Mc tiuK c nhng thuc chnh thng dng trong qu trnh gy m v hi sc.S dng ng cc thuc thng dng trong gy m v hi sc.Phi hp thuc ng cch tng hiu qu v hn ch tc dng ph.

1. Thuc tin mMc ch:An tm, an thn, bt lo u. Lm qunLm gim nn i, gim co tht. C tnh gy ng.

Nhm Benzodiazepin

- Gm: Midazolam, Diazepam, Lorazepam. - u im ca thuc nhm Benzodiazepin: t gy tc dng ph, t c ch h hp v nht l chng t gy try tim mch

Nhm Benzodiazepin

1.1. Tc dng:H TKTW: Gy an thn, gy ng, gy qun, chng co git, gy dn c H tim mch: gy dn mch v gim cung lng tim nh. Nhp tim thng khng thay i. H hp: lm gim tn s th v th tch thng lu ty theo liu dng. c ch h hp nu dng km vi nhm thuc phin

Nhm Benzodiazepin1.2. Tc dng ph: Tng tc thuc: Dng Benzodiazepin trn BN ng kinh ang iu tr vi Valproat c th gy ln cn tm thn cp.C thai v sinh : thuc c th gy d tt cho bo thai nh st mi, ch vm nu dng trong ba thng u thai k. Thuc qua nhau c th gy suy h hp tr s sinh.

Nhm BenzodiazepinMidazolam: Hypnovel - Tc dng ngn, tan trong nc, khng c cht t dc, thuc c tc dng gy qun mnh nht v ko di- Tin m: Liu dng 0,5 - 1 mg TM/mt ln

Nhm Benzodiazepinb. Diazepam: Valium, Seduxen - Thuc c s dng trong GMHS rt sm, c tnh kch thch tnh mch, gy au ni chch v c th gy d ng, ngay c gy sc qu mn. - Tin m: Liu dng 05 - 10 mg ung khong 0,5 - 1 gi trc m.

2. Thuc khng i giao cm: Atropin, Scopolamin2.1.Tc dng:Tng nhp tim: dng nga nhp tim chm do phn x i giao cm H hp: c ch tit m nht, dn ph qun gy gim sc cn ng thTKTW: gy vt v, bt rt, o gic. Mt: dn ng t v mt iu titH niu - sinh dc: gim trng lc niu o v bng quang do dn c trn gy b tiu.Chng tit: nc bt, gim p lc co tht thc qun di.

Atropin

Liu tin m 0,01 0,02 mg/kg TB hay TMAtropin dng thn trng ngi b tng nhn p gc ng, ph i tuyn tin lit hay hp c bng quang

Scopolamin- Tc dng chng tit nc bt mnh hn Atropin v c tc dng nhiu hn trn h thn kinh trung ng so vi Atropin. - Liu dng lm sng thng gy bun ng v qun, c th km bt rt, ni sng, nht l i vi ngi gi. - Scopolamin cn nga say tu xe. Nn thn trng hay trnh dng cho ngi gi, tng nhn p.

3. THUC GiM AU H MORPHIN- L nhng thuc gim au rt mnh, thng c dng trong GMHS hay gim au sau m. - Thuc c tc dng ng vn (agonist) hay i vn (antagonist) trn nhng th th morphiniques no v sng sau ty sng. - Kch thch cc th th (mu), th th (kappa) v th th (delta) bng thuc ng vn n thun s cho tc dng: + Th th , : Gim au, c ch h hp + Th th : Sng khoi, gy nghin + Th th : An thn

3. THUC GiM AU H MORPHIN- Phn loi theo:+ Thuc ng vn n thun: Morphin, Pethidin, Fentanyl, Sufentanil, Alfentanil v Remifentanil.+ Thuc ng vn mt phn/i vn: Buprenorphin, Nalbuphin, Tramadol.+ Thuc i vn n thun: Naloxon.

3. THUC GiM AU H MORPHIN gim au ca cc thuc phin c nh nh sau: - gim au ca Morphin # 1- gim au ca Meperidin # 1/10- gim au ca Fentanyl # 100 - gim au ca Remifentanil # 100 - gim au ca Sufentanil # 1000

3. THUC GiM AU H MORPHIN3.1. H thn kinh trung ng: - Gy an thn t, gim au ty theo liu, gy sng khoi. - Liu cao c th gy qun v mt tri gic.3.2. H tim mch: - t thay i sc co bp c tim, ngoi tr thuc Meperidin l cht gy c ch c tim trc tip.Gim nh sc cn mch mu ngoi vi. Lm chm nhp tim ty theo liu, ngoi tr Meperidin gy tng nhp tim- Tnh n nh tim mch cao

3. THUC GiM AU H MORPHIN3.3. H h hp:Gy c ch h hp ty thuc liu dng. Ban u, thuc gy gim tn s th, liu cao, s gim th tch kh thng lu. C th gy ngng th do c ch h hp hay co cng c thnh ngc. Cc thuc phin, c bit l Fentanyl, Sufentanil, Alfentanil gy co cng c thnh ngc lm ngi bnh th kh, cng nh h hp iu khin kh khn. c ch phn x ho ty theo liu.

3. THUC GiM AU H MORPHIN3.4. H tiu ha:- Lm chm thi gian lm trng d dy v gy to bn do gim nhu ng.- Tng trng lc c vng lm co tht ng mt gy cn au qun mt v b tiu.Bun nn v nn i do kch thch trung tm nn.3.5. Tc dng ph khc:- Nga da: iu tr vi Naloxon.- Gy nghin v dung np thuc:

MORPHIN

- Gim au hiu qu trn mi loi au: au ni tng, au do chn thng, gim au v gim lo u trong nhi mu c tim. - Morphin lm dn tnh mch nn rt tt iu tr ph phi cp do suy tim tri cp v lm gim cm gic kh th. Liu dng: Morphin tim tnh mch liu 0,05 - 0,1mg/kg, nn chn liu nh t 1 - 2 mg/ln, hay tim bp 0,1 - 0,2 mg/kg

Fentanyl- Fentanyl l thuc phin tng hp, tan trong m nhiu hn Morphin, mnh gn 100 ln hn Morphin. - Thi gian tim phc nhanh hn: 3 - 5 pht, tnh n nh huyt ng tt hn v c ch h hp mnh hn. - Liu cao Fentanyl tim tnh mch nhanh c th gy cng c thnh ngc. Fentanyl gy nga mt v ton thn.

FentanylLiu dng: Gy m: liu dng 1- 2 mcg/kg bnh nhn t th, cuc m ngn khong 30 - 40 pht; liu dng 5 - 10 mcg/kg phu thut ln, c th myFentanyl 10 - 25 mcg pha chung vi thuc t ti ch Bupivacain trong t ty sng lm tng tc dng t v ko di thi gian tc dng ca thuc t. Cho Fentanyl vo khoang NMC qua catheter liu 0,3 mcg/kg/gi hay cho tng liu 50 - 100 mcg/ln.

Meperidin (Pethidin, Dolargan)Liu 1 - 2 mg/kg (TB), 0,5 mg/kg (TMC). Thuc c thi gian tc dng ngn hn Morphin v gy bun nn, nn i, gy tt huyt p nhiu hn Morphin do phng thch Histamin- Meperidin liu 25 - 50 mg TM thng rt hiu qu iu tr chng lnh run trong hay sau khi phu thut

RemifentanilRemifentanil l thuc phin c tc dng ngn nht hin nay, thng thi gian tc dng khong 3 5 pht nn thuc dng truyn tnh mch, do b thy phn bi men esterase trong mu v m; Remifentanil (0,3 - 0,4 mcg/kg/pht TM) vi Propofol (75 mcg/kg/pht TM).

Sufentanil- Sufentanil l thuc phin tng hp mnh nht hin nay- Tc dng tng t nh Fentanyl nhng thi gian tc dng ngn hn v t b tch t thuc so vi Fentanyl. - Dng duy tr trong gy m cn bng, Sufentanil cho tng liu 0,1 - 0,2 mcg/kg TM hay truyn tnh mch lin tc 0,2 - 1 mcg/kg/gi.

4. THUC DNG KHI M

- Thuc khi m, thuc dn u l nhng thuc khi dng gip cho ngi bnh i vo gic ng m i, m du hn, trnh cho bnh nhn phi i qua thi k II kch ng v kh chu cho ngi bnh

4. THUC M TNH MCHCc thuc m tnh mch dng : + Khi m, + Lm cc th thut ngn: ph rung tim, + iu tr cn ng kinh khng p ng vi cc thuc chng ng kinh khc, + Gy m tnh mch hon ton+ An thn khi th my.

THUOC ME LY TNG

Tnh me nhanh, lam quen.Khong tang ap suat noi so, me nhanh em, khong kch thch.Huyet ong on nh.Thong kh de dang.De s dung, on nh trong dung dch.Dung nap tot tnh mach, khong aut phong thch Histamine, phan ng phu, qua man.Nhng chat chuyen hoa t tac dung, t tch tu. Khong co thuoc me n thuan " LY TNG ".

4.1. Sodium thiopenton: (Thiopental, Nesdonal)Thiopental l thuc barbituric c s dng sm nht trong GMHS v hin nay vn cn c s dng, nht l trong gy m phu thut TKSNThi gian tc dng: 30 - 45 giyThi gian tc dng: 5 - 10 pht

4.1. Sodium thiopentonTc dng:- TKTW: Thiopental l thuc chng ng kinh rt mnh, v nhanh. Lm gim CH no, gim LL mu no v gim ALNS. C tc dng bo v no. TM: Gy tt huyt p do c ch c tim v dn tnh mch v tng nhp timH hp: Lm gim tn s th v th tch kh thng lu. Ngng th thng xy ra khong 30 - 90 giy sau liu gy ng.

4.1. Sodium thiopentonb. Tc dng ph: - Thuc gy au ni tim do kch thch tnh mch. - Gy hoi t m nu tim ra ngoi TM. - Nu tim nhm vo M gy au nhc d di v hoi t tay do tnh kim cao ca dung dch thuc nyc. Liu dng: - Khi m: Liu 3 - 5 mg/kg

4.2. KetaminC ch tc dng cha r, nhng c tc dng i khng ti th th N-methyl-D-aspartat (NMDA). Thuc chuyn ha ti gan, thnh nhiu cht chuyn ha trong vi cht c hot tnh. Thi gian tc dng: 1 pht Thi gian tc dng: 10 - 20 pht. Liu: 2 3 mg/kg TMC

4.2. Ketamina. Tc dng:TKTW: Ketamin lm tng LL mu no, CH no v tng ALNS. Ketamin l thuc gy m phn ly, c tnh gy qun v gim au.TM: Ketamin lm tng tn s tim, tng HA M h thng v M phi do phng thch catecholamin ni sinh. HH: t c ch h hp.

4.2. Ketamina. Tc dng ph:Ketamin gy tng tit nc btKetamin gy vt v, bt rt trong lc tnh m, gy o gic v c mng trong v sau mLm tng ALNS nn khng dng BN CTSN hay tng ALNSTr em t b o gic hn ngi ln. Khng nn dng Ketamin cho BN c RL tm thn.Gy run c khi c kch thch. Lm tng trng lc c.

4.3. PropofolDng khi m v duy tr m, Chn la cho BN m v trong ngy v: tnh m nhanh, cht lng khi tnh m tt, khng b ngy ngt khi tnh m, t b bun nn v t nn i sau gy mLiu khi m 2 3 mg/kg, Thi gian tc dng: 30 45s Thi gian tc dng: 5 - 10 pht

4.3. Propofola. Tc dng:TKTW: Liu cao, gy mt tri gic, liu thp gy an thn nhng bnh nhn vn tnh to. Gim CH no, gim LL mu no v gim ALNS. TM: Gy tt huyt p do dn mch v gim cung lng tim. Gim nhp timHH: Propofol c ch phn x thanh qun, kh qun nn t b co tht thanh qun khi t ng ni kh qun, nn rt thun li khi t mask thanh qun.C th truyn tnh mch lin tc duy tr m.

4.3. Propofolb. Tc dng ph: - BN thng b au ni tim thuc - Dng nh tng gip vi khun pht trin nn phi ch gi v trng khi ly thuc, v b ng thuc m khng dng sau khong 6 gi trnh b nhim khun.

4.4. Etomidat

Etomidat l cht Imidazol c tnh gy m, gy ng, c dng khi m. Thi gian tc dng : 30 giyThi gian tc dng: 4 - 6 pht. Etomidat c chuyn ha ti gan v men esterase trong mu thnh cht chuyn ha khng c hot tnh

4.4. EtomidatTc dng: - TKTW: Gim CH no, LL mu no v gim ALNS. Etomidat c tc dng chng ng kinh nhng gy thay i sng in no gip nh v c ng kinh. - TM: t thay i nhp tim, huyt p v cung lng tim - HH: c ch h hp ngng th thong qua. - Khng gy phng thch histamin v t b phn ng d ng nn l thuc c chn cho bnh nhn b tng phn ng ng th.

b. Tc dng ph: - au ni tim- Run git c v c ng ngoi thp- Bun nn v i thng xy ra sau m, nhiu hn cc thuc m khc.- Kch thch tnh mch gy au ni chch.- Etomidat c ch tuyn thng thn tit Cortisol trong 24 gi, nn khng dng liu lp li hay truyn tnh mch ko di. c. Liu dng : Khi m: Liu 0,3 0,4 mg/kg.

4.4. Etomidat

DC NG HC

THN KINH TWTIM MCHH HPTHIOPENTAL Gim TT oxy Gim LL mu Gim ALNS Tng nhp tim Gim HA n cp mu MV Co tht TQ, KQ V kh LT: KETAMIN Tng LL mu Tng ALNS Gim au Tng nhp tim Tng LL tim, sc cn nn tng HA Dn PQ Tng titPROPOFOL Gim LL mu Gim ALNS M mt sm Gim nhp tim Gim HA t nh hng MV Tn s: Gim V kh LT: Gim KT PQETOMIDATE Gim LL mu Gim ALNS- Tnh nhanh Nhp tim: tng t Huyt ng n nh Tn s: Tng V kh LT: Khng gy co tht PQ

CH NH CHNG CH NH

5. Duy tr m: Thuc m h hpNhm Halogen:HalothanIsofluranSevofluran

5.1. Halothan- Thuc m h hp, khng mu, c mi thm nh mi tri to chn, v ngt, t gy kch thch ng h hp nn c th dng khi m, nht l tr em. - Khi m nng 2 - 3%, duy tr m vi nng 0,5 - 1,5.

5.2. HalothanTc dng: - TKTW: Tng LL mu no v tng ALNS - TM: gy tt huyt p, gy lon nhp tim, thng l nhp tim chm v nhp nt - HH: Halothan gy th nhanh, nng. Gy dn ph qun v lm gim phn x hu v thanh qun

5.2. HalothanTc dng: - Dn c trn v c vn, k c c t cung lm chy mu nhiu khi m bt con. - Gim LL mu thn, gim lc cu thn v lng nc tiu do tt huyt p v gim cung lng tim. - Gim LL mu qua gan do gim cung lng tim.

5.2. Halothanb. Tc dng ph:Gy khi pht st cao c tnh.Gy vim gan do Halothan, tng i him, t l khong 1:35.000 trng hp v c th gy hoi t gan khi gy m lin tip nhiu ln trong mt thi gian ngn.

5.2. ISOFLURAN - Isofluran l thuc m bc hi, khng mu, c mi hi nng cay, gy kch thch ng h hp nn t c dng khi m. - Duy tr m thng nng 2 - 3% phi hp vi dng kh (O2) hay hn hp N2O v O2. - Tnh m nhanh, t phn ng ca thuc m nn Isofluran c dng trong gy m BN ngoi tr hay v trong ngy

5.2. ISOFLURANTc dng: - TKTW: t nh hng trn LL mu no v ALNS nng thp - TM: Gy tt huyt p t l vi nng thuc m do dn mch ngoi vi. Mch tng i n nh hoc tng nhanh nh - HH: Gy c ch h hp nh, nhng t gy th nhanh.

5.2. ISOFLURANTc dng: - C tc dng dn c tt, tng tc dng ca thuc dn c khng kh cc v gy dn c t cung. - Isofluran gy gim lu lng mu qua gan, nhng s cung cp dng kh cho t bo gan c duy tr

5.3. SEVOFLURAN- Sevofluran c mi d chu, khng kch thch ng h hp nn c chn dng lm thuc khi m ng h hp hiu qu, nhanh v m du cho c tr em v ngi ln. - Cht Sevofluran l thuc m h hp yu hn cht Isofluran, nhng nh ha tan trong mu thp nn thuc cho tc dng nhanh, rt d dng v khi m nhanh, d iu chnh thay i m v c thi gian tnh m nhanh. - Hin nay c gi kh cao.

5.3. SEVOFLURANTc dng: - TKTW: Tng LL mu no v ALNS nh Isofluran. Lm gim chuyn ha no. - TM: c ch co bp c tim rt nh. Gim nh sc cn ngoi vi v t gy h HA M v t gy mch nhanh. Sevofluran lm gim s tiu th oxy c tim, gim sc cn mch vnh nhng khng gy n cp mu ng mch vnh. - HH: Sevofluran gy c ch h hp v gy dn n ph qun nh Isofluran

5.3. SEVOFLURANTc dng: - Thn kinh - c: dn c va BN chu ng c th thut t ng NKQ tr em sau khi m bng ng h hp, c th lm khi pht cn st cao c tnh, nhng t l thp hn so vi Halothan. - Gan: Gim LL mu TM ca nhng tng LL mu M gan nn duy tr c LL mu qua gan v cung cp dng kh cho gan. - Thn: lm gim nh LL mu qua thn. Cht chuyn ha l gc ion fluor t do gy h hi ng thn

5.3. SEVOFLURANb. Tc dng ph:- Khong 5% Sevofluran c chuyn ha ti gan bng men P450 to ra ion fluor t do gy c cho thn. - Thuc m h hp Sevofluran b hp thu v bin i bi vi Soda hay Baralym thnh cht vinyl ether, hay hp cht A, hp cht ny c c tnh cao cho chc nng thn, chc nng gan v thn kinh no b

TC DNG CA THUC M H HP

TNH METKTW

HO HAPTIM MACHNhp timHA TBDan MVHalothanCham LLMN:

ALNS: c che Dan PQ Tang TS ChamGiamKhongIsofluraneTrung bnh LLMN: t

ALNS: t c che Dan PQ - Giam TS NhanhGiam ang keSevofluraneNhanh LLMN: t ALNS: t Giam CH c che Dan PQ Giam TS On nhGiamTrung bnh

Tc dng ca thuc m h hp

DAN CGANTHANHalothanTrung bnhGiam LL mau LL mau: Giam

o loc: Giam

IsofluraneNhieu Giam LL mau Van duy tr oxy gan LL mau: Giam

o loc: GiamSevofluraneNhieu Giam LL mau TM Tang LL mau M BN X gan LL mau: Giam

o loc: Giam

6. THUC DN C- Thuc dn c, hay nn gi ng hn l thuc ngn chn s dn truyn thn kinh c (Neuromuscular Blocking Drugs), l nhng thuc khi dng cho bnh nhn, n s lm mm c vn, cn c trn v c tim n khng c tc dng

6. THUC DN CC 2 cch chia thuc dn c:Dn c kh cc (Suxamethonium) v dn c khng kh cc (Vecuronium, Rocuronium, Atracurium)Dn c ngn (Suxamethonium) , dn c trung bnh (Vecuronium, Rocuronium, Atracurium) v dn c di.

6.1. Suxamethonium Tc dng ph: au c sau m.Tng ion kali mu Gy d ng nh ni m ay, nga v nng nht l sc phn v.Gy nhp tim chm v lon nhpTng nhn p v tng p lc ni sTng p lc trong d dyCo cng thong qua c hm khi t ni kh qunTng t l st cao c tnh.

6.1. Suxamethonium - Liu khong 1 - 1,5 mg/kg, tim tnh mch, s gy run c v tip theo gy lit c trong vng 45 - 60 giy, v ko di khong 5 - 7 pht - Ch nh: + BN tin lng t ni kh qun kh + M cp cu BN c d dy y

6.2. Thuc dn c khng kh cc6.2.1. Vecuronium: (NorcuronR)Liu t ni kh qun l 0,08 - 0,1 mg/kg, lp liu - liu ban uThi gian tc dng: 3 pht, Thi gian tc dng: 30 45 pht. Duy tr truyn tnh mch lin tc 1 - 2mcg/kg/pht. Vecuronium thi qua thn 30%, phn cn li qua gan

6.2. Thuc dn c kh cc6.2.2. Rocuronium: (EsmeronR)Liu 0,6 mg/kg, Liu cao t NKQ nhanhThi gian tc dng: 90 giyThi gian tc dng: 30 - 45 phtThuc thi nguyn dng qua thn v gan, nn thi gian tc dng s ko di nu suy gan suy thn.

6.2. Thuc dn c kh cc6.2.3. Atracurium: - Liu 0,5 mg/kg - Thi gian tc dng 2 - 2,5 pht, - Thi gian tc dng khong 20 - 25 pht. - y l thuc c chn cho bnh nhn suy thn, suy gan - Thuc khng c tc dng tim mch trc tip, nhng c th phng thch histamin, gy ni m ay v da quanh ni chch, tt huyt p nh.

6. THUC HA GII: ProstigminSau mt thi gian nht nh thuc dn c s ht tc dng v ngi bnh s t th li hiu qu;Khi cuc m kt thc nhng thi gian tc dng thuc dn c vn cn, ngi gy m c th dng thuc Prostigmin ha giiLiu: 0,02 0,04 mg/kg ha gii thuc dn c v pha Atropin liu 0,01 0,02 mg/kg cng lc

KT LUNGy m hi sc l chuyn khoa thng dng nhng thuc mi, thuc c.Thuc c dng trong Gy m Hi sc rt a dng, a chng loi.Nm tht vng nhng tnh cht ca mi loi thuc s dng cho ng.Tun th nhng nguyn tc khi s dng thuc nht l nhng thuc mi.

Thank you for your attention!

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