{"id":2234,"date":"2023-03-07T12:58:23","date_gmt":"2023-03-07T05:58:23","guid":{"rendered":"https:\/\/hienbacsi.com\/?p=2234"},"modified":"2023-03-07T12:58:23","modified_gmt":"2023-03-07T05:58:23","slug":"digoxin-trong-thuc-hanh-lam-sang","status":"publish","type":"post","link":"https:\/\/hienbacsi.com\/index.php\/2023\/03\/07\/digoxin-trong-thuc-hanh-lam-sang\/","title":{"rendered":"Digoxin trong th\u1ef1c h\u00e0nh l\u00e2m s\u00e0ng"},"content":{"rendered":"\n
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ThS BS Tr\u1ea7n H\u1eefu Hi\u1ec1n<\/p>\n\n\n\n

T\u1ed1t nghi\u1ec7p B\u1eb1ng DIU \u0111\u1ea1i h\u1ecdc Corse C\u1ed9ng Ho\u00e0 Ph\u00e1p.<\/p>\n\n\n\n


Digoxin l\u00e0 thu\u1ed1c l\u00e0m t\u0103ng co b\u00f3p c\u01a1 tim, hormone th\u1ea7n kinh v\u00e0 ho\u1ea1t \u0111\u1ed9ng \u0111i\u1ec7n sinh l\u00fd. \u0110\u00f3 l\u00e0 c\u01a1 s\u1edf cho vi\u1ec7c s\u1eed d\u1ee5ng n\u00f3 trong hai t\u00ecnh hu\u1ed1ng l\u00e2m s\u00e0ng: suy tim do r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng t\u00e2m thu, v\u00e0 nh\u1ecbp nhanh tr\u00eanth\u1ea5t. Kh\u1ea3 n\u0103ng gi\u1ea3m h\u1ec7 giao c\u1ea3m c\u0169ng \u0111\u00e3 \u0111\u01b0\u1ee3c ghi nh\u1eadn.<\/p>\n\n\n\n

KH\u1edeI \u0110\u1ea6U \u0110I\u1ec0U TR\u1eca
X\u00e9t nghi\u1ec7m ion \u0111\u1ed3 v\u00e0 ch\u1ee9c th\u1eadn n\u00ean \u0111\u01b0\u1ee3c ki\u1ec3m tra tr\u01b0\u1edbc v\u00e0 \u0111\u1ecbnh k\u1ef3 trong qu\u00e1 tr\u00ecnh \u0111i\u1ec1u tr\u1ecb.<\/p>\n\n\n\n

<\/figure>\n\n\n\n

T\u1ed5ng li\u1ec1u t\u1ea3i digoxin thay \u0111\u1ed5i t\u1eebng b\u1ec7nh nh\u00e2n nh\u01b0ng th\u01b0\u1eddng n\u1eb1m trong kho\u1ea3ng 0,75-1,5 mg ti\u00eam t\u0129nhm\u1ea1ch v\u00e0 1-2 mg u\u1ed1ng.<\/p>\n\n\n\n

Li\u1ec1u t\u1ea3i \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch – l\u00e0 \u0111\u01b0\u1eddng nhanh nh\u1ea5t \u0111\u1ea1t digonxin hi\u1ec7u qu\u1ea3 trong m\u00e1u (digitalization). M\u1ed9t li\u1ec1u ti\u00eam t\u0129nh m\u1ea1ch ban \u0111\u1ea7u 0,25-0,5 mg digoxin \u0111\u01b0\u1ee3c \u0111\u01b0a ra trong v\u00e0i ph\u00fat, ti\u1ebfp theo l\u00e0 0,25 mg m\u1ed7i 6 gi\u1eddcho m\u1ed9t t\u1ed5ng li\u1ec1u c\u1ee7a 0,75-1,5 mg. Digoxin t\u0129nh m\u1ea1ch b\u1eaft \u0111\u1ea7u t\u00e1c d\u1ee5ng trong v\u00f2ng 15 \u0111\u1ebfn 30 ph\u00fat, v\u00e0 \u0111\u1ec9nh t\u00e1c d\u1ee5ng sau 1-5 gi\u1edd.<\/p>\n\n\n\n

Li\u1ec1u t\u1ea3i \u0111\u01b0\u1eddng u\u1ed1ng – cho 0,5 mg ban \u0111\u1ea7u theo sau l\u00e0 0,25 mg m\u1ed7i s\u00e1u gi\u1edd v\u1edbi t\u1ed5ng li\u1ec1u n\u1ea1p 0,75-1,5 mg.<\/p>\n\n\n\n

Li\u1ec1u t\u1ea3i ch\u1eadm – c\u00f3 th\u1ec3 \u0111\u1ea1t \u0111\u01b0\u1ee3c b\u1eb1ng c\u00e1ch b\u1eaft \u0111\u1ea7u m\u1ed9t li\u1ec1u duy tr\u00ec 0,125-0,25 mg m\u1ed7i ng\u00e0y. Tr\u1ea1ng th\u00e1i \u1ed5n \u0111\u1ecbnh s\u1ebd \u0111\u1ea1t \u0111\u01b0\u1ee3c sau n\u0103m chu k\u1ef3 c\u1ee7a th\u1eddi gian b\u00e1n hu\u1ef7 thu\u1ed1c, \u0111\u00f3 l\u00e0 kho\u1ea3ng 7-10 ng\u00e0y.<\/p>\n\n\n\n

Duy tr\u00ec li\u1ec1u digoxin – \u0110\u1ed1i v\u1edbi h\u1ea7u h\u1ebft b\u1ec7nh nh\u00e2n, li\u1ec1u duy tr\u00ec c\u1ee7a digoxin n\u1eb1m gi\u1eefa 0,125 mg v\u00e0 0,25 mgm\u1ed7i ng\u00e0y. Tuy nhi\u00ean li\u1ec1u duy tr\u00ec thay \u0111\u1ed5i ph\u1ee5 thu\u1ed9c nhi\u1ec1u y\u1ebfu t\u1ed1, bao g\u1ed3m ch\u1ee9c n\u0103ng th\u1eadn v\u00e0 c\u00e1c thu\u1ed1c d\u00f9ng chung.<\/p>\n\n\n\n

Suy tim – Khi digoxin \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng trong \u0111i\u1ec1u tr\u1ecb suy tim, m\u1ee9c \u0111\u1ed9 digoxin trong huy\u1ebft thanh n\u00ean \u0111\u01b0\u1ee3c \u0111o7-10 ng\u00e0y sau khi kh\u1edfi \u0111\u1ea7u digoxin ho\u1eb7c thay \u0111\u1ed5i li\u1ec1u digoxin. \u0110\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n suy tim, n\u1ed3ng \u0111\u1ed9 huy\u1ebft thanh m\u1ee5c ti\u00eau cho hi\u1ec7u qu\u1ea3 t\u1ed1i \u0111a v\u00e0 nguy c\u01a1 \u0111\u1ed9c t\u00ednh t\u1ed1i thi\u1ec3u l\u00e0 t\u1eeb 0,5 \u0111\u1ebfn 0,8 ng \/ mL (0,65-1 nmol \/ L) (h\u00ecnh 1) [4]<\/p>\n\n\n\n

C\u00e1c th\u1eed nghi\u1ec7m l\u00e2m s\u00e0ng \u1edf b\u1ec7nh nh\u00e2n c\u00f3 nh\u1ecbp xoang b\u00ecnh th\u01b0\u1eddng m\u00e0 ch\u1ee9ng minh l\u1ee3i \u00edch t\u1eeb vi\u1ec7c \u0111i\u1ec1u tr\u1ecbdigoxin \u0111\u00e3 nh\u1eafm m\u1ee5c ti\u00eau n\u1ed3ng \u0111\u1ed9 digoxin huy\u1ebft thanh trung b\u00ecnh dao \u0111\u1ed9ng 0,5-1,75 ng \/ mL (0,65-2,25 nmol \/ L) [5-7]. Li\u1ec1u s\u1eed d\u1ee5ng \u0111\u1ec3 \u0111\u1ea1t \u0111\u01b0\u1ee3c nh\u1eefng gi\u00e1 tr\u1ecb n\u00e0y dao \u0111\u1ed9ng 0,125-0,5 mg m\u1ed7i ng\u00e0y [5]. B\u00e0i hocph\u00e2n t\u00edch t\u1eeb c\u00e1c th\u1eed nghi\u1ec7m DIG ch\u1ee9ng minh k\u1ebft qu\u1ea3 c\u1ea3i thi\u1ec7n \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 n\u1ed3ng \u0111\u1ed9 digoxin trong huy\u1ebft thanh c\u1ee7a 0,5-0,8 ng \/ mL (0,65-1 nmol \/ L) [4,8,9]. Ng\u01b0\u1ee3c l\u1ea1i, n\u1ed3ng \u0111\u1ed9 cao h\u01a1n c\u00f3 li\u00ean quanv\u1edbi t\u1ef7 l\u1ec7 t\u1eed vong t\u0103ng l\u00ean.
H\u00ecnh 1<\/p>\n\n\n\n

Rung nh\u0129 – Digoxin th\u01b0\u1eddng l\u00e0 k\u00e9m hi\u1ec7u qu\u1ea3 \u0111\u1ec3 ki\u1ec3m so\u00e1t t\u1ea7n s\u1ed1 trong rung nh\u0129 (AF) so v\u1edbi thu\u1ed1c ch\u1eb9n beta ho\u1eb7c thu\u1ed1c ch\u1eb9n k\u00eanh canxi, \u00edt c\u00f3 kh\u1ea3 n\u0103ng \u0111\u1ec3 ki\u1ec3m so\u00e1t nh\u1ecbp th\u1ea5t khi g\u1eafng s\u1ee9c (khi ho\u1ea1t \u0111\u1ed9ng th\u1ea7n kinh ph\u1ebf v\u1ecb th\u1ea5p v\u00e0 th\u1ea7n kinh giao c\u1ea3m cao), c\u00f3 \u00edt ho\u1eb7c kh\u00f4ng c\u00f3 kh\u1ea3 n\u0103ng ch\u1ea5m d\u1ee9t t\u00ecnh tr\u1ea1ng lo\u1ea1n nh\u1ecbp, v\u00e0 th\u01b0\u1eddng kh\u00f4ng l\u00e0m ch\u1eadm t\u1ea7n s\u1ed1 tim v\u1edbi rung nh\u0129 t\u00e1i ph\u00e1t. Do \u0111\u00f3, li\u1ec1u cao digoxin th\u01b0\u1eddng \u0111\u01b0\u1ee3c y\u00eau c\u1ea7u cho \u0111\u01a1n tr\u1ecb li\u1ec7u v\u00e0 b\u1ec7nh nh\u00e2n th\u01b0\u1eddng xuy\u00ean c\u1ea7n th\u00eam m\u1ed9t \u1ee9c ch\u1ebf beta ho\u1eb7c ch\u1eb9n k\u00eanh calci \u0111\u1ec3 ki\u1ec3m so\u00e1tt\u1ea7n s\u1ed1 t\u1ed1i \u01b0u.<\/p>\n\n\n\n

Khi digoxin \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng nghi\u00eam ng\u1eb7t \u0111\u1ec3 ki\u1ec3m so\u00e1t t\u1ef7 l\u1ec7 th\u1ea5t trong AF, n\u1ed3ng \u0111\u1ed9 digoxin trong huy\u1ebft thanh n\u00ean \u0111\u01b0\u1ee3c theo d\u00f5i \u0111\u1ecbnh k\u1ef3, m\u1eb7c d\u00f9 n\u1ed3ng \u0111\u1ed9 thu\u1ed1c th\u01b0\u1eddng kh\u00f4ng t\u01b0\u01a1ng quan v\u1edbi ki\u1ec3m so\u00e1t t\u1ea7n s\u1ed1 th\u1ea5t.<\/p>\n\n\n\n

Li\u00ean quan \u0111\u1ebfn ng\u1ed9 \u0111\u1ed9c digoxin – C\u00e1c t\u00e1c d\u1ee5ng sympatholytic c\u1ee7a digoxin c\u00f3 th\u1ec3 x\u1ea3y ra \u1edf n\u1ed3ng \u0111\u1ed9 thu\u1ed1c trong huy\u1ebft thanh th\u1ea5p h\u01a1n nh\u1eefng ng\u01b0\u1eddi s\u1eed d\u1ee5ng \u0111\u1ec3 t\u1ea1o ra m\u1ed9t hi\u1ec7u \u1ee9ng co b\u00f3p. Nh\u01b0 m\u1ed9t v\u00ed d\u1ee5, m\u1ed9t nghi\u00ean c\u1ee9u cho th\u1ea5y r\u1eb1ng vi\u1ec7c t\u0103ng li\u1ec1u digoxin t\u1eeb m\u1ed9t trung b\u00ecnh c\u1ee7a 0,2-0,39 mg \/ ng\u00e0y (t\u01b0\u01a1ng \u1ee9ng v\u1edbi s\u1ef1 gia t\u0103ng n\u1ed3ng \u0111\u1ed9 trong huy\u1ebft thanh 0,67-1,22 ng \/ mL [0,85-1,55 nmol \/ L]) t\u0103ng ph\u00e2n su\u1ea5t t\u1ed1ng m\u00e1u; Tuy nhi\u00ean, kh\u00f4ng c\u00f3 s\u1ef1 gia t\u0103ng kh\u1ea3 n\u0103ng dung n\u1ea1p g\u1eafng s\u1ee9c ho\u1eb7c gi\u1ea3m n\u1ed3ng \u0111\u1ed9 norepinephrine t\u0129nhm\u1ea1ch [10].<\/p>\n\n\n\n

\u0110I\u1ec0U CH\u1ec8NH LI\u1ec0U<\/p>\n\n\n\n

Li\u1ec1u \u0111i\u1ec1u ch\u1ec9nh trong b\u1ec7nh th\u1eadn – Kho\u1ea3ng 70 \u0111\u1ebfn 80 ph\u1ea7n tr\u0103m c\u1ee7a digoxin \u0111\u01b0\u1ee3c th\u1ea3i tr\u1eeb \u0111\u1ed5i trong n\u01b0\u1edbc ti\u1ec3u, d\u1eabn \u0111\u1ebfn k\u00e9o d\u00e0i th\u1eddi gian b\u00e1n th\u1ea3i \u1edf b\u1ec7nh nh\u00e2n suy th\u1eadn.<\/p>\n\n\n\n

Li\u1ec1u \u0111i\u1ec1u ch\u1ec9nh v\u1edbi b\u1ec7nh gan – B\u1ec7nh gan c\u00f3 r\u1ea5t \u00edt \u1ea3nh h\u01b0\u1edfng \u0111\u1ebfn s\u1ef1 trao \u0111\u1ed5i ch\u1ea5t digoxin do \u0111\u00f3, kh\u00f4ngc\u1ea7n \u0111i\u1ec1u ch\u1ec9nh li\u1ec1u.<\/p>\n\n\n\n

C\u1ea7n \u0111i\u1ec1u ch\u1ec9nh li\u1ec1u \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n b\u00e9o ph\u00ec d\u1ef1a v\u00e0o BMI theo t\u00e1c gi\u1ea3 Erstad BL
Li\u1ec1u l\u01b0\u1ee3ng \u0111i\u1ec1u ch\u1ec9nh \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u1ee7a tr\u1ecdng l\u01b0\u1ee3ng c\u01a1 th\u1ec3 th\u1ea5p – B\u1ec7nh nh\u00e2n c\u00f3 th\u1ec3 tr\u1ecdng nh\u1ecf h\u01a1n45 kg n\u00ean nh\u1eadn \u0111\u01b0\u1ee3c 50 ph\u1ea7n tr\u0103m li\u1ec1u t\u1ea3i v\u00e0 duy tr\u00ec li\u1ec1u b\u00ecnh th\u01b0\u1eddng.<\/p>\n\n\n\n

Li\u1ec1u \u0111i\u1ec1u ch\u1ec9nh v\u1edbi c\u00e1c thu\u1ed1c d\u00f9ng \u0111\u1ed3ng th\u1eddi – C\u00f3 m\u1ed9t s\u1ed1 t\u01b0\u01a1ng t\u00e1c thu\u1ed1c quan tr\u1ecdng:<\/p>\n\n\n\n

Quinidin, Propafenone, Verapamil (t\u0103ng 50-75%) v\u00e0 Amiodarone c\u00f3 th\u1ec3 l\u00e0m t\u0103ng n\u1ed3ng \u0111\u1ed9 digoxin trong huy\u1ebft thanh. Quinidine KHI d\u00f9ng \u0111\u1ed3ng th\u1eddi th\u00ec li\u1ec1u digoxin n\u00ean \u0111\u01b0\u1ee3c gi\u1ea3m m\u1ed9t n\u1eeda [14-17].<\/p>\n\n\n\n

Cholestyramine v\u00e0 c\u00e1c thu\u1ed1c kh\u00e1ng acid, m\u1eb7t kh\u00e1c, c\u00f3 th\u1ec3 l\u00e0m gi\u1ea3m s\u1ef1 h\u1ea5p thu \u0111\u01b0\u1eddng ru\u1ed9t c\u1ee7a digoxin 20 \u0111\u1ebfn 35 ph\u1ea7n tr\u0103m, c\u1ea7n t\u0103ng li\u1ec1u h\u00e0ng ng\u00e0y. \u0110\u1ec3 tr\u00e1nh nh\u1eefng t\u01b0\u01a1ng t\u00e1c n\u00e0y, digoxin n\u00ean \u0111\u01b0\u1ee3c \u0111\u1ecbnh l\u01b0\u1ee3ng m\u1ed9t gi\u1edd tr\u01b0\u1edbc ho\u1eb7c 2-3 gi\u1edd sau khi dung kh\u00e1ng acid v\u00e0 cholestyramine.<\/p>\n\n\n\n

Thu\u1ed1c l\u1ee3i ti\u1ec3u c\u00f3 th\u1ec3 l\u00e0m t\u0103ng \u0111\u1ed9c t\u00ednh c\u1ee7a digitalis nh\u01b0 l\u00e0 k\u1ebft qu\u1ea3 c\u1ee7a s\u1ef1 suy gi\u1ea3m t\u1ed1c \u0111\u1ed9 l\u1ecdc c\u1ea7u th\u1eadn v\u00e0s\u1ef1 ph\u00e1t tri\u1ec3n c\u1ee7a c\u00e1c b\u1ea5t th\u01b0\u1eddng \u0111i\u1ec7n gi\u1ea3i, \u0111\u1eb7c bi\u1ec7t l\u00e0 h\u1ea1 kali huy\u1ebft.<\/p>\n\n\n\n

Tetracycline v\u00e0 erythromycin c\u00f3 th\u1ec3 c\u1ea3n tr\u1edf con \u0111\u01b0\u1eddng th\u1ee7y ph\u00e2n li\u00ean t\u1ee5c c\u1ee7a qu\u00e1 tr\u00ecnh chuy\u1ec3n h\u00f3adigoxin (b\u1eaft \u0111\u1ea7u t\u1eeb trong d\u1ea1 d\u00e0y v\u00e0 ch\u1ecbu tr\u00e1ch nhi\u1ec7m \u00edt h\u01a1n 15 ph\u1ea7n tr\u0103m c\u1ee7a s\u1ef1 trao \u0111\u1ed5i ch\u1ea5t trong h\u1ea7u h\u1ebft c\u00e1c b\u1ec7nh nh\u00e2n nh\u01b0ng c\u00f3 th\u1ec3 l\u00e0 \u0111\u00e1ng k\u1ec3 ho\u1ea1t \u0111\u1ed9ng nhi\u1ec1u h\u01a1n \u1edf m\u1ed9t s\u1ed1 \u00edt b\u1ec7nh nh\u00e2n). Nh\u01b0 v\u1eady, c\u00e1clo\u1ea1i thu\u1ed1c n\u00e0y l\u00e0m t\u0103ng n\u1ed3ng \u0111\u1ed9 digoxin trong kho\u1ea3ng 10 ph\u1ea7n tr\u0103m b\u1ec7nh nh\u00e2n m\u00e0 con \u0111\u01b0\u1eddng n\u00e0y l\u00e0 m\u1ed9t th\u00e0nh ph\u1ea7n quan tr\u1ecdng c\u1ee7a qu\u00e1 tr\u00ecnh chuy\u1ec3n h\u00f3a c\u1ee7a thu\u1ed1c.<\/p>\n\n\n\n

Digoxin trong thai k\u1ef3 – Digoxin qua \u0111\u01b0\u1ee3c nhau thai v\u00e0 \u0111\u00e3 \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng cho c\u1ea3 hai ch\u1ec9 \u0111\u1ecbnh tim thai nhi v\u00e0m\u1eb9 m\u00e0 kh\u00f4ng b\u00e1o c\u00e1o v\u1ec1 t\u00e1c h\u1ea1i b\u00e0o thai ho\u1eb7c sinh qu\u00e1i thai [18]. Nh\u01b0 v\u1eady, kh\u00f4ng c\u00f3 ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh cho s\u1eed d\u1ee5ng digoxin trong khi mang thai ho\u1eb7c cho con b\u00fa.
Digoxin \u1edf ng\u01b0\u1eddi gi\u00e0: th\u1eddi gian b\u00e1n hu\u1ef7 k\u00e9o d\u00e0i \u0111\u1ebfn 73 gi\u1edd so v\u1edbi 36 gi\u1edd \u1edf ng\u01b0\u1eddi tr\u1ebb. Li\u1ec1u n\u00ean th\u1ea5p h\u01a1n0,125mg m\u1ed7i ng\u00e0y, th\u01b0\u1eddng n\u00ean l\u00e0 0,125mg m\u1ed7i hai ng\u00e0y.<\/p>\n\n\n\n

Ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh: B\u1ec7nh c\u01a1 tim ph\u00ec \u0111\u1ea1i t\u1eafc ngh\u1ebdn, h\u1ed9i ch\u1ee9ng Wolff-Parkinson-White k\u00e8m rung nh\u0129, block nh\u0129th\u1ea5t cao \u0111\u1ed9.<\/p>\n\n\n\n

Ng\u1ed9 \u0111\u1ed9c Digoxin<\/p>\n\n\n\n