprotein.Vvy,vncnhbonguyc mt s cp tng tc nghim trng v c k hoch b sung thm kin thc v tng tc thuc l cng vic m khoa dc bnh vin E nn sm trin khai gim thiu nguy c tc dng bt li nh hng ti sc khe bnh nhn. 50 KT LUN V XUT KT LUN Qua thu thp thng tin tng tc trn 301 nthuc ca 58 bnh nhn iu trnitrtikhoaHisctchcc-BnhvinEvquanstct ngangthchnh lmsnglinquanntngtcthucvphngvntrctipbcstikhoat ngy 21/04/2014 n 25/04/2014 chng ti rt ra kt lun sau: Kho st tng tc thuc bt li tim n ti khoa Hi sc tch cc - Tlnthucctngtcthucl78,1%tngngvi93,1%sbnh nhn c t nht mt tng tc thuc tim n trong thi gian iu tr ni tr. S n ctngtctmcnghimtrngtrlnchim59,8%(180n).Trungbnh mt n c 2,1 tng tc thuc. S lng tng tc trong n 1 n 4 chimtl cao nht (66,8%),n thuc c trn 10 tng tc chim 1,0%. - Cc tng tc ph bin thng gp nht bao gm: perindopril-kali (10,7%), levofloxacin-methylprednisolon(7,5%),insulin-levofloxacin(6,7%),diazepam-esomeprazol(6,4%),aspirin-perindopril(5,9),perindoprill-spironolacton(5,4%), fursemid-perindopril (4,6%), kali-spironolacton (3.7%), diazepam-morphin (3,7%), diazepam-propofol (3,7%). Trong 5 cp in nghing l c mc nghim trng. - Theo mc khi pht, 40,5% lt tng tc thuc c khi pht chm lin quann17tngtcthuc.Tngtckhiphtnhanhchim34,6%linquan n 18 cp tng tc.- V khuyn co qun l tng tc, 89,3% lt tngtc c khuyn co nn theo di khi dng ng thi, 5,9% lt tng tc c khuyn khng nn phi hp v 35,3% lt nn hiu chnh liu khi dng ngthi. - Tng tc thuc nh hng n nhiu c quan, bphn, qu trnh trong c th: 16,6% nh hng ti qu trnh dc ng hc ca thuc, 19,3% nh hng ti htunhon-huytp,19,5%nhhngtihthnkinhtrungng,15,8%nh hng ti chc nng thn v mt s c quan khc nh gn c, tiu ha- C mi lin quan gia s lng thuc trong n v s lng tng tc thuc timn.Khngcskhcbitvt lxuthintngtcgianhmbnhnhn 51 trn65tuivdi65tui.Bnhnhncbnhmckmckhnngxuthin tng tc thuc cao hn c ngha thng k so vi nhm khng c bnh mc km. M t thc hnh v kin thc-thi cu cc bc s i vi tng tc thuc ti khoa Hi sc tch cc Trongthigianquansttrctipthchnhlmsngvphngvnlin quan nmtstngtcxyratrongthigiantincu,ti araccktlun sau: - Mt s tng tc thuc ph bin c cc bc s bit n cc thng tin v c ch, hu qu v cch qun l: cc tng tc lin quan n cc thuc nh hng ti nngkali(perindopril,kali,spironolacton),tngtcgiaaspirinv methylprednisolon,digoxinvfuoremid,cctngtcgiamorphin,fentanyl, diazepam.Qunlnhngcptngtcnyccthchin,nhngvnc trng hp khng qun l cht ch. - Mt s tng tc thuc khng c cc bc s bit n:amiodaron-digoxin, theophyllin-cirprofloxacin,diazepam-esomeprazol,levofloxacin-methylprednisolon. Do , cng khng c qun l lm sng c bit trn bnh nhn. - Cc tng tc theo c ch dc ng hc t c bc s bit n. -Mt s tng tc bc s c bit n tuy nhin thng tin cha r rng: c ch men chuyn-li tiu quai, c ch men chuyn-NSAID v qun l cc tng tc ny cha y (da vo nhng thng tin v hu qu, c chc bit). 52 XUT - Nn c dc s lm sng ti khoa h tr cc bc s trong pht hin, x tr vgimsttngtcthuc.Dcsvbcscngphihpvaraccbin php nhm hn ch tng tc bt li. - Xy dng danh sch tng tc cn ch ti khoa iu tr c s ng gp kin t c pha bc s v iu dng ti khoa, xa hn trong tng lai c th s dng phnmmkntchhpchc nngduyttngtcthucvcsdliuca phn mm c xy dng da trn c kin ca bc s, iu dng ti khoa. Khoa dc c k hoch tp hun nhm nng cao kin thc v tng tc thuc c v pht hin v gim st, x tr tng tc thuc. PH LC Ph lc 1. Cc tng tc tim n thuc ph bin trong mt s nghin cu ti khoa hi sc tch cc. Tiliutham kho s Tng tc ph bin [10]1. Courmarin - cefamandol 2. Courmarin - khng sinh (tr cotrimoxazol/metronidazol/ cefamandol) 3. Mui kali - li tiu gi kali 4. Courmarin - amiodaron/ propafenon 5. c ch men chuyn - li tiu 6. c ch rennin-angiotensin-aldosterol - li tiu gi kali 7. Courmarin - aspirin (70) Khuyn co - Theodinngkalithngxuynkhikthp.Nunngkalitngtrn 0.5mmol/ngy th xc nh r nguyn nhn v loi b - Xt nghim nng kali v chc nng thn trc khi phi hp. - Trnh kt hp khi mc lc cu thn 60 tui). C th xy ra vim gn trong khi hoc sau khi ngng dng levofloxacin. Qun l: - Ngng thuc nu bnh nhn thy au, c biu hin ca vim gn, t gn. - Ngng tp th dc, hn ch vn ng n khi hi phc hon ton 7.2.4. Tng tc lin quan ti thuc c ch kinh trung ng (gy m, gim au) Morphin-fentanyl/ diazepam -fentanyl/ diazepam-morphin - Mc : nghim trng - C ch: hip ng tc dng trn thn kinh trung ng - Hu qu: Tng nguy c c ch thn kinh trung ng, suy h hp, an thn su, tim n nguy c t vong - Qun l: Theo di cht ch bnh nhn. Gim liu mt trong hai thuc nu cn Diazepam-esomeprazol - Mc : trung bnh - C ch- hu qu: esomeprazole c ch enzyme chuyn ha ti gan CYP2C19 ca diazepam=>nguyctngnngdiazepamtrongmudotimnnguyc ng c. - Khi pht: khng r 7.2.5. Tng tc nh hng ti chc nng thn c ch men chuyn-li tiu quai - Mc nng: trung bnh - Hu qu: cng tc dng trn h huyt p; nguy c tn thng thn (c th suy thn cp). - Qun l: Theo di huyt p thng xuyn Theo di chc nng thn, nu nng creatinin, ure mu tng th gim liu hoc dng thuc li tiu v/ hoc CMC NSAID (meloxicam)-perindopril - Mc nng: Trung bnh - Huqu:gimGimhiuquhhuytpcaperindopril;Nguyctnthng thn - Qunl:theodi huytp,theodichcnngthn nhknhmphngsuy thn 7.2.6. Cp tng tc khc Ciprofloxacin-theophylin- Mc nng: nghim trng - Khi pht: chm - Hu qu: Tng nng trong huyt tng, tng thi gian bn thi, tng nguy c c tnh do theophylin ( nn, bun nn, co git) - Qunl:Theodinngtheophylinhuytthanhvhiuchnhliuph hp Aspirin-methylprednisolon - Mc nng: trung bnh - Khi pht: chm - Huqu:Tng nguytcdngphtrnngtiuha (chymutiuha, lot d dy) v gim hiu qu iu tr ca aspirin - Qun l: Theo di bnh nhn Ph lc 8. Kt qu theo di Kali v creatinin ( thi gian theo di t 21/4-25/4) Cp tng tcH v tn Yu t nguy c Theo di xt nghim kali v creatininGhi ch Perindorpil-kali Trng Cng T Khng- Xt nghim K+ trc khi dng ng thi: ngy 18/4: 4,1 mmol/l) - Xt nghim creatinin trc khi dng ng thi: khng c kt qu trong vng 1 tun trc - Theo di K+ thng xuyn: 2 ln/ 7 ngy (20/4,21/4) Dng ng thi ngy 19/4 Vn L- Tui cao (72) - i tho ng - Xt nghim K+ trc khi dng ng thi: ngy 12/4: 3,7 mmol/l - Xt nghim creatinin trc khi dng ng thi: ngy 12/4-96 mmol/l - Theo di K+ thng xuyn: 3 ln/14 ngy (14/4;21/4;23/4) - Dng ng t ngy 12/4 Nguyn nh L - Tui cao (72) - Xt nghim K+ trc khi dng ng thi: ngy 20/4: 4,4 mmol/l - Xt nghim creatinin thn trc khi dng ng thi: khng c kt qu trong vng 1 tun trc - Theo di K+ thng xuyn:2 ln/ 5 ngy (21/4, 23/4) - Dng ng thi t ngy 21/4 Nguyn Vn C - i tho ng - Xt nghim K+ trc khi dng ng thi: ngy 21/4:3,3 mmol/l - Xt nghim creatinin trc khi dng ng thi: ngy 21/4:100 mmol/l - Theo di K+ thng xuyn: 0 (khng c xt nghim Kali trong nhng ngy tip theo) - Dng ng thi t 21/4-23/4 - Bt u t 24/4 b sung thm spironolacton, furosol) Nguyn Hu N - Tui cao (88) - Xt nghim K+ trc khi dng ng thi: khng c xt nghim kali trong 4 ngy trc - Xt nghim creatinin trc khi dng ng thi: khng c kt qu trong vng 1 tun trc - Theo di K+ thng xuyn: 0 (khng c xt nghim Kali trong nhng ngy tip theo) - Dng ng thi t 22/4 Trn Vn Q - Tui cao (73) - Xt nghim K+ trc khi dng ng thi: ngy 18/4: 3,4 mmol/l - Xt nghim creattinin trc khi dng ng thi: ngy 18/4: 100mmol/l - Theo di K+ thng xuyn:2 ln/7 ngy(21/4-23/4) - Dng ng thi t 19/4 Nguyn Vn Ch Khng- Xt nghim K+ trc khi dng ng thi: ngy 21/4: 3,3mmol/l - Xt nghim chc nng thn trc khi dng ng thi: khng c kt qu trong 3 ngy trc - Theo di K+ thng xuyn:3 ln/5 ngy (22/4, 23/4, 24/4) Dng ng thi t 21/4 Perindorpil-kali-furosemid Nguyn Hu T - Tui cao (70) - Xt nghim K+ trc khi dng ng thi: ngy 23/4: 4,5mmol/l - Xt nghim creatinin trc khi dng ng thi: ngy 23/4: 145mmol/l - Theo di K+ thng xuyn: 4 ln/3 ngy(mi ngy 2 ln n ngy 25/4) Dng ng thi 23/4 L Th D- Tui cao (92) - Xt nghim K+ trc khi dng ng thi: ngy 21/4: 3,7 mmol/l - Xt nghim chc nng thn trc khi dng ng thi: c 21/4: 100 mmol/l - Theo di K+ thng xuyn: 0 ln (khng lm xt nghim 22/4,23/4) Dng ng thi t 21/4 (vo khoa) Ngy 24/4, dng thm spironolacton LmTh A - Tui cao (78) - Xt nghim K+ trc khi dng ng thi: ngy 18/4: 3,6 mmol/l - Xt nghim chc nng thn trc khi dng ng thi: khng c xt nghim trong 4 ngy trc - Theo di K+ thng xuyn: 2 ln/ 3 ngy (19/4-21/4) -Dng ng thi t 19/4-22/4 -T ngy 24/4 c dng thm spironolacton Spironolacton-kali-furosemid Trnh Ngc Tr Khng- Xt nghim K+ trc khi dng ng thi: ngy 21/4: 4,3 mmol/l - Xt nghim creatinin khi dng ng thi: ngy 21/4: 128 mmol/ - Theo di K+ thng xuyn:1 ln/ 3 ngy (23/4) Dng ng thi t ngy 22/4 Perindopril-kali-spironolacton L Th D- Tui cao (92) - Xt nghim K+ trc khi dng ng thi: ngy 24/4: 4,1 mmol/l - Xt nghim creatinin trc khi dng ng thi: Khng c kt qu trong 7 ngy trc - Theo di K+ thng xuyn:0 (khng c xt nghim 25/4) Dng ng thi t 24/4 LmTh A - Tui cao (78) - Xt nghim K+ trc khi dng ng thi: ngy 24/4: 4,3 mmol/l - Xt nghim creatinin trc khi dng ng thi: ngy 24/4: 100 mmol/l - Theo di K+ thng xuyn: 0 (khng c kt qu ngy 25/4) Dng ng thi t 24/4 Perindopril-kali-spironolaction-furosemid Nguyn Th T - Tui cao (70) - i tho ng - Suy thn - Xt nghim K+ trc khi dng ng thi: ngy 15/4: 3,8 mmol/l - Xt nghim creatinin trc khi dng ng thi: ngy 15/4-120 mmol/l - Theo di K+ thng xuyn: 7 ln/ 10 ngy (16/4,17/4,18/4,21/4,22/4,23/4,25/4) Dng ng thi t 16/4 Nguyn Vn C - i tho ng - Xt nghim K+ trc khi dng ng thi: khng c kt qu trong 3 ngy trc - Xt nghim chc nng thn trc khi dng ng thi:Khng c xt nghim trong 3 ngy trc (21/4: 100 mmol/l) - Theo di K+ thng xuyn: 0 (24/4, 25/4 khng lm xt nghim) Dng ng thi t 24/4 TI LIU THAM KHO Ting vit 1.Dng Tun Anh (2013), nh gi tng tc thuc bt li trn bnh n iu tr ni tr ti khoa ni tiu ha tit niu bnh vin a khoa trung ng Thi Nguyn,LunvndcschuynkhoacpI,ihcDcHNi,H Ni. 2.B Y T (2006), Dc th quc gia Vit Nam, H Ni. 3.NgChDng(2007),Lachnphnmmduyttngtcthucvng dngkhostbnhntimtskhoacabnhvinBchMai,Lunvn thc s dc hc, i hc Dc H Ni, H Ni. 4.Nguyn Th Huy (2013), nh gi tng tc thuc bt li trn bnh n iu tr ni tr ti khoa ni tim mch bnh vin a khoa tnh Bc Giang, Lun vn dc s chuyn khoa cp I, i hc Dc H Ni, H Ni. 5.Hong Th Kim Huyn (2011), Dc lm sng, Nh xut bn Y hc, H Ni 6.Nguyn Thanh Sn (2011), nh gi tng tc bt li trn n thuc iu tr ngoitrtibnhvinakhoaHng,Lunvnthcsdchc,ihc Dc H Ni, H Ni. 7.L Ngc Trng, Khng Chin (2006),Tng tc thuc v ch khi ch nh, Nh xut bn Y hc, H Ni. 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