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TRl/ONG OAI HOC Dl/OC HA NOI BO MON Dl/OC LAM SANG Dime LAM SANG VA DIEU TRI • • (Tai ban Ian this hai co sCta chCra va bo sung) Dfil HOC VO TPCtldNQ T06N THl/VIEN NHA XUAT BAN Y HOC HA NOI - 2007 LOI NOI DAU "Duoc lam sang & dieu tri" la mon hoc phuc vu cho chuong trinh giang day cua trucmg Dai hoc Duoc, chuyen nganh duoc lam sang Mon hoc duoc hoc sau sinh vien da co nhirng kien thuc ca ban ve duoc lam sang dai cuong "Duoc lam sang & dieu tri" cung cap nhung kien thufc lien quan den viec su dung thuoc dieu tri Sach duoc xuat ban Ian dau tien vao nam 2001 va tai ban Ian thir nhat vao nam 2005 Day la Ian tai ban thir hai v6i noi dung duoc sua chua va bo sung de cap nhat nhirng kien thuc moi nhat Noi dung cuon sach bao gom 16 chuong chia phan: - Phan 1: Duoc lam sang thuc hanh benh vien Phan gom chuong, nham cung cap nhung kien thuc co ban cho hoat dong cua cac duoc si lam sang tai benh vien - Phan 2: Su dung thuoc dieu tri Phan hien tai chi gom 11 chuong, de cap den viec su dung thuoc dieu tri mot so nhom benh; tuong lai phan se duoc mo rong them de co the bao quat duoc hau het cac benh ma nguoi duoc si lam sang can n&m vung Do sir doi moi nhanh chong linh vuc dieu tri va sir ddi nhieu thuoc moi, nhieu kien thirc dieu tri hien khong phu hop nua Trong Ian xuat ban nay, cac tac gia co bo sung nhung kien thuc ve thuoc va phac dieu tri de giiip nguoi hoc tiep can kip thoi voi nhung thay doi linh vuc Y, Duoc thdi gian vira qua Hau het cac chuong deu duoc cap nhat lai kien thuc, mot so chuong duoc viet lai hoan toan Mac du da co nhieu co gang song han che ve thofi gian nen chdc ch^n vln nhieu thieu sot Chung toi rat mong nhan duoc y kien dong gop cua cac dong nghiep Y va Duoc Thu tu lien he xin giri ve theo dia chi: Bo mon Duoc lam sang Trudng dai hoc Duoc Ha Noi, 13 - 15 Le Thanh Tong Dienthoai: 049.330771 Xin tran cam on! Cac tac gia Phan I Dl/OC LAM SANG • TRONG THl/C HANH BENH VIEN Chirong I THONG TIN THUOC I DAI CUONG VE THONG TIN 1.1 Y nghia - Thong tin da tro mot bon nguon luc ca ban (Nhan luc, vat luc, tai lire, tin luc) quan ly dieu hanh va quyet dinh de trien khai mot chuong trinh, mot du an, mot cong viec lorn nho, lap ke hoach cong tac dai han, ngan han Kho co viec gi co the hoan tot lai khong can den ca ngu6n luc khong the thieu tin lire Tin luc bao gom ca thong tin - giao due - truyen thong (Information, Education, Communication, viet t&t la IEC) Nhirng thap ky trudc day 6* Viet Nam rat thieu thong tin, thieu tCr cac nguon thong tin, den mot he thong to chire ve thong tin, thieu mot co che thu thap va cung ting thong tin dieu da gay nhirng tro ngai va hau qua cac hoat dong kinh te, xa hoi, khoa hoc ky thuat Nhirng nam gan day, tinh hinh thong tin 6* Viet Nam da tot hon, phong phu han nhung chua he thong, chua bien va chua co the noi la thoat canh lac hau v& thong tin moi linh vuc hoat dong Mot to chire thong tin hoat dong huu hieu luon la mot cong cu dac luc cho viec hoan nhiem vu, la niem tu hao cho mot nganh, mot linh vuc, mot dan vi, mot to chuc nao vi la kho tang tri thufc cua the gidi da ndm duoc de su dung Thong tin la mot quy6n lai ca ban doi song ngucri duac luat phap nhieu nu6c ghi nhan la quyen duoc thong tin 1.2 Phan loai thong tin : Co nhieu each phan loai • Phan loai theo nguon tai lieu chira dung thong tin - Tai lieu cap I: Cac bai bao, cong trinh goc dang tai day du ban chup, microfiche - Tai lieu cap II: Cac bai torn tat cong trinh, cac tin trich dan - Cac tac pham kinh dien, cac chuyen luan, chuyen khao • Phan loai theo linh vuc thong tin - Thong tin ve sure khoe - Thong tin ve thuoc - Thong tin dan so ' - Thong tin kinh te, thuang mai, san xuat - • V V Phan loai theo tinh chat cua thong tin - Thong tin ca ban : So lieu ve dat nude, ngudi, tai nguyen, hau - Thong tin ve cau true ( Structure Information): So lieu ve to enure bo may, cac cau tu can thiet - Thong tin ve qua trinh (Process Information): So lieu ve ca che hoat dong, quy trinh hoat dong - Thong tin ve ket qua (Outcome Information): So lieu ve hieu qua cua hoat dong • Phan loai khac theo muc tieu cua du lieu - Thong tin ve mot ca sd san xuat, mot cong ty kinh doanh - Thong tin ve phan umg bat lai cua mot thuoc(Adverse Drug Reactions-ADR) - Thong tin cho tung loai doi tuang: Ngudi co chuyen mon, quan chung nhan dan, ngudi tieu dung II THONG TIN THUOC 2.1 Noi dung thong tin thuoc bao gom - Cac thong tin ca ban ve mot thuoc - Thong tin cho thay thuoc ke dan - Thong tin cho duac si va nhan vien ban thuoc - Thong tin cho benh nhan, nguoi dung thuoc - Thong tin nang cao dan tri Nhirng thap ky dau the ky XX, cac chung loai thuoc chua co nhieu, cac can bo chuyen mon Y Duac de nam bat thuoc chira benh nao Nhung nay, nhung thap ky cudi cua the ky XX, cac tuu khoa hoc 1dm lao thong qua cong nghe rat phat trien da san xuat rat nhieu chung loai thuoc vdi nhirng tac dung tri benh tinh vi han nhieu Cac thong tin ve thuoc cang phurc tap va phong phu - nguoi duac si phai giup cac nha dieu tri hoc chon duac thuoc nao it phan ring phu, it nguy ca xay phan ung doi nghich nhat de tri mot benh cu the cho tung benh nhan rieng biet, giup cac nhan vien y te cham soc benh nhan dung thuoc dung lieu, dung luc, dung each nhat de phat huy hieu luc toi uu cua thuoc, tranh duac cac tac hai tuang tac cua thuoc va giup cho benh nhan, nguoi dung thuoc tuan thu dan thuoc va each dung dung dan Nguoi duac si phai thong qua cac phuong tien truyen thong dai chung de giao due ve thuoc cho nhan dan d mirc thich hop ttr dang di hoc d cac trucmg thong den ngudi ldn tudi de nang cao dan tri, cd hieu biet ve thuoc, biet dung thuoc de bao ve sure khoe, biet tuan thu cac chi dinh dieu tri cua thay thuoc, each dung duac si hudng din, biet tu dung thuoc gidi han duoc quy dinh de chua tri mot sd trieu chirng benh thong thudng cd hieu qua va it ton kem nhat Dieu dat cho cac duac si phai quan tarn dac biet viec cung cap thong tin thuoc cho ngudi dan De thuc hien duac muc tieu su dung thuoc hap ly, an toan va it ton kem, ngudi duac si phai cd chire nang lam tot cong tac thong tin thuoc 2.2 Doi tuang cua thong tin thuoc - - Nhirng ngudi cung irng cac dich vu cham soc va bao ve sue khoe: + Thay thuoc ke dan + Y ta dieu duang + Duac si benh vien, cua hang + Ngudi ban thuoc Nhirng ngudi sir dung dich vu cham soc sire khoe: + Benh nhan, ngudi dung thuoc + Nhan dan, ngudi tieu dung thuoc 2.3 Phuong tien thong tin - Sach bao, tai lieu chuyen mon, cong trinh nghien ciru, khao sat, cac hoi thao chuyen de, tap huan, cac thong bao v.v - Cac phuong tien truyen thong dai chung nhu bao viet, bao hinh, bao tieng, cac tai lieu cap, so dien thoai giai dap, tu van, cac bang hinh, bang tieng, cac chien dich truyen thong v.v 2.4 To chuc thong tin thuoc - Can cd Trung tarn thong tin thuoc (TTTTT) qudc gia, dia phuang, j j j j j cua cac ca sd dieu tri ldn, cac co sd dao tao, cac ca sd nghien ciru khoa hoc y te - Cac thu vien, tu sach, tu lieu d cac ca sd y te cac cap Yeu cau cua mot to chitc thong tin: - Tuy theo dieu kien kinh te va chuc nang nhiem vu, cd the to chire theo nhieu co ldn nhd khac nhau: Tu mot so cap tu lieu, vai chuc dau sach d mot ca sd y te nhd nhat den mot hai tu quay tu lieu sach vd d mot ca sd y te ldn han, tir mot gian phdng den mot day nha, mot thu vien ldn - Phuang tien trang thiet bi, dieu kien kinh te cd the trang bi tir mot so danh muc tai lieu, sach vd hoac hop phieu due 16 den he thong may tinh noi mang hien dai, cac dia compact (CD-ROM), cac tai lieu kinh dien cap I, cap II, cac tap chi chuyen khoa dat mua cap nhat - Cd nhan lire duac dao tao chuyen ve thong tin, tin hoc - Cd ky nang, ky thuat khai thac thong tin - Cd ke hoach hoat dong nang dong hieu qua - Cd dong ca say me nghe nghiep, ky nang giao tiep, tinh than phuc vu 2.5 Chuc nang cua mot trung tam thong tin - Thu thap tfch luy thong tin - Xir ly thong tin, phan loai, sap xep - Luu trtr thong tin cd he thong de d6 khai thac - Bien tap thong tin phuc vu cac nhu cau - Cung irng, phan phat thong tin - Thu thap thong tin phan hoi tir ngudi dimg tin 2.6 Trung tam thong tin thuoc 2.6.1 Su can thiet phai co trung tam thong tin thuoc - Theo khuyen cao cua To chuc Y te The gidi (WHO) va xuat phat tu nhu cau va lai ich cua tung qudc gia, nhieu nude tren the gidi da phat trien va dang phat trien deu cd hai trung tam thong tin thuoc va chat doc hoac rieng re hoac phdi hap d cap qudc gia Muc dich cua cac trung tam deu thu thap va cung cap thong tin ve thuoc chira benh va tac hai ciia chat doc doi vdi sire khoe ngudi - Ngudi ta nhan thay sach vd, bao chi, tap chi, tai lieu cong bd, xuat ban cang nhieu nen can phai cd mot to chuc vdi cntic nang thu thap va cung cap thong tin thuoc va chat doc cho moi ngudi 2.6.2 Gidi thieu mot trung tam thong tin quoc gia ve thuoc vd chat doc phoi hap (Integrated Drug and Poison Information National Centre) Chuc nang ciia trung tam: - Thu thap, danh gia, tong hap, sap xep cac thong tin lien quan den thuoc va sire khoe - Trien khai mot he thong tra ciru tin nhanh chdng, chfnh xac va phan tfch he thong b^ng may tinh Cung cap nhirng dich vu thong tin hieu qua va die luc ve thuoc chua benh, chat doc lien quan den sire khoe cho cac nhan vien y te va quan chung nhan dan de viec cham sdc sire khoe cho ngudi benh tot han 10 Dich vu thong tin co tai trung tam: Nhirng dich vu thong tin rat da dang Do dieu kien va phuang tien truyen tin phat trien nen ngudi ta da to chuc: - Dich vu dien thoai (phonelines) giai dap thac mac, cung cap thong tin thuoc va chat doc lien quan den stic khoe my pham, thuc pham, cac hoa chat dimg ddi song hang - Dich vu mang may vi tfnh khai thac thong tin thuoc chira benh va chat doc vdi chi phi rat ft (it han 800 dong mdi phut) - Dich vu mang truyen hinh va bo giai ma vdi nhieu kenh khac duac hdi va giai dap Vf du: Kenh cung cap thong tin ve thuc pham (Foodinfo) ve thuoc trtr sau (Pestinfo) ve hoa chat (cheminfo), kenh giai dap va cap kien thuc cho cong dong (Public Infoline) ve thuoc chua benh (Drug line) ve chat doc (Poison line) Hai kenh sau danh cho can bo cd chuyen mon Mot trung tam nhu vay d mot nude thuoc khu vuc ASEAN, hai nam da cung cap 52000 tin, 54% cac cau giai dap thac mac ve thuoc la cua ngudi dan binh thudng cong dong, lai la cua can bo y te Cac thong tin co the khai thac duac tai trung tam: - Danh muc thuoc dang ky - Thong tin ve phac dieu tri & thuoc cho benh vien - Thong tin ve thuoc - Thong tin ve chat doc - Dich vu torn t&t va trich dan thong tin thuoc - Thong tin ve thuoc trir sau - Thong tin ve hoa chat cong nghiep va ho gia dinh - Thong tin ve cay thuoc va thuoc co truyen - Theo doi va bao cao ve phan umg bat lai cua thuoc - Theo doi dieu tri bang thuoc (chi dinh dieu tri va tu dieu tri) - Cung cap thong tin ve dan vi lieu dung - Theo doi su dung thuoc khang sinh - Thong tin ve ky thuat san xuat, cong nghe bao che thuoc - Thong tin ve nhu cau, kinh doanh, gia ca thi trudng thuoc - Thong tin ve chat luang thuoc - Thong tin ve quan ly thuoc, cac chfnh sach va qui che 11 III YEU CAU CUA THONG TIN THUOC Cac thong tin phai: - Khach quan, trung thuc - Chfnh xac, day du - Duac phan tfch va so sanh - Duac bieu di£n dudi dang bang bieu, hinh ve - Duac dinh hudng thong tin can cho - Luon duac cap nhat theo doi - Luon duac he thong hoa - Luon duac phan phat 3.1 Thong tin thuoc vdi quan chung - Noi dung ngan gon, nen dung dang tranh anh hinh ve, ft tir ngir, tap trung theo tirng chu de khac - Kien thuc chung dan gian dt hieu, ldi ndi, vi du phai dan da - Sir dung moi phuang tien truyen thong - Nhac di nhac lai - Cd ca quan giai dap thac mac cho nhan dan - Phoi hap nhieu linh vuc y-duac-xa hoi hoc-kinh te hoc-dan toe hoc - Thong tin gidi thieu thuoc cho nhan dan theo tieu chuan dao dure cua To churc Y te The gidi, va chfnh sach thong tin thuoc cua Nha nude ta 3.2 Thong tin thuoc quang cao Nghi quyetciiaHoi dong Y te The gidi, so 41.17 13/5/1988 cong nhan va ban hanh tieu chuan dao dire quang cao gidi thieu thuoc de sir dung thuoc hop ly va dam bao cham sdc stic khoe, khuyen cao cac nude hoi vien dua vao tinh hinh chfnh tri-kinh te-xa hoi-van hoa-giao duc-khoa hoc-ky thuat-phap che, mo hinh benh tat, tap quan, trinh he thong y te ma ban hanh quy che cho nude minh thuc hien, keu goi cac hang san xuat, cong ty, ca sd phan phoi, mua ban thuoc, ke dan, cac trudng, vien, cac hiep hoi nghe nghiep, ngudi tieu dung, ngudi benh, cac he thong truyen thong dai chung thuc hien va bien tieu chuan Tieu chuan dao dure (Thai urng xu thfch hop thong tin gidi thieu thuoc): 12 - Trung thuc, tin cay - Chfnh xac Tieu chuan dao due quang cao gidi thieu thuoc nham nang cao chat lugng cham sdc sire khoe thong qua viec sir dung thuoc hap ly Tieu chuan dao due ap dung vao viec thong tin gidi thieu ca thuoc ke dan va thuoc khong can dan (OTC), ca thuoc co truyen & san pham chira benh cho moi ngudi cd nganh nghe khac nhau, nganh cong nghiep dugc, can bo y te ke dan, can bo cung ung, phan phoi, cap phat'thudc, cac trudng dao tao, cac hoi nghe nghiep, hoi ngudi tieu dung va benh nhan, cac phuang tien truyen thong Thong tin ve thuoc can: Can nh&c ky luang, chirng minh duac, lai le khach quan dung muc Khong dugc khang dinh dieu khong the kiem tra dugc Khong dugc phien dien gay hieu lam dan den sir dung khong dung gay rui ro Cach trinh bay quang cao gidi thieu thuoc khong dugc mang tinh khuyen du sir dung, mua hang, gay hieu lam, hieu sai ve hai mat lgi hai cua thuoc Khong dugc quang cao gidi thieu thuoc vi muc dfch lgi fch vat chat, tai chfnh Khong dung cac phuang phap nham tac dong de can bo y te ke dan, dung thuoc Khong dugc cd tinh sir dung cac hoat dong khoa hoc va giao due vao muc dfch quang cao thuoc Cac du kien khoa hoc ve thuoc la tai san chung, phai sa~n sang cung cap cho can bo y te va bat ky ngudi nao khac cd yeu cau 3.3 Thong tin gidi thieu (TTGT) thuoc cho can bo y te - Ldi le va hinh anh moi TTGT thuoc cho y bac si & can bo y te phai dung vdi cac du* lieu khoa hoc da dugc thua nhan vdi ldi le d£ doc, d& hieu - Noi dung ca ban bao gom: Ten cac hoat chat theo ten thuoc qudc te INN, ten gdc Ten thuang mai Ham lugng hoat chat dan vi pham Tac dung dieu tri Dang bao che Tac dung phu va phan irng cd hai Chdng chi dinh va de phdng Tuang tac cua thuoc Ten, dia chi nha san xuat va cong ty Tai lieu khoa hoc tuang ung de tham khao v.v 13 cua P.vivax, P malariae va P.ovale nhung khdng cd tic dung vdi giao bao cua P.falciparum h) Tdc dung bdt lai - Ddc tinh cap tinh: Rdi loan thi giic, tang phan, kich ddng, hdn me, co giat, loan nhip tim, lieu chet la gam (ngudi ldn) hoac gam (tre em) - Neu dung keo dai cd the inh hudng de'n thi giic nhu benh giic mac nhe nhung cd phuc hdi, benh vdng mac hiem gap nhung nguy hiem (cd the xiy d ngudi cao tuoi dung dai hoac d ngudi tiep xuc vdi inh sing manh) - Di ting: Phat ban dd rit-sin - Rdi loan tieu hoi: Trudng bung, budn ndn, di long, rudt ke't bi kich ting nhe - Viem da ban dd - Thay doi sic to: bac long tdc, da xam nau den - Chdng mat, ddc vdi thinh giic, thay doi dien tim do, thie'u miu tan huye't c) Chi dinh: & Viet Nam va mdt so khu vuc tren the gidi, loai Plasmodium falciparum da khing cao vdi chloroquin Hien chloroquin dugc chi dinh dieu tri sd't ret nhiem Plasmodium vivax , Plasmodium malariae, Plasmodium ovale d) Chdng chi dinh: Benh gan nang, rdi loan tieu hoi, rdi loan ve miu va thin kinh nang, nhugc ca, ca dia di ting e) Lieu luang: Tong lieu la 25 mg base/kg, chia dieu tri: Ngay 1: 10 mg base/kg can nang; Ngay 2: 10 mg base/kg can nang; Ngay 3: mg base/kg can nang Bdng 16.4: Lieu chloroquin tinh theo lira tuoi (neu khong cdn benh nhan) Ngay (vien) Ngay (vien) Ngay (vien) v2 v2 v4 - dudi tuoi 1 '/2 - dudi 12 tuoi 2 12 - dudi 15 tuoi 3 172 Tir 15 tuoi trd len 4 Tuoi Dudi tuoi 2.5 Quinin Quinin la alcaloid cua vd cay quinquina Vd cay quinquina cd chtia han 20 loai alcaloid, quan trgng nhat la quinin, quinidin, cinchonin, cinchonidin nhung hay dung nhat la quinin 2.5.7 Duac dong hoc Quinin dugc hap thu nhanh va hoan toan qua rudt, dat ndng dd tdi da huye't tuang tti 1-3 gid va he't a gid thti 8, ndng dd huye't tuang thudng gap 2-7 lan hdng ciu 296 Cd 80% thud'c chuyen hoi qua gan va dao thii theo mat, phan va 20% dao thii qua nude tieu Khdng tich luy, thdi gian bin thii tti 11 de'n 18 gid 2.5.2 Duac luc hoc a) Tdc dung Quinin cd tic dung chu ye'u tren the vd tinh ndi hdng ciu, chu ye'u lam thay ddi bao tuang cua ky sinh trung, diet ky sinh trung nhanh, dung dieu tri cit can, dac biet trudng hgp sdt ret the7 ic tinh Ddi vdi cic giai doan khic cua chu ky rat it tic dung b) Tdc dung bdt lai Mdt sd tai bien dung quinin: - Quinin truyen tinh manh cd the gay loan nhip, khoing QT keo dai, huye't ip tut, cd ngting tim Quinin lam tang insulin miu, cd the7 gay dudng huyet dac biet d phu nir cd thai - Hdi chting quinin (cinchonism): u tai, nhtic diu, chdng mat, budn ndn va ndn) - Do dac ting: cd ngudi dung lieu thap quinin da dd da, ngtia, phit ban, sdt, dau da day, khd thd, ti tai, rdi loan thi giic - Do qui lieu hoac dung lau dai: sdt, ndn, kich thich, lo sg, nhim lin, me sing, ngat, truy hd hap, da lanh, tim xanh, giim than nhiet, giim huye't ip, mach yeu; inh hudng thinh giic (ti tai, chdng mat, cd die'e); giim thi luc (nhin md, rdi loan mau sac, nhin ddi, sg inh sing, tdi nhin khdng rd, giim thi trudng, im diem, gian ddng tti) c) Chi dinh Dung dieu tri sdt ret P falciparum da khing vdi chloroquin, sdt ret the ic tinh d) Chdng chi dinh Vdi nhung ngudi dac ting vdi quinin, nhung ngudi cd trang thii benh ve tai, mat, tim mach e) Lieu luang - Quinin sulfat: dang vien dung theo dudng udng 250 mg, lieu 30 mg/kg/24 gid (chia lam lin udng mdi ngay), dieu tri - Quinin dichlohydrat: dng 500 mg, pha natri clorid 9%o hoac glucose 5% de truyen tinh mach Truyen tinh mach vdi lieu 20 mg/kg truyen lin diu, sau gid truyen 10 mg/kg, cac sau lieu 30mg/kg chia lan cho de'n benh nhan tinh thi chuyen sang tiem bap hoac vien udng cho du lieu dieu tri - Quinin chlohydrat: dng 500 mg, lieu tiem bap: 30 mg/kg/24 gid Mdi dot dieu tri 297 Bdng 16.5 Lieu quinin chlohydrat tinh theo lua tuoi (neu khong cdn benh nhan) Tuoi Lieu lan tiem Dirdi tuoi V8 dng x lan / - dudi tuoi 74 - V2dng x lin/ngay - dudi 12 tuoi 2/3 dng x lan / 12 - dirdi 15 tuoi dng x lan / Tir 15 tuoi trd len dng x lan / Chit y: Tiem quinin de gay ip xe, cin tiem bip sau va bio dim vd trung Mefloquin Mefloquin la mdt loai thud'c cd nguon gdc tong hgp hoi hgc tti din chat methanol ciia 4-quinolin va cd lien quan ve mat hoa hgc vdi quinin 2.6.1 Duac dong hoc Do nang kich ting tai chd manh neu dung dudng tiem nen mefloquin chi dugc dung dudng udng Sau udng, thuoc dugc hap thu tot va dat cic ndng dinh huyet tuang khoing 17-24 gid Mdt lieu nha't 250 mg cd the tao dugc ndng thud'c huyet tuang dao ddng tti 290-340 ng/ml Neu dung lieu keo dai nhieu thi cd the dat dugc ndng dd thuoc on dinh huyet tuang tti 560-1250 ng/ml Chi cin dat dugc ndng d mtic 200-300 mg/ml la du de diet dugc ky sinh trung Thud'c cd nang gin manh vao protein ciia huyet tuang (98%) vi tap trung hdng ciu, phan bd tot cic md khic, ke ci he thin kinh trung uang Tuy nhien, d cic benh nhan bi sot ret the nao ngudi ta khdng phit hien dugc mefloquin dich nao tuy, cd le vi nd da lien ket vdi protein huyet tuang vdi ty le qui cao Mefloquin dugc chuyen hoi tai gan Cic sin pham dudi dang acid carboxylic cua nd dugc dao thii cham va chii yeu la theo phan ngoai Thdi gian bin thii cua thud'c dao ddng tti 13 de'n 33 va cd xu hudng rut ngin han a nhung benh nhan bi benh sdt ret cap tinh Thuoc cd the dugc phit hien miu nhieu thing sau udng 2.6.2 Duac luc hoc a) Tdc dung Mefloquin cd tic dung tren the vd tinh hdng ciu ddi vdi cic loai ky sinh trung sot ret, ke ci P.falciparum da khing vdi chloroquin va phdi hgp thuoc sulfadoxinprimethamin (Fansidar), nhung khdng cd tic dung ddi vdi cac the huu tinh hoac cac the gan b)Tdc dung bdt lai Benh nhan dung mefloquin cd the gap mdt sd dau hieu ngoai y mudn nhu: dau diu, budn ndn va ndn, dac biet gap cac rdi loan ve tinh thin kinh nhu cudng sang, rdi loan tam thin nhe c) Tuang tdc thuoc Cac benh nhan mic cac benh tim mach cd dung cic thud'c chen beta, chen calci, digitalis cin rat than trgng dung phd'i hop vdi mefloquin Da cd tai bien ngirng hd hap va tim sau dung mdt lieu nhat mefloquin d benh nhan dang dung propanolol 298 Dung ddng thdi vdi primaquin cd the lam tang tin suit xuat hien cac tic dung phu ciia mefloquin Ddi vdi nhung ngudi dung mefloquin vdi muc dich phdng benh sot ret thi cin cinh giic sir dung cic thud'c an thin, tran kinh, giii lo au, chdng trim cim qui trinh dieu tri du phdng Tot han ci la nen tam ngting dung mefloquin Nhirng b^nh nhan dung cic thud'c chdng co giat, dac biet la acid valproic va natri divalproat, cin tam ngting dung cic thud'c dieu tri sd't ret nhu mefloquin, quinin va chloroquin bdi vi se cd nguy ca gia tang co giat d) Chi dinh Dung dieu tri cit can sdt, dac biet trudng hgp sd't ret P.falciparum da khing vdi chloroquin Thud'c cd thai gian bin thii keo dai nen sir dung dieu tri du phdng cd hieu qui quan e) Chdng chi dinh Khdng dugc dung thud'c cho nhung ngudi cd tien sti bi ddng kinh, cd rdi loan tam thin, cac benh ve din truyen thinkinh tim, cd cam vdi quinidin va cic thud'c cung hg Thud'c cung khdng nen dung cho tre em dudi kg the trgng hoac dudi thing tuoi vi d nhirng ddi tugng nang dung nap thud'c cdn chua dugc tot Chdng chi dinh dung phdi hgp vdi cic thud'c dieu tri sd't ret khic nhu quinin, quinidin va halofantrin Neu nhu trudc da sir dung cic thud'c thi phii 12 gid sau mdi dugc bit diu dung mefloquin Do thai gian ban thii dai cua mefloquin nen het stic than trgng chi dinh dung quinin hoac quinidin sau da dieu tri bang mefloquin Thud'c cung khdng nen dung cho nhung ngudi ma nghe nghiep ddi hdi nhung thao tic phdi hgp tinh te' va phi cdng Ddi vdi nhung ngudi dung mefloquin lau dai, cin cd dinh ky kiem tra chtic nang gan va khim mit f) Lieu luang - Khi sti dung mefloquin dieu tri cat can sd't vdi lieu 15 mg/kg udng lin nhat, hoac lieu 25 mg/kg chia lin udng - Khi sir dung mefloquin dieu tri du phdng vdi lieu mg/kg udng hang tuin, thdi gian udng bit diu 2-3 tuin trudc vao khu vuc sd't ret luu hanh va sau 2-3 tuin khdi khu vuc sd't ret 2.7 Pyrimethamin 2.7.1 Duac dong hoc Pyrimethamin phd'i hgp vdi sulfadoxin (Fansidar) dugc dung dudng udng cung nhu tiem bip Sau udng thud'c, cac ndng dd dinh huye't tuang dat dugc vdng gid Ne'u tiem bap, thud'c hap thu cham va chi dat cic ndng dd dinh huye't tuang sau 1-2 Thud'c cd the tich phan bd la 21/kg, ndng dd huye't tuong va 299 miu toan phin la tuang duang Tren 90% lugng thud'c dugc gin ket vdi protein cua huye't tuang Pyrimethamin duac chuyen hoi gan nhung lai dugc dao thii qua dudng nude tieu dudi dang khdng thay doi Thai gian bin thii trung binh huyet tuang cua thud'c la vao khoing 2.7.2 Duac luc hoc a) Tdc dung Pyrimethamin la chat tic che su khir dihydrofolat Pyrimethamin (2,4diaminopyrimidin) cd cau true hoi hgc rat gin vdi trimethoprim - mdt chat thudng dugc dung de dieu tri cic benh nhiem khuan Pyrimethamin cd hieu luc tren cic the hdng ciu cua P falciparum va tic dung kem han ddi vdi cic loai P vivax, P malariae va P ovale Thud'c cung cd tic dung tic che cic the huu tinh phit trien ca the mudi nen cd tic dung ngan chan su lan truyen benh cdng ddng Sau thdi gian ngin sti dung thi da xuat hien P.falciparum khing vdi pyrimethamin Hien khdng dung pyrimethamin dan thuin de dieu tri sd't ret mi chi dung phdi hgp vdi thud'c sdt ret khic b) Tdc dung.bdt lai Dang ket hgp pyrimethamin-sulfadoxin (Fansidar) cd the gay cic phin ting nghiem ngoai da Khi dung pyrimethamin dan thuin, thud'c dugc dung nap tot va it xiy cic tai bien nguy hiem Khi dung lau dai, thud'c cd inh hudng den cic te bao miu nhu suy giim ddng bach ciu hat, thie'u miu dang nguyen bao khong Id Tuy nhien cd the ngan ngtia bang cich dung acid folic Vdi phu nit mang thai: Pyrimethamin va sulfadoxin (Fansidar) khdng dung cho phu nu dang mang thai c) Chi dinh Dieu tri cat can vdi sdt ret P.falciparum da khing vdi chloroquin, hoac cd the dung dieu tri du phdng d cic khu vuc cdn nhay vdi loai thud'c Tuy nhien, hien P.falciparum da khing cao vdi Fansidar nen khdng dugc khuyen dung Nam 2003, Bd Y te Viet Nam cung da bd Fansidar khdi cic loai thud'c sd't ret thiet yeu dung chuang trinh qudc gia phdng chdng sd't ret d) Chdng chi dinh: Trudng hgp benh nhan cam vdi thud'c 2.8 Proguanil 2.8.1 Duac dong hoc Proguanil chi cd dang thud'c udng Nd dugc hap thu nhanh chdng nhung sinh dung tuyet ddi cdn chua rd Sau udng lieu nhat 200 mg proguanil hydroclorid, cic ndng dinh dat dugc huyet tuang sau khoing 2-3 gid Proguanil dugc chuyen hoi tai gan, ndng dd cic chat chuyen hoi cua nd la cycloguanil (CG) va 4clorophenylbiguanid (CPB) dat dugc huyet tuang tuin tu li 24% vi 6% so vdi chit me Cic ndng dd huyet tuang vi miu toan phin cua proguanil vi cic chat chuyen hoi ciia nd giim song song vdi nhau; thai gian bin thii cudi cung la vao khoing 16 gid Cic nghien ctiu gin day cho thay, thud'c dugc loai trti khoing 50% qua dudng nude tieu, cdn CG chi la 30% va CPB la 10% 300 2.8.2 Duac luc hoc a) Tdc dung Proguanil cd tic dung tren the tien hdng ciu cua P falciparum nen cd tic dung phdng benh Ngoai nd cdn cd tic dung tren cac the7 huu tinh tuang tu nhu pyrimethamin Thud'c phit huy hieu luc thdng qua mdt chat chuyen hoi la cycloguanil Hien khdng sir dung dan thuin proguanil di dieu tri vi ky sinh trting sd't ret khang nhanh vdi proguanil Proguanil dung phd'i hgp vdi atovaquon cd hieu luc cao dieu tri benh sd't ret b) Tdc dung bdt lai Proguanil cd dung nap rat td't va rat it xiy tic dung phu, nhat la ddi vdi nhirng ngudi cd chtic nang than binh thudng Ddi cd the gay loet niem mac mieng va khd chiu vung thugng vi Dung lieu cao cd the7 gay ndn, huye't nieu Vdi phu nu mang thai vd cho bu: Proguanil deu cd the dung dugc nhung nen trinh thing diu Thud'c bai xuat qua sua me nhung khdng inh hudng gi tdi viec phit trien cua tre dang bti me; Tuy nhien ndng dd thud'c sua khdng du bio ve cho dtia tre bi sd't ret 2.9 Primaquin Primaquin la din chat tong hgp cua 8-aminoquinolein 2.9.1 Duac dong hoc Khi udng, primaquin dugc hap thu nhanh va gin nhu toan bd Dd dung sinh hgc tuyet ddi cua nd khoing 96% Sau dung lieu nhat 45 mg, ndng dinh cua thud'c huyet tuang a mtic 150-200 ng/ml vdng 2-3 gid Thud'c dugc phan bd nhieu cic md ca the vdi the tich phan bd vao khoing 3-4 lit/kg Primaquin la mdt loai thud'c cd dd thii thap (24,2-7,4 lit/gid) va dugc thii trti chu ye'u bang dudng chuyen hoi Thud'c dugc thii trti gin nhu hoan toan 24 gid diu, thdi gian ban thii huyet tuang vio khoing gid Chi cd khoing 1% lieu udng dugc thii trti dudi dang khdng thay doi qua than sau 24 gid Chat chuyen hoi chinh la carboxyprimaquin dugc tim thay a miu va mdt chat khic nua li 6methoxyprimaquin dugc tim thay nude tieu vdi ham lugng rat thap Chat carboxyprimaquin cd the tich tu huye't tuang vdi cic him lugng cao han nhieu so vdi chit me vi nd dugc dao thii cham khdi ca the 2.9.2 Duac luc hoc a) Tdc dung Ca che' tic dung hien cdn chua dugc biet rd Cd the cic din chat trung gian quinolin-quinon cua primaquin la cic hgp chat cd tic dung van chuyen dien tti cic qua trinh oxy hoi khu cua te' bao da gay su tan huye't va sin sinh methemoglobin Tic dung manh tren cic the huu tinh cua tat ci cic loai Plasmodium, do cd tic dung td't ddi vdi viec ngan chan su lan truyen benh Ddng thdi cd tic dung trdn the ngu gan cua ky sinh trting sdt ret P vivax va P.ovale 301 b) Tdc dung bdt lai Primaquin la mdt loai thud'c cd dd dung nap td't d lieu dieu tri 15 mg/ va keo dai 14 Tuy nhien, ne'u udng thud'c ddi thi thudng cd nhung bieu hien nhu dau bung, dau vung thugng vi Cic trieu chting ve dudng tieu hoi thudng xiy dung lieu cao: budn ndn, ndn mtia Hiem gap cic bieu hien nang han nhu tut huyet ip vi rdi loan nhip tim Tic dung gay ddc chu ye'u cua primaquin la gay thieu miu tin huye't thudng gap d nhirng ngudi bi thieu hut enzym glucose-6-phosphat dehydrogenase (G6PD) Cin biet ring tren the gidi cd tdi 200-300 trieu ngudi bi thieu hut enzym nay, dd la dieu cin luu y dieu tri bang primaquin Tai bien tren thudng xiy sau dung thud'c 1-3 Mdt thay nude tieu cd bie'u hien sim mau thi nen dting viec dung thud'c Cd the kiem tra bang phuang phip him lugng uroglobulin nude tieu vi ty le huyet sic to miu Primaquin cung cd the gay su xuat hien methemoglobin miu; suy cd the7 gap nhung rat hie'm Vdi phu nit mang thai vd cho bit: Tuy chua cd nhieu so lieu ve viec gay cic tai bien quii thai cua primaquin tren ca the7 ddng vat va ngudi nhung khdng nen dung nd cho phu nu dang mang thai vi thud'c cd the ngam qua thai ma vao thai nhi gay tinh trang thieu miu huyet tin d nhung dtia tre thieu hut men G6PD Do thud'c cd dao thii qua sua me nen nhirng ba me dang dung thud'c khdng nen nudi bang sua ciia minh c) Chi dinh - Dieu tri chdng tii phit xa (diet the7 ngu gan) ddivdi sd't retP.vivax va P.ovale - Dieu tri chdng lay lan (diet giao bao) ddi vdi sd't ret P.falciparum d) Lieu luang Primaquin dugc dung dudi dang vien 13,2 mg, cd chtia 7,5 mg base - Lieu dung dieu tri the ngu gan: 0,25 mg base/kg/ngay, udng lien tuc 14 ngay; hoac 0,5 mg base/kg/ngiy, udng lien tuc 10 (Bo Y teViet Nam, 2007) - Lieu dung diet the huu tinh cua P.falciparum: 0,5 mg base/kg udng lan Bdng 16.6: Lieu primaquin tinh theo lira tuoi (neu khdng cdn benh nhan) Tuoi P falciparum dieu tri lan P.vivax dieu tri 10 - dudi tuoi vien udng lin vien / ngiy x 10 - dudi 12 tuoi vien udng lin vien /ngay x 10 12 -dudi 15 tuoi vien udng lin vien /ngiy x 10 Tti 15 tuoi trd len vien udng lin vien / x 10 Chii y: Khdng dung primaquin cho tre em dudi tuoi va phu nu cd thai, ngudi cd benh gan vi ngudi thieu men G6PD 302 III DIEU TRI BENH SOT RET Phan loai dap ting dieu tri Cdc tieu chuan de phan loai dap itng dieu tri theo WHO- 2005 nhu sau: * That bai dieu tri sdm (Early Treatment Failure -ETF): Dugc coi la that bai dieu tri sdm ne'u benh nhan xuat hienmdt nhung diem sau: - Cd nhung dau hieu nguy hie'm hoac sd't ret nang vao Ngay 1, Ngay hoac Ngay va cd ky sinh trung (KST) miu - Mat dd KST miu vao Ngay cao han Ngiy - Cd KST a Ngiy vi nhiet dd a nich > 37,5°C - Mat dd KST miu Ngay > 25% so vdi Ngay * That bai lam sang mudn (Late Clinical Failure -LCF): That bai dieu tri mudn neu benh nhan xuat hien mdt nhung die'm sau: - Cd nhung dau hieu nguy hiem hoac sd't ret nang sau Ngay va trudc dd khdng gap bat ky tieu chuan nao ve dieu tri that bai sdm - Cd KST miu va nhiet dd d nich > 37,5°C a bat cti nao tti thti den 28 * That bai ky sinh triing mudn (Late Parasitogical Failure - LPF): Neu d benh nhan phit hien cd KST mau vao bat ky nao tti Ngay den Ngay 28 va nhiet dd d nich < 37°C va trudc khdng gap tieu chuan nao ve dieu tri that bai sdm hoac that bai lam sang mudn thi dugc ggi la that bai ky sinh trting mudn * Dap irng tot lam sang vd ky sinh trimg (Adequate Clinical and Parasitological Response -ACPR) Dip ting td't lam sang va ky sinh trung hay cdn ggi la khdi benh d benh nhan khdng cd KST miu tai Ngay 28 va trudc khdng gap tieu chuan nao ve dieu tri that bai sdm hoac that bai lam sang mudn hoac that bai ky sinh trung mudn Theo doi hieu luc dieu tri - Theo ddi lam sang: Cin theo ddi benh nhan qua trinh dieu tri, ne'u benh dien bie'n nang hoac dieu tri ma benh nhan vin sd't, hoac tinh trang benh xiu di va cd KSTSR thi phii thay thud'c sdt ret khic - Theo ddi ky sinh triing: Cin lay lam mau xet nghiem, xic djnh chung loai ky sinh trung, dem mat KSTSR vao bat diu dieu tri, thti va ngiy sau dieu tri di dinh gia hieu luc cua thud'c sd't ret dang dugc dung Xti tri cac trudng hgp dieu tri that bai: - Cac trudng hop dieu tri that bai phii dugc dieu tri thay the' bang loai thud'c sd't ret khac cd hieu luc cao han 303 - Neu gap nhieu trudng hop dieu tri that bai ddi vdi mdt loai thud'c sd't ret tai ca sd dieu tri, cin bio len tuyen tren de tien hinh xic minh KSTSR khing thud'c - Neu ket qui xet nghiem chi cd giao bao (gametocyt) ma benh nhan khdng sd't thi khdng phii la dieu tri that bai, trudng hgp cin dung primaquin de chdng lay lan Phac dieu tri cho tirng the benh sdt ret Mdi loai thud'c sd't ret cd tic dung tren KSTSR khic nhau, ddng thdi cung cd cic tic dung ngoai y mudn Do vay chi dinh dieu tri cho mdi benh nhan sd't ret, cin dua vao ket qui xet nghiem va the trang cua ngudi benh de lua chgn loai thud'c sd't ret cd hieu luc va an toan De bio dim hieu qui td't, cin hudng din va giim sit benh nhan dung thud'c sdt ret du lieu ngiy va du so dieu tri 4.1 Dieu tri sdt ret the thong thudng (sd't ret chua bie'n chting- uncomplicated malaria) Hudng din lua chgn thud'c dieu tri cic the sd't ret dugc trinh bay bing 16.7 Bdng 16.7 Lua chon thuoc sdt ret diing cho tirng the benh sdt ret Nhom benh Nghi sot ret Sot ret Sot ret Sdt ret nhiem nhan (SRLS) P.falciparum P.vivax phdi hop tuoi trd xudng Artesunat hoac Chloroquin Chloroquin Artesunat Chloroquin + Primaquin Primaquin Quinin Chloroquin Quinin Artesunat Chloroquin Artesunat Artesunat Artesunat + Artesunat hoac Tren tuoi Phu nu cd Chloroquin thai Quinin hoac dudi thing Chloroquin Phu nir co thai tir Artesunat hoac thing trd len Chloroquin Primaquin hoac CV-8 Artesunat + Ghi chu: - SRLS: sdt ret lam sang 4.7.7 Dieu tri sdt ret nhiem P.vivax dan thuan Theo ke't qui giim sit hieu luc dieu tri ciia chuong trinh phdng chdng sd't ret (PCSR) Qudc gia cho thay, sot ret P.vivax vin cdn dip ting td't vdi chloroquin Dac diem cua loai P.vivax la ngoii the ky sinh hdng ciu gay can sd't cdn cd the ngu a gan gay nhung can sd't tii phit xa Ddi vdi sd't ret P.vivax cin sti dung chloroquin de diet the7 vd tinh ndi hdng ciu de dieu tri cat can vi ddng thai sir dung primaquin (cic trudng hgp dien chi dinh sti dung) de diet the ngu gan dieu tri chdng can tii phit xa 4.1.2 Dieu trisdt retdo P.falciparum hoac sdt retnhiem phdi hop dd co Pfalciparum Hien Plasmodium falciparum da khing cao vdi chloroquin va cd ty le khing thap vdi mefloquin, Theo hudng din cua WHO (2006) & Bd Y te Viet Nam (2007) khuyen cio sti dung thud'c sd't ret phd'i hgp de dieu tri sd't ret P.falciparum chua bien chting 304 4.2 Dieu tri sdt ret P falciparum khdng thud'c Ky sinh trung sd't ret khing thud'c la nang cua mdt loai ky sinh trung cd the song sdt va phit trien, mac du benh nhan dugc dieu tri va hap thu mdt lieu lugng thud'c bang hoac cao han lieu thdng thudng (WHO, 1981) Viet Nam nam vung P.falciparum khing thud'c, thdng thudng sau nam se cd dieu chinh chinh sich thud'c sdt ret nham lua chgn phic tdi uu dieu tri chdng khing va phu hgp vdi dieu kien nguon lire thuc te cua dat nude 4.2.1 Cdc phac dd thuoc phdi hap duac dung a Viet Nam * Dihydroartemisinin - piperaquin phosphat(Hudng din ciia Bd Y te'Viet Nam-2007) Mdi vien cd chtia 40 mg dihydroartemisinin + 320 mg piperaquin phosphat (ten biet duac: Artekin, Arterakine, Obelix) Lieu trinh dieu tri ngay, lieu luang nhu bing 16.8 Bdng 16.8: Lieu luang dihydroartemisinin - piperaquin tinh theo Ida tuoi Ngay Ngay Ngay Tuoi Dirdi tuoi Gift dau Sau gid Sau 24 gid Sau 48 gid 72 vien 72 vien 72 vien 72 vien vien vien vien vien 172 vien 172 vien 172 vien 172 vien vien vien vien vien - dudi tudi - dudi 15 tuoi Tir 15 tuoi trd len Chii y: Khdng dung cho phu nir cd thai thing diu * Vien sd't ret CV-8 (Hudng din cua Bd Y te Viet Nam- 2003 & 2007) Mdi vien CV-8 cd phan gom: 32 mg dihydroartemisinin + 320 mg piperaquin phosphat + 90 mg trimethoprim + mg primaquin phosphat Lieu trinh dieu tri ngiy, lieu lugng bing 16.9 Bdng 16.9 Lieu luang thude phdi hap CV-8 tinh theo lira tuoi Ngay (vien) Tuoi Ngay (vien) Ngay (vien) GidO sau gid 72 72 72 % - dudi 12 tuoi l l l i 12 - dudi 15 tuoi 172 172 172 l'/2 Tir 15 tuoi trd len 2 2 - dudi tuoi Chii y: Khdng dung CV-8 cho tre em dudi tudi, phu nti cd thai, ngudi cd benh gan va ngudi thieu men G6PD * Phd'i hgp artesunat + mefloquin (Hudng din cua Bd Y te Viet Nam- 2003) Dieu tri phdi hgp thud'c artesunat, vien 50 mg udng va mefloquin, vien 250 mg udng vao thti lieu lugng nhu sau: - Lieu tinh theo can nang: 305 + Artesunat, vien 50 mg, lieu mg/kg diu, va mdi mg/kg + - Mefloquin, vien 250 mg, lieu 15 mg/kg udng vao thti Lieu tinh theo ltia tuoi (ne'u khdng can benh nhan) bing 16.10: Bdng 16.10 Lieu luang artesunat + mefloquin tinh theo Ida tuoi Ngay Ngay Ngay Tuoi Artesunat Artesunat (vien) (vien) Artesunat Mefloquin (vien) (vien) 72 72 74 - dudi tuoi l l 72 - dudi 12 tuoi 2 l 12 - dudi 15 tuoi 2 Tu 15 tuoi trd len 2 Dirdi tuoi 4.2.2 Mot sdphac dd thuoc phdi hap duac WHO khuyen cao sir dung * Artemether - lumefantrine Mdi vien cd chtia 20 mg artemether + 120 mg lumefantrine (ten biet dugc: Coartem) Lieu trinh dieu tri ngay, lieu lugng nhu bing 16 11 Bdng 16.11: Lieu luang artemether-lumefantrine tinh theo kg trpng luang benh nhan So vien diing tai cac thai diem Trongluong (kg) Ogid gid 24 gid 36 giti 48 gid 60 gid 10- 14 1 1 1 15-24 2 2 2 25-34 3 3 3 >35 4 4 4 * Atovaquone - proguanil Mdi vien cd chtia 250 mg atovaquone va 100 mg proguanil (ten biet dugc Malarone) Lieu trinh dieu tri ngay, lieu lugng nhu bing 16.12 Bdng 16.12: Lieu luang atovaquone-proguanil tinh theo kg trpng luang benh nhan So vien dung tai cac thdi diem Trong lugng (kg) Ngay Ngay Ngay 11-20 1 21 -30 2 31 -40 3 >40 4 306 Ghi chu: Malarone dugc khuyen dung a cic nude khdng cd sd't ret luu hanh, dung cho ci dieu tri cit va dieu tri du phdng du lich vao khu vuc cd sd't ret luu hanh * Phdi hgp thuoc sdt ret vdi mgt sd khang sinh: Doxycyclin: cd the dung phd'i hgp hoac dung don thuin di dieu tri ca benh sd't ret Tuy nhien, dung cin chii y loai trti nhung benh nhan thude dien chdng chi dinh thud'c nhu: tre em dudi tudi; ngudi cd cim vdi tetracyclin; phu nti cd thai vi cic ba me dang cho bu; ngudi cd benh gan - Dieu tri ky sinh trung sd't ret khing thud'c: + + Phd'i hgp vdi quinin: quinin mg base/kg, udng lin hang ngay, udng va doxycyclin 100 mg/kg hang ngay, udng Phd'i hgp vdi artesunat hoac mefloquin cho nhung khu vuc cd P.falciparum da khing thud'c (multiresistant) - Dieu tri du phdng: udng 1,5 mg/kg hang ngay, nhung khdng dung cho tre dudi tuoi va trgng lugng dudi 25 kg Tetracyclin: cd the dung phdi hgp vdi mdt so thud'c sd't ret khac di tang hieu luc dieu tri benh sd't ret Tuy nhien, dung cin chii y loai trti nhirng benh nhan thude dien chdng chi dinh thud'c nhu: tre em dudi tuoi; ngudi cd cim vdi tetracyclin; phu nti cd thai va cic ba me dang cho bu; ngudi cd benh than, benh gan Quinin mg base/kg, udng lin hang ngay, udng Tetracyclin 250 mg/kg, udng lin hang ngay, udng lien Clindamycin: cd the dung phdi hgp vdi mdt sd thud'c sd't ret khic de tang hieu luc dieu tri benh sd't ret Tuy nhien, dung cin chii y loai trti nhung benh nhan thude dien chdng chi dinh thud'c nhu: ngudi cd cam vdi clindamycin hoac lincomycin, cd tien sir da day, viem rudt ke't, suy than, benh gan Quinin mg base/kg, udng lin ngay, udng Clindamycin 300 mg, udng lin hang hang, udng 4.3 Dieu tri sdt ret the dc tinh (severe malaria) 4.3.1 Quy dinh dieu tri benh sot ret the dc tinh tai thon budn vd xa a) Y te thon budn Theo ddi benh nhan cd mdt cic dau hieu du bio sd't ret the ac tinh, cin cho udng thud'c artesunat hoac dihydroartemisinin - piperaquin va dua benh nhan len tram y te' xa b) Tram y te xa Chan doin sdm benh nhan sd't ret the thdng thudng, dieu tri sdm bang thud'c dac hieu va theo ddi chat che ca benh Benh nhan cd cic dau hieu du bio sd't ret the ic tinh can xti tri nhu sau: 307 - Tiem artesunat, ne'u khdng cd thud'c tiem thi dung vien artesunat dat hau mdn Sau chuyen benh nhan len tuyen tren Ne'u thdi gian van chuyen qui dii thi can cho cic lieu tiep theo - Khdng van chuyen nhung trudng hgp benh nhan dang tinh trang sdc (mach nhanh nhd khd bit, chan tay lanh, va md hdi, tut huyet ip), phu phdi cap, co giat - Trudng hgp khdng the chuyen len tuyen tren dugc, cin de nghi tuyen tren tdi tang cudng bang phuang tien nhanh nhat, ddng thai tiep tuc dieu tri tich cue chd dgi c) Dieu tri benh sdt ret the dc tinh tai tuyen benh vien * Dieu tri dac hieu: Sti dung mot cic thud'c sdt ret theo thti tu uu tien nhu sau: - Artesunat tiem: Lg 60 mg pha vdi ml natri bicarbonat 5%, lie ky cho bdt artesunat tan hoan toan, dung dich sudt, sau pha them ml natri clorua 9%o de tiem tinh mach hoac tiem bip thit (neu khdng tiem dugc tinh mach) - Vien artesunat dat hau mdn: Loai 50 mg va lOOmg Sir dung benh nhan khdng udng dugc, khdng tieu chiy, nai khdng cd dieu kien tiem truyen, sd't ret tre em (lieu lugng xem bing 16.3) - Quinin dichlohydrat: Ong 500 mg (neu khdng cd artesunat), thud'c dugc pha natri clorua 9%o hoac glucose 5%, truyen tinh mach vdi lieu 20 mg/kg gid diu, sau 10 mg/kg gid mdt lin cho de'n benh nhan tinh thi chuyen sang tiem bip hoac vien udng cho du lieu dieu tri (lieu lugng xem chuong IV muc 13) 4.3.2 Dieu tri trieu chirng vd bien chung Theo quy dinh dieu tri chung ciia Bd Y te' Viet Nam 4.4 Dieu tri sdt ret dc tinh cho mot sd ddi tuang dac biet 4.4.1 Dieu tri sdt ret dc tinh d tre em Sdt ret d tre em neu khdng dieu tri kip thai de chuyen nhanh sang sd't ret ic tinh (SRAT), vdi cic tai bie'n nang nhu sd't cao co giat, thie'u miu, dudng huye't, hdn me va de tti vong Tre em bi sdt ret, dac biet ddi vdi tre em sdng khu vuc sdt ret luu hanh thudng cd lugng ca the rat thap so vdi tre cung ltia tuoi sdng d nai cd mtic sdng cao, vay dung thud'c can dugc tinh theo kg trgng lugng ca the Dieu tri SRAT ddi vdi tre em cung nhu phin dieu tri chung, nhung cin chii y: + Chdng co giat -I- Xti tri dudng huye't + Xti tri tinh trang thie'u miu + Dieu chinh tinh trang mat nude, rdi loan dien giii, kiem-toan Thud'c uu tien la artesunat vien dat hau mdn, artesunat tiem hoac quinin 308 4.4.2 Dieu tri sdt ret dc tinh a phu nu co thai Phu nti cd thai mic sd't ret de bi thieu miu, dudng huyet, phu phoi cap, de chuye'n SRAT Hau qui ciia SRAT la cd the say thai, thai chet luu, de thieu thing va din den tti vong Tich cue dieu tri diet ky sinh trung sd't ret, trieu chting, bien chting - Dieu tri dac hieu: + Artesunat tiem: Lg 60 mg pha vdi ml natri bicarbonat 5%, lie ky cho bdt artesunat tan hoan toan, dung dich sudt, sau pha them ml dung dich natri clorua 9%o di tiem tinh mach hoac tiem bip (ne'u khdng tiem dugc tinh mach), lieu lugng xem bing 16.1 va 16.2 + Quinin dichlohydrat: dng 500 mg (neu khdng cd artesunat), thud'c dugc pha natri clorid 0,9% hoac glucose 5%, truyen tinh mach vdi lieu 20 mg/kg gid diu, sau 10 mg/kg gid mdt lin cho den benh nhin tinh thi chuyen sang tiem bip hoac vien udng cho du lieu dieu tri (lieu lugng xem bing 16.5) - Dieu tri trieu chting, bien chting: + Nhu phin dieu tri chung ve SRAT nhung cin chti y: Xti tri dudng huyet, thie'u miu, dieu chinh tinh trang mat nude, rdi loan dien giii, kiem-toan + Trudng hgp chdng bdi nhiem cd the dung clindamycin 309 MUC LUC Ldi ndi diu Phan 1: Dl/OC LAM SANG TRONG THl/C HANH BENH Vl£N Chuang 1: Thdng tin thud'c (PGS Phuang Dinh Thu) Chuang 2: Cic sir dung benh vien 30 (DSCK11 Vu Chu Hung) Chuang 3: Ve sinh benh vien 37 (DSCKII Vu Chu Hung) Chuang 4: Dich tiem truyen tinh mach 58 (PGS.TS Hoang Thi Kim Huyen) Chuang 5: Miu vi cic che' pham tti miu 77 (GS.TSKH Dd Trung Phan) Phan 2: SIT DUNG THUOC TRONG Dl£u TRI 95 Chuang 6: Sir dung thud'c trongdieu tri cic benh ve mat 96 (PGS.TS Hoang Thi Minh Chau) Chuang 7: Sir dung thud'c dieu tri cic benh a tai mui hgng 118 (GSTS Ngo Ngpc Lien) Chuang 8: Thud'c dieu tri tang lipid miu 133 (PGS.TS Hoang Thi Kim Huyen) Chuang 9: Thud'c dieu tri dii thio dudng 151 (TS Dd Trung Quan) Chuang 10: Sti dung thud'c dieu tri suy tim 171 (GS.TS Nguyen Ldn Viet) Chuang 11: Sti dung thud'c dieu tri benh tang huyet ip 197 (GS.TS Pham Gia Khdi) Chuang 12: Sir dung thud'c dieu tri benh ddng kinh 218 (GS.TS Le Ddc Hinh) Chuang 13: Sti dung thud'c dieu tri benh Parkinson 246 (GS.TS Le Dice Hinh) Chuang 14: Sti dung thud'c dieu tri loet da day - ti trang 262 (PGS.TS Pham Thi Thu Hd) Chuang 15: Su dung thud'c dieu tri benh giun - sin 272 (TS Kieu Khac Don) Chuang 16: Thud'c sir dung dieu tri benh sd't ret 290 (TS Nong Thi Tien) 310