{"id":111471,"date":"2025-03-12T13:08:14","date_gmt":"2025-03-12T06:08:14","guid":{"rendered":"https:\/\/vnras.com\/drug\/?p=111471"},"modified":"2025-03-12T13:08:30","modified_gmt":"2025-03-12T06:08:30","slug":"chapter-14-tiep-can-lam-sang-shock-ths-bs-ho-hoang-kim-edicu-bv-nguyen-tri-phuong","status":"publish","type":"post","link":"https:\/\/vnras.com\/drug\/chapter-14-tiep-can-lam-sang-shock-ths-bs-ho-hoang-kim-edicu-bv-nguyen-tri-phuong\/","title":{"rendered":"Chapter 14. TI\u1ebeP C\u1eacN L\u00c2M S\u00c0NG SHOCK &#8211; Ths. Bs H\u1ed2 HO\u00c0NG KIM \u2013 EDICU \u2013 BV NGUY\u1ec4N TRI PH\u01af\u01a0NG"},"content":{"rendered":"<p>M\u1ed9t trong nh\u1eefng \u0111\u1eb7c \u0111i\u1ec3m d\u1ec5 nh\u1eadn bi\u1ebft c\u1ee7a t\u00ecnh tr\u1ea1ng l\u00e2m s\u00e0ng \u0111\u01b0\u1ee3c g\u1ecdi l\u00e0 &#8220;s\u1ed1c&#8221; l\u00e0 t\u00ean c\u1ee7a n\u00f3, kh\u00f4ng c\u00f3 b\u1ea5t k\u1ef3 gi\u00e1 tr\u1ecb khoa h\u1ecdc ho\u1eb7c b\u1ec7nh l\u00fd n\u00e0o, v\u00e0 \u0111\u01b0\u1ee3c chia s\u1ebb b\u1edfi c\u00e1c th\u1ef1c th\u1ec3 phi l\u00e2m s\u00e0ng xa x\u00f4i nh\u01b0 c\u00e1c ho\u1ea1t \u0111\u1ed9ng qu\u00e2n s\u1ef1 (&#8220;s\u1ed1c v\u00e0 kinh ho\u00e0ng&#8221;). Vi\u1ec7c s\u1eed d\u1ee5ng thu\u1eadt ng\u1eef n\u00e0y trong l\u00e2m s\u00e0ng c\u00f3 th\u1ec3 b\u1eaft ngu\u1ed3n t\u1eeb n\u0103m <strong>1731<\/strong>, khi m\u1ed9t b\u00e1c s\u0129 ph\u1eabu thu\u1eadt ng\u01b0\u1eddi Ph\u00e1p t\u00ean l\u00e0 <strong>Henri LeDran <\/strong>c\u00f4ng b\u1ed1 kinh nghi\u1ec7m c\u1ee7a m\u00ecnh v\u1edbi c\u00e1c v\u1ebft th\u01b0\u01a1ng do s\u00fang b\u1eafn v\u00e0 s\u1eed d\u1ee5ng thu\u1eadt ng\u1eef &#8220;chock&#8221; \u0111\u1ec3 m\u00f4 t\u1ea3 c\u00e1c v\u1ebft th\u01b0\u01a1ng th\u01b0\u1eddng d\u1eabn \u0111\u1ebfn t\u1eed vong (1). Trong b\u1ea3n d\u1ecbch ti\u1ebfng Anh lu\u1eadn v\u0103n sau \u0111\u00f3 c\u1ee7a LeDran, &#8220;s\u1ed1c&#8221; \u0111\u00e3 b\u1ecb d\u1ecbch sai th\u00e0nh ch\u1ec9 qu\u00e1 tr\u00ecnh l\u00e2m s\u00e0ng c\u1ee7a c\u00e1c v\u1ebft th\u01b0\u01a1ng thay v\u00ec ch\u00ednh c\u00e1c v\u1ebft th\u01b0\u01a1ng. Sau \u0111\u00f3, &#8220;s\u1ed1c l\u00e2m s\u00e0ng&#8221; tr\u1edf th\u00e0nh t\u1eeb \u0111\u1ed3ng ngh\u0129a v\u1edbi t\u00ecnh tr\u1ea1ng \u0111e d\u1ecda t\u00ednh m\u1ea1ng v\u00e0 x\u1ea5u \u0111i nhanh ch\u00f3ng. Tuy nhi\u00ean, s\u1ed1c l\u00e0 h\u1eadu qu\u1ea3 c\u1ee7a nhi\u1ec1u th\u1ef1c th\u1ec3 b\u1ec7nh l\u00fd v\u00e0 vi\u1ec7c t\u00ecm ra \u0111i\u1ec3m chung c\u00f3 th\u1ec3 l\u00e0 m\u1ed9t th\u00e1ch th\u1ee9c.<\/p>\n<p>Ch\u01b0\u01a1ng n\u00e0y l\u00e0 ch\u01b0\u01a1ng \u0111\u1ea7u ti\u00ean trong m\u1ed9t lo\u1ea1t c\u00e1c ch\u01b0\u01a1ng d\u00e0nh ri\u00eang cho s\u1ed1c l\u00e2m s\u00e0ng v\u00e0 c\u1ed1 g\u1eafng tr\u00ecnh b\u00e0y m\u1ed9t quan \u0111i\u1ec3m th\u1ed1ng nh\u1ea5t v\u1ec1 s\u1ed1c, bao g\u1ed3m s\u1ed1c l\u00e0 g\u00ec, c\u00e1ch ph\u00e2n lo\u1ea1i, c\u00e1ch bi\u1ec3u hi\u1ec7n v\u00e0 c\u00e1ch x\u1eed l\u00fd. Ti\u1ebfp theo l\u00e0 ba ch\u01b0\u01a1ng d\u00e0nh ri\u00eang cho c\u00e1c h\u1ed9i ch\u1ee9ng s\u1ed1c ch\u00ednh: t\u1ee9c l\u00e0 s\u1ed1c gi\u1ea3m th\u1ec3 t\u00edch, s\u1ed1c tim v\u00e0 s\u1ed1c nhi\u1ec5m tr\u00f9ng. N\u00f3i m\u1ed9t c\u00e1ch \u0111\u01a1n gi\u1ea3n, \u0111\u00e2y l\u00e0 nh\u1eefng t\u00ecnh tr\u1ea1ng kh\u00f3 kh\u0103n nh\u1ea5t m\u00e0 b\u1ea1n s\u1ebd g\u1eb7p ph\u1ea3i trong ICU.<\/p>\n<h2>SHOCK L\u00c2M S\u00c0NG L\u00c0 G\u00cc?<\/h2>\n<p>\u0110\u1ecbnh ngh\u0129a v\u1ec1 s\u1ed1c l\u00e2m s\u00e0ng \u0111\u00e3 c\u00f3 nhi\u1ec1u l\u1ea7n l\u1eb7p l\u1ea1i, bao g\u1ed3m c\u1ea3 m\u00f4 t\u1ea3 \u0111\u1ea7y m\u00e0u s\u1eafc trong tr\u00edch d\u1eabn m\u1edf \u0111\u1ea7u c\u1ee7a Samuel Gross, m\u1ed9t trong nh\u1eefng ng\u01b0\u1eddi kh\u1ed5ng l\u1ed3 c\u1ee7a ng\u00e0nh ph\u1eabu thu\u1eadt v\u00e0o th\u1ebf k\u1ef7 19, ng\u01b0\u1eddi \u0111\u00e3 \u0111\u01b0a m\u00f4 t\u1ea3 v\u1ec1 s\u1ed1c n\u00e0y v\u00e0o s\u00e1ch gi\u00e1o khoa ph\u1ed5 bi\u1ebfn c\u1ee7a m\u00ecnh (a). M\u1ed9t \u0111\u1ecbnh ngh\u0129a c\u1eadp nh\u1eadt v\u00e0 c\u1ea3i ti\u1ebfn v\u1ec1 s\u1ed1c s\u1ebd n\u00eau r\u1eb1ng <strong>s\u1ed1c l\u00e0 m\u1ed9t r\u1ed1i lo\u1ea1n tu\u1ea7n ho\u00e0n \u0111e d\u1ecda t\u00ednh m\u1ea1ng \u0111\u01b0\u1ee3c \u0111\u1eb7c tr\u01b0ng b\u1edfi vi\u1ec7c s\u1eed d\u1ee5ng oxy c\u1ee7a t\u1ebf b\u00e0o kh\u00f4ng \u0111\u1ea7y \u0111\u1ee7 <\/strong>(2). S\u1ed1c c\u00f3 th\u1ec3 l\u00e0 k\u1ebft qu\u1ea3 c\u1ee7a vi\u1ec7c oxy h\u00f3a m\u00f4 kh\u00f4ng \u0111\u1ee7 ho\u1eb7c qu\u00e1 tr\u00ecnh x\u1eed l\u00fd <strong>oxy kh\u00f4ng \u0111\u1ea7y \u0111\u1ee7 c\u1ee7a ty th\u1ec3<\/strong>, nh\u01b0ng k\u1ebft qu\u1ea3 l\u00e0 nh\u01b0 nhau; t\u1ee9c l\u00e0 c\u00f3 s\u1ef1 <strong>thi\u1ebfu h\u1ee5t trong s\u1ea3n xu\u1ea5t ATP <\/strong>oxy h\u00f3a. H\u1eadu qu\u1ea3 l\u00e2m s\u00e0ng c\u1ee7a s\u1ef1 r\u1ed1i lo\u1ea1n n\u00e0y l\u00e0 <strong>r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng <\/strong>\u1edf m\u1ed9t ho\u1eb7c nhi\u1ec1u c\u01a1 quan quan tr\u1ecdng, c\u00f3 th\u1ec3 ti\u1ebfn tri\u1ec3n th\u00e0nh <strong>suy \u0111a c\u01a1 quan <\/strong>v\u00e0 <strong>t\u1eed vong<\/strong>.<\/p>\n<h3>C\u00e1c \u0111\u1eb7c \u0111i\u1ec3m l\u00e2m s\u00e0ng<\/h3>\n<p>Bi\u1ec3u hi\u1ec7n l\u00e2m s\u00e0ng c\u1ee7a s\u1ed1c th\u01b0\u1eddng bao g\u1ed3m c\u00e1c tri\u1ec7u ch\u1ee9ng sau:<\/p>\n<ul>\n<li>Gi\u1ea3m huy\u1ebft \u00e1p, th\u01b0\u1eddng d\u1eabn \u0111\u1ebfn h\u1ea1 huy\u1ebft \u00e1p, \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 <strong>huy\u1ebft \u00e1p t\u00e2m thu &lt;90 mm Hg <\/strong>ho\u1eb7c <strong>huy\u1ebft \u00e1p trung b\u00ecnh &lt;70 mm Hg <\/strong>(2). (Xem ph\u1ea7n ti\u1ebfp theo \u0111\u1ec3 bi\u1ebft th\u00eam v\u1ec1 h\u1ea1 huy\u1ebft \u00e1p trong s\u1ed1c l\u00e2m s\u00e0ng.)<\/li>\n<li>T\u0103ng n\u1ed3ng \u0111\u1ed9 <strong>lactat huy\u1ebft t\u01b0\u01a1ng (&gt;2 mmol\/L)<\/strong>, \u0111\u01b0\u1ee3c coi l\u00e0 b\u1eb1ng ch\u1ee9ng v\u1ec1 t\u00ecnh tr\u1ea1ng suy gi\u1ea3m s\u1eed d\u1ee5ng O2 c\u1ee7a t\u1ebf b\u00e0o (m\u1eb7c d\u00f9 c\u00f3 nh\u1eefng gi\u1ea3i th\u00edch kh\u00e1c, nh\u01b0 \u0111\u01b0\u1ee3c m\u00f4 t\u1ea3 trong Ch\u01b0\u01a1ng 9)<\/li>\n<li>C\u00e1c d\u1ea5u hi\u1ec7u l\u00e2m s\u00e0ng c\u1ee7a r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng c\u01a1 quan, th\u01b0\u1eddng b\u1eaft \u0111\u1ea7u l\u00e0 <strong>thi\u1ec3u ni\u1ec7u <\/strong>(l\u01b0\u1ee3ng n\u01b0\u1edbc ti\u1ec3u &lt;0,5 mL\/kg m\u1ed7i gi\u1edd) v\u00e0 <strong>thay \u0111\u1ed5i tinh th\u1ea7n &#8211; tri gi\u00e1c <\/strong>(v\u00ed d\u1ee5, k\u00edch \u0111\u1ed9ng, l\u00fa l\u1eabn ho\u1eb7c suy gi\u1ea3m \u00fd th\u1ee9c), v\u00e0 c\u00f3 th\u1ec3 ti\u1ebfn tri\u1ec3n li\u00ean quan \u0111\u1ebfn b\u1ea5t k\u1ef3 v\u00e0 t\u1ea5t c\u1ea3 c\u00e1c c\u01a1 quan ch\u00ednh.<\/li>\n<li>Trong tr\u01b0\u1eddng h\u1ee3p <strong>&#8220;s\u1ed1c l\u01b0u l\u01b0\u1ee3ng th\u1ea5p: low-flow shock&#8221;<\/strong>, da c\u00f3 th\u1ec3 m\u00e1t l\u1ea1nh khi ch\u1ea1m v\u00e0o v\u00e0 c\u00f3 th\u1ec3 c\u00f3 nh\u1eefng thay \u0111\u1ed5i t\u00edm t\u00e1i \u1edf c\u00e1c chi xa. S\u1ef1 ti\u1ebfn tri\u1ec3n c\u1ee7a t\u00ecnh tr\u1ea1ng l\u01b0u l\u01b0\u1ee3ng th\u1ea5p c\u00f3 th\u1ec3 g\u00e2y ra ch\u1ee9ng xanh t\u00edm kh\u00f4ng \u0111\u1ec1u \u0111\u01b0\u1ee3c g\u1ecdi l\u00e0 <strong>\u201cda l\u1ed1m \u0111\u1ed1m\u201d <\/strong>ho\u1eb7c b\u1ec7nh m\u1ea1ng l\u01b0\u1edbi livedo.<\/li>\n<\/ul>\n<p><strong>H\u1ea1 Huy\u1ebft \u00e1p<\/strong><\/p>\n<p>H\u1ea1 huy\u1ebft \u00e1p l\u00e0 m\u1ed9t trong nh\u1eefng ti\u00eau chu\u1ea9n l\u00e2m s\u00e0ng \u0111\u1ec3 ch\u1ea9n \u0111o\u00e1n s\u1ed1c l\u00e2m s\u00e0ng, nh\u01b0ng <strong>\u0111\u1ed9 tin c\u1eady <\/strong>c\u1ee7a h\u1ea1 huy\u1ebft \u00e1p nh\u01b0 m\u1ed9t d\u1ea5u hi\u1ec7u c\u1ee7a s\u1ed1c l\u00e2m s\u00e0ng v\u1eabn <strong>c\u00f2n \u0111ang nghi ng\u1edd<\/strong>. V\u00ed d\u1ee5, c\u00e1c nghi\u00ean c\u1ee9u l\u00e2m s\u00e0ng \u0111\u00e3 ch\u1ec9 ra r\u1eb1ng huy\u1ebft \u00e1p c\u00f3 th\u1ec3 b\u00ecnh th\u01b0\u1eddng khi c\u00f3 b\u1eb1ng ch\u1ee9ng v\u1ec1 t\u00ecnh tr\u1ea1ng oxy h\u00f3a m\u00f4 kh\u00f4ng \u0111\u1ee7 (s\u1eed d\u1ee5ng n\u1ed3ng \u0111\u1ed9 lactat ho\u1eb7c \u0111\u1ed9 b\u00e3o h\u00f2a O2 t\u0129nh m\u1ea1ch trung t\u00e2m) (3). H\u01a1n n\u1eefa (nh\u01b0 b\u1ea5t k\u1ef3 ai \u0111\u00e3 d\u00e0nh th\u1eddi gian trong ICU c\u00f3 th\u1ec3 x\u00e1c minh), h\u1ea1 huy\u1ebft \u00e1p kh\u00f4ng ph\u1ea3i l\u00fac n\u00e0o c\u0169ng \u0111i k\u00e8m v\u1edbi b\u1eb1ng ch\u1ee9ng v\u1ec1 vi\u1ec7c s\u1eed d\u1ee5ng O2 kh\u00f4ng \u0111\u1ee7 trong c\u00e1c m\u00f4. Do nh\u1eefng quan s\u00e1t nh\u01b0 th\u1ebf n\u00e0y, \u201cm\u1ed9t s\u1ed1 h\u01b0\u1edbng d\u1eabn \u0111\u1ed3ng thu\u1eadn \u0111\u00e3 khuy\u1ebfn ngh\u1ecb r\u1eb1ng h\u1ea1 huy\u1ebft \u00e1p n\u00ean b\u1ecb lo\u1ea1i b\u1ecf nh\u01b0 m\u1ed9t d\u1ea5u hi\u1ec7u c\u1ee7a s\u1ed1c l\u00e2m s\u00e0ng\u201d (4).<\/p>\n<h3>C\u00e1c lo\u1ea1i S\u1ed0C l\u00e2m s\u00e0ng<\/h3>\n<p>C\u00f3 <strong>4 lo\u1ea1i s\u1ed1c <\/strong>kh\u00e1c nhau (h\u1ed9i ch\u1ee9ng s\u1ed1c) v\u00e0 ch\u00fang c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh b\u1eb1ng c\u00e1ch s\u1eed d\u1ee5ng c\u00e1c m\u1ed1i quan h\u1ec7 th\u1ee7y l\u1ef1c sau: t\u1ee9c l\u00e0, d\u00f2ng ch\u1ea3y \u1ed5n \u0111\u1ecbnh (Q) qua m\u1ed9t m\u1ea1ch th\u1ee7y l\u1ef1c k\u00edn c\u00f3 li\u00ean quan tr\u1ef1c ti\u1ebfp \u0111\u1ebfn \u0111\u1ed9 ch\u00eanh \u00e1p su\u1ea5t (\u00e1p su\u1ea5t \u0111\u1ea9y t\u1ea1o ra d\u00f2ng ch\u1ea3y) tr\u00ean to\u00e0n m\u1ea1ch (Pin &#8211; Pout) v\u00e0 li\u00ean quan ngh\u1ecbch v\u1edbi s\u1ee9c c\u1ea3n d\u00f2ng ch\u1ea3y (R) qua m\u1ea1ch.<\/p>\n<p>Q = (Pin &#8211; Pout)\/R (14.1)<\/p>\n<p>N\u1ebfu m\u1ea1ch th\u1ee7y l\u1ef1c n\u00e0y l\u00e0 h\u1ec7 th\u1ed1ng tu\u1ea7n ho\u00e0n, th\u00ec d\u00f2ng ch\u1ea3y l\u00e0 l\u01b0u l\u01b0\u1ee3ng tim (CO), \u00e1p su\u1ea5t d\u00f2ng ch\u1ea3y v\u00e0o l\u00e0 \u00e1p su\u1ea5t \u0111\u1ed9ng m\u1ea1ch trung b\u00ecnh (MAP), \u00e1p su\u1ea5t d\u00f2ng ch\u1ea3y ra l\u00e0 \u00e1p su\u1ea5t t\u00e2m nh\u0129 ph\u1ea3i (RAP) v\u00e0 s\u1ee9c c\u1ea3n d\u00f2ng ch\u1ea3y l\u00e0 s\u1ee9c c\u1ea3n m\u1ea1ch m\u00e1u to\u00e0n th\u00e2n (SVR). Ph\u01b0\u01a1ng tr\u00ecnh 14.1 hi\u1ec7n \u0111\u01b0\u1ee3c bi\u1ec3u th\u1ecb l\u1ea1i nh\u01b0 sau:<\/p>\n<p>CO = (MAP &#8211; RAP)\/SVR (14.2)<\/p>\n<p>V\u00ec huy\u1ebft \u00e1p gi\u1ea3m l\u00e0 t\u00ecnh tr\u1ea1ng th\u01b0\u1eddng g\u1eb7p trong s\u1ed1c, n\u00ean c\u00e1c thu\u1eadt ng\u1eef trong ph\u01b0\u01a1ng tr\u00ecnh tr\u00ean c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eafp x\u1ebfp l\u1ea1i \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh c\u00e1c y\u1ebfu t\u1ed1 quy\u1ebft \u0111\u1ecbnh huy\u1ebft \u00e1p \u0111\u1ed9ng m\u1ea1ch trung b\u00ecnh (l\u00e0 \u00e1p l\u1ef1c th\u00fac \u0111\u1ea9y l\u01b0u l\u01b0\u1ee3ng m\u00e1u):<\/p>\n<p>MAP = (CO X SVR) + RAP (14.3)<\/p>\n<p>Sau \u0111\u00f3, c\u00e1c h\u1ed9i ch\u1ee9ng s\u1ed1c kh\u00e1c nhau \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh b\u1eb1ng c\u00e1c <strong>y\u1ebfu t\u1ed1 quy\u1ebft \u0111\u1ecbnh MAP<\/strong>: t\u1ee9c l\u00e0,<\/p>\n<ol>\n<li><strong>RAP th\u1ea5p <\/strong>= s\u1ed1c gi\u1ea3m th\u1ec3 t\u00edch m\u00e1u<\/li>\n<li><strong>CO th\u1ea5p <\/strong>= s\u1ed1c tim, s\u1ed1c t\u1eafc ngh\u1ebdn<\/li>\n<li><strong>SVR th\u1ea5p <\/strong>= s\u1ed1c gi\u00e3n m\u1ea1ch<\/li>\n<\/ol>\n<p>D\u1ea1ng thay \u0111\u1ed5i huy\u1ebft \u0111\u1ed9ng \u1edf t\u1eebng lo\u1ea1i s\u1ed1c \u0111\u01b0\u1ee3c th\u1ec3 hi\u1ec7n trong B\u1ea3ng 14.1, c\u00f9ng v\u1edbi t\u1ef7 l\u1ec7 m\u1eafc b\u1ec7nh \u0111\u00e3 b\u00e1o c\u00e1o c\u1ee7a t\u1eebng lo\u1ea1i (2). L\u01b0u \u00fd r\u1eb1ng 3 trong s\u1ed1 4 h\u1ed9i ch\u1ee9ng s\u1ed1c c\u00f3 li\u00ean quan \u0111\u1ebfn l\u01b0u l\u01b0\u1ee3ng tim th\u1ea5p v\u00e0 SVR cao. <strong>S\u1ef1 gia t\u0103ng SVR (t\u1ee9c l\u00e0 co m\u1ea1ch) l\u00e0 ph\u1ea3n \u1ee9ng b\u00f9 tr\u1eeb cho tr\u1ea1ng th\u00e1i l\u01b0u l\u01b0\u1ee3ng th\u1ea5p v\u00e0 h\u1ea1n ch\u1ebf s\u1ef1 s\u1ee5t gi\u1ea3m huy\u1ebft \u00e1p<\/strong>. Ph\u1ea3n \u1ee9ng n\u00e0y l\u00e0 do ho\u1ea1t \u0111\u1ed9ng t\u0103ng l\u00ean c\u1ee7a h\u1ec7 th\u1ea7n kinh giao c\u1ea3m v\u00e0 k\u00edch ho\u1ea1t h\u1ec7 th\u1ed1ng renin-angiotensin-aldosterone.<\/p>\n<table>\n<tbody>\n<tr>\n<td colspan=\"4\" width=\"602\"><strong>B\u1ea2NG 14.1 C\u00e1c m\u00f4 h\u00ecnh huy\u1ebft \u0111\u1ed9ng trong h\u1ed9i ch\u1ee9ng s\u1ed1c<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"151\"><strong>C\u00e1c h\u1ed9i ch\u1ee9ng s\u1ed1cf<\/strong><\/td>\n<td width=\"124\"><strong>CVP<\/strong><\/td>\n<td width=\"177\"><strong>Cung l\u01b0\u1ee3ng tim<\/strong><\/td>\n<td width=\"151\"><strong>SVR<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"151\">Gi\u1ea3m th\u1ec3 t\u00edch (16%)<\/td>\n<td width=\"124\">Th\u1ea5p<\/td>\n<td width=\"177\">Th\u1ea5p<\/td>\n<td width=\"151\">Cao<\/td>\n<\/tr>\n<tr>\n<td width=\"151\">T\u1eafc ngh\u1ebdn (2%)<\/td>\n<td width=\"124\">Th\u1ea5p<\/td>\n<td width=\"177\">Th\u1ea5p<\/td>\n<td width=\"151\">Cao<\/td>\n<\/tr>\n<tr>\n<td width=\"151\">S\u1ed1c tim (16%)<\/td>\n<td width=\"124\">Cao<\/td>\n<td width=\"177\">Th\u1ea5p<\/td>\n<td width=\"151\">Cao<\/td>\n<\/tr>\n<tr>\n<td width=\"151\">S\u1ed1c d\u00e3n m\u1ea1ch (66%)<\/td>\n<td width=\"124\">Th\u1ea5p<\/td>\n<td width=\"177\">B\u00ecnh th\u01b0\u1eddng ho\u1eb7c Cao<\/td>\n<td width=\"151\">Th\u1ea5p<\/td>\n<\/tr>\n<tr>\n<td width=\"151\">C\u00e1c s\u1ed1 trong ngo\u1eb7c \u0111\u01a1n<\/td>\n<td colspan=\"3\" width=\"452\">bi\u1ec3u th\u1ecb t\u1ea7n su\u1ea5t x\u1ea3y ra t\u01b0\u01a1ng \u0111\u1ed1i (t\u1eeb T\u00e0i li\u1ec7u tham kh\u1ea3o 2). CVP = \u00e1p l\u1ef1c t\u0129nh<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>m\u1ea1ch trung t\u00e2m, SVR = s\u1ee9c c\u1ea3n m\u1ea1ch m\u00e1u to\u00e0n th\u00e2n.<\/p>\n<p><strong>S\u1ed1c gi\u1ea3m th\u1ec3 t\u00edch<\/strong><\/p>\n<p>S\u1ed1c gi\u1ea3m th\u1ec3 t\u00edch m\u00e1u <strong>h\u1ea7u nh\u01b0 lu\u00f4n l\u00e0 k\u1ebft qu\u1ea3 c\u1ee7a m\u1ea5t m\u00e1u<\/strong>, v\u00e0 th\u01b0\u1eddng xu\u1ea5t hi\u1ec7n khi l\u01b0\u1ee3ng m\u00e1u gi\u1ea3m v\u01b0\u1ee3t qu\u00e1 30% (5). M\u1ea5t n\u01b0\u1edbc (v\u00ed d\u1ee5, do n\u00f4n m\u1eeda ho\u1eb7c ti\u00eau ch\u1ea3y) th\u01b0\u1eddng kh\u00f4ng d\u1eabn \u0111\u1ebfn s\u1ed1c v\u00ec m\u1ea5t n\u01b0\u1edbc d\u1eabn \u0111\u1ebfn t\u0103ng \u00e1p su\u1ea5t th\u1ea9m th\u1ea5u keo c\u1ee7a huy\u1ebft t\u01b0\u01a1ng, l\u00e0m k\u00e9o d\u1ecbch k\u1ebd v\u00e0o khoang m\u1ea1ch m\u00e1u. Gi\u1ea3m huy\u1ebft \u00e1p do m\u1ea5t n\u01b0\u1edbc d\u1ec5 d\u00e0ng \u0111\u01b0\u1ee3c \u0111i\u1ec1u ch\u1ec9nh b\u1eb1ng d\u1ecbch truy\u1ec1n t\u0129nh m\u1ea1ch.<\/p>\n<p><strong>S\u1ed1c do tim<\/strong><\/p>\n<p>S\u1ed1c do suy b\u01a1m tim th\u01b0\u1eddng l\u00e0 k\u1ebft qu\u1ea3 c\u1ee7a h\u1ed9i ch\u1ee9ng v\u00e0nh c\u1ea5p, chi\u1ebfm g\u1ea7n m\u1ed9t n\u1eeda s\u1ed1 tr\u01b0\u1eddng h\u1ee3p s\u1ed1c tim (6). C\u00e1c nguy\u00ean nh\u00e2n \u00edt g\u1eb7p h\u01a1n bao g\u1ed3m b\u1ec7nh c\u01a1 tim kh\u00f4ng do thi\u1ebfu m\u00e1u c\u1ee5c b\u1ed9 (28% tr\u01b0\u1eddng h\u1ee3p) v\u00e0 r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng van tim ho\u1eb7c lo\u1ea1n nh\u1ecbp tim (17% tr\u01b0\u1eddng h\u1ee3p). S\u1ed1c tim l\u00e0 th\u00e1ch th\u1ee9c l\u1edbn nh\u1ea5t trong vi\u1ec7c x\u1eed tr\u00ed s\u1ed1c; t\u1ee9c l\u00e0, m\u1eb7c d\u00f9 c\u00f3 nh\u1eefng ti\u1ebfn b\u1ed9 trong t\u00e1i th\u00f4ng m\u1ea1ch m\u00e1u v\u00e0 h\u1ed7 tr\u1ee3 tim c\u01a1 h\u1ecdc, t\u1ef7 l\u1ec7 t\u1eed vong v\u1eabn \u1edf m\u1ee9c kho\u1ea3ng <strong>50% <\/strong>(7).<\/p>\n<p><strong>S\u1ed1c t\u1eafc ngh\u1ebdn<\/strong><\/p>\n<p>S\u1ed1c t\u1eafc ngh\u1ebdn l\u00e0 do c\u00e1c t\u00ecnh tr\u1ea1ng <strong>c\u1ea3n tr\u1edf <\/strong>ho\u1eb7c <strong>ch\u1eb7n qu\u00e1 tr\u00ecnh \u0111\u1ed5 \u0111\u1ea7y c\u00e1c bu\u1ed3ng tim<\/strong>, ch\u1eb3ng h\u1ea1n nh\u01b0 thuy\u00ean t\u1eafc ph\u1ed5i l\u1edbn, tr\u00e0n kh\u00ed m\u00e0ng ph\u1ed5i c\u00f3 \u00e1p l\u1ef1c v\u00e0 ch\u00e8n \u00e9p tim. T\u00ecnh tr\u1ea1ng n\u00e0y kh\u00f4ng ph\u1ed5 bi\u1ebfn v\u00e0 ch\u1ec9 chi\u1ebfm <strong>2% <\/strong>c\u00e1c tr\u01b0\u1eddng h\u1ee3p s\u1ed1c l\u00e2m s\u00e0ng (2). \u0110i\u1ec1u tr\u1ecb h\u01b0\u1edbng \u0111\u1ebfn t\u00ecnh tr\u1ea1ng n\u1ec1n g\u00e2y ra.<\/p>\n<p><strong>S\u1ed1c d\u00e3n m\u1ea1ch<\/strong><\/p>\n<p>S\u1ed1c gi\u00e3n m\u1ea1ch (c\u00f2n \u0111\u01b0\u1ee3c g\u1ecdi l\u00e0 \u201cs\u1ed1c ph\u00e2n ph\u1ed1i\u201d) l\u00e0 t\u00ecnh tr\u1ea1ng gi\u00e3n m\u1ea1ch lan r\u1ed9ng li\u00ean quan \u0111\u1ebfn c\u1ea3 \u0111\u1ed9ng m\u1ea1ch v\u00e0 t\u0129nh m\u1ea1ch. \u0110\u00e2y l\u00e0 <strong>lo\u1ea1i s\u1ed1c th\u01b0\u1eddng g\u1eb7p nh\u1ea5t <\/strong>(xem B\u1ea3ng 14.1) v\u00e0 <strong>s\u1ed1c nhi\u1ec5m tr\u00f9ng chi\u1ebfm ph\u1ea7n l\u1edbn <\/strong>c\u00e1c tr\u01b0\u1eddng h\u1ee3p. S\u1ed1c nhi\u1ec5m tr\u00f9ng l\u00e0 nguy\u00ean nh\u00e2n h\u00e0ng \u0111\u1ea7u g\u00e2y t\u1eed vong trong b\u1ec7nh vi\u1ec7n t\u1ea1i Hoa K\u1ef3 (8) v\u00e0 c\u0169ng \u0111\u01b0\u1ee3c coi l\u00e0 nguy\u00ean nh\u00e2n t\u1eed vong h\u00e0ng \u0111\u1ea7u tr\u00ean to\u00e0n th\u1ebf gi\u1edbi (9). C\u00e1c ngu\u1ed3n s\u1ed1c gi\u00e3n m\u1ea1ch \u00edt ph\u1ed5 bi\u1ebfn h\u01a1n bao g\u1ed3m s\u1ed1c ph\u1ea3n v\u1ec7, cho\u00e1ng t\u1ee7y v\u00e0 c\u01a1n th\u01b0\u1ee3ng th\u1eadn c\u1ea5p.<\/p>\n<h2>THEO D\u00d5I HUY\u1ebeT \u00c1P<\/h2>\n<p>Theo d\u00f5i huy\u1ebft \u00e1p l\u00e0 b\u1eaft bu\u1ed9c trong tr\u01b0\u1eddng h\u1ee3p s\u1ed1c l\u00e2m s\u00e0ng v\u00e0 <strong>n\u00ean ghi tr\u1ef1c ti\u1ebfp huy\u1ebft \u00e1p \u0111\u1ed9ng m\u1ea1ch<\/strong>.<\/p>\n<h3>C\u00e1c ph\u01b0\u01a1ng ph\u00e1p \u0111o tr\u1ef1c ti\u1ebfp<\/h3>\n<p>B\u1ea3n ghi \u00e1p su\u1ea5t \u0111\u1ed9ng m\u1ea1ch tr\u1ef1c ti\u1ebfp \u0111\u01b0\u1ee3c l\u1ea5y t\u1eeb \u0111\u1ed9ng m\u1ea1ch quay, c\u00e1nh tay, n\u00e1ch ho\u1eb7c \u0111\u00f9i v\u00e0 v\u1ecb tr\u00ed \u0111\u1eb7t catheter c\u00f3 th\u1ec3 \u1ea3nh h\u01b0\u1edfng \u0111\u1ebfn d\u1ea1ng s\u00f3ng \u0111\u01b0\u1ee3c ghi l\u1ea1i (xem ti\u1ebfp).<\/p>\n<p><strong>S\u00f3ng huy\u1ebft \u00e1p \u0111\u1ed9ng m\u1ea1ch<\/strong><\/p>\n<p>D\u1ea1ng s\u00f3ng \u00e1p su\u1ea5t \u0111\u1ed9ng m\u1ea1ch thay \u0111\u1ed5i khi di chuy\u1ec3n ra xa \u0111\u1ed9ng m\u1ea1ch ch\u1ee7 g\u1ea7n, nh\u01b0 th\u1ec3 hi\u1ec7n trong H\u00ecnh 14.1. L\u01b0u \u00fd r\u1eb1ng khi s\u00f3ng \u00e1p su\u1ea5t di chuy\u1ec3n v\u1ec1 ph\u00eda ngo\u1ea1i vi, <strong>\u00e1p su\u1ea5t t\u00e2m thu t\u0103ng d\u1ea7n <\/strong>v\u00e0 <strong>ph\u1ea7n t\u00e2m thu c\u1ee7a d\u1ea1ng s\u00f3ng thu h\u1eb9p l\u1ea1i<\/strong>. \u00c1p su\u1ea5t t\u00e2m thu c\u00f3 th\u1ec3 t\u0103ng t\u1edbi 20 mm Hg t\u1eeb \u0111\u1ed9ng m\u1ea1ch ch\u1ee7 g\u1ea7n \u0111\u1ebfn \u0111\u1ed9ng m\u1ea1ch quay ho\u1eb7c \u0111\u1ed9ng m\u1ea1ch \u0111\u00f9i (10). S\u1ef1 gia t\u0103ng \u00e1p su\u1ea5t t\u00e2m thu \u0111\u1ec9nh n\u00e0y \u0111\u01b0\u1ee3c b\u00f9 \u0111\u1eafp b\u1eb1ng s\u1ef1 thu h\u1eb9p c\u1ee7a s\u00f3ng \u00e1p su\u1ea5t t\u00e2m thu, do \u0111\u00f3 <strong>\u00e1p su\u1ea5t \u0111\u1ed9ng m\u1ea1ch trung b\u00ecnh v\u1eabn kh\u00f4ng \u0111\u1ed5i<\/strong>.<\/p>\n<p>&nbsp;<\/p>\n<figure id=\"attachment_111474\" aria-describedby=\"caption-attachment-111474\" style=\"width: 1200px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-111474\" src=\"https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/14.1.jpg\" alt=\"H\u00ccNH 14.1 D\u1ea1ng s\u00f3ng \u00e1p l\u1ef1c \u0111\u1ed9ng m\u1ea1ch t\u1ea1i c\u00e1c \u0111i\u1ec3m c\u1ee5 th\u1ec3 trong h\u1ec7 tu\u1ea7n ho\u00e0n \u0111\u1ed9ng m\u1ea1ch\" width=\"1200\" height=\"916\" title=\"\" srcset=\"https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/14.1.jpg 1200w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/14.1-524x400.jpg 524w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/14.1-1048x800.jpg 1048w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/14.1-768x586.jpg 768w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/14.1-350x267.jpg 350w\" sizes=\"auto, (max-width: 1200px) 100vw, 1200px\" \/><figcaption id=\"caption-attachment-111474\" class=\"wp-caption-text\">H\u00ccNH 14.1 D\u1ea1ng s\u00f3ng \u00e1p l\u1ef1c \u0111\u1ed9ng m\u1ea1ch t\u1ea1i c\u00e1c \u0111i\u1ec3m c\u1ee5 th\u1ec3 trong h\u1ec7 tu\u1ea7n ho\u00e0n \u0111\u1ed9ng m\u1ea1ch<\/figcaption><\/figure>\n<p><strong>S\u1ef1 khu\u1ebfch \u0111\u1ea1i s\u00f3ng t\u00e2m thu<\/strong><\/p>\n<p>S\u1ef1 gia t\u0103ng huy\u1ebft \u00e1p t\u00e2m thu \u1edf \u0111\u1ed9ng m\u1ea1ch ngo\u1ea1i vi l\u00e0 k\u1ebft qu\u1ea3 c\u1ee7a s\u00f3ng \u00e1p su\u1ea5t ph\u1ea3n x\u1ea1 tr\u1edf l\u1ea1i t\u1eeb c\u00e1c nh\u00e1nh m\u1ea1ch m\u00e1u v\u00e0 c\u00e1c m\u1ea1ch m\u00e1u h\u1eb9p (11). S\u00f3ng ph\u1ea3n x\u1ea1 di chuy\u1ec3n nhanh h\u01a1n khi \u0111\u1ed9ng m\u1ea1ch c\u1ee9ng v\u00e0 ch\u00fang \u0111\u1ea1t \u0111\u1ebfn d\u1ea1ng s\u00f3ng \u00e1p su\u1ea5t \u0111\u1ed9ng m\u1ea1ch tr\u01b0\u1edbc khi n\u00f3 c\u00f3 th\u1eddi gian gi\u1ea3m. S\u1ef1 h\u1ed9i t\u1ee5 c\u1ee7a s\u00f3ng \u00e1p su\u1ea5t thu\u1eadn v\u00e0 ngh\u1ecbch sau \u0111\u00f3 c\u00f3 t\u00e1c d\u1ee5ng l\u00e0m t\u0103ng \u0111\u1ec9nh c\u1ee7a d\u1ea1ng s\u00f3ng \u00e1p su\u1ea5t. (B\u1ea1n c\u00f3 th\u1ec3 th\u1ea5y hi\u1ec7u \u1ee9ng n\u00e0y khi s\u00f3ng bi\u1ec3n g\u1eb7p nhau t\u1eeb h\u01b0\u1edbng ng\u01b0\u1ee3c nhau. Hi\u1ec7u \u1ee9ng ph\u00f3ng \u0111\u1ea1i n\u00e0y c\u00f3 li\u00ean quan \u0111\u1ebfn s\u1ef1 h\u00ecnh th\u00e0nh c\u1ee7a &#8220;s\u00f3ng qu\u00e1i v\u1eadt&#8221;.) V\u00ec khu\u1ebfch \u0111\u1ea1i t\u00e2m thu l\u00e0 k\u1ebft qu\u1ea3 c\u1ee7a s\u00f3ng \u00e1p su\u1ea5t ngh\u1ecbch, <strong>n\u00f3 l\u00e0m t\u0103ng h\u1eadu t\u1ea3i th\u1ea5t tr\u00e1i<\/strong>, nh\u01b0ng kh\u00f4ng th\u00fac \u0111\u1ea9y l\u01b0u l\u01b0\u1ee3ng m\u00e1u to\u00e0n th\u00e2n.<\/p>\n<p><strong>Huy\u1ebft \u00e1p \u0111\u1ed9ng m\u1ea1ch trung b\u00ecnh &#8211; MAP<\/strong><\/p>\n<p>\u00c1p su\u1ea5t \u0111\u1ed9ng m\u1ea1ch trung b\u00ecnh (MAP) l\u00e0 \u00e1p su\u1ea5t \u0111\u01b0\u1ee3c \u01b0a chu\u1ed9ng \u0111\u1ec3 theo d\u00f5i huy\u1ebft \u0111\u1ed9ng v\u00ec hai l\u00fd do: \u0111\u00e2y l\u00e0 <strong>l\u1ef1c \u0111\u1ea9y ch\u00ednh th\u00fac \u0111\u1ea9y l\u01b0u l\u01b0\u1ee3ng m\u00e1u to\u00e0n th\u00e2n <\/strong>(10,12) v\u00e0 <strong>kh\u00f4ng thay \u0111\u1ed5i khi d\u1ea1ng s\u00f3ng \u00e1p su\u1ea5t di chuy\u1ec3n ngo\u1ea1i vi <\/strong>(kh\u00f4ng gi\u1ed1ng nh\u01b0 \u00e1p su\u1ea5t t\u00e2m thu). MAP \u0111\u01b0\u1ee3c \u0111o b\u1eb1ng thu\u1eadt to\u00e1n \u0111i\u1ec7n t\u1eed d\u01b0\u1edbi d\u1ea1ng di\u1ec7n t\u00edch d\u01b0\u1edbi s\u00f3ng \u00e1p su\u1ea5t \u0111\u1ed9ng m\u1ea1ch, chia cho th\u1eddi gian c\u1ee7a chu k\u1ef3 tim. <strong>Vi\u1ec7c qu\u1ea3n l\u00fd s\u1ed1c l\u00e2m s\u00e0ng s\u1eed d\u1ee5ng m\u1ee5c ti\u00eau MAP &gt; 65 mm Hg <\/strong>(2).<\/p>\n<h3>C\u00e1ch \u0111o gi\u00e1n ti\u1ebfp<\/h3>\n<p>Vi\u1ec7c ghi l\u1ea1i huy\u1ebft \u00e1p tr\u1ef1c ti\u1ebfp kh\u00f4ng ph\u1ea3i l\u00fac n\u00e0o c\u0169ng c\u00f3 s\u1eb5n ho\u1eb7c kh\u1ea3 thi, do \u0111\u00f3 c\u1ea7n c\u00f3 m\u00f4 t\u1ea3 ng\u1eafn g\u1ecdn v\u1ec1 ph\u00e9p \u0111o huy\u1ebft \u00e1p gi\u00e1n ti\u1ebfp.<\/p>\n<p><strong>Nguy\u00ean l\u00fd<\/strong><\/p>\n<p>\u0110o huy\u1ebft \u00e1p gi\u00e1n ti\u1ebfp (HA) s\u1eed d\u1ee5ng m\u1ed9t t\u00fai b\u01a1m h\u01a1i (g\u1eafn v\u00e0o b\u00ean d\u01b0\u1edbi c\u1ee7a \u1ed1ng v\u1ea3i) \u0111\u01b0\u1ee3c qu\u1ea5n quanh c\u00e1nh tay tr\u00ean ho\u1eb7c \u0111\u00f9i \u1edf v\u00f9ng n\u1eb1m tr\u00ean \u0111\u1ed9ng m\u1ea1ch ch\u00ednh. Sau \u0111\u00f3, t\u00fai trong \u1ed1ng v\u1ea3i \u0111\u01b0\u1ee3c b\u01a1m h\u01a1i \u0111\u1ec3 n\u00e9n \u0111\u1ed9ng m\u1ea1ch b\u00ean d\u01b0\u1edbi. C\u00e1c t\u00e1c \u0111\u1ed9ng c\u1ee7a l\u1ef1c n\u00e9n \u0111\u1ed9ng m\u1ea1ch \u0111\u01b0\u1ee3c minh h\u1ecda trong H\u00ecnh 14.2. Khi \u00e1p su\u1ea5t cuff t\u0103ng l\u00ean v\u00e0 \u0111\u1ed9ng m\u1ea1ch b\u00ean d\u01b0\u1edbi b\u1ecb n\u00e9n, c\u00e1c xung \u0111\u1ed9ng trong \u0111\u1ed9ng m\u1ea1ch t\u0103ng d\u1ea7n r\u1ed3i gi\u1ea3m d\u1ea7n cho \u0111\u1ebfn khi \u0111\u1ed9ng m\u1ea1ch b\u1ecb t\u1eafc ngh\u1ebdn. C\u00e1c &#8220;ph\u1ea3n xung \u0111\u1ed9ng&#8221; n\u00e0y t\u1ea1o ra c\u00e1c dao \u0111\u1ed9ng \u00e1p su\u1ea5t trong t\u00fai v\u00e0 c\u00e1c thi\u1ebft b\u1ecb \u0111o huy\u1ebft \u00e1p t\u1ef1 \u0111\u1ed9ng (l\u00e0 ti\u00eau chu\u1ea9n trong c\u00e1c khoa ICU) sau \u0111\u00f3 \u0111o c\u00e1c dao \u0111\u1ed9ng n\u00e0y v\u00e0 chuy\u1ec3n \u0111\u1ed5i ch\u00fang th\u00e0nh c\u00e1c ph\u00e9p \u0111o \u00e1p su\u1ea5t t\u00e2m thu, t\u00e2m tr\u01b0\u01a1ng v\u00e0 trung b\u00ecnh. \u0110\u00e2y l\u00e0 ph\u01b0\u01a1ng ph\u00e1p \u0111o dao \u0111\u1ed9ng \u0111\u1ec3 \u0111o HA. C\u00e1c ph\u1ea3n xung \u0111\u1ed9ng c\u0169ng c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c chuy\u1ec3n \u0111\u1ed5i th\u00e0nh s\u00f3ng \u00e2m, \u0111\u00e2y l\u00e0 c\u01a1 s\u1edf cho ph\u01b0\u01a1ng ph\u00e1p nghe tim c\u0169 h\u01a1n \u0111\u1ec3 \u0111o HA.<\/p>\n<figure id=\"attachment_111472\" aria-describedby=\"caption-attachment-111472\" style=\"width: 1200px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-111472\" src=\"https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/14.2.jpg\" alt=\"H\u00ccNH 14.2 Ph\u01b0\u01a1ng ph\u00e1p \u0111o huy\u1ebft \u00e1p b\u1eb1ng dao \u0111\u1ed9ng k\u1ebf v\u00e0 nghe tim. Xem ph\u1ea7n gi\u1ea3i th\u00edch trong b\u00e0i.\" width=\"1200\" height=\"824\" title=\"\" srcset=\"https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/14.2.jpg 1200w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/14.2-583x400.jpg 583w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/14.2-1165x800.jpg 1165w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/14.2-768x527.jpg 768w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/14.2-350x240.jpg 350w\" sizes=\"auto, (max-width: 1200px) 100vw, 1200px\" \/><figcaption id=\"caption-attachment-111472\" class=\"wp-caption-text\">H\u00ccNH 14.2 Ph\u01b0\u01a1ng ph\u00e1p \u0111o huy\u1ebft \u00e1p b\u1eb1ng dao \u0111\u1ed9ng k\u1ebf v\u00e0 nghe tim. Xem ph\u1ea7n gi\u1ea3i th\u00edch trong b\u00e0i.<\/figcaption><\/figure>\n<p><strong>C\u00e1c l\u1ed7i th\u00f4ng th\u01b0\u1eddng<\/strong><\/p>\n<p>Ph\u1ea3n xung c\u00f3 th\u1ec3 t\u00e1i t\u1ea1o \u0111\u01b0\u1ee3c nhi\u1ec1u h\u01a1n v\u00e0 c\u00e1c ph\u00e9p \u0111o HA \u0111\u00e1ng tin c\u1eady h\u01a1n khi \u0111\u1ed9ng m\u1ea1ch b\u1ecb <strong>n\u00e9n \u0111\u1ed3ng \u0111\u1ec1u<\/strong>. N\u00e9n \u0111\u1ed3ng \u0111\u1ec1u c\u00f3 nhi\u1ec1u kh\u1ea3 n\u0103ng x\u1ea3y ra h\u01a1n n\u1ebfu <strong>k\u00edch th\u01b0\u1edbc c\u1ee7a t\u00fai h\u01a1i ph\u00f9 h\u1ee3p v\u1edbi chu vi c\u1ee7a c\u00e1nh tay <\/strong>tr\u00ean. M\u1ed1i quan h\u1ec7 t\u1ed1i \u01b0u gi\u1eefa chi\u1ec1u cao v\u00e0 chi\u1ec1u r\u1ed9ng c\u1ee7a t\u00fai h\u01a1i v\u00f2ng b\u00edt v\u00e0 chu vi c\u00e1nh tay tr\u00ean \u0111\u01b0\u1ee3c th\u1ec3 hi\u1ec7n trong H\u00ecnh 14.3. Sau \u0111\u00e2y l\u00e0 m\u1ed9t s\u1ed1 \u0111i\u1ec3m quan tr\u1ecdng v\u1ec1 m\u1ed1i quan h\u1ec7 gi\u1eefa k\u00edch th\u01b0\u1edbc t\u00fai h\u01a1i v\u00e0 k\u00edch th\u01b0\u1edbc c\u00e1nh tay:<\/p>\n<ul>\n<li>\u0110\u1ec3 t\u1ea1o ra s\u1ef1 t\u1eafc ngh\u1ebdn \u0111\u1ed9ng m\u1ea1ch \u0111\u1ed3ng \u0111\u1ec1u, chi\u1ec1u d\u00e0i c\u1ee7a t\u00fai h\u01a1i ph\u1ea3i b\u1eb1ng \u00edt nh\u1ea5t <strong>80% <\/strong>chu vi c\u1ee7a c\u00e1nh tay tr\u00ean (\u0111o \u1edf gi\u1eefa vai v\u00e0 khu\u1ef7u tay) v\u00e0 chi\u1ec1u r\u1ed9ng c\u1ee7a t\u00fai ph\u1ea3i b\u1eb1ng <strong>\u00edt nh\u1ea5t 40% <\/strong>chu vi c\u00e1nh tay tr\u00ean (13).<\/li>\n<li>N\u1ebfu t\u00fai h\u01a1i qu\u00e1 nh\u1ecf so v\u1edbi k\u00edch th\u01b0\u1edbc c\u1ee7a c\u00e1nh tay tr\u00ean, c\u00e1c ph\u00e9p \u0111o \u00e1p su\u1ea5t s\u1ebd b\u1ecb cao gi\u1ea3 t\u1ea1o (1). (C\u00e1c l\u1ed7i \u0111o l\u01b0\u1eddng \u00edt r\u00f5 r\u1ec7t h\u01a1n nhi\u1ec1u khi t\u00fai qu\u00e1 l\u1edbn so v\u1edbi chu vi c\u00e1nh tay.)<\/li>\n<li>Vi\u1ec7c s\u1eed d\u1ee5ng t\u00fai h\u01a1i c\u00e1nh tay c\u00f3 k\u00edch th\u01b0\u1edbc kh\u00f4ng ph\u00f9 h\u1ee3p l\u00e0 ngu\u1ed3n l\u1ed7i ph\u1ed5 bi\u1ebfn nh\u1ea5t trong c\u00e1c ph\u00e9p \u0111o HA gi\u00e1n ti\u1ebfp (13,14). Trong m\u1ed9t nghi\u00ean c\u1ee9u li\u00ean quan \u0111\u1ebfn b\u1ec7nh nh\u00e2n ICU, hai ph\u1ea7n ba s\u1ed1 ph\u00e9p \u0111o HA gi\u00e1n ti\u1ebfp \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n b\u1eb1ng k\u00edch th\u01b0\u1edbc v\u00f2ng b\u00edt kh\u00f4ng ph\u00f9 h\u1ee3p v\u00e0 trong nh\u1eefng tr\u01b0\u1eddng h\u1ee3p n\u00e0y, 62% s\u1ed1 ph\u00e9p \u0111o HA kh\u00e1c v\u1edbi c\u00e1c ph\u00e9p \u0111o tr\u1ef1c ti\u1ebfp, trong \u0111\u1ed9ng m\u1ea1ch h\u01a1n <strong>10 mm Hg <\/strong>(14).<\/li>\n<\/ul>\n<figure id=\"attachment_111475\" aria-describedby=\"caption-attachment-111475\" style=\"width: 1200px\" class=\"wp-caption aligncenter\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-111475\" src=\"https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/14.3.png\" alt=\"H\u00ccNH 14.3 M\u1ed1i quan h\u1ec7 t\u1ed1i \u01b0u gi\u1eefa chi\u1ec1u cao (H) v\u00e0 chi\u1ec1u r\u1ed9ng (W) c\u1ee7a t\u00fai h\u01a1i v\u00e0 chu vi (C) c\u1ee7a c\u00e1nh tay tr\u00ean.\" width=\"1200\" height=\"578\" title=\"\" srcset=\"https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/14.3.png 1200w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/14.3-800x385.png 800w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/14.3-768x370.png 768w, https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/14.3-350x169.png 350w\" sizes=\"auto, (max-width: 1200px) 100vw, 1200px\" \/><figcaption id=\"caption-attachment-111475\" class=\"wp-caption-text\">H\u00ccNH 14.3 M\u1ed1i quan h\u1ec7 t\u1ed1i \u01b0u gi\u1eefa chi\u1ec1u cao (H) v\u00e0 chi\u1ec1u r\u1ed9ng (W) c\u1ee7a t\u00fai h\u01a1i v\u00e0 chu vi (C) c\u1ee7a c\u00e1nh tay tr\u00ean.<\/figcaption><\/figure>\n<p>\u0110\u1ec3 gi\u00fap l\u1ef1a ch\u1ecdn k\u00edch th\u01b0\u1edbc v\u00f2ng b\u00edt ph\u00f9 h\u1ee3p, B\u1ea3ng 14.2 tr\u00ecnh b\u00e0y k\u00edch th\u01b0\u1edbc v\u00f2ng b\u00edt \u0111\u01b0\u1ee3c khuy\u1ebfn ngh\u1ecb cho c\u00e1c k\u00edch th\u01b0\u1edbc kh\u00e1c nhau c\u1ee7a c\u00e1nh tay tr\u00ean (ho\u1eb7c \u0111\u00f9i). M\u1ed9t c\u00e1ch d\u1ec5 d\u00e0ng h\u01a1n \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh k\u00edch th\u01b0\u1edbc v\u00f2ng b\u00edt ph\u00f9 h\u1ee3p \u0111\u01b0\u1ee3c m\u00f4 t\u1ea3 ti\u1ebfp theo.<\/p>\n<table>\n<tbody>\n<tr>\n<td colspan=\"3\" width=\"602\"><strong>B\u1ea2NG 14.2 K\u00edch th\u01b0\u1edbc cuff \u0111o huy\u1ebft \u00e1p ph\u00f9 h\u1ee3p v\u1edbi chu vi c\u00e1nh tay tr\u00ean<\/strong><\/td>\n<\/tr>\n<tr>\n<td rowspan=\"2\" width=\"236\"><strong>V\u00f2ng chu vi c\u00e1nh tay tr\u00ean<\/strong><\/td>\n<td colspan=\"2\" width=\"366\"><strong>Cuff \u0111o huy\u1ebft \u00e1p<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"189\"><strong>K\u00edch c\u1ee1<\/strong><\/td>\n<td width=\"177\"><strong>K\u00edch th\u01b0\u1edbc<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"236\">22 to 26 cm<\/td>\n<td width=\"189\">Ng\u01b0\u1eddi l\u1edbn nh\u1ecf<\/td>\n<td width=\"177\">12 x 24 cm<\/td>\n<\/tr>\n<tr>\n<td width=\"236\">27 to 34 cm<\/td>\n<td width=\"189\">Ng\u01b0\u1eddi l\u1edbn<\/td>\n<td width=\"177\">16 x 30 cm<\/td>\n<\/tr>\n<tr>\n<td width=\"236\">35 to 44 cm<\/td>\n<td width=\"189\">Ng\u01b0\u1eddi l\u1edbn to<\/td>\n<td width=\"177\">16 x 36 cm<\/td>\n<\/tr>\n<tr>\n<td width=\"236\">45 to 52 cm<\/td>\n<td width=\"189\">\u0110\u00f9i ng\u01b0\u1eddi l\u1edbn<\/td>\n<td width=\"177\">16 x 42 cm<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><strong>Ph\u01b0\u01a1ng ph\u00e1p \u0111\u01a1n gi\u1ea3n \u0111\u1ec3 \u0111\u00e1nh gi\u00e1 k\u00edch th\u01b0\u1edbc v\u00f2ng b\u00edt<\/strong><\/p>\n<p>C\u0103n ch\u1ec9nh v\u00f2ng b\u00edt sao cho tr\u1ee5c d\u00e0i c\u1ee7a cuff ch\u1ea1y d\u1ecdc theo tr\u1ee5c d\u00e0i c\u1ee7a c\u00e1nh tay. Sau \u0111\u00f3 l\u1eadt v\u00f2ng b\u00edt l\u1ea1i sao cho t\u00fai \u1edf m\u1eb7t d\u01b0\u1edbi c\u1ee7a v\u00f2ng b\u00edt h\u01b0\u1edbng l\u00ean tr\u00ean v\u00e0 qu\u1ea5n v\u00f2ng b\u00edt quanh c\u00e1nh tay tr\u00ean. T\u00fai h\u01a1i (chi\u1ec1u r\u1ed9ng) ph\u1ea3i bao quanh g\u1ea7n m\u1ed9t n\u1eeda (40%) c\u00e1nh tay tr\u00ean. N\u1ebfu t\u00fai h\u01a1i bao quanh \u00edt h\u01a1n m\u1ed9t n\u1eeda c\u00e1nh tay tr\u00ean, v\u00f2ng b\u00edt qu\u00e1 nh\u1ecf v\u00e0 n\u00ean s\u1eed d\u1ee5ng v\u00f2ng b\u00edt l\u1edbn h\u01a1n. Kh\u00f4ng c\u1ea7n thay \u0111\u1ed5i k\u00edch th\u01b0\u1edbc v\u00f2ng b\u00edt n\u1ebfu t\u00fai h\u01a1i qu\u00e1 l\u1edbn (t\u1ee9c l\u00e0 n\u1ebfu n\u00f3 bao quanh h\u1ea7u h\u1ebft c\u00e1nh tay tr\u00ean), v\u00ec s\u1ef1 kh\u00e1c bi\u1ec7t n\u00e0y kh\u00f4ng t\u1ea1o ra l\u1ed7i \u0111\u00e1ng k\u1ec3 trong ph\u00e9p \u0111o (13).<\/p>\n<p><strong>\u0110\u1ed9 ch\u00ednh x\u00e1c<\/strong><\/p>\n<p>\u0110\u1ed9 ch\u00ednh x\u00e1c h\u1ea1n ch\u1ebf c\u1ee7a ph\u00e9p \u0111o HA gi\u00e1n ti\u1ebfp \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ec7nh n\u1eb7ng \u0111\u00e3 \u0111\u01b0\u1ee3c nghi\u00ean c\u1ee9u \u0111\u1ea7y \u0111\u1ee7 (14,15). \u0110i\u1ec1u n\u00e0y \u0111\u01b0\u1ee3c ch\u1ee9ng minh trong m\u1ed9t ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p g\u1ea7n \u0111\u00e2y c\u1ee7a 7 nghi\u00ean c\u1ee9u so s\u00e1nh ph\u00e9p \u0111o HA t\u1ef1 \u0111\u1ed9ng v\u00e0 tr\u1ef1c ti\u1ebfp \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n ICU (15), cho th\u1ea5y ph\u00e9p \u0111o HA t\u1ef1 \u0111\u1ed9ng c\u00f3 th\u1ec3 kh\u00e1c v\u1edbi HA tr\u1ef1c ti\u1ebfp t\u1edbi <strong>55 mm Hg <\/strong>(t\u1eeb -15 mm Hg \u0111\u1ebfn +40 mm Hg) \u1edf t\u1eebng b\u1ec7nh nh\u00e2n. \u0110\u00e2y l\u00e0 ph\u1ea1m vi bi\u1ebfn thi\u00ean <strong>kh\u00f4ng th\u1ec3 ch\u1ea5p nh\u1eadn <\/strong>\u0111\u01b0\u1ee3c v\u00e0 n\u00f3 ch\u1ee9ng minh nhu c\u1ea7u (14.4) ghi HA tr\u1ef1c ti\u1ebfp \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ec7nh n\u1eb7ng.<\/p>\n<h2>T\u01af\u1edaI M\u00c1U M\u00d4 &amp; OXI H\u00d3A<\/h2>\n<p>Ph\u01b0\u01a1ng ph\u00e1p ti\u1ebfp c\u1eadn s\u1ed1c \u0111\u00f2i h\u1ecfi nhi\u1ec1u h\u01a1n l\u00e0 theo d\u00f5i huy\u1ebft \u00e1p, v\u00ec c\u00e1c bi\u1ec7n ph\u00e1p t\u01b0\u1edbi m\u00e1u m\u00f4 v\u00e0 oxy h\u00f3a l\u00e0 c\u1ea7n thi\u1ebft cho c\u1ea3 vi\u1ec7c ph\u00e1t hi\u1ec7n v\u00e0 qu\u1ea3n l\u00fd s\u1ed1c. C\u00e1c th\u00f4ng s\u1ed1 n\u00e0y \u0111\u01b0\u1ee3c th\u1ec3 hi\u1ec7n trong B\u1ea3ng 14.3, c\u00f9ng v\u1edbi gi\u00e1 tr\u1ecb ng\u01b0\u1ee1ng c\u1ee7a t\u1eebng s\u1ed1 \u0111o cho bi\u1ebft s\u1ed1c c\u00f3 th\u1ec3 x\u1ea3y ra ho\u1eb7c c\u00f3 kh\u1ea3 n\u0103ng x\u1ea3y ra. M\u1ed7i gi\u00e1 tr\u1ecb trong s\u1ed1 n\u00e0y \u0111\u00e3 \u0111\u01b0\u1ee3c m\u00f4 t\u1ea3 \u1edf n\u01a1i kh\u00e1c trong s\u00e1ch v\u00e0 nh\u1eefng n\u1ed9i dung sau \u0111\u00e2y ch\u1ec9 l\u00e0 b\u1ea3n t\u00f3m t\u1eaft ng\u1eafn g\u1ecdn.<\/p>\n<table>\n<tbody>\n<tr>\n<td colspan=\"3\" width=\"603\"><strong>B\u1ea2NG 14.3 C\u00e1c th\u00f4ng s\u1ed1 to\u00e0n th\u00e2n v\u1ec1 t\u01b0\u1edbi m\u00e1u m\u00f4 v\u00e0 oxy h\u00f3a<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"265\"><strong>Th\u00f4ng s\u1ed1<\/strong><\/td>\n<td width=\"161\"><strong>Ng\u01b0\u1ee1ng n\u1eb7ng<\/strong><\/td>\n<td width=\"177\"><strong>Gi\u1ea3i th\u00edch<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"265\">Ch\u1ec9 s\u1ed1 tim<\/td>\n<td width=\"161\">(CI) &lt;2.5 L\/min\/m2<\/td>\n<td width=\"177\">Inadequate Perfusion<\/td>\n<\/tr>\n<tr>\n<td colspan=\"3\" width=\"603\"><strong>V\u1eadn chuy\u1ec3n oxi<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"265\">Ph\u00e2n ph\u1ed1i Oxi (DO2)<\/p>\n<p>Ti\u00eau th\u1ee5 Oxy (VO2)<\/p>\n<p>Chi\u1ebft xu\u1ea5t Oxy(VO2 \/DO2)<\/td>\n<td width=\"161\">&lt;300 mL\/min\/m2<\/p>\n<p>&lt;110 mL\/min\/m2<\/p>\n<p>&gt;50%<\/p>\n<p>&lt;20%<\/td>\n<td width=\"177\">Cung c\u1ea5p O2 kh\u00f4ng \u0111\u1ee7 S\u1eed d\u1ee5ng O2 kh\u00f4ng \u0111\u1ee7f Cung c\u1ea5p O2 kh\u00f4ng \u0111\u1ee7 Chi\u1ebft xu\u1ea5t O2 kh\u00f4ng \u0111\u1ee7<\/td>\n<\/tr>\n<tr>\n<td width=\"265\">B\u00e3o h\u00f2a O2 t\u0129nh m\u1ea1ch trung (ScvO2)<\/td>\n<td width=\"161\">&lt;50%<\/p>\n<p>&gt;80%<\/td>\n<td width=\"177\">Cung c\u1ea5p O2 kh\u00f4ng \u0111\u1ee7<\/p>\n<p>Chi\u1ebft xu\u1ea5t O2 kh\u00f4ng \u0111\u1ee7<\/td>\n<\/tr>\n<tr>\n<td width=\"265\">PCO2 Gap<\/td>\n<td width=\"161\">&gt;6 mm Hg (&gt;0.8 kPa)<\/td>\n<td width=\"177\">T\u01b0\u1edbi m\u00e1u m\u00f4 kh\u00f4ng \u0111\u1ee7<\/td>\n<\/tr>\n<tr>\n<td width=\"265\">Lactate huy\u1ebft t\u01b0\u01a1ng<\/td>\n<td width=\"161\">&gt;2 mmol\/L<\/td>\n<td width=\"177\">S\u1eed d\u1ee5ng O2 kh\u00f4ng \u0111\u1ee7f<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Hi\u1ec7n di\u1ec7n \u1edf m\u1ecdi lo\u1ea1i s\u1ed1c.<\/p>\n<h3>C\u00e1c th\u00f4ng s\u1ed1 v\u1eadn chuy\u1ec3n Oxy<\/h3>\n<p>C\u00f3 ba th\u00f4ng s\u1ed1 \u0111\u00e1nh gi\u00e1 v\u1eadn chuy\u1ec3n oxy to\u00e0n th\u00e2n: <strong>cung c\u1ea5p oxy (DO2)<\/strong>, <strong>h\u1ea5p th\u1ee5 oxy (VO2) <\/strong>v\u00e0 <strong>chi\u1ebft xu\u1ea5t oxy (VO2\/DO2)<\/strong>. C\u00e1c bi\u1ebfn s\u1ed1 n\u00e0y, \u0111\u01b0\u1ee3c m\u00f4 t\u1ea3 chi ti\u1ebft trong Ch\u01b0\u01a1ng 9, cung c\u1ea5p \u0111\u00e1nh gi\u00e1 v\u1ec1 s\u1ef1 c\u00e2n b\u1eb1ng to\u00e0n th\u00e2n gi\u1eefa cung c\u1ea5p O2 v\u00e0 nhu c\u1ea7u O2, b\u1ecb m\u1ea5t c\u00e2n b\u1eb1ng trong m\u1ecdi h\u00ecnh th\u1ee9c s\u1ed1c.<\/p>\n<p><strong>Ch\u1ec9 s\u1ed1 tim<\/strong><\/p>\n<p>V\u1eadn chuy\u1ec3n oxy ph\u1ee5 thu\u1ed9c v\u00e0o cung l\u01b0\u1ee3ng tim, \u0111\u01b0\u1ee3c \u0111o ch\u00ednh x\u00e1c nh\u1ea5t b\u1eb1ng k\u1ef9 thu\u1eadt pha lo\u00e3ng nhi\u1ec7t s\u1eed d\u1ee5ng catheter \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i (xem Ch\u01b0\u01a1ng 8). C\u00e1c ph\u01b0\u01a1ng ph\u00e1p thay th\u1ebf bao g\u1ed3m x\u00e1c \u0111\u1ecbnh th\u1ec3 t\u00edch nh\u00e1t b\u00f3p t\u1eeb d\u1ea1ng s\u00f3ng \u00e1p l\u1ef1c \u0111\u1ed9ng m\u1ea1ch (xem H\u00ecnh 11.5) ho\u1eb7c \u0111o v\u1eadn t\u1ed1c d\u00f2ng ch\u1ea3y \u0111\u1ed9ng m\u1ea1ch ch\u1ee7 b\u1eb1ng si\u00eau \u00e2m Doppler. (Nh\u1eefng ph\u01b0\u01a1ng ph\u00e1p n\u00e0y \u0111\u01b0\u1ee3c m\u00f4 t\u1ea3 trong Ch\u01b0\u01a1ng 11.) Th\u1ec3 t\u00edch nh\u00e1t b\u00f3p \u0111\u01b0\u1ee3c nh\u00e2n v\u1edbi nh\u1ecbp tim \u0111\u1ec3 c\u00f3 \u0111\u01b0\u1ee3c cung l\u01b0\u1ee3ng tim.<\/p>\n<p>Nh\u01b0 \u0111\u00e3 gi\u1ea3i th\u00edch trong Ch\u01b0\u01a1ng 8, c\u00e1c ph\u00e9p \u0111o huy\u1ebft \u0111\u1ed9ng th\u01b0\u1eddng \u0111\u01b0\u1ee3c bi\u1ec3u th\u1ecb theo k\u00edch th\u01b0\u1edbc c\u01a1 th\u1ec3 b\u1eb1ng c\u00e1ch s\u1eed d\u1ee5ng di\u1ec7n t\u00edch b\u1ec1 m\u1eb7t c\u01a1 th\u1ec3 t\u00ednh b\u1eb1ng m\u00e9t vu\u00f4ng. Cung l\u01b0\u1ee3ng tim \u0111i\u1ec1u ch\u1ec9nh theo k\u00edch th\u01b0\u1edbc \u0111\u01b0\u1ee3c g\u1ecdi l\u00e0 <strong>ch\u1ec9 s\u1ed1 tim (CI) <\/strong>v\u00e0 ph\u1ea1m vi b\u00ecnh th\u01b0\u1eddng l\u00e0 <strong>2,4-4 L\/ph\u00fat\/m2 <\/strong>(xem B\u1ea3ng 8.1). CI d\u01b0\u1edbi m\u1ee9c b\u00ecnh th\u01b0\u1eddng (&lt;2,5 L\/ph\u00fat\/m2) \u0111\u01b0\u1ee3c coi l\u00e0 b\u1eb1ng ch\u1ee9ng c\u1ee7a t\u00ecnh tr\u1ea1ng t\u01b0\u1edbi m\u00e1u m\u00f4 kh\u00f4ng \u0111\u1ea7y \u0111\u1ee7.<\/p>\n<p><strong>Ph\u00e2n ph\u1ed1i Oxy<\/strong><\/p>\n<p>T\u1ed1c \u0111\u1ed9 cung c\u1ea5p oxy trong m\u00e1u \u0111\u1ed9ng m\u1ea1ch (DO2) \u0111\u01b0\u1ee3c t\u00ednh b\u1eb1ng t\u00edch c\u1ee7a ch\u1ec9 s\u1ed1 tim (CI) v\u00e0 n\u1ed3ng \u0111\u1ed9 oxy trong m\u00e1u \u0111\u1ed9ng m\u1ea1ch (CaO2); t\u1ee9c l\u00e0,<\/p>\n<p><strong>DO2 = CI X CaO2 <\/strong>(14.4)<\/p>\n<p>(\u0110\u1ec3 bi\u1ebft bi\u1ec3u th\u1ee9c chi ti\u1ebft h\u01a1n v\u1ec1 ph\u01b0\u01a1ng tr\u00ecnh n\u00e0y, h\u00e3y xem Ph\u01b0\u01a1ng tr\u00ecnh 9.8.) Gi\u1ea3m cung c\u1ea5p O2 l\u00e0 th\u1ee7 ph\u1ea1m g\u00e2y ra ba trong b\u1ed1n lo\u1ea1i s\u1ed1c l\u00e2m s\u00e0ng (t\u1ee9c l\u00e0 s\u1ed1c gi\u1ea3m th\u1ec3 t\u00edch, s\u1ed1c tim v\u00e0 s\u1ed1c t\u1eafc ngh\u1ebdn). DO2 th\u01b0\u1eddng l\u00e0 <em>520-600 mL\/ph\u00fat\/m2<\/em> (xem B\u1ea3ng 9.2) v\u00e0 <strong>DO2 l\u00e0 300 mL\/ph\u00fat\/m2 \u0111\u00e3 \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh l\u00e0 ng\u01b0\u1ee1ng oxy h\u00f3a m\u00f4 kh\u00f4ng \u0111\u1ee7 <\/strong>(16). Tuy nhi\u00ean, \u0111\u00e2y kh\u00f4ng ph\u1ea3i l\u00e0 d\u1ea5u ch\u1ee9ng nh\u1ea5t qu\u00e1n v\u00e0 m\u1ed9t s\u1ed1 nghi\u00ean c\u1ee9u kh\u00f4ng th\u1ec3 x\u00e1c \u0111\u1ecbnh \u0111\u01b0\u1ee3c \u0111i\u1ec3m DO2 l\u00e0m suy y\u1ebfu qu\u00e1 tr\u00ecnh chuy\u1ec3n h\u00f3a hi\u1ebfu kh\u00ed (17).<\/p>\n<p><strong>Ti\u00eau th\u1ee5 Oxy<\/strong><\/p>\n<p>T\u1ed1c \u0111\u1ed9 h\u1ea5p th\u1ee5 oxy v\u00e0o m\u00f4 (VO2), t\u01b0\u01a1ng \u0111\u01b0\u01a1ng v\u1edbi l\u01b0\u1ee3ng ti\u00eau th\u1ee5 O2, \u0111\u01b0\u1ee3c t\u00ednh b\u1eb1ng t\u00edch c\u1ee7a ch\u1ec9 s\u1ed1 tim v\u00e0 s\u1ef1 ch\u00eanh l\u1ec7ch n\u1ed3ng \u0111\u1ed9 O2 gi\u1eefa (14.5) m\u00e1u \u0111\u1ed9ng m\u1ea1ch v\u00e0 t\u0129nh m\u1ea1ch (CaO2 &#8211; CvO2); t\u1ee9c l\u00e0,<\/p>\n<p><strong>VO2 = CO X (CaO2 &#8211; CvO2) <\/strong>(14.5)<\/p>\n<p>(\u0110\u1ec3 bi\u1ebft bi\u1ec3u th\u1ee9c chi ti\u1ebft h\u01a1n v\u1ec1 ph\u01b0\u01a1ng tr\u00ecnh n\u00e0y, h\u00e3y xem Ph\u01b0\u01a1ng tr\u00ecnh 9.10.) VO2 b\u00ecnh th\u01b0\u1eddng l\u00e0 110- 160 mL\/ph\u00fat\/m2 v\u00e0 <strong>VO2 th\u1ea5p b\u1ea5t th\u01b0\u1eddng (&lt;110 mL\/ph\u00fat\/m2) l\u00e0 b\u1eb1ng ch\u1ee9ng c\u1ee7a vi\u1ec7c s\u1eed d\u1ee5ng O2 b\u1ecb suy gi\u1ea3m <\/strong>(khi kh\u00f4ng c\u00f3 t\u00ecnh tr\u1ea1ng gi\u1ea3m chuy\u1ec3n h\u00f3a hi\u1ebfu kh\u00ed, t\u00ecnh tr\u1ea1ng n\u00e0y kh\u00f4ng ph\u1ed5 bi\u1ebfn \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ec7nh n\u1eb7ng).<\/p>\n<p><strong>Chi\u1ebft xu\u1ea5t Oxy<\/strong><\/p>\n<p>Chi\u1ebft xu\u1ea5t oxy l\u00e0 t\u1ef7 l\u1ec7 gi\u1eefa l\u01b0\u1ee3ng O2 h\u1ea5p th\u1ee5 v\u00e0 l\u01b0\u1ee3ng O2 cung c\u1ea5p, x\u00e1c \u0111\u1ecbnh t\u1ef7 l\u1ec7 oxy cung c\u1ea5p \u0111\u01b0\u1ee3c \u0111\u01b0a v\u00e0o c\u00e1c m\u00f4.<\/p>\n<p><strong>Chi\u1ebft xu\u1ea5t O2 = VO2\/DO2 <\/strong>(14.6)<\/p>\n<p>Khi \u0111\u1ed9 b\u00e3o h\u00f2a O2 \u0111\u1ed9ng m\u1ea1ch g\u1ea7n 100%, Ph\u01b0\u01a1ng tr\u00ecnh 14.6 c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c r\u00fat g\u1ecdn th\u00e0nh c\u00e1c bi\u1ebfn d\u1ec5 theo d\u00f5i; t\u1ee9c l\u00e0,<\/p>\n<p><strong>Chi\u1ebft xu\u1ea5t O2 = (SaO2 &#8211; ScvO2) <\/strong>(14.7)<\/p>\n<p>trong \u0111\u00f3 SaO2 v\u00e0 ScvO2 l\u1ea7n l\u01b0\u1ee3t l\u00e0 \u0111\u1ed9 b\u00e3o h\u00f2a O2 \u0111\u1ed9ng m\u1ea1ch v\u00e0 t\u0129nh m\u1ea1ch trung t\u00e2m. (\u0110\u1ec3 bi\u1ebft c\u00e1ch suy ra ph\u01b0\u01a1ng tr\u00ecnh n\u00e0y, h\u00e3y xem Ph\u01b0\u01a1ng tr\u00ecnh 9.12-9.14.) Ph\u01b0\u01a1ng tr\u00ecnh n\u00e0y th\u1ec3 hi\u1ec7n qu\u00e1 tr\u00ecnh chi\u1ebft xu\u1ea5t O2 l\u00e0 m\u1ee9c \u0111\u1ed9 m\u1ea5t b\u00e3o h\u00f2a hemoglobin khi m\u00e1u ch\u1ea3y qua c\u00e1c mao m\u1ea1ch.<\/p>\n<p>Qu\u00e1 tr\u00ecnh chi\u1ebft xu\u1ea5t O2 th\u01b0\u1eddng l\u00e0 <strong>0,2-0,3 (20-30%) <\/strong>v\u00e0 c\u00f3 th\u1ec3 <strong>t\u0103ng l\u00ean kho\u1ea3ng 0,5 (50%) <\/strong>\u0111\u1ec3 \u0111\u00e1p \u1ee9ng v\u1edbi s\u1ef1 gi\u1ea3m DO2, gi\u00fap duy tr\u00ec VO2 kh\u00f4ng \u0111\u1ed5i (xem H\u00ecnh 9.3). Vi\u1ec7c gi\u1ea3m DO2 th\u00eam n\u1eefa v\u01b0\u1ee3t qu\u00e1 \u0111i\u1ec3m n\u00e0y s\u1ebd kh\u00f4ng g\u00e2y ra s\u1ef1 gia t\u0103ng b\u00f9 tr\u1eeb trong qu\u00e1 tr\u00ecnh chi\u1ebft xu\u1ea5t O2 v\u00e0 VO2 s\u1ebd b\u1eaft \u0111\u1ea7u gi\u1ea3m (ch\u1ec9 ra s\u1ef1 kh\u1edfi \u0111\u1ea7u c\u1ee7a qu\u00e1 tr\u00ecnh chuy\u1ec3n h\u00f3a k\u1ef5 kh\u00ed). Do \u0111\u00f3, qu\u00e1 tr\u00ecnh <strong>chi\u1ebft xu\u1ea5t O2 &gt;50% cho th\u1ea5y vi\u1ec7c cung c\u1ea5p O2 \u0111\u1ee7 th\u1ea5p \u0111\u1ec3 \u0111e d\u1ecda <\/strong>ho\u1eb7c l\u00e0m suy y\u1ebfu qu\u00e1 tr\u00ecnh chuy\u1ec3n h\u00f3a hi\u1ebfu kh\u00ed (18). Ngo\u00e0i ra c\u00f2n c\u00f3 nh\u1eefng t\u00ecnh tr\u1ea1ng l\u00e0m suy y\u1ebfu qu\u00e1 tr\u00ecnh chi\u1ebft xu\u1ea5t O2 (v\u00ed d\u1ee5, nhi\u1ec5m tr\u00f9ng huy\u1ebft, suy gan) v\u00e0 nh\u1eefng t\u00ecnh tr\u1ea1ng n\u00e0y c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh b\u1eb1ng c\u00e1ch chi\u1ebft xu\u1ea5t O2 c\u1ed1 \u0111\u1ecbnh (t\u1ee9c l\u00e0 kh\u00f4ng t\u0103ng l\u00ean khi DO2 gi\u1ea3m) ho\u1eb7c &lt;20%. Trong t\u00ecnh hu\u1ed1ng n\u00e0y, chi\u1ebft xu\u1ea5t O2 kh\u00f4ng ph\u1ea3i l\u00e0 ch\u1ec9 b\u00e1o \u0111\u00e1ng tin c\u1eady v\u1ec1 nh\u1eefng thay \u0111\u1ed5i trong qu\u00e1 tr\u00ecnh cung c\u1ea5p O2.<\/p>\n<p><strong>\u0110\u1ed9 b\u00e3o h\u00f2a O2 t\u0129nh m\u1ea1ch trung t\u00e2m<\/strong><\/p>\n<p>Khi SaO2 kh\u00f4ng \u0111\u1ed5i ho\u1eb7c g\u1ea7n b\u1eb1ng 1,0 (100%), Ph\u01b0\u01a1ng tr\u00ecnh 14.7 c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c vi\u1ebft l\u1ea1i th\u00e0nh:<\/p>\n<p>Chi\u1ebft xu\u1ea5t O2 = (1 &#8211; ScvO2) (14.8)<\/p>\n<p>Do \u0111\u00f3, \u0111\u1ed9 b\u00e3o h\u00f2a O2 t\u0129nh m\u1ea1ch trung t\u00e2m (ScvO2) c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng ri\u00eang \u0111\u1ec3 theo d\u00f5i qu\u00e1 tr\u00ecnh tr\u00edch xu\u1ea5t O2 (19). ScvO2 b\u00ecnh th\u01b0\u1eddng l\u00e0 kho\u1ea3ng <strong>65-75% <\/strong>v\u00e0 vi\u1ec7c t\u0103ng qu\u00e1 tr\u00ecnh tr\u00edch xu\u1ea5t O2 s\u1ebd l\u00e0m gi\u1ea3m ScvO2 xu\u1ed1ng d\u01b0\u1edbi ph\u1ea1m vi n\u00e0y. Qu\u00e1 tr\u00ecnh tr\u00edch xu\u1ea5t O2 t\u1ed1i \u0111a (kho\u1ea3ng 50%) t\u01b0\u01a1ng \u1ee9ng v\u1edbi ScvO2 kho\u1ea3ng 50% v\u00e0 do \u0111\u00f3, <strong>ScvO2 &lt;50% c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng l\u00e0m d\u1ea5u hi\u1ec7u c\u1ee7a t\u00ecnh tr\u1ea1ng oxy h\u00f3a m\u00f4 b\u1ecb \u0111e d\u1ecda ho\u1eb7c suy gi\u1ea3m <\/strong>(20).<\/p>\n<p>\u1ede \u0111\u1ea7u kia, <strong>ScvO2 cao b\u1ea5t th\u01b0\u1eddng (&gt;80%) l\u00e0 b\u1eb1ng ch\u1ee9ng c\u1ee7a t\u00ecnh tr\u1ea1ng tr\u00edch xu\u1ea5t O2 m\u00f4 b\u1ecb suy gi\u1ea3m<\/strong>, \u0111\u00e2y l\u00e0 m\u1ed9t \u0111\u1eb7c \u0111i\u1ec3m \u0111\u1eb7c tr\u01b0ng c\u1ee7a s\u1ed1c nhi\u1ec5m tr\u00f9ng. Trong t\u00ecnh hu\u1ed1ng n\u00e0y, ScvO2 c\u0169ng c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c c\u1ed1 \u0111\u1ecbnh (t\u1ee9c l\u00e0 kh\u00f4ng thay \u0111\u1ed5i theo nh\u1eefng thay \u0111\u1ed5i v\u1ec1 qu\u00e1 tr\u00ecnh cung c\u1ea5p O2) v\u00e0 n\u1ebfu \u0111i\u1ec1u n\u00e0y x\u1ea3y ra, ScvO2 kh\u00f4ng ph\u1ea3i l\u00e0 ch\u1ec9 b\u00e1o \u0111\u00e1ng tin c\u1eady v\u1ec1 nh\u1eefng thay \u0111\u1ed5i trong qu\u00e1 tr\u00ecnh cung c\u1ea5p O2. Khi \u0111\u00f3 n\u00ean t\u00ednh \u0111\u1ebfn kho\u1ea3ng c\u00e1ch PCO2 (xem ph\u1ea7n ti\u1ebfp theo).<\/p>\n<p><strong>\u0110\u1ed9 ch\u00eanh PCO2<\/strong><\/p>\n<p>\u0110\u1ed9 ch\u00eanh PCO2 t\u0129nh m\u1ea1ch \u0111\u1ed9ng m\u1ea1ch, c\u00f2n \u0111\u01b0\u1ee3c g\u1ecdi l\u00e0 kho\u1ea3ng tr\u1ed1ng PCO2, l\u00e0 ph\u00e9p \u0111o gi\u00e1n ti\u1ebfp qu\u00e1 tr\u00ecnh <strong>r\u1eeda tr\u00f4i CO2 kh\u1ecfi c\u00e1c m\u00f4 <\/strong>(t\u1ee9c l\u00e0 t\u01b0\u1edbi m\u00e1u m\u00f4). Kho\u1ea3ng tr\u1ed1ng PCO2 th\u01b0\u1eddng l\u00e0 2-5 mm Hg (0,3-0,7 kPa) v\u00e0 vi\u1ec7c <strong>t\u0103ng kho\u1ea3ng tr\u1ed1ng l\u00ean &gt;6 mm Hg (&gt;0,8 kPa) l\u00e0 b\u1eb1ng ch\u1ee9ng c\u1ee7a t\u00ecnh tr\u1ea1ng gi\u1ea3m t\u01b0\u1edbi m\u00e1u m\u00f4 <\/strong>(21). Kh\u00f4ng gi\u1ed1ng nh\u01b0 ScvO2<strong>, kho\u1ea3ng tr\u1ed1ng PCO2 ch\u1ec9 ph\u1ee5 thu\u1ed9c v\u00e0o t\u01b0\u1edbi m\u00e1u m\u00f4 v\u00e0 kh\u00f4ng cung c\u1ea5p th\u00f4ng tin v\u1ec1 oxy h\u00f3a to\u00e0n th\u00e2n<\/strong>. Kho\u1ea3ng tr\u1ed1ng PCO2 d\u1ec5 d\u00e0ng thu \u0111\u01b0\u1ee3c v\u00e0 n\u00ean \u0111\u01b0\u1ee3c theo d\u00f5i \u1edf t\u1ea5t c\u1ea3 c\u00e1c b\u1ec7nh nh\u00e2n b\u1ecb s\u1ed1c, \u0111\u1eb7c bi\u1ec7t l\u00e0 nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ecb s\u1ed1c l\u01b0u l\u01b0\u1ee3ng th\u1ea5p (s\u1ed1c gi\u1ea3m th\u1ec3 t\u00edch, s\u1ed1c tim v\u00e0 s\u1ed1c t\u1eafc ngh\u1ebdn). N\u00f3 c\u0169ng c\u00f3 th\u1ec3 h\u1eefu \u00edch \u0111\u1ec3 ph\u00e1t hi\u1ec7n tr\u1ea1ng th\u00e1i l\u01b0u l\u01b0\u1ee3ng th\u1ea5p trong s\u1ed1c nhi\u1ec5m tr\u00f9ng, th\u01b0\u1eddng th\u1ea5y \u1edf c\u00e1c tr\u01b0\u1eddng h\u1ee3p ti\u1ebfn tri\u1ec3n. (L\u01b0u \u00fd: <strong>Nhi\u1ec5m toan chuy\u1ec3n h\u00f3a c\u00f3 th\u1ec3 l\u00e0m t\u0103ng kho\u1ea3ng c\u00e1ch PCO2<\/strong>. \u0110\u00e2y l\u00e0 k\u1ebft qu\u1ea3 c\u1ee7a vi\u1ec7c t\u0103ng s\u1ea3n xu\u1ea5t CO2 kh\u00f4ng chuy\u1ec3n h\u00f3a v\u00e0 c\u00f3 th\u1ec3 b\u1ecb hi\u1ec3u sai l\u00e0 b\u1eb1ng ch\u1ee9ng c\u1ee7a t\u00ecnh tr\u1ea1ng gi\u1ea3m t\u01b0\u1edbi m\u00e1u m\u00f4. Khi c\u00f3 nhi\u1ec5m toan chuy\u1ec3n h\u00f3a, ch\u1ec9 c\u00f3 kho\u1ea3ng c\u00e1ch PCO2 b\u00ecnh th\u01b0\u1eddng m\u1edbi c\u00f3 li\u00ean quan.)<\/p>\n<p><strong>Lactate huy\u1ebft t\u01b0\u01a1ng<\/strong><\/p>\n<p>N\u1ed3ng \u0111\u1ed9 lactat huy\u1ebft t\u01b0\u01a1ng \u0111\u01b0\u1ee3c coi l\u00e0 m\u1ed9t trong nh\u1eefng th\u00f4ng s\u1ed1 quan tr\u1ecdng nh\u1ea5t trong t\u00ecnh tr\u1ea1ng s\u1ed1c l\u00e2m s\u00e0ng v\u00e0 c\u00f3 c\u1ea3 \u1ee9ng d\u1ee5ng ch\u1ea9n \u0111o\u00e1n v\u00e0 ti\u00ean l\u01b0\u1ee3ng. Nh\u01b0 \u0111\u00e3 \u0111\u1ec1 c\u1eadp tr\u01b0\u1edbc \u0111\u00f3, n\u1ed3ng \u0111\u1ed9 lactat huy\u1ebft t\u01b0\u01a1ng &gt;2 mmol\/L \u0111\u01b0\u1ee3c coi l\u00e0 b\u1eb1ng ch\u1ee9ng v\u1ec1 vi\u1ec7c s\u1eed d\u1ee5ng O2 c\u1ee7a t\u1ebf b\u00e0o kh\u00f4ng \u0111\u1ea7y \u0111\u1ee7, khi kh\u00f4ng c\u00f3 c\u00e1c t\u00ecnh tr\u1ea1ng kh\u00e1c g\u00e2y ra \u201ct\u0103ng lactat huy\u1ebft hi\u1ebfu kh\u00ed\u201d (xem B\u1ea3ng 9.5). N\u1ebfu s\u1ed1c l\u00e0 nguy\u00ean nh\u00e2n g\u00e2y ra n\u1ed3ng \u0111\u1ed9 lactat t\u0103ng cao, th\u00ec vi\u1ec7c kh\u00f4ng b\u00ecnh th\u01b0\u1eddng h\u00f3a n\u1ed3ng \u0111\u1ed9 trong v\u00f2ng 24 gi\u1edd s\u1ebd c\u00f3 t\u00e1c \u0111\u1ed9ng ti\u00eau c\u1ef1c \u0111\u1ebfn k\u1ebft qu\u1ea3 kh\u1ea3 quan (xem H\u00ecnh 9.4). (N\u1ed3ng \u0111\u1ed9 lactat huy\u1ebft t\u01b0\u01a1ng \u0111\u01b0\u1ee3c m\u00f4 t\u1ea3 chi ti\u1ebft trong Ch\u01b0\u01a1ng 9.)<\/p>\n<h2>QU\u1ea2N L\u00dd \u0110I\u1ec0U TR\u1eca T\u1ed4NG QU\u00c1T<\/h2>\n<p>Vi\u1ec7c qu\u1ea3n l\u00fd s\u1ed1c l\u00e2m s\u00e0ng c\u00f3 hai th\u00e0nh ph\u1ea7n: <strong>\u0111i\u1ec1u tr\u1ecb t\u00ecnh tr\u1ea1ng g\u00e2y s\u1ed1c <\/strong>v\u00e0 <strong>qu\u1ea3n l\u00fd huy\u1ebft \u0111\u1ed9ng h\u1ecdc <\/strong>t\u1ed5ng qu\u00e1t. Th\u00e0nh ph\u1ea7n sau l\u00e0 tr\u1ecdng t\u00e2m \u1edf \u0111\u00e2y.<\/p>\n<p>H\u1ed3i s\u1ee9c th\u1ec3 t\u00edch<\/p>\n<p>Truy\u1ec1n d\u1ecbch t\u0129nh m\u1ea1ch l\u00e0 b\u01b0\u1edbc \u0111\u1ea7u ti\u00ean trong qu\u00e1 tr\u00ecnh x\u1eed tr\u00ed s\u1ed1c, b\u1ea5t k\u1ec3 lo\u1ea1i s\u1ed1c n\u00e0o. (\u0110i\u1ec1u n\u00e0y c\u00f3 v\u1ebb ph\u1ea3n t\u00e1c d\u1ee5ng trong s\u1ed1c tim, nh\u01b0ng \u00e1p l\u1ef1c \u0111\u1ed5 \u0111\u1ea7y tim th\u01b0\u1eddng kh\u00f4ng t\u1ed1i \u01b0u trong suy tim c\u1ea5p, \u0111\u1eb7c bi\u1ec7t l\u00e0 khi suy tim li\u00ean quan \u0111\u1ebfn b\u00ean ph\u1ea3i tim.) Truy\u1ec1n d\u1ecbch tinh th\u1ec3 \u0111\u01b0\u1ee3c \u01b0u ti\u00ean, m\u1eb7c d\u00f9 kho\u1ea3ng 75% l\u01b0\u1ee3ng d\u1ecbch tinh th\u1ec3 truy\u1ec1n v\u00e0o l\u00e0m t\u0103ng th\u1ec3 t\u00edch k\u1ebd, kh\u00f4ng ph\u1ea3i th\u1ec3 t\u00edch huy\u1ebft t\u01b0\u01a1ng (xem Ch\u01b0\u01a1ng 11).<\/p>\n<p><strong>Th\u1ec3 t\u00edch truy\u1ec1n<\/strong><\/p>\n<p>Th\u1ec3 t\u00edch truy\u1ec1n ban \u0111\u1ea7u c\u00f3 th\u1ec3 ph\u1ee5 thu\u1ed9c v\u00e0o m\u1ed9t s\u1ed1 bi\u1ebfn s\u1ed1 (v\u00ed d\u1ee5: lo\u1ea1i s\u1ed1c, lo\u1ea1i b\u1ec7nh nh\u00e2n). \u0110\u1ed1i v\u1edbi h\u1ed9i ch\u1ee9ng s\u1ed1c ph\u1ed5 bi\u1ebfn nh\u1ea5t (s\u1ed1c nhi\u1ec5m tr\u00f9ng), th\u1ec3 t\u00edch h\u1ed3i s\u1ee9c \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o l\u00e0 &gt;30 mL\/kg, s\u1eed d\u1ee5ng tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 l\u00fd t\u01b0\u1edfng, trong 3 gi\u1edd \u0111\u1ea7u ti\u00ean (22). Th\u1ec3 t\u00edch truy\u1ec1n t\u1ed1i thi\u1ec3u cho <strong>ng\u01b0\u1eddi l\u1edbn 70 kg <\/strong>sau \u0111\u00f3 s\u1ebd l\u00e0 kho\u1ea3ng <strong>2 l\u00edt <\/strong>v\u00e0 \u0111\u1ed1i v\u1edbi <strong>d\u1ecbch tinh th\u1ec3<\/strong>, \u0111i\u1ec1u n\u00e0y c\u00f3 ngh\u0129a l\u00e0 <strong>kho\u1ea3ng 500 mL (25%) s\u1ebd \u0111\u01b0\u1ee3c th\u00eam v\u00e0o th\u1ec3 t\u00edch huy\u1ebft t\u01b0\u01a1ng <\/strong>v\u00e0 <strong>1,5 l\u00edt c\u00f2n l\u1ea1i (75%) s\u1ebd g\u00f3p ph\u1ea7n h\u00ecnh th\u00e0nh ph\u00f9 n\u1ec1<\/strong>. S\u1ef1 gia t\u0103ng th\u1ec3 t\u00edch huy\u1ebft t\u01b0\u01a1ng n\u00e0y chi\u1ebfm kho\u1ea3ng 15% th\u1ec3 t\u00edch huy\u1ebft t\u01b0\u01a1ng \u0111\u1ed1i v\u1edbi nam gi\u1edbi tr\u01b0\u1edfng th\u00e0nh 70 kg (c\u00f3 th\u1ec3 t\u00edch huy\u1ebft t\u01b0\u01a1ng kho\u1ea3ng 40 mL\/kg), \u0111i\u1ec1u n\u00e0y c\u00f3 v\u1ebb h\u1ee3p l\u00fd n\u1ebfu b\u1ea1n coi r\u1eb1ng m\u1ee9c gi\u1ea3m 15% th\u1ec3 t\u00edch m\u00e1u l\u00e0 ng\u01b0\u1ee1ng g\u00e2y ra c\u00e1c tri\u1ec7u ch\u1ee9ng (xem ch\u01b0\u01a1ng ti\u1ebfp theo). Tuy nhi\u00ean, c\u00e1ch ti\u1ebfp c\u1eadn &#8220;m\u1ed9t k\u00edch th\u01b0\u1edbc ph\u00f9 h\u1ee3p v\u1edbi t\u1ea5t c\u1ea3&#8221; n\u00e0y c\u00f3 th\u1ec3 kh\u00f4ng ph\u00f9 h\u1ee3p v\u1edbi ng\u01b0\u1eddi l\u1edbn c\u00f3 k\u00edch th\u01b0\u1edbc c\u01a1 th\u1ec3 kh\u00e1c nhau v\u00e0 \u0111\u1ed1i v\u1edbi ph\u1ee5 n\u1eef (c\u00f3 th\u1ec3 t\u00edch huy\u1ebft t\u01b0\u01a1ng th\u1ea5p h\u01a1n nam gi\u1edbi). Sau \u0111\u00e2y l\u00e0 m\u1ed9t s\u1ed1 khuy\u1ebfn ngh\u1ecb v\u1ec1 h\u1ed3i s\u1ee9c d\u1ecbch ban \u0111\u1ea7u:<\/p>\n<ul>\n<li>Th\u1ec3 t\u00edch h\u1ed3i s\u1ee9c ban \u0111\u1ea7u <strong>n\u00ean t\u00ednh \u0111\u1ebfn lo\u1ea1i s\u1ed1c <\/strong>(n\u1ebfu bi\u1ebft) v\u00e0 <strong>lo\u1ea1i b\u1ec7nh nh\u00e2n <\/strong>(v\u00ed d\u1ee5: k\u00edch th\u01b0\u1edbc c\u01a1 th\u1ec3 v\u00e0 gi\u1edbi t\u00ednh), v\u00e0 c\u00f3 l\u1ebd <strong>kh\u00f4ng n\u00ean v\u01b0\u1ee3t qu\u00e1 2 l\u00edt <\/strong>(d\u1ecbch tinh th\u1ec3) trong v\u00f2ng 1-2 gi\u1edd.<\/li>\n<li>M\u1ee5c ti\u00eau tr\u01b0\u1edbc m\u1eaft l\u00e0 <strong>ph\u1ee5c h\u1ed3i huy\u1ebft \u00e1p c\u01a1 b\u1ea3n<\/strong>.<\/li>\n<li>N\u1ebfu kh\u00f4ng \u0111\u1ea1t \u0111\u01b0\u1ee3c m\u1ee5c ti\u00eau huy\u1ebft \u00e1p v\u00e0 c\u00f3 b\u1eb1ng ch\u1ee9ng kh\u00e1c v\u1ec1 t\u00ecnh tr\u1ea1ng suy tu\u1ea7n ho\u00e0n (v\u00ed d\u1ee5: l\u01b0\u1ee3ng n\u01b0\u1edbc ti\u1ec3u th\u1ea5p, thay \u0111\u1ed5i tr\u1ea1ng th\u00e1i tinh th\u1ea7n ho\u1eb7c n\u1ed3ng \u0111\u1ed9 lactat t\u0103ng cao), th\u00ec n\u00ean <strong>b\u1eaft \u0111\u1ea7u truy\u1ec1n thu\u1ed1c co m\u1ea1ch<\/strong>.<\/li>\n<li>H\u1ed3i s\u1ee9c th\u1ec3 t\u00edch sau giai \u0111o\u1ea1n ban \u0111\u1ea7u <strong>n\u00ean \u0111\u01b0\u1ee3c h\u01b0\u1edbng d\u1eabn <\/strong>b\u1eb1ng c\u00e1ch \u0111\u00e1nh gi\u00e1 <strong>kh\u1ea3 n\u0103ng \u0111\u00e1p \u1ee9ng v\u1edbi d\u1ecbch <\/strong>(\u0111\u01b0\u1ee3c m\u00f4 t\u1ea3 trong Ch\u01b0\u01a1ng 11).<\/li>\n<\/ul>\n<p><strong>Truy\u1ec1n thu\u1ed1c v\u1eadn m\u1ea1ch<\/strong><\/p>\n<p>V\u1ea5n \u0111\u1ec1 \u0111\u1ea7u ti\u00ean xu\u1ea5t hi\u1ec7n \u0111\u1ed1i v\u1edbi truy\u1ec1n thu\u1ed1c co m\u1ea1ch l\u00e0 khuy\u1ebfn c\u00e1o truy\u1ec1n th\u1ed1ng r\u1eb1ng thu\u1ed1c co m\u1ea1ch n\u00ean \u0111\u01b0\u1ee3c truy\u1ec1n qua catheter t\u0129nh m\u1ea1ch trung t\u00e2m (\u0111\u1ec3 gi\u1ea3m thi\u1ec3u nguy c\u01a1 thu\u1ed1c tho\u00e1t m\u1ea1ch v\u00e0 ho\u1ea1i t\u1eed m\u00f4). \u0110\u00e2y l\u00e0 ngu\u1ed3n g\u1ed1c c\u1ee7a s\u1ef1 lo l\u1eafng khi truy\u1ec1n thu\u1ed1c co m\u1ea1ch l\u00e0 nhu c\u1ea7u c\u1ea5p thi\u1ebft v\u00e0 kh\u00f4ng c\u00f3 \u0111\u01b0\u1eddng truy\u1ec1n trung t\u00e2m l\u01b0u. May m\u1eafn thay, \u00edt nh\u1ea5t 16 nghi\u00ean c\u1ee9u l\u00e2m s\u00e0ng \u0111\u00e3 ch\u1ec9 ra r\u1eb1ng thu\u1ed1c co m\u1ea1ch c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c <strong>truy\u1ec1n an to\u00e0n qua catheter ngo\u1ea1i vi <\/strong>(\u1edf c\u00e1nh tay tr\u00ean) trong t\u1ed1i \u0111a 48 gi\u1edd (23) v\u00e0 truy\u1ec1n d\u1ecbch thu\u1ed1c co m\u1ea1ch qua catheter \u0111\u01b0\u1eddng gi\u1eefa \u0111\u00e3 ti\u1ebfp t\u1ee5c trong 7 ng\u00e0y m\u00e0 kh\u00f4ng c\u00f3 s\u1ef1 c\u1ed1 n\u00e0o (24). N\u1ebfu c\u00f3 v\u1ea5n \u0111\u1ec1 trong vi\u1ec7c c\u1ed1 \u0111\u1ecbnh catheter ngo\u1ea1i vi l\u01b0u, th\u00ec vi\u1ec7c \u0111\u01b0a catheter v\u00e0o x\u01b0\u01a1ng s\u1ebd cung c\u1ea5p gi\u1ea3i ph\u00e1p t\u1ea1m th\u1eddi (xem Ch\u01b0\u01a1ng 1).<\/p>\n<p><strong>Thu\u1ed1c tho\u00e1t m\u1ea1ch<\/strong><\/p>\n<p>Vi\u1ec7c tho\u00e1t m\u1ea1ch c\u1ee7a thu\u1ed1c co m\u1ea1ch n\u00ean \u0111\u01b0\u1ee3c x\u1eed l\u00fd nh\u01b0 sau:<\/p>\n<ul>\n<li>Khi l\u1ea7n \u0111\u1ea7u ti\u00ean ph\u00e1t hi\u1ec7n c\u00f3 hi\u1ec7n t\u01b0\u1ee3ng tho\u00e1t m\u1ea1ch, h\u00e3y <strong>d\u1eebng truy\u1ec1n ngay l\u1eadp t\u1ee9c<\/strong>, ng\u1eaft k\u1ebft n\u1ed1i \u0111\u01b0\u1eddng truy\u1ec1n t\u0129nh m\u1ea1ch v\u00e0 g\u1eafn v\u00e0o \u1ed1ng ti\u00eam, nh\u1eb9 nh\u00e0ng h\u00fat h\u1ebft dung d\u1ecbch c\u00f2n l\u1ea1i trong catheter v\u00e0 b\u1ea5t k\u1ef3 d\u1ecbch tho\u00e1t m\u1ea1ch n\u00e0o c\u00f3 th\u1ec3 l\u1ea5y ra \u0111\u01b0\u1ee3c. Sau \u0111\u00f3, th\u00e1o catheter. Kh\u00f4ng plus \u0111\u01b0\u1eddng truy\u1ec1n tr\u01b0\u1edbc khi th\u00e1o ra.<\/li>\n<li>Thu\u1ed1c \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng trong t\u00ecnh hu\u1ed1ng n\u00e0y l\u00e0 <strong>phentolamine<\/strong>, thu\u1ed1c ch\u1eb9n alpha t\u00e1c d\u1ee5ng k\u00e9o d\u00e0i. Li\u1ec1u d\u00f9ng l\u00e0 <strong>5-10 mg trong 10 mL dung d\u1ecbch mu\u1ed1i \u0111\u1eb3ng tr\u01b0\u01a1ng<\/strong>, \u0111\u01b0\u1ee3c ti\u00eam tr\u1ef1c ti\u1ebfp v\u00e0o v\u00f9ng tho\u00e1t m\u1ea1ch (25). N\u1ebfu c\u00f3 hi\u1ec7n t\u01b0\u1ee3ng da t\u00e1i nh\u1ee3t (do co m\u1ea1ch t\u1ea1i ch\u1ed7), hi\u1ec7n t\u01b0\u1ee3ng n\u00e0y s\u1ebd bi\u1ebfn m\u1ea5t g\u1ea7n nh\u01b0 ngay l\u1eadp t\u1ee9c.<\/li>\n<li>Phentolamine ph\u1ea3i \u0111\u01b0\u1ee3c <strong>s\u1eed d\u1ee5ng trong v\u00f2ng 12 gi\u1edd <\/strong>sau khi x\u1ea3y ra hi\u1ec7n t\u01b0\u1ee3ng n\u00e0y \u0111\u1ec3 c\u00f3 hi\u1ec7u qu\u1ea3.<\/li>\n<\/ul>\n<p>Huy\u1ebft \u00e1p m\u1ee5c ti\u00eau<\/p>\n<p>Khuy\u1ebfn c\u00e1o \u0111\u1ed3ng thu\u1eadn l\u00e0 n\u00ean chu\u1ea9n \u0111\u1ed9 truy\u1ec1n thu\u1ed1c co m\u1ea1ch \u0111\u1ec3 duy tr\u00ec <strong>huy\u1ebft \u00e1p \u0111\u1ed9ng m\u1ea1ch trung b\u00ecnh <\/strong>(MAP) <strong>\u00edt nh\u1ea5t l\u00e0 65 mm Hg <\/strong>(2,4,22), \u0111\u00e2y l\u00e0 huy\u1ebft \u00e1p t\u1ed1i thi\u1ec3u c\u1ea7n thi\u1ebft \u0111\u1ec3 <strong>duy tr\u00ec t\u1ef1 \u0111i\u1ec1u h\u00f2a n\u00e3o <\/strong>(qu\u00e1 tr\u00ecnh duy tr\u00ec l\u01b0u l\u01b0\u1ee3ng m\u00e1u n\u00e3o khi huy\u1ebft \u00e1p gi\u1ea3m) (26). M\u1ed1i lo ng\u1ea1i r\u1eb1ng huy\u1ebft \u00e1p m\u1ee5c ti\u00eau cao h\u01a1n c\u00f3 th\u1ec3 c\u1ea7n thi\u1ebft \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ecb t\u0103ng huy\u1ebft \u00e1p l\u00e2u n\u0103m v\u1eabn ch\u01b0a \u0111\u01b0\u1ee3c x\u00e1c nh\u1eadn trong c\u00e1c nghi\u00ean c\u1ee9u l\u00e2m s\u00e0ng (27).<\/p>\n<h2>C\u00c1C THU\u1ed0C CO M\u1ea0CH<\/h2>\n<p>C\u00f3 nhi\u1ec1u lo\u1ea1i thu\u1ed1c co m\u1ea1ch kh\u00e1c nhau, v\u00e0 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng ch\u1ee7 y\u1ebfu trong s\u1ed1c gi\u00e3n m\u1ea1ch (nhi\u1ec5m tr\u00f9ng huy\u1ebft). H\u1ea7u h\u1ebft l\u00e0 catecholamine th\u00fac \u0111\u1ea9y co m\u1ea1ch b\u1eb1ng c\u00e1ch k\u00edch th\u00edch th\u1ee5 th\u1ec3 adrenergic lo\u1ea1i al. C\u00e1c thu\u1ed1c co m\u1ea1ch hi\u1ec7n c\u00f3 \u0111\u01b0\u1ee3c li\u1ec7t k\u00ea trong B\u1ea3ng 14.4, c\u00f9ng v\u1edbi ph\u1ea1m vi li\u1ec1u cho t\u1eebng lo\u1ea1i thu\u1ed1c. C\u00e1c thu\u1ed1c n\u00e0y \u0111\u01b0\u1ee3c truy\u1ec1n li\u00ean t\u1ee5c (kh\u00f4ng c\u00f3 li\u1ec1u t\u1ea3i), b\u1eaft \u0111\u1ea7u \u1edf li\u1ec1u th\u1ea5p v\u00e0 t\u0103ng d\u1ea7n khi c\u1ea7n. Kh\u00e1ng thu\u1ed1c co m\u1ea1ch li\u1ec1u cao th\u01b0\u1eddng th\u00fac \u0111\u1ea9y vi\u1ec7c b\u1ed5 sung th\u00eam thu\u1ed1c th\u1ee9 hai, m\u1eb7c d\u00f9 kh\u00f4ng c\u00f3 b\u1eb1ng ch\u1ee9ng n\u00e0o v\u1ec1 l\u1ee3i \u00edch s\u1ed1ng s\u00f3t t\u1eeb ph\u01b0\u01a1ng ph\u00e1p n\u00e0y (xem L\u1edcI CU\u1ed0I \u1edf cu\u1ed1i ch\u01b0\u01a1ng).<\/p>\n<p>Norepinephrine<\/p>\n<p>Norepinephrin l\u00e0 thu\u1ed1c co m\u1ea1ch \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng r\u1ed9ng r\u00e3i nh\u1ea5t v\u00e0 l\u00e0 thu\u1ed1c co m\u1ea1ch \u0111\u01b0\u1ee3c \u01b0a chu\u1ed9ng trong s\u1ed1c nhi\u1ec5m tr\u00f9ng (22,28). T\u00e1c d\u1ee5ng ch\u00ednh c\u1ee7a n\u00f3 l\u00e0 <strong>co m\u1ea1ch qua trung gian th\u1ee5 th\u1ec3 al<\/strong>, nh\u01b0ng n\u00f3 c\u0169ng l\u00e0 ch\u1ea5t <strong>ch\u1ee7 v\u1eadn th\u1ee5 th\u1ec3 p y\u1ebfu<\/strong>, t\u1ea1o ra m\u1ed9t s\u1ed1 m\u1ee9c \u0111\u1ed9 k\u00edch th\u00edch tim. \u0110i\u1ec1u n\u00e0y c\u00f3 th\u1ec3 gi\u1ea3i th\u00edch t\u1ea1i sao co m\u1ea1ch t\u1eeb norepinephrin (\u1edf li\u1ec1u th\u00f4ng th\u01b0\u1eddng) kh\u00f4ng l\u00e0m suy gi\u1ea3m ch\u1ee9c n\u0103ng th\u1eadn (29).<\/p>\n<p><strong>Ch\u1ebf \u0111\u1ed9 li\u1ec1u l\u01b0\u1ee3ng<\/strong><\/p>\n<p>Truy\u1ec1n norepinephrine th\u01b0\u1eddng b\u1eaft \u0111\u1ea7u \u1edf <strong>t\u1ed1c \u0111\u1ed9 5-10 \u00b5g\/ph\u00fat<\/strong>, t\u0103ng d\u1ea7n khi c\u1ea7n thi\u1ebft. K\u00edch th\u00edch th\u1ee5 th\u1ec3 p c\u00f3 th\u1ec3 l\u00e0m t\u0103ng l\u01b0u l\u01b0\u1ee3ng tim \u1edf ph\u1ea1m vi li\u1ec1u th\u1ea5p (&lt;10 \u00b5g\/ph\u00fat), trong khi co m\u1ea1ch do k\u00edch th\u00edch th\u1ee5 th\u1ec3 a b\u1eaft \u0111\u1ea7u chi\u1ebfm \u01b0u th\u1ebf \u1edf li\u1ec1u tr\u00ean 10 p.g\/ph\u00fat. Khi <strong>li\u1ec1u \u0111\u1ea1t 30 \u00b5g\/ph\u00fat<\/strong>, vi\u1ec7c t\u0103ng th\u00eam li\u1ec1u kh\u00f4ng c\u00f3 kh\u1ea3 n\u0103ng t\u1ea1o ra ph\u1ea3n \u1ee9ng co m\u1ea1ch nhi\u1ec1u h\u01a1n v\u00e0 c\u00f3 th\u1ec3 th\u00eam thu\u1ed1c co m\u1ea1ch <strong>th\u1ee9 hai <\/strong>t\u1ea1i th\u1eddi \u0111i\u1ec3m n\u00e0y.<\/p>\n<p><strong>C\u00e1c t\u00e1c d\u1ee5ng ph\u1ee5<\/strong><\/p>\n<p>C\u00e1c t\u00e1c d\u1ee5ng ph\u1ee5 nghi\u00eam tr\u1ecdng li\u00ean quan \u0111\u1ebfn truy\u1ec1n norepinephrine bao g\u1ed3m c\u00e1c <strong>bi\u1ebfn c\u1ed1 thi\u1ebfu m\u00e1u c\u1ee5c b\u1ed9 <\/strong>(thi\u1ebfu m\u00e1u c\u1ee5c b\u1ed9 c\u01a1 tim, n\u00e3o ho\u1eb7c chi) v\u00e0 <strong>lo\u1ea1n nh\u1ecbp tim <\/strong>(nh\u1ecbp tim nhanh v\u00e0 nh\u1ecbp tim ch\u1eadm). Nh\u1eefng bi\u1ebfn ch\u1ee9ng n\u00e0y \u0111\u00e3 \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o \u1edf kho\u1ea3ng <strong>10% b\u1ec7nh nh\u00e2n <\/strong>(30), nh\u01b0ng c\u00f3 th\u1ec3 nhi\u1ec1u bi\u1ebfn ch\u1ee9ng n\u00e0y l\u00e0 k\u1ebft qu\u1ea3 c\u1ee7a s\u1ed1c ch\u1ee9 kh\u00f4ng ph\u1ea3i thu\u1ed1c co m\u1ea1ch.<\/p>\n<p><strong>\u1ee8C CH\u1ebe MI\u1ec4N D\u1ecaCH: <\/strong>C\u00f3 b\u1eb1ng ch\u1ee9ng cho th\u1ea5y ho\u1ea1t h\u00f3a b\u1ea1ch c\u1ea7u do c\u00e1c s\u1ea3n ph\u1ea9m c\u1ee7a vi khu\u1ea9n (l\u00e0 m\u1ed9t ph\u1ea7n quan tr\u1ecdng c\u1ee7a ph\u1ea3n \u1ee9ng mi\u1ec5n d\u1ecbch) b\u1ecb \u1ee9c ch\u1ebf trong qu\u00e1 tr\u00ecnh truy\u1ec1n norepinephrine (31). \u0110i\u1ec1u n\u00e0y \u0111\u01b0\u1ee3c cho l\u00e0 do norepinephrine li\u00ean k\u1ebft v\u1edbi c\u00e1c th\u1ee5 th\u1ec3 adrenergic tr\u00ean b\u1ec1 m\u1eb7t b\u1ea1ch c\u1ea7u, v\u00e0 n\u00f3 l\u00e0m t\u0103ng kh\u1ea3 n\u0103ng norepinephrine ho\u1ea1t \u0111\u1ed9ng nh\u01b0 m\u1ed9t ch\u1ea5t \u1ee9c ch\u1ebf mi\u1ec5n d\u1ecbch v\u00e0 l\u00e0m t\u0103ng nguy c\u01a1 nhi\u1ec5m tr\u00f9ng. \u00dd ngh\u0129a l\u00e2m s\u00e0ng c\u1ee7a \u0111i\u1ec1u n\u00e0y v\u1eabn ch\u01b0a r\u00f5 r\u00e0ng, nh\u01b0ng \u00fd ngh\u0129a tr\u1edb tr\u00eau th\u00ec kh\u00e1 r\u00f5 r\u00e0ng, x\u00e9t \u0111\u1ebfn s\u1ef1 ph\u1ed5 bi\u1ebfn c\u1ee7a norepinephrine trong \u0111i\u1ec1u tr\u1ecb s\u1ed1c nhi\u1ec5m tr\u00f9ng.<\/p>\n<table>\n<tbody>\n<tr>\n<td colspan=\"3\" width=\"603\"><strong>B\u1ea2NG 14.4 Thu\u1ed1c l\u00e0m co m\u1ea1ch ngo\u00e0i \u0111\u01b0\u1eddng ti\u00eau h\u00f3a<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"116\"><strong>Thu\u1ed1c<\/strong><\/td>\n<td width=\"140\"><strong>Li\u1ec1u<\/strong><\/td>\n<td width=\"347\"><strong>B\u00e0n lu\u1eadn<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"116\">Norepinephrine<\/td>\n<td width=\"140\">5-40 \u00b5g\/ph\u00fat<\/td>\n<td width=\"347\">Thu\u1ed1c co m\u1ea1ch \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng r\u1ed9ng r\u00e3i nh\u1ea5t trong s\u1ed1c l\u00e2m s\u00e0ng<\/td>\n<\/tr>\n<tr>\n<td width=\"116\">Epinephrine<\/td>\n<td width=\"140\">0.1-0.5\u00b5g\/kg\/ph\u00fat<\/td>\n<td width=\"347\">Thu\u1ed1c l\u1ef1a ch\u1ecdn cho t\u00ecnh tr\u1ea1ng s\u1ed1c ph\u1ea3n v\u1ec7 v\u00e0 l\u00e0 thu\u1ed1c \u0111i\u1ec1u tr\u1ecb th\u1ee9 hai cho t\u00ecnh tr\u1ea1ng s\u1ed1c nhi\u1ec5m tr\u00f9ng Th\u00fac \u0111\u1ea9y s\u1ea3n xu\u1ea5t lactat<\/td>\n<\/tr>\n<tr>\n<td width=\"116\">Dopamine<\/td>\n<td width=\"140\">5-50 \u00b5g\/kg\/ph\u00fat<\/td>\n<td width=\"347\">Tr\u01b0\u1edbc \u0111\u00e2y ph\u1ed5 bi\u1ebfn nh\u01b0ng b\u1ecb h\u1ea1n ch\u1ebf b\u1edfi k\u00edch th\u00edch tim kh\u00f4ng mong mu\u1ed1n<\/td>\n<\/tr>\n<tr>\n<td width=\"116\">Phenylephrine<\/td>\n<td width=\"140\">0.5-6 \u00b5g\/kg\/ph\u00fat<\/td>\n<td width=\"347\">M\u1ed9t ch\u1ea5t ch\u1ee7 v\u1eadn a thu\u1ea7n t\u00fay \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng ch\u1ee7 y\u1ebfu \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb h\u1ea1 huy\u1ebft \u00e1p li\u00ean quan \u0111\u1ebfn g\u00e2y m\u00ea<\/td>\n<\/tr>\n<tr>\n<td width=\"116\">Vasopressin<\/td>\n<td width=\"140\">0.01-0.04 Unit\/h<\/td>\n<td width=\"347\">\u0110\u01b0\u1ee3c s\u1eed d\u1ee5ng nh\u01b0 m\u1ed9t thu\u1ed1c th\u1ee9 hai trong c\u00e1c tr\u01b0\u1eddng h\u1ee3p s\u1ed1c nhi\u1ec5m tr\u00f9ng tr\u01a1 v\u1edbi norepinephrine<\/td>\n<\/tr>\n<tr>\n<td width=\"116\">Angiotensin II<\/td>\n<td colspan=\"2\" width=\"487\">0.02-0.08 \u00b5g\/kg\/ph\u00fat ban \u0111\u1ea7u, sau \u0111\u00f3 truy\u1ec1n &lt;0.04 \u00b5g\/kg\/ph\u00fat<\/p>\n<p>C\u00f3 th\u1ec3 th\u00fac \u0111\u1ea9y huy\u1ebft kh\u1ed1i t\u0129nh m\u1ea1ch<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>Epinephrine<\/p>\n<p>Epinephrine l\u00e0 m\u1ed9t ch\u1ea5t ch\u1ee7 v\u1eadn th\u1ee5 th\u1ec3 \u03b2 m\u1ea1nh t\u1ea1o ra s\u1ef1 gia t\u0103ng <strong>ph\u1ee5 thu\u1ed9c v\u00e0o li\u1ec1u <\/strong>l\u01b0\u1ee3ng v\u1ec1 <strong>nh\u1ecbp tim<\/strong>, <strong>th\u1ec3 t\u00edch nh\u00e1t b\u00f3p <\/strong>v\u00e0 <strong>huy\u1ebft \u00e1p <\/strong>(32). N\u00f3 c\u00f3 vai tr\u00f2 quan tr\u1ecdng trong h\u1ed3i s\u1ee9c tim ph\u1ed5i (xem Ch\u01b0\u01a1ng 21) v\u00e0 trong h\u1ed3i s\u1ee9c s\u1ed1c ph\u1ea3n v\u1ec7 (xem Ch\u01b0\u01a1ng 17), nh\u01b0ng n\u00f3 <strong>l\u00e0 thu\u1ed1c co m\u1ea1ch h\u00e0ng th\u1ee9 hai trong s\u1ed1c nhi\u1ec5m tr\u00f9ng <\/strong>v\u00e0 \u0111\u01b0\u1ee3c d\u00e0nh ri\u00eang cho c\u00e1c tr\u01b0\u1eddng h\u1ee3p h\u1ea1 huy\u1ebft \u00e1p kh\u00f4ng \u0111\u00e1p \u1ee9ng v\u1edbi norepinephrine.<\/p>\n<p><strong>Chi\u1ebfn l\u01b0\u1ee3c li\u1ec1u<\/strong><\/p>\n<p>Li\u1ec1u l\u01b0\u1ee3ng khuy\u1ebfn c\u00e1o cho epinephrine trong h\u1ed3i s\u1ee9c tim ph\u1ed5i v\u00e0 s\u1ed1c ph\u1ea3n v\u1ec7 \u0111\u01b0\u1ee3c tr\u00ecnh b\u00e0y l\u1ea7n l\u01b0\u1ee3t trong Ch\u01b0\u01a1ng 21 v\u00e0 17. \u0110\u1ed1i v\u1edbi s\u1ed1c nhi\u1ec5m tr\u00f9ng, epinephrine \u0111\u01b0\u1ee3c truy\u1ec1n li\u00ean t\u1ee5c m\u00e0 kh\u00f4ng c\u00f3 li\u1ec1u t\u1ea3i, b\u1eaft \u0111\u1ea7u t\u1eeb <strong>0,1 \u00b5g\/kg\/ph\u00fat <\/strong>v\u00e0 t\u0103ng d\u1ea7n khi c\u1ea7n. Li\u1ec1u <strong>t\u1ed1i \u0111a l\u00e0 0,5 \u00b5g\/kg\/ph\u00fat <\/strong>(27).<\/p>\n<p><strong>C\u00e1c t\u00e1c d\u1ee5ng ph\u1ee5<\/strong><\/p>\n<p>C\u00e1c t\u00e1c d\u1ee5ng ph\u1ee5 c\u1ee7a epinephrine bao g\u1ed3m k\u00edch th\u00edch tim kh\u00f4ng mong mu\u1ed1n (t\u1ee9c l\u00e0 nh\u1ecbp tim nhanh v\u00e0 lo\u1ea1n nh\u1ecbp tim), v\u00e0 <strong>gi\u1ea3m t\u01b0\u1edbi m\u00e1u t\u1ea1ng <\/strong>do co m\u1ea1ch qua trung gian a (33), c\u00f3 th\u1ec3 <strong>l\u00e0m h\u1ecfng h\u00e0ng r\u00e0o ni\u00eam m\u1ea1c <\/strong>trong ru\u1ed9t. Epinephrine c\u0169ng c\u00f3 c\u00e1c t\u00e1c d\u1ee5ng chuy\u1ec3n h\u00f3a kh\u00f4ng mong mu\u1ed1n, bao g\u1ed3m <strong>t\u0103ng t\u1ef7 l\u1ec7 chuy\u1ec3n h\u00f3a <\/strong>(ph\u1ea3n t\u00e1c d\u1ee5ng trong h\u1ed9i ch\u1ee9ng s\u1ed1c), <strong>t\u0103ng \u0111\u01b0\u1eddng huy\u1ebft <\/strong>(do \u1ee9c ch\u1ebf ti\u1ebft insulin qua trung gian th\u1ee5 th\u1ec3 a) v\u00e0 <strong>t\u0103ng n\u1ed3ng \u0111\u1ed9 lactat <\/strong>huy\u1ebft t\u01b0\u01a1ng (do t\u0103ng s\u1ea3n xu\u1ea5t lactat hi\u1ebfu kh\u00ed) (34). S\u1ef1 gia t\u0103ng n\u1ed3ng \u0111\u1ed9 lactat c\u00f3 th\u1ec3 g\u00e2y hi\u1ec3u l\u1ea7m trong h\u1ed9i ch\u1ee9ng s\u1ed1c.<\/p>\n<p>Dopamine<\/p>\n<p>Dopamine l\u00e0 m\u1ed9t catecholamine n\u1ed9i sinh \u0111\u00f3ng vai tr\u00f2 l\u00e0 <strong>ti\u1ec1n ch\u1ea5t c\u1ee7a norepinephrine<\/strong>. Tr\u01b0\u1edbc \u0111\u00e2y, n\u00f3 l\u00e0 thu\u1ed1c l\u00e0m co m\u1ea1ch \u0111\u01b0\u1ee3c \u01b0a chu\u1ed9ng trong s\u1ed1c nhi\u1ec5m tr\u00f9ng, nh\u01b0ng xu h\u01b0\u1edbng g\u00e2y nh\u1ecbp tim nhanh v\u00e0 lo\u1ea1n nh\u1ecbp tim \u0111\u00e1ng k\u1ec3 \u0111\u00e3 khi\u1ebfn n\u00f3 kh\u00f4ng c\u00f2n \u0111\u01b0\u1ee3c \u01b0a chu\u1ed9ng n\u1eefa. Dopamine c\u00f3 nhi\u1ec1u t\u00e1c d\u1ee5ng ph\u1ee5 thu\u1ed9c v\u00e0o li\u1ec1u l\u01b0\u1ee3ng (35):<\/p>\n<ul>\n<li>\u1ede t\u1ed1c \u0111\u1ed9 truy\u1ec1n th\u1ea5p <strong>(&lt;3 \u00b5g\/kg\/ph\u00fat)<\/strong>, dopamine k\u00edch ho\u1ea1t ch\u1ecdn l\u1ecdc c\u00e1c th\u1ee5 th\u1ec3 \u0111\u1eb7c hi\u1ec7u dopamine trong tu\u1ea7n ho\u00e0n th\u1eadn v\u00e0 t\u1ea1ng, d\u1eabn \u0111\u1ebfn t\u0103ng l\u01b0u l\u01b0\u1ee3ng m\u00e1u \u1edf c\u00e1c v\u00f9ng n\u00e0y.<\/li>\n<li>\u1ede t\u1ed1c \u0111\u1ed9 truy\u1ec1n v\u1eeba ph\u1ea3i <strong>(3-10 \u00b5g\/kg\/ph\u00fat)<\/strong>, dopamine k\u00edch th\u00edch c\u00e1c th\u1ee5 th\u1ec3 p \u1edf tim v\u00e0 tu\u1ea7n ho\u00e0n ngo\u1ea1i vi, t\u1ea1o ra s\u1ef1 gia t\u0103ng cung l\u01b0\u1ee3ng nh\u00e1t b\u00f3p tim.<\/li>\n<li>\u1ede t\u1ed1c \u0111\u1ed9 truy\u1ec1n cao <strong>(&gt;10 \u00b5g\/kg\/ph\u00fat)<\/strong>, dopamine t\u1ea1o ra s\u1ef1 k\u00edch ho\u1ea1t ph\u1ee5 thu\u1ed9c v\u00e0o li\u1ec1u l\u01b0\u1ee3ng c\u1ee7a c\u00e1c th\u1ee5 th\u1ec3 a trong tu\u1ea7n ho\u00e0n ngo\u1ea1i vi, d\u1eabn \u0111\u1ebfn co m\u1ea1ch ti\u1ebfn tri\u1ec3n v\u00e0 t\u0103ng s\u1ee9c c\u1ea3n m\u1ea1ch m\u00e1u to\u00e0n th\u00e2n. T\u00e1c d\u1ee5ng l\u00e0m co m\u1ea1ch n\u00e0y l\u00e0m <strong>t\u0103ng h\u1eadu t\u1ea3i t\u00e2m th\u1ea5t <\/strong>v\u00e0 c\u00f3 th\u1ec3 <strong>\u0111\u1ed1i kh\u00e1ng s\u1ef1 gia t\u0103ng th\u1ec3 t\u00edch nh\u00e1t b\u00f3p <\/strong>do li\u1ec1u dopamine th\u1ea5p h\u01a1n g\u00e2y ra.<\/li>\n<\/ul>\n<p><strong>Chi\u1ebfn l\u01b0\u1ee3c li\u1ec1u<\/strong><\/p>\n<p>Dopamine th\u01b0\u1eddng \u0111\u01b0\u1ee3c b\u1eaft \u0111\u1ea7u \u1edf li\u1ec1u 5 \u00b5g\/kg\/ph\u00fat v\u00e0 \u0111\u01b0\u1ee3c t\u0103ng d\u1ea7n khi c\u1ea7n thi\u1ebft. Li\u1ec1u 5-10 \u00b5g\/kg\/ph\u00fat th\u01b0\u1eddng s\u1ebd l\u00e0m t\u0103ng cung l\u01b0\u1ee3ng tim, nh\u01b0ng c\u00f3 th\u1ec3 c\u1ea7n li\u1ec1u cao h\u01a1n (&gt;10 \u00b5g\/kg\/ph\u00fat) \u0111\u1ec3 l\u00e0m t\u0103ng huy\u1ebft \u00e1p. L\u1ee3i \u00edch c\u1ee7a dopamine th\u01b0\u1eddng th\u1ea5y <strong>\u1edf li\u1ec1u 5-20 \u00b5g\/kg\/ph\u00fat<\/strong>, nh\u01b0ng li\u1ec1u 50 \u00b5g\/kg\/ph\u00fat v\u00e0 th\u1eadm ch\u00ed cao h\u01a1n \u0111\u00e3 \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o (35).<\/p>\n<p><strong>C\u00e1c t\u00e1c d\u1ee5ng ph\u1ee5<\/strong><\/p>\n<p>R\u1ee7i ro ch\u00ednh v\u1edbi dopamine l\u00e0 <strong>nh\u1ecbp tim nhanh <\/strong>v\u00e0 <strong>lo\u1ea1n nh\u1ecbp nhanh <\/strong>(v\u00ed d\u1ee5, rung nh\u0129), x\u1ea3y ra th\u01b0\u1eddng xuy\u00ean h\u01a1n v\u1edbi dopamine so v\u1edbi c\u00e1c thu\u1ed1c l\u00e0m co m\u1ea1ch kh\u00e1c (36). Nh\u01b0 \u0111\u00e3 \u0111\u1ec1 c\u1eadp, r\u1ee7i ro n\u00e0y \u0111\u00e3 d\u1eabn \u0111\u1ebfn s\u1ef1 suy gi\u1ea3m \u0111\u00e1ng k\u1ec3 v\u1ec1 m\u1ee9c \u0111\u1ed9 s\u1eed d\u1ee5ng ph\u1ed5 bi\u1ebfn c\u1ee7a dopamine \u0111\u1ed1i v\u1edbi c\u1ea3 s\u1ed1c tim v\u00e0 s\u1ed1c nhi\u1ec5m tr\u00f9ng. M\u1ed9t r\u1ee7i ro kh\u00e1c v\u1edbi dopamine \u0111\u00e1ng \u0111\u01b0\u1ee3c \u0111\u1ec1 c\u1eadp l\u00e0 <strong>t\u0103ng nh\u00e3n \u00e1p<\/strong>, \u0111\u00e3 \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o \u1edf li\u1ec1u th\u1ea5p (1-4 <strong>\u00b5<\/strong>g\/kg\/ph\u00fat) (37).<\/p>\n<p>Phenylephrine<\/p>\n<p>Phenylephrine l\u00e0 ch\u1ea5t <strong>ch\u1ee7 v\u1eadn th\u1ee5 th\u1ec3 \u03b1 tinh khi\u1ebft <\/strong>g\u00e2y co m\u1ea1ch lan r\u1ed9ng, c\u00f3 th\u1ec3 \u0111i k\u00e8m v\u1edbi <strong>nh\u1ecbp tim ch\u1eadm<\/strong>, <strong>gi\u1ea3m cung l\u01b0\u1ee3ng tim <\/strong>(th\u01b0\u1eddng \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n suy tim) v\u00e0 gi\u1ea3m t\u01b0\u1edbi m\u00e1u th\u1eadn v\u00e0 ru\u1ed9t. C\u00f4ng d\u1ee5ng ch\u00ednh c\u1ee7a phenylephrine l\u00e0 \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb h\u1ea1 huy\u1ebft \u00e1p do g\u00e2y m\u00ea (t\u1ee7y s\u1ed1ng ho\u1eb7c to\u00e0n th\u00e2n), trong \u0111\u00f3 thu\u1ed1c th\u01b0\u1eddng \u0111\u01b0\u1ee3c d\u00f9ng v\u1edbi li\u1ec1u bolus. <strong>Phenylephrine kh\u00f4ng \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o cho b\u1ea5t k\u1ef3 h\u1ed9i ch\u1ee9ng s\u1ed1c n\u00e0o <\/strong>(22,38), m\u1eb7c d\u00f9 m\u1ed9t nghi\u00ean c\u1ee9u l\u00e2m s\u00e0ng so s\u00e1nh phenylephrine v\u00e0 norepinephrine trong s\u1ed1c nhi\u1ec5m tr\u00f9ng cho th\u1ea5y kh\u00f4ng c\u00f3 s\u1ef1 kh\u00e1c bi\u1ec7t v\u1ec1 t\u00e1c d\u1ee5ng huy\u1ebft \u0111\u1ed9ng ho\u1eb7c k\u1ebft qu\u1ea3 l\u00e2m s\u00e0ng v\u1edbi b\u1ea5t k\u1ef3 lo\u1ea1i thu\u1ed1c n\u00e0o (39). Trong ICU, phenylephrine h\u1eefu \u00edch trong vi\u1ec7c ki\u1ec3m so\u00e1t s\u1ed1c nhi\u1ec5m tr\u00f9ng \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ecb rung nh\u0129 nhanh (quan s\u00e1t c\u1ee7a t\u00e1c gi\u1ea3).<\/p>\n<p><strong>Chi\u1ebfn l\u01b0\u1ee3c li\u1ec1u<\/strong><\/p>\n<ul>\n<li>\u0110\u1ec3 \u0111i\u1ec1u tr\u1ecb h\u1ea1 huy\u1ebft \u00e1p trong khi g\u00e2y m\u00ea, phenylephrine c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c d\u00f9ng d\u01b0\u1edbi d\u1ea1ng <strong>li\u1ec1u bolus 50-100 \u00b5g<\/strong>, c\u00f3 th\u1ec3 l\u1eb7p l\u1ea1i m\u1ed9t l\u1ea7n sau v\u00e0i ph\u00fat n\u1ebfu c\u1ea7n. N\u1ebfu h\u1ea1 huy\u1ebft \u00e1p kh\u00f4ng gi\u1ea3m, th\u00ec n\u00ean truy\u1ec1n li\u00ean t\u1ee5c thu\u1ed1c, b\u1eaft \u0111\u1ea7u v\u1edbi li\u1ec1u 10-35 \u00b5g\/ph\u00fat v\u00e0 t\u0103ng d\u1ea7n. Li\u1ec1u t\u1ed1i \u0111a \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o l\u00e0 200 \u00b5g\/ph\u00fat (38).<\/li>\n<li>\u0110\u1ec3 ki\u1ec3m so\u00e1t s\u1ed1c nhi\u1ec5m tr\u00f9ng, phenylephrine \u0111\u01b0\u1ee3c d\u00f9ng d\u01b0\u1edbi d\u1ea1ng truy\u1ec1n li\u00ean t\u1ee5c m\u00e0 kh\u00f4ng c\u1ea7n li\u1ec1u bolus ban \u0111\u1ea7u, b\u1eaft \u0111\u1ea7u v\u1edbi li\u1ec1u <strong>0,5 \u00b5g\/kg\/ph\u00fat <\/strong>v\u00e0 t\u0103ng d\u1ea7n khi c\u1ea7n. Li\u1ec1u tr\u00ean 6 \u00b5g\/kg\/ph\u00fat kh\u00f3 c\u00f3 th\u1ec3 mang l\u1ea1i b\u1ea5t k\u1ef3 l\u1ee3i \u00edch n\u00e0o n\u1eefa (38).<\/li>\n<\/ul>\n<p>Vasopressin<\/p>\n<p>Vasopressin, c\u00f2n \u0111\u01b0\u1ee3c g\u1ecdi l\u00e0 hormone ch\u1ed1ng b\u00e0i ni\u1ec7u, g\u00e2y co m\u1ea1ch do c\u00e1c <strong>th\u1ee5 th\u1ec3 vasopressin (V1) <\/strong>chuy\u00ean bi\u1ec7t tr\u00ean c\u01a1 tr\u01a1n m\u1ea1ch m\u00e1u. Co m\u1ea1ch n\u1ed5i b\u1eadt nh\u1ea5t \u1edf <strong>da, c\u01a1 x\u01b0\u01a1ng <\/strong>v\u00e0 <strong>tu\u1ea7n ho\u00e0n t\u1ea1ng <\/strong>(39). Vasopressin kh\u00f4ng l\u00e0m t\u0103ng huy\u1ebft \u00e1p \u1edf nh\u1eefng ng\u01b0\u1eddi t\u00ecnh nguy\u1ec7n kh\u1ecfe m\u1ea1nh, nh\u01b0ng n\u00f3 c\u00f3 th\u1ec3 g\u00e2y t\u0103ng huy\u1ebft \u00e1p \u0111\u00e1ng k\u1ec3 \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n b\u1ecb s\u1ed1c gi\u00e3n m\u1ea1ch (40). C\u00e1c t\u00e1c d\u1ee5ng kh\u00e1c c\u1ee7a vasopressin bao g\u1ed3m t\u0103ng c\u01b0\u1eddng t\u00e1i h\u1ea5p thu n\u01b0\u1edbc \u1edf \u1ed1ng th\u1eadn xa (qua trung gian th\u1ee5 th\u1ec3 V2) v\u00e0 k\u00edch th\u00edch tuy\u1ebfn y\u00ean tr\u01b0\u1edbc gi\u1ea3i ph\u00f3ng ACTH (qua trung gian th\u1ee5 th\u1ec3 V3).<\/p>\n<p><strong>S\u1eed d\u1ee5ng nh\u01b0 l\u00e0 m\u1ed9t thu\u1ed1c co m\u1ea1ch<\/strong><\/p>\n<p>Vasopressin c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng trong c\u00e1c t\u00ecnh hu\u1ed1ng l\u00e2m s\u00e0ng sau.<\/p>\n<ul>\n<li>Trong qu\u00e1 tr\u00ecnh h\u1ed3i s\u1ee9c ng\u1eebng tim, vasopressin c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c d\u00f9ng d\u01b0\u1edbi d\u1ea1ng <strong>li\u1ec1u IV duy nh\u1ea5t (40 \u0111\u01a1n v\u1ecb) <\/strong>\u0111\u1ec3 thay th\u1ebf li\u1ec1u epinephrine \u0111\u1ea7u ti\u00ean ho\u1eb7c th\u1ee9 hai.<\/li>\n<li>Trong tr\u01b0\u1eddng h\u1ee3p s\u1ed1c nhi\u1ec5m tr\u00f9ng kh\u00e1ng v\u1edbi h\u1ed7 tr\u1ee3 huy\u1ebft \u0111\u1ed9ng b\u1eb1ng norepinephrine (th\u01b0\u1eddng \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 <strong>li\u1ec1u norepinephrine &gt;0,2 \u00b5g\/kg\/ph\u00fat <\/strong>m\u00e0 kh\u00f4ng c\u00f3 huy\u1ebft \u00e1p th\u00edch h\u1ee3p), n\u00ean b\u1ed5 sung vasopressin (22), v\u00ec \u0111i\u1ec1u n\u00e0y c\u00f3 th\u1ec3 l\u00e0m t\u0103ng huy\u1ebft \u00e1p v\u00e0 gi\u1ea3m nhu c\u1ea7u catecholamine (t\u00e1c d\u1ee5ng <strong>ti\u1ebft ki\u1ec7m catecholamine<\/strong>). Tuy nhi\u00ean, vi\u1ec7c b\u1ed5 sung vasopressin kh\u00f4ng c\u00f3 l\u1ee3i \u00edch s\u1ed1ng s\u00f3t \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ee9ng minh (41).<\/li>\n<\/ul>\n<p><strong>Chi\u1ebfn l\u01b0\u1ee3c li\u1ec1u<\/strong><\/p>\n<p>\u0110\u1ed1i v\u1edbi s\u1ed1c nhi\u1ec5m tr\u00f9ng, vasopressin \u0111\u01b0\u1ee3c truy\u1ec1n li\u00ean t\u1ee5c v\u1edbi <strong>t\u1ed1c \u0111\u1ed9 0,03-0,04 \u0111\u01a1n v\u1ecb\/gi\u1edd<\/strong>. Li\u1ec1u l\u01b0\u1ee3ng n\u00e0y kh\u00f4ng \u0111\u01b0\u1ee3c chu\u1ea9n \u0111\u1ed9 (kh\u00f4ng gi\u1ed1ng nh\u01b0 thu\u1ed1c l\u00e0m co m\u1ea1ch catecholamine). C\u00e1c t\u00e1c d\u1ee5ng ph\u1ee5 c\u1ee7a vasopressin t\u01b0\u01a1ng t\u1ef1 v\u1ec1 lo\u1ea1i v\u00e0 t\u1ea7n su\u1ea5t nh\u01b0 nh\u1eefng t\u00e1c d\u1ee5ng ph\u1ee5 \u0111\u00e3 \u0111\u1ec1 c\u1eadp tr\u01b0\u1edbc \u0111\u00f3 \u0111\u1ed1i v\u1edbi norepinephrine (30).<\/p>\n<p>Angiotensin II<\/p>\n<p>Angiotensin II l\u00e0 m\u1ed9t ch\u1ea5t t\u01b0\u01a1ng t\u1ef1 t\u1ed5ng h\u1ee3p c\u1ee7a angiotensin \u1edf ng\u01b0\u1eddi, t\u00e1c \u0111\u1ed9ng l\u00ean c\u01a1 tr\u01a1n m\u1ea1ch m\u00e1u \u0111\u1ec3 th\u00fac \u0111\u1ea9y co m\u1ea1ch to\u00e0n th\u00e2n v\u00e0 c\u0169ng k\u00edch th\u00edch gi\u1ea3i ph\u00f3ng vasopressin t\u1eeb tuy\u1ebfn y\u00ean sau. Thu\u1ed1c \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ea5p thu\u1eadn s\u1eed d\u1ee5ng trong s\u1ed1c gi\u00e3n m\u1ea1ch v\u00e0o n\u0103m 2018 v\u00e0 ch\u1ee7 y\u1ebfu \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng trong c\u00e1c tr\u01b0\u1eddng h\u1ee3p tr\u01a1 norepinephrine. Thu\u1ed1c \u0111\u00e3 l\u00e0m t\u0103ng huy\u1ebft \u00e1p \u1edf 67% c\u00e1c tr\u01b0\u1eddng h\u1ee3p (42), nh\u01b0ng t\u00e1c \u0111\u1ed9ng \u0111\u1ebfn t\u1ef7 l\u1ec7 t\u1eed vong v\u1eabn ch\u01b0a nh\u1ea5t qu\u00e1n (42,43).<\/p>\n<p><strong>Chi\u1ebfn l\u01b0\u1ee3c li\u1ec1u<\/strong><\/p>\n<p>Angiotensin II \u0111\u01b0\u1ee3c d\u00f9ng b\u1eb1ng c\u00e1ch truy\u1ec1n t\u0129nh m\u1ea1ch li\u00ean t\u1ee5c: li\u1ec1u kh\u1edfi \u0111\u1ea7u l\u00e0 20 ng\/kg\/ph\u00fat (0,02 \u00b5g\/kg\/ph\u00fat), c\u00f3 th\u1ec3 t\u0103ng li\u1ec1u sau m\u1ed7i 10-15 ph\u00fat n\u1ebfu c\u1ea7n, l\u00ean \u0111\u1ebfn 80 ng\/kg\/ph\u00fat (0,08 \u00b5g\/kg\/ph\u00fat) trong 3 gi\u1edd \u0111\u1ea7u ti\u00ean (44). Sau \u0111\u00f3, li\u1ec1u duy tr\u00ec <strong>kh\u00f4ng \u0111\u01b0\u1ee3c v\u01b0\u1ee3t qu\u00e1 40 ng\/kg\/ph\u00fat <\/strong>(0,04 \u00b5g\/kg\/ph\u00fat). Kh\u00f4ng c\u00f3 s\u1ef1 \u0111i\u1ec1u ch\u1ec9nh li\u1ec1u cho t\u00ecnh tr\u1ea1ng suy gan ho\u1eb7c suy th\u1eadn.<\/p>\n<p><strong>C\u00e1c t\u00e1c d\u1ee5ng ph\u1ee5<\/strong><\/p>\n<p>R\u1ee7i ro ch\u00ednh v\u1edbi angiotensin II l\u00e0 <strong>huy\u1ebft kh\u1ed1i t\u0129nh m\u1ea1ch<\/strong>. Angiotensin k\u00edch th\u00edch gi\u1ea3i ph\u00f3ng ch\u1ea5t \u1ee9c ch\u1ebf ho\u1ea1t h\u00f3a plasminogen-1 t\u1eeb c\u01a1 tr\u01a1n m\u1ea1ch m\u00e1u, ng\u0103n ch\u1eb7n qu\u00e1 tr\u00ecnh ti\u00eau fibrin v\u00e0 c\u0169ng l\u00e0m t\u0103ng s\u1ef1 k\u1ebft d\u00ednh ti\u1ec3u c\u1ea7u. Trong m\u1ed9t th\u1eed nghi\u1ec7m l\u00e2m s\u00e0ng, t\u1ef7 l\u1ec7 c\u00e1c bi\u1ebfn c\u1ed1 huy\u1ebft kh\u1ed1i v\u1edbi angiotensin II cao g\u1ea5p \u0111\u00f4i so v\u1edbi t\u1ef7 l\u1ec7 v\u1edbi gi\u1ea3 d\u01b0\u1ee3c (l\u1ea7n l\u01b0\u1ee3t l\u00e0 13% so v\u1edbi 5%) (44).<\/p>\n<p>Midodrine<\/p>\n<p>Midodrine l\u00e0 thu\u1ed1c <strong>ch\u1ee7 v\u1eadn th\u1ee5 th\u1ec3 a <\/strong>d\u00f9ng <strong>\u0111\u01b0\u1eddng u\u1ed1ng <\/strong>\u0111\u00e3 \u0111\u01b0\u1ee3c FDA ch\u1ea5p thu\u1eadn v\u00e0o n\u0103m 1996 \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb h\u1ea1 huy\u1ebft \u00e1p t\u01b0 th\u1ebf \u0111\u1ee9ng. Kinh nghi\u1ec7m l\u00e2m s\u00e0ng v\u1edbi midodrine trong ICU \u0111\u01b0\u1ee3c t\u00f3m t\u1eaft d\u01b0\u1edbi \u0111\u00e2y.<\/p>\n<ul>\n<li>Midodrine \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ee9ng minh l\u00e0 c\u00f3 hi\u1ec7u qu\u1ea3 trong vi\u1ec7c h\u1ea1n ch\u1ebf ho\u1eb7c ng\u0103n ng\u1eeba h\u1ea1 huy\u1ebft \u00e1p trong qu\u00e1 tr\u00ecnh th\u1ea9m ph\u00e2n m\u00e1u (45). Li\u1ec1u hi\u1ec7u qu\u1ea3 thay \u0111\u1ed5i t\u1eeb 5 mg \u0111\u1ebfn 20 mg, d\u00f9ng 20-30 ph\u00fat tr\u01b0\u1edbc khi th\u1ea9m ph\u00e2n. C\u00f3 th\u1ec3 d\u00f9ng th\u00eam m\u1ed9t li\u1ec1u nh\u1ecf h\u01a1n trong qu\u00e1 tr\u00ecnh th\u1ea9m ph\u00e2n n\u1ebfu c\u1ea7n.<\/li>\n<li>\u0110i\u1ec1u tr\u1ecb b\u1ed5 tr\u1ee3 b\u1eb1ng midodrine (20 mg m\u1ed7i 8 gi\u1edd) kh\u00f4ng l\u00e0m t\u0103ng t\u1ed1c \u0111\u1ed9 ng\u1eebng li\u1ec7u ph\u00e1p thu\u1ed1c co m\u1ea1ch ngo\u00e0i \u0111\u01b0\u1eddng ti\u00eau h\u00f3a (46,47).<\/li>\n<\/ul>\n<p>M\u1eb7c d\u00f9 \u0111\u01b0\u1ee3c coi l\u00e0 thu\u1ed1c co m\u1ea1ch d\u1ec5 d\u00f9ng, midodrine kh\u00f4ng mang l\u1ea1i l\u1ee3i \u00edch g\u00ec trong vi\u1ec7c ki\u1ec3m so\u00e1t t\u00ecnh tr\u1ea1ng s\u1ed1c.<\/p>\n<h2>C\u00c1C M\u1ee4C TI\u00caU H\u1ed2I S\u1ee8C<\/h2>\n<p>M\u1ee5c ti\u00eau h\u1ed3i s\u1ee9c cho t\u00ecnh tr\u1ea1ng s\u1ed1c l\u00e2m s\u00e0ng \u0111\u00e3 \u0111\u01b0\u1ee3c \u0111\u1ec1 c\u1eadp trong su\u1ed1t ch\u01b0\u01a1ng n\u00e0y v\u00e0 \u0111\u01b0\u1ee3c t\u00f3m t\u1eaft ng\u1eafn g\u1ecdn t\u1ea1i \u0111\u00e2y. C\u00e1c m\u1ee5c ti\u00eau c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c nh\u00f3m th\u00e0nh hai lo\u1ea1i, <strong>t\u01b0\u1edbi m\u00e1u m\u00f4 <\/strong>v\u00e0 <strong>v\u1eadn chuy\u1ec3n oxy<\/strong>, nh\u01b0 th\u1ec3 hi\u1ec7n trong B\u1ea3ng 14.5.<\/p>\n<p>T\u01b0\u1edbi m\u00e1u m\u00f4<\/p>\n<p>T\u1ea7m quan tr\u1ecdng c\u1ee7a <strong>l\u01b0u l\u01b0\u1ee3ng m\u00e1u <\/strong>trong t\u00ecnh tr\u1ea1ng s\u1ed1c d\u1ec5 th\u1ea5y khi b\u1ea1n xem x\u00e9t r\u1eb1ng ba trong b\u1ed1n lo\u1ea1i s\u1ed1c (t\u1ee9c l\u00e0 gi\u1ea3m th\u1ec3 t\u00edch m\u00e1u, s\u1ed1c do tim v\u00e0 s\u1ed1c t\u1eafc ngh\u1ebdn) l\u00e0 t\u00ecnh tr\u1ea1ng l\u01b0u l\u01b0\u1ee3ng m\u00e1u th\u1ea5p. M\u1ed9t trong nh\u1eefng <strong>m\u1ee5c ti\u00eau \u0111\u1ea7u ti\u00ean <\/strong>trong h\u1ed3i s\u1ee9c s\u1ed1c l\u00e0 <strong>\u0111o ch\u00ednh x\u00e1c huy\u1ebft \u00e1p \u0111\u1ed9ng m\u1ea1ch trung b\u00ecnh (MAP)<\/strong>, \u0111\u00e2y l\u00e0 \u00e1p su\u1ea5t th\u00fac \u0111\u1ea9y l\u01b0u l\u01b0\u1ee3ng m\u00e1u ngo\u1ea1i vi. \u0110i\u1ec1u n\u00e0y \u0111\u00f2i h\u1ecfi ph\u1ea3i ghi l\u1ea1i \u00e1p su\u1ea5t \u0111\u1ed9ng m\u1ea1ch tr\u1ef1c ti\u1ebfp t\u1eeb catheter \u0111\u1ed9ng m\u1ea1ch. Khi \u0111\u1ea1t \u0111\u01b0\u1ee3c \u0111i\u1ec1u n\u00e0y, MAP ph\u1ea3i \u0111\u01b0\u1ee3c duy tr\u00ec \u1edf <strong>m\u1ee9c &gt;65 mm Hg<\/strong>. <strong>Kh\u00f4ng theo d\u00f5i huy\u1ebft \u00e1p t\u00e2m thu <\/strong>(n\u1ebfu c\u00f3 th\u1ec3), v\u00ec \u0111\u00e2y l\u00e0 s\u00f3ng \u00e1p su\u1ea5t ph\u1ea3n x\u1ea1 truy\u1ec1n tr\u1edf l\u1ea1i tim (t\u1ee9c l\u00e0 ra kh\u1ecfi ngo\u1ea1i vi). H\u00e3y nh\u1edb r\u1eb1ng l\u01b0u l\u01b0\u1ee3ng m\u00e1u trong h\u1ec7 tu\u1ea7n ho\u00e0n vi m\u00f4 l\u00e0 <strong>d\u00f2ng ch\u1ea3y t\u1ea7ng<\/strong>, <strong>kh\u00f4ng ph\u1ea3i d\u00f2ng ch\u1ea3y xung <\/strong>v\u00e0 kh\u00f4ng c\u00f3 th\u00e0nh ph\u1ea7n t\u00e2m thu v\u00e0 t\u00e2m tr\u01b0\u01a1ng.<\/p>\n<p>Theo d\u00f5i cung l\u01b0\u1ee3ng tim b\u1eb1ng <strong>catheter \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i (PA) <\/strong>t\u1eebng l\u00e0 ph\u01b0\u01a1ng ph\u00e1p ch\u00ednh trong qu\u1ea3n l\u00fd ch\u0103m s\u00f3c \u0111\u1eb7c bi\u1ec7t, nh\u01b0ng ph\u01b0\u01a1ng ph\u00e1p n\u00e0y \u0111\u00e3 gi\u1ea3m m\u1ea1nh c\u00e1ch \u0111\u00e2y kho\u1ea3ng 25 n\u0103m do c\u00f3 b\u1eb1ng ch\u1ee9ng cho th\u1ea5y catheter \u0111\u1ed9ng m\u1ea1ch ph\u1ed5i kh\u00f4ng c\u1ea3i thi\u1ec7n kh\u1ea3 n\u0103ng s\u1ed1ng s\u00f3t \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n nguy k\u1ecbch. (<strong>M\u1ed9t ph\u00e1n \u0111o\u00e1n kh\u1eafc nghi\u1ec7t, v\u00ec catheter l\u00e0 thi\u1ebft b\u1ecb theo d\u00f5i, kh\u00f4ng ph\u1ea3i l\u00e0 li\u1ec7u ph\u00e1p<\/strong>.) N\u1ebfu c\u00f3 th\u1ec3 \u0111o cung l\u01b0\u1ee3ng tim, m\u1ee5c ti\u00eau l\u00e0 duy tr\u00ec cung l\u01b0\u1ee3ng tim \u0111i\u1ec1u ch\u1ec9nh theo k\u00edch th\u01b0\u1edbc <strong>(ch\u1ec9 s\u1ed1 tim) tr\u00ean 2,5 L\/ph\u00fat\/m2<\/strong>.<\/p>\n<p>C\u0169ng c\u00f3 th\u1ec3 \u0111\u00e1nh gi\u00e1 t\u01b0\u1edbi m\u00e1u m\u00f4 b\u1eb1ng c\u00e1ch s\u1eed d\u1ee5ng <strong>kho\u1ea3ng tr\u1ed1ng PCO2<\/strong>, \u0111\u00e2y l\u00e0 ph\u00e9p \u0111o l\u01b0\u1ee3ng CO2 \u0111\u00e0o th\u1ea3i kh\u1ecfi m\u00f4. <strong>Kho\u1ea3ng tr\u1ed1ng PCO2 &lt;6 mm Hg <\/strong>\u0111\u01b0\u1ee3c coi l\u00e0 b\u1eb1ng ch\u1ee9ng t\u01b0\u1edbi m\u00e1u m\u00f4 \u0111\u1ea7y \u0111\u1ee7. Ph\u00e9p \u0111o n\u00e0y d\u1ec5 d\u00e0ng thu \u0111\u01b0\u1ee3c v\u00e0 n\u00ean \u0111\u01b0\u1ee3c theo d\u00f5i \u1edf t\u1ea5t c\u1ea3 b\u1ec7nh nh\u00e2n b\u1ecb s\u1ed1c, ngay c\u1ea3 khi c\u00f3 th\u1ec3 \u0111o cung l\u01b0\u1ee3ng tim (v\u00ec l\u01b0u l\u01b0\u1ee3ng vi tu\u1ea7n ho\u00e0n c\u00f3 th\u1ec3 ch\u1eadm khi l\u01b0u l\u01b0\u1ee3ng tim to\u00e0n ph\u1ea7n \u1edf m\u1ee9c b\u00ecnh th\u01b0\u1eddng). L\u01b0u \u00fd: Nhi\u1ec5m toan chuy\u1ec3n h\u00f3a c\u00f3 th\u1ec3 l\u00e0m t\u0103ng s\u1ea3n xu\u1ea5t CO2 kh\u00f4ng chuy\u1ec3n h\u00f3a v\u00e0 \u0111i\u1ec1u n\u00e0y c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn s\u1ef1 gia t\u0103ng kh\u00f4ng mong mu\u1ed1n kho\u1ea3ng tr\u1ed1ng PCO2.<\/p>\n<p>Cu\u1ed1i c\u00f9ng, c\u00f3 th\u1ec3 \u0111\u00e1nh gi\u00e1 t\u01b0\u1edbi m\u00e1u m\u00f4 b\u1eb1ng c\u00e1ch theo d\u00f5i ch\u1ee9c n\u0103ng c\u01a1 quan v\u00e0 l\u01b0\u1ee3ng n\u01b0\u1edbc ti\u1ec3u ph\u00f9 h\u1ee3p cho m\u1ee5c \u0111\u00edch n\u00e0y v\u00ec l\u01b0\u1ee3ng n\u01b0\u1edbc ti\u1ec3u gi\u1ea3m th\u01b0\u1eddng l\u00e0 m\u1ed9t trong nh\u1eefng d\u1ea5u hi\u1ec7u s\u1edbm nh\u1ea5t c\u1ee7a t\u00ecnh tr\u1ea1ng s\u1ed1c s\u1eafp x\u1ea3y ra. V\u00ec thi\u1ec3u ni\u1ec7u \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh b\u1eb1ng l\u01b0\u1ee3ng <strong>n\u01b0\u1edbc ti\u1ec3u &lt;0,5 mL\/kg\/gi\u1edd<\/strong>, m\u1ee5c ti\u00eau h\u1ed3i s\u1ee9c l\u00e0 v\u01b0\u1ee3t ng\u01b0\u1ee1ng n\u00e0y. Tr\u1ea1ng th\u00e1i tinh th\u1ea7n c\u0169ng c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c theo d\u00f5i, nh\u01b0ng kh\u00f4ng d\u1ec5 \u0111\u1ecbnh l\u01b0\u1ee3ng nh\u01b0 l\u01b0\u1ee3ng n\u01b0\u1edbc ti\u1ec3u.<\/p>\n<table>\n<tbody>\n<tr>\n<td colspan=\"2\" width=\"603\"><strong>B\u1ea2NG 14.5 M\u1ee5c ti\u00eau h\u1ed3i s\u1ee9c cho b\u1ec7nh nh\u00e2n s\u1ed1c<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"255\"><strong>Ph\u00e2n lo\u1ea1i<\/strong><\/td>\n<td width=\"347\"><strong>C\u00e1c m\u1ee5c ti\u00eau<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"255\"><strong>T\u01b0\u1edbi m\u00e1u m\u00f4<\/strong><\/td>\n<td width=\"347\">\u2022\u00a0\u00a0\u00a0\u00a0\u00a0 MAP &gt;65 mm Hg<\/p>\n<p>\u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 CI &gt;2.5 L\/ph\u00fat\/m2<\/p>\n<p>\u2022\u00a0\u00a0\u00a0\u00a0\u00a0 PCO2 Gap &lt;6 mm Hg<\/p>\n<p>\u2022\u00a0\u00a0\u00a0\u00a0\u00a0 L\u01b0u l\u01b0\u1ee3ng n\u01b0\u1edbc ti\u1ec3u &gt;0.5 mL\/kg\/hr<\/td>\n<\/tr>\n<tr>\n<td width=\"255\"><strong>V\u1eadn chuy\u1ec3n Oxy<\/strong><\/td>\n<td width=\"347\">\u2022\u00a0\u00a0\u00a0\u00a0\u00a0 DO2 &gt;300 mL\/ph\u00fat\/m2.<\/p>\n<p>\u2022\u00a0\u00a0\u00a0\u00a0\u00a0 VO2 &gt;110 mL\/ph\u00fat\/m2<\/p>\n<p>\u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Chi\u1ebft xu\u1ea5t O2 &lt;50%<\/p>\n<p>\u2022\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 ScvO2 &gt;50%<\/p>\n<p>\u2022\u00a0\u00a0\u00a0\u00a0\u00a0 Lactate &lt;2 mmol\/L<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<p>V\u1eadn chuy\u1ec3n Oxy<\/p>\n<p>Vi\u1ec7c theo d\u00f5i c\u00e1c bi\u1ebfn s\u1ed1 v\u1eadn chuy\u1ec3n O2 c\u00f3 \u00fd ngh\u0129a r\u00f5 r\u00e0ng v\u00ec s\u1ef1 r\u1ed1i lo\u1ea1n \u1edf m\u1ed9t trong nh\u1eefng bi\u1ebfn s\u1ed1 n\u00e0y g\u00e2y ra t\u00ecnh tr\u1ea1ng s\u1ed1c l\u00e2m s\u00e0ng.<\/p>\n<ul>\n<li>Ba trong s\u1ed1 c\u00e1c h\u1ed9i ch\u1ee9ng s\u1ed1c ch\u00ednh (s\u1ed1c gi\u1ea3m th\u1ec3 t\u00edch, s\u1ed1c tim v\u00e0 s\u1ed1c t\u1eafc ngh\u1ebdn) l\u00e0 k\u1ebft qu\u1ea3 c\u1ee7a vi\u1ec7c cung c\u1ea5p O2 kh\u00f4ng \u0111\u1ee7 cho c\u00e1c m\u00f4, th\u01b0\u1eddng l\u00e0 do cung l\u01b0\u1ee3ng tim kh\u00f4ng \u0111\u1ee7, v\u1edbi s\u1ef1 g\u00f3p ph\u1ea7n c\u1ee7a m\u1ee9c hemoglobin th\u1ea5p trong m\u1ed9t tr\u01b0\u1eddng h\u1ee3p (s\u1ed1c m\u1ea5t m\u00e1u). M\u1ee5c ti\u00eau trong nh\u1eefng tr\u01b0\u1eddng h\u1ee3p n\u00e0y l\u00e0 ch\u1ec9 s\u1ed1 tim (CI) &gt;2,5 L\/ph\u00fat\/m2, cung c\u1ea5p O2 (DO2) &gt;300 mL\/ph\u00fat\/m2 v\u00e0 h\u1ea5p th\u1ee5 O2 (VO2) &gt;110 mL\/ph\u00fat\/m2. N\u1ebfu c\u00e1c bi\u1ebfn s\u1ed1 n\u00e0y kh\u00f4ng \u0111\u01b0\u1ee3c theo d\u00f5i (\u0111i\u1ec1u n\u00e0y x\u1ea3y ra trong h\u1ea7u h\u1ebft c\u00e1c tr\u01b0\u1eddng h\u1ee3p), th\u00ec m\u1ee5c ti\u00eau h\u1ed3i s\u1ee9c l\u00e0 \u0111\u1ed9 b\u00e3o h\u00f2a O2 t\u0129nh m\u1ea1ch trung t\u00e2m <strong>(ScvO2) &gt;50% <\/strong>v\u00e0 n\u1ed3ng \u0111\u1ed9 <strong>lactat huy\u1ebft t\u01b0\u01a1ng &lt;2 mmol\/L<\/strong>.<\/li>\n<li>S\u1ed1c nhi\u1ec5m tr\u00f9ng <strong>KH\u00d4NG <\/strong>ph\u1ea3i l\u00e0 k\u1ebft qu\u1ea3 c\u1ee7a vi\u1ec7c cung c\u1ea5p O2 kh\u00f4ng \u0111\u1ee7, m\u00e0 l\u00e0 k\u1ebft qu\u1ea3 c\u1ee7a <strong>khi\u1ebfm khuy\u1ebft <\/strong>trong qu\u00e1 tr\u00ecnh phosphoryl h\u00f3a oxy h\u00f3a \u1edf ty th\u1ec3 b\u1ecb r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng (48,49). T\u00ecnh tr\u1ea1ng n\u00e0y \u0111\u01b0\u1ee3c g\u1ecdi l\u00e0 t\u00ecnh tr\u1ea1ng <strong>thi\u1ebfu oxy t\u1ebf b\u00e0o <\/strong>(48) v\u00e0 c\u00f3 th\u1ec3 li\u00ean quan \u0111\u1ebfn khi\u1ebfm khuy\u1ebft trong qu\u00e1 tr\u00ecnh <strong>chi\u1ebft xu\u1ea5t O2 <\/strong>t\u1eeb m\u00e1u mao m\u1ea1ch. M\u1ee5c ti\u00eau qu\u1ea3n l\u00fd trong tr\u01b0\u1eddng h\u1ee3p n\u00e0y bao g\u1ed3m chi\u1ebft xu\u1ea5t O2 &lt;80% v\u00e0 h\u1ea5p th\u1ee5 O2 (VO2) &gt;110 mL\/ph\u00fat\/m2. (ScvO2 c\u00f3 th\u1ec3 kh\u00f4ng \u0111\u00e1ng tin c\u1eady trong nhi\u1ec5m tr\u00f9ng huy\u1ebft do qu\u00e1 tr\u00ecnh chi\u1ebft xu\u1ea5t O2 b\u1ecb khi\u1ebfm khuy\u1ebft.) N\u1ebfu c\u00e1c bi\u1ebfn s\u1ed1 n\u00e0y kh\u00f4ng \u0111\u01b0\u1ee3c theo d\u00f5i, m\u1ee5c ti\u00eau h\u1ed3i s\u1ee9c ch\u1ec9 \u0111\u01a1n gi\u1ea3n l\u00e0 m\u1ee9c lactat huy\u1ebft t\u01b0\u01a1ng b\u00ecnh th\u01b0\u1eddng. (Vi\u1ec7c qu\u1ea3n l\u00fd s\u1ed1c nhi\u1ec5m tr\u00f9ng \u0111\u01b0\u1ee3c tr\u00ecnh b\u00e0y chi ti\u1ebft trong Ch\u01b0\u01a1ng 17.)<\/li>\n<li>M\u1ee5c ti\u00eau chung c\u1ee7a h\u1ed3i s\u1ee9c trong m\u1ecdi d\u1ea1ng s\u1ed1c l\u00e0 b\u00ecnh th\u01b0\u1eddng h\u00f3a m\u1ee9c lactat huy\u1ebft t\u01b0\u01a1ng (&lt;2 mmol\/L).<\/li>\n<\/ul>\n<p>T\u1ea5t nhi\u00ean, m\u1ee5c ti\u00eau ng\u1ea7m c\u1ee7a h\u1ed3i s\u1ee9c trong s\u1ed1c l\u00e2m s\u00e0ng l\u00e0 <strong>s\u1ef1 s\u1ed1ng c\u00f2n<\/strong>.<\/p>\n<h2>L\u1edcI K\u1ebeT<\/h2>\n<p><strong>H\u1ea1 huy\u1ebft \u00e1p l\u00e0 h\u1eadu qu\u1ea3, kh\u00f4ng ph\u1ea3i l\u00e0 nguy\u00ean nh\u00e2n, c\u1ee7a s\u1ed1c<\/strong><\/p>\n<p>Vi\u1ec7c h\u1ed3i s\u1ee9c s\u1ed1c ch\u1ee7 y\u1ebfu l\u00e0 do mong mu\u1ed1n t\u0103ng huy\u1ebft \u00e1p, d\u1ef1a tr\u00ean gi\u1ea3 \u0111\u1ecbnh r\u1eb1ng huy\u1ebft \u00e1p th\u1ea5p l\u00e0 nguy\u00ean nh\u00e2n g\u00e2y ra s\u1ed1c. Nh\u1eefng quan s\u00e1t sau \u0111\u00e2y t\u1ea1o ra m\u1ed9t s\u1ed1 nghi ng\u1edd v\u1ec1 c\u00e1ch ti\u1ebfp c\u1eadn n\u00e0y.<\/p>\n<ul>\n<li>S\u1ed1c \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 s\u1ef1 <strong>r\u1ed1i lo\u1ea1n trong vi\u1ec7c s\u1eed d\u1ee5ng O2 c\u1ee7a t\u1ebf b\u00e0o <\/strong>(2), kh\u00f4ng ph\u1ea3i l\u00e0 s\u1ef1 r\u1ed1i lo\u1ea1n trong huy\u1ebft \u00e1p.<\/li>\n<li>Gi\u1ea3m h\u1ea1 huy\u1ebft \u00e1p l\u00e0 tr\u1ecdng t\u00e2m ch\u00ednh c\u1ee7a vi\u1ec7c qu\u1ea3n l\u00fd s\u1ed1c trong h\u01a1n 70 n\u0103m (k\u1ec3 t\u1eeb khi norepinephrine \u0111\u01b0\u1ee3c \u0111\u01b0a v\u00e0o s\u1eed d\u1ee5ng l\u00e2m s\u00e0ng v\u00e0o n\u0103m 1950), tuy nhi\u00ean t\u1ef7 l\u1ec7 t\u1eed vong do s\u1ed1c v\u1eabn \u1edf m\u1ee9c cao kh\u00f4ng th\u1ec3 ch\u1ea5p nh\u1eadn \u0111\u01b0\u1ee3c v\u00e0 vi\u1ec7c s\u1eed d\u1ee5ng hai ho\u1eb7c th\u1eadm ch\u00ed ba thu\u1ed1c co m\u1ea1ch kh\u00f4ng mang l\u1ea1i l\u1ee3i \u00edch v\u1ec1 kh\u1ea3 n\u0103ng s\u1ed1ng s\u00f3t (50).<\/li>\n<li><strong>Huy\u1ebft \u00e1p th\u1ea5p x\u1ea3y ra trong c\u00e1c t\u00ecnh tr\u1ea1ng kh\u00e1c ngo\u00e0i s\u1ed1c <\/strong>(v\u00ed d\u1ee5: b\u1ec7nh th\u1ea7n kinh t\u1ef1 ch\u1ee7, suy tuy\u1ebfn th\u01b0\u1ee3ng th\u1eadn, <strong>5% <\/strong>ng\u01b0\u1eddi l\u1edbn kh\u1ecfe m\u1ea1nh) v\u00e0 ch\u00fang g\u00e2y t\u1ed5n th\u01b0\u01a1ng c\u01a1 quan thi\u1ebfu oxy ho\u1eb7c t\u0103ng n\u1ed3ng \u0111\u1ed9 lactat. Tr\u00ean th\u1ef1c t\u1ebf, huy\u1ebft \u00e1p th\u1ea5p \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ee9ng minh l\u00e0 c\u00f3 l\u1ee3i trong c\u00e1c v\u1ebft th\u01b0\u01a1ng xuy\u00ean th\u1ea5u b\u1eb1ng c\u00e1ch h\u1ea1n ch\u1ebf m\u1ea5t m\u00e1u (xem ch\u01b0\u01a1ng ti\u1ebfp theo).<\/li>\n<\/ul>\n<p>M\u1ed9t l\u1eddi gi\u1ea3i th\u00edch kh\u1ea3 thi cho nh\u1eefng quan s\u00e1t n\u00e0y l\u00e0 <strong>h\u1ea1 huy\u1ebft \u00e1p kh\u00f4ng g\u00e2y ra s\u1ed1c<\/strong>, m\u00e0 thay v\u00e0o \u0111\u00f3 <strong>l\u00e0 h\u1eadu qu\u1ea3 c\u1ee7a s\u1ed1c<\/strong>. S\u1ed1c \u0111\u01b0\u1ee3c bi\u1ebft \u0111\u1ebfn l\u00e0 nguy\u00ean nh\u00e2n g\u00e2y ra r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng \u0111a c\u01a1 quan, v\u00e0 m\u1ed9t trong nh\u1eefng c\u01a1 quan r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng c\u00f3 th\u1ec3 l\u00e0 m\u1ea1ch m\u00e1u. N\u1ebfu \u0111\u00fang nh\u01b0 v\u1eady, th\u00ec vi\u1ec7c \u0111i\u1ec1u ch\u1ec9nh huy\u1ebft \u00e1p s\u1ebd kh\u00f4ng \u0111i\u1ec1u ch\u1ec9nh \u0111\u01b0\u1ee3c t\u00ecnh tr\u1ea1ng s\u1ed1c (ho\u1eb7c c\u1ea3i thi\u1ec7n kh\u1ea3 n\u0103ng s\u1ed1ng s\u00f3t), gi\u1ed1ng nh\u01b0 vi\u1ec7c ch\u1ea1y th\u1eadn nh\u00e2n t\u1ea1o \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb suy th\u1eadn li\u00ean quan \u0111\u1ebfn s\u1ed1c s\u1ebd kh\u00f4ng \u0111i\u1ec1u ch\u1ec9nh \u0111\u01b0\u1ee3c t\u00ecnh tr\u1ea1ng s\u1ed1c (ho\u1eb7c c\u1ea3i thi\u1ec7n kh\u1ea3 n\u0103ng s\u1ed1ng s\u00f3t).<\/p>\n<h2>T\u00e0i li\u1ec7u tham kh\u1ea3o<\/h2>\n<ol>\n<li>Manji R, Wood KE, Kuman A. The history and evolution of circulatory shock. Crit Care Clin 2009; 25:1-29.<\/li>\n<\/ol>\n<p>What is Shock?<\/p>\n<ol start=\"2\">\n<li>Vincent J-L, De Backer D. Circulatory shock. N Engl J Med 2013; 369:1726-1734.<\/li>\n<li>Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345:1368-1377.<\/li>\n<li>Cecconi M, De Backer D, Antonelli M, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med 2014; 40:1795-1815.<\/li>\n<li>Advanced Trauma Life Support\u00ae Student Course Manual. 10th ed., Chicago: American College of Surgeons, 2012; 49-50.<\/li>\n<li>Berg DD, Bohula EA, Morrow DA. Epidemiology and causes of cardiogenic shock. Curr Opin Crit Care 2021; 27:401-408.<\/li>\n<li>Rob D, B\u1ebdlohl\u00e1vek J. The mechanical support of cardiogenic shock. Curr Opin Crit Care 2021; 27:440-446.<\/li>\n<li>Liu V, Escobar GJ, Greene JD, et al. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA 2014; 312:90-92.<\/li>\n<li>Rudd KE, Johnson SC, Agesa KM, et al. Global, regional, and national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden of Disease Study. Lancet 2020; 395:200\u00ad211.<\/li>\n<\/ol>\n<p>Blood Pressure Monitoring<\/p>\n<ol start=\"10\">\n<li>Augusto J-L, Teboul J-L, Radermacher P, Asfar P. Interpretation of blood pressure signal: physiological bases, clinical relevance, and objectives during shock states. Intensive Care Med 2011; 37:411-419.<\/li>\n<li>Nichols WW, O\u2019Rourke MF. McDonald\u2019s blood flow in arteries. 3rd ed. Philadelphia: Lea &amp; Febiger, 1990; 251-269.<\/li>\n<li>Shapiro DS, Loiacono LA. Mean arterial pressure: therapeutic goals and pharmacologic support. Crit Care Clin 2010; 26:285-293.<\/li>\n<li>Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals: Part 1: Blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation 2005; 111:697-716.<\/li>\n<li>Bur A, Hirschl M, Herkner H, et al. Accuracy of oscillometric blood pressure measurement according to the relation between cuff size and upper-arm circumference in critically ill patients. Crit Care Med 2000; 28:371-376.<\/li>\n<li>Nedel WL, Vasconcellos AT, Gunsch KA, Soares PHR. Accuracy and precision of oscillometric noninvasive blood pressure measurement in critically ill patients: systematic review and meta\u00adanalysis. Anaesthesiol Intensive Ther 2022; 54:425-431.<\/li>\n<\/ol>\n<p>Tissue Perfusion and Oxygenation<\/p>\n<ol start=\"16\">\n<li>Komatsu T, Shibutani K, Okamoto K, et al. Critical level of O2 delivery after cardiopulmonary bypass. Crit Care Med 1987; 15:194-197.<\/li>\n<li>Mohsenifar Z, Goldbach P, Tashkin DP, et al. Relationship between O2 delivery and O2 consumption in the adult respiratory distress syndrome. Chest 1983; 84:267-272.<\/li>\n<li>Wilkerson DK, Rosen AL, Gould SA, et al. Oxygen extraction ratio: a valid indicator of myocardial metabolism in anemia. J Surg Res 1987; 42:629-634.<\/li>\n<li>Maddirala S, Khan A. Optimizing hemodynamic support in septic shock using central venous and mixed venous oxygen saturation. Crit Care Clin 2010; 26:323-333.<\/li>\n<li>Vallet B, Robin E, Lebuffe G. Venous oxygen saturation as a physiologic transfusion trigger. Crit Care 2010; 14:213-217.<\/li>\n<li>Scheeren TWL, Wicke JN, Teboul J-L. Understanding the carbon dioxide gaps. Curr Opin Crit Care 2018; 24:181-189.<\/li>\n<\/ol>\n<p>General Management<\/p>\n<ol start=\"22\">\n<li>Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247.<\/li>\n<li>Owen VS, Rosgren B, Cherak SJ, et al. Adverse events associated with administration of vasopressor medications through a peripheral intravenous catheter: a systematic review and meta-analysis. Crit Care 2021; 25:146.<\/li>\n<li>Prasanna N, Yamane D, Haridasa N, et al. Safety and efficacy of vasopressor administration through midline catheters. J Crit Care 2021; 61:1-4.<\/li>\n<li>Phentolamine mesylate. AHFS Drug Information, 2022. Bethesda, MD: American Society for Health System Pharmacists, 2022; 1436-1439.<\/li>\n<li>Guyton AC, Hall JE. Medical Physiology. 10th ed. Philadelphia: W.B. Saunders, Co., 2000; 178.<\/li>\n<li>Asfar P, Meziani F, Hamel JF, et al. High versus low blood-pressure target in patients with septic shock. N Engl J Med 2014; 370:1583-1593.<\/li>\n<\/ol>\n<p>Vasopressor Drugs<\/p>\n<ol start=\"28\">\n<li>Russell JA. Vasopressor therapy in critically ill patients with shock. Intensive Care Med 2019; 45:1503-1517.<\/li>\n<li>Desairs P, Pinaud M, Bugnon D, Tasseau F. Norepinephrine therapy has no deleterious renal effects in human septic shock. Crit Care Med 1989; 17:426-429.<\/li>\n<li>Anantasit N, Boyd JH, Walley KR, Russell JA. Serious adverse events associated with vasopressin and norepinephrine infusion in septic shock. Crit Care Med 2014; 42:1812-1820.<\/li>\n<li>Stolk RF, van der Pasch E, Naumann F, et al. Norepinephrine dysregulated the immune response and compromises host defense during sepsis. Am J Respir Crit Care Med 2020; 202:830-842.<\/li>\n<li>AHFS Drug Information, 2022. Bethesda, MD: American Society of Health\u00adSystem Pharmacists, 2022; 1424-1431.<\/li>\n<li>De Backer D, Creteur J, Silva E, Vincent J-L. Effects of dopamine, norepinephrine, and epinephrine on the splanchnic circulation in septic shock: Which is best? Crit Care Med 2003; 31:1659-1667.<\/li>\n<li>Levy B. Bench-to-bedside review: Is there a place for epinephrine in septic shock? Crit Care 2005; 9:561-565.<\/li>\n<li>Dopamine hydrochloride. AHFS Drug Information, 2022. Bethesda, MD: American Society of Health-System Pharmacists, 2022; 1388-1392.<\/li>\n<li>Avni T, Lador A, Lev S, et al. Vasopressors for the treatment of septic shock: systematic review and meta-analysis. PLoS One 2015; 10:e0129305.<\/li>\n<li>Brath PC, MacGregor DA, Ford JG, Prielipp RC. Dopamine and intraocular pressure in critically ill patients. Anesthesiology 2000; 93:1398-1400.<\/li>\n<li>Phenylephrine hydrochloride. AHFS Drug Information, 2022. Bethesda, MD: American Society of Health System Pharmacists, 2022; 1379-1384.<\/li>\n<li>Morelli A, Ertmer C, Rehberg S, et al. Phenylephrine versus norepinephrine for initial hemodynamic support of patients with septic shock: a randomized, controlled trial. Crit Care 2008; 12:R143.<\/li>\n<li>Treschan TA, Peters J. The vasopressin system: physiology and clinical strategies. Anesthesiology 2006; 105:599-612.<\/li>\n<li>Polito A, Parisini E, Ricci Z, et al. Vasopressin for treatment of vasodilatory shock: an ESICM systematic review and metaanalysis. Intensive Care Med 2012; 38:9-19.<\/li>\n<li>Wieruszewski PM, Wittwer ED, Kashani KB, et al. Angiotensin II infusion for shock. A multicenter study of postmarketing use. Chest 2021; 159:596-605.<\/li>\n<li>Khanna A, English SW, Wang XS, et al. Angiotensin II for treatment of vasodilatory shock. N Engl J Med 2017; 377:419-430.<\/li>\n<li>giapreza.com. Accessed June 23, 2023.<\/li>\n<li>Chang TI. Impact of drugs on intradialytic hypotension: antihypertensive and vasoconstrictors. Semin Dial 2017; 30:532-536.<\/li>\n<li>Santer P, Anstey MH, Patrocinio MD, et al. Effect of midodrine versus placebo on time to vasopressor discontinuation in patients with persistent hypotension in the intensive care unit (MIDAS): an international randomized clinical trial. Intensive Care Med 2020; 46:1884-1893.<\/li>\n<li>Costa-Pinto R, Yong Z-T, Yanase F, et al. A pilot, feasibility, randomized controlled trial of midodrine as adjunctive vasopressor for low-dose vasopressor-dependent hypotension in intensive care patients: The MAVERIC study. J Crit Care 2022; 67:166-171.<\/li>\n<\/ol>\n<p>Goals of Resuscitation<\/p>\n<ol start=\"48\">\n<li>Fink MP. Cytopathic hypoxia. Mitochondrial dysfunction as mechanism contributing to organ dysfunction in sepsis. Crit Care Clin 2001; 17:219-237.<\/li>\n<li>Ruggieri AJ, Levy RJ, Deutschman CS. Mitochondrial dysfunction and resuscitation in sepsis. Crit Care Clin 2010; 26:567-575.<\/li>\n<\/ol>\n<p>A Final Word<\/p>\n<ol start=\"50\">\n<li>Oriyanka P, Chang C-CH, Chawla LS, et al. Vasopressor-resistant hypotension, combination vasopressor therapy, and shock phenotypes in critically ill adults with vasodilatory shock. Shock 2022; 58:260-268.<\/li>\n<\/ol>\n<p>T\u1ea2I FILE PDF <a href=\"https:\/\/vnras.com\/drug\/wp-content\/uploads\/2025\/03\/Chapter-14-Tiep-can-lam-sang-soc-ICUBOOK-5TH-2025.pdf\">T\u1ea0I \u0110\u00c2Y<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>M\u1ed9t trong nh\u1eefng \u0111\u1eb7c \u0111i\u1ec3m d\u1ec5 nh\u1eadn bi\u1ebft c\u1ee7a t\u00ecnh tr\u1ea1ng l\u00e2m s\u00e0ng \u0111\u01b0\u1ee3c g\u1ecdi l\u00e0 &#8220;s\u1ed1c&#8221; l\u00e0 t\u00ean c\u1ee7a n\u00f3, kh\u00f4ng c\u00f3 b\u1ea5t k\u1ef3 gi\u00e1 tr\u1ecb khoa h\u1ecdc ho\u1eb7c b\u1ec7nh l\u00fd n\u00e0o, v\u00e0 \u0111\u01b0\u1ee3c chia s\u1ebb b\u1edfi c\u00e1c th\u1ef1c th\u1ec3 phi l\u00e2m s\u00e0ng xa x\u00f4i nh\u01b0 c\u00e1c ho\u1ea1t \u0111\u1ed9ng qu\u00e2n s\u1ef1 (&#8220;s\u1ed1c v\u00e0 kinh [&#8230;]\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-111471","post","type-post","status-publish","format-standard","hentry","category-y-te-suc-khoe"],"acf":[],"_links":{"self":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts\/111471","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/comments?post=111471"}],"version-history":[{"count":2,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts\/111471\/revisions"}],"predecessor-version":[{"id":111477,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts\/111471\/revisions\/111477"}],"wp:attachment":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/media?parent=111471"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/categories?post=111471"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/tags?post=111471"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}