DƯỢC LÂM SÀNG VÀ ĐIỀU TRỊ TÁI BẢN LẦN THỨ HAI CÓ SỬA CHỮA VÀ BỔ SUNG NXB Y HỌC 2007 (TRÍCH ĐOẠN) by Dạy Kèm Quy Nhơn Official

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TRl/ONG OAI HOC Dl/OC HA NOI

ẠO

TP .Q U

H Ơ

BO MON Dl/OC LAM SANG

ẦN

Dime LAM SANG VA DIEU TRI •

•

Dfil HOC VO TPCtldNQ T06N

THl/VIEN

D IỄ

Đ ÀN

ÁN

-L

Í-

Ó A

(Tai ban Ian this hai co sCta chCra va bo sung)

NHA XUAT BAN Y HOC HA NOI - 2007

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LOI NOI DAU

H Ơ

"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 nay duoc hoc sau khi sinh vien da co nhirng kien thuc ca ban ve duoc lam sang dai cuong.

Noi dung cuon sach bao gom 16 chuong chia thanh 2 phan: Phan 1: Duoc lam sang trong thuc hanh benh vien.

ẠO

TP .Q U

"Duoc lam sang & dieu tri" cung cap nhung kien thufc lien quan den viec su dung thuoc trong 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.

Phan nay gom 5 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 trong dieu tri.

ẦN

Phan nay hien tai chi gom 11 chuong, de cap den viec su dung thuoc trong dieu tri mot so nhom benh; trong tuong lai phan nay 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 trong linh vuc dieu tri va sir ra ddi nhieu thuoc moi, nhieu kien thirc trong dieu tri hien khong con phu hop nua. Trong Ian xuat ban nay, cac tac gia co bo sung nhung kien thuc ve thuoc va phac do dieu tri de giiip nguoi hoc tiep can kip thoi voi nhung thay doi trong linh vuc Y, Duoc trong 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 do han che ve thofi gian nen chdc ch^n vln con

Ó A

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:

Í-

Bo mon Duoc lam sang

-L

Trudng dai hoc Duoc Ha Noi, 13 - 15 Le Thanh Tong

ÁN

Dienthoai: 049.330771.

Cac tac gia

D IỄ

Đ ÀN

Xin tran trong cam on!

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TP .Q U

H Ơ

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ẠO

Phan I

Dl/OC LAM SANG Ư

•

D IỄ

Đ ÀN

ÁN

-L

Í-

Ó A

ẦN

TRONG THl/C HANH BENH VIEN

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Chirong I

THONG TIN THUOC

H Ơ

I. DAI CUONG VE THONG TIN

1.1. Y nghia

TP .Q U

- Thong tin ngay nay da tro thanh mot trong bon nguon luc ca ban (Nhan luc, vat luc, tai lire, tin luc) trong quan ly dieu hanh va ra 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 thanh tot lai khong can den ca 4 ngu6n luc do trong do khong the

ẠO

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 do da gay nhirng tro ngai va hau qua trong cac hoat dong kinh te, xa hoi, khoa

ẦN

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 pho bien va chua co the noi la thoat canh lac hau v& thong

tin trong moi linh vuc hoat dong.

Mot to chire thong tin hoat dong huu hieu luon la mot cong cu dac luc cho viec hoan thanh nhiem vu, la niem tu hao cho mot nganh, mot linh vuc, mot dan vi, mot to chuc

Ó A

nao do vi do la kho tang tri thufc cua the gidi da ndm duoc de su dung.

Í-

Thong tin con la mot quy6n lai ca ban trong doi song con ngucri duac luat phap nhieu nu6c ghi nhan la quyen duoc thong tin.

Phan loai theo nguon tai lieu chira dung thong tin.

ÁN

•

-L

1.2. Phan loai thong tin : Co nhieu each phan loai.

- Tai lieu cap I: Cac bai bao, cong trinh goc dang tai day du ban chup,

D IỄ

Đ ÀN

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.

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- Thong tin dan so.

' - Thong tin kinh te, thuang mai, san xuat... -

Phan loai theo tinh chat cua thong tin.

- Thong tin ca ban : So lieu ve dat nude, con ngudi, tai nguyen, khi hau...

H Ơ

- Thong tin ve cau true ( Structure Information): So lieu ve to enure bo may, cac

•

V...V...

cau tu can thiet...

- Thong tin ve qua trinh (Process Information): So lieu ve ca che hoat dong, quy

TP .Q U

trinh hoat dong.

- Thong tin ve ket qua (Outcome Information): So lieu ve hieu qua cua hoat dong. - Thong tin ve mot ca sd san xuat, mot cong ty kinh doanh.

ẠO

• Phan loai khac tuy theo muc tieu cua du lieu.

- 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....

2.1. Noi dung thong tin thuoc bao gom

- Cac thong tin ca ban ve mot thuoc.

ẦN

II. THONG TIN THUOC

- Thong tin cho thay thuoc ke dan.

Ó A

- Thong tin cho duac si va nhan vien ban thuoc. - Thong tin cho benh nhan, nguoi dung thuoc.

Í-

- Thong tin nang cao dan tri.

ÁN

-L

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 nay chira benh nao. Nhung ngay nay, nhung thap ky cudi cua the ky XX, cac thanh tuu khoa hoc 1dm lao thong qua cong nghe rat phat

trien da san xuat ra rat nhieu chung loai thuoc vdi nhirng tac dung tri benh tinh vi han nhieu. Cac thong tin ve thuoc ngay cang phurc tap va phong phu - nguoi duac si phai

Đ ÀN

giup cac nha dieu tri hoc chon duac thuoc nao it phan ring phu, it nguy ca xay ra 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

D IỄ

hieu luc toi uu cua thuoc, tranh duac cac tac hai do tuang tac cua thuoc va giup cho

benh nhan, nguoi dung thuoc tuan thu dan thuoc va each dung dung dan. Nguoi duac si con phai thong qua cac phuong tien truyen thong dai chung de giao due ve thuoc cho nhan dan d mirc do thich hop ngay ttr khi con dang di hoc d cac trucmg pho thong den

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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 do duac si hudng

din, biet tu dung thuoc trong gidi han duoc quy dinh de chua tri mot sd trieu chirng

H Ơ

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.

Thay thuoc ke dan.

Y ta dieu duang

Duac si benh vien, cua hang.

Ngudi ban thuoc

ẠO

TP .Q U

Nhirng ngudi cung irng cac dich vu cham soc va bao ve sue khoe:

Benh nhan, ngudi dung thuoc.

Nhan dan, ngudi tieu dung thuoc.

Nhirng ngudi sir dung dich vu cham soc sire khoe:

ẦN

2.2. Doi tuang cua thong tin thuoc -

benh thong thudng cd hieu qua va it ton kem nhat. Dieu nay dat ra cho cac duac si phai quan tarn dac biet viec cung cap thong tin thuoc cho ngudi dan.

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...

Ó A

- Cac phuong tien truyen thong dai chung nhu bao viet, bao hinh, bao tieng, cac tai lieu pho cap, so dien thoai giai dap, tu van, cac bang hinh, bang tieng, cac chien dich truyen thong v.v...

-L

Í-

2.4. To chuc thong tin thuoc

Cac thu vien, tu sach, tu lieu d cac ca sd y te cac cap.

ÁN

- 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.

Đ ÀN

Yeu cau cua mot to chitc thong tin:

D IỄ

- 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, tuy 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

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compact (CD-ROM), cac tai lieu kinh dien cap I, cap II, cac tap chi chuyen khoa dat 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.

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.

ẠO

TP .Q U

2.5. Chuc nang cua mot trung tam thong tin

H Ơ

mua cap nhat.

ẦN

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 nay deu thu thap va cung cap thong tin ve thuoc chira benh

Ó A

va tac hai ciia chat doc doi vdi sire khoe con ngudi.

Ngudi ta nhan thay sach vd, bao chi, tap chi, tai lieu cong bd, xuat ban ngay cang nhieu nen can phai cd mot to chuc vdi cntic nang thu thap va cung cap thong tin

-L

Í-

thuoc va chat doc cho moi ngudi.

ÁN

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

Đ ÀN

khoe.

D IỄ

- 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.

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Dich vu thong tin co tai trung tam:

Nhirng dich vu thong tin nay 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 trong my pham, thuc pham, cac hoa chat dimg

H Ơ

trong ddi song hang ngay...

- 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).

TP .Q U

- Dich vu mang truyen hinh va bo giai ma vdi nhieu kenh khac nhau duac hdi va

ẠO

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 pho 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, trong hai nam da cung cap 52000 tin, trong do 54% cac cau giai dap thac mac ve thuoc la cua ngudi dan binh thudng trong cong dong, con lai la cua can bo y te.

ẦN

Cac thong tin co the khai thac duac tai trung tam:

- Danh muc thuoc dang ky.

- Thong tin ve phac do dieu tri & thuoc cho benh vien.

- Thong tin ve chat doc.

- Thong tin ve thuoc.

Ó A

- Dich vu torn t&t va trich dan thong tin thuoc.

- Thong tin ve thuoc trir sau.

-L

Í-

- Thong tin ve hoa chat cong nghiep va ho gia dinh.

ÁN

- 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).

Đ ÀN

- Cung cap thong tin ve dan vi lieu dung.

D IỄ

- 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.

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III. YEU CAU CUA THONG TIN THUOC

Cac thong tin phai: - Khach quan, trung thuc.

- Chfnh xac, day du.

H Ơ

- Duac phan tfch va so sanh.

- Duac bieu di£n dudi dang bang bieu, hinh ve.

TP .Q U

- Duac dinh hudng thong tin nay can cho ai. - Luon duac cap nhat theo doi. - Luon duac he thong hoa.

ẠO

- 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 nhau.

- Sir dung moi phuang tien truyen thong Nhac di nhac lai.

ẦN

- Kien thuc chung dan gian dt hieu, ldi ndi, vi du phai dan da.

- 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.

Ó A

- 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 trong quang cao

Đ ÀN

ÁN

-L

Í-

Nghi quyetciiaHoi dong Y te The gidi, so 41.17 ngay 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 do 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

D IỄ

pho bien tieu chuan

Tieu chuan dao dure (Thai do urng xu thfch hop trong thong tin gidi thieu thuoc): -

Trung thuc, tin cay

Chfnh xac.

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Tieu chuan dao due trong 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

TP .Q U

Can nh&c ky luang, chirng minh duac, lai le khach quan dung muc.

Thong tin ve thuoc can:

H Ơ

va benh nhan, cac phuang tien truyen thong.

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.

ẠO

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

ẦN

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 khi cd yeu cau.

Ldi le va hinh anh trong moi TTGT thuoc cho y bac si & can bo y te phai dung

3.3. Thong tin gidi thieu (TTGT) thuoc cho can bo y te

Noi dung ca ban bao gom:

Ó A

vdi cac du* lieu khoa hoc da dugc thua nhan vdi ldi le d£ doc, d& hieu.

Í-

Ten cac hoat chat theo ten thuoc qudc te INN, ten gdc.

-L

Ten thuang mai.

ÁN

Ham lugng hoat chat trong 1 dan vi thanh pham.

Tac dung dieu tri.

Đ ÀN

Dang bao che. Tac dung phu va phan irng cd hai.

D IỄ

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...

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- Khi TTGT thuoc da quen dung ft nhat phai cd: Ten thuang mai, ten INH, ten cac hoat chat, ten va dia chi nha san xuat va cong ty de cung cap thong tin khi cd yeu cau.

- De giup moi ngudi cd du hieu biet khi quyet dinh mua nhirng thuoc khong can

H Ơ

dan (OTC).

3.4. Thong tin gidi thieu thuoc cho cong chung

- Khong dugc lgi dung moi lo ldng ve sue khoe cua ngudi dan.

TP .Q U

- Khong dugc quang cao thuoc phai mua theo dan, thuoc chi dung a benh vien, thuoc ngii & tam than.

- Khong dugc quang cao thuoc tdi tre em.

ẠO

- Tac dung tri benh, khdi benh dua ra quang cao phai la nhung du lieu da dugc

chirng minh khoa hoc.

- Noi ro nhirng han che ciia thuoc.

- Dung ngon ngu thong dung nhung khong dugc khac vdi du kien khoa hoc da dugc duyet va nop khi xin phep. Khong dung ldi le khoa truang, hoac gay sg hai,

ẦN

that vong.

- Noi dung gom: Ten gdc cac hoat chat, ten thuang mai cua thuoc, chi dinh chfnh, chdng chi dinh, nhirng de phdng, ten va dia chi nha san xuat, cong ty va gia ban

le.

Ó A

IV. THUC HANH THONG TIN THUOC TAI BENH VIEN 4.1. Yeu cau

ÁN

-L

Í-

Thu thap thong tin, phan loai, danh gia, xir ly va chuyen giao thong tin la mot nhiem vu quan trong cua mot dugc si lam sang vdi tu each mot chuyen gia ve thuoc, mot tham van dugc hoc. Trong chuong trinh cua Dai hoc Dugc, nam thir 5 la nam sinh vien dugc tiep can lam sang ma noi dung chu yeu la cong viec thong tin va truyen thong ve thuoc.

Thuc hanh dugc lam sang la mot viec mang tinh tfch cue, cd nghla la huy dong tfnh

Đ ÀN

nang dong ciia sinh vien, ma giang vien chi giir vai tro dinh hudng, chi dan phuang phap, khuyen bao; vi vay cd nhung dac diem cua phuang phap su pham tfch cue sau:

D IỄ

- Tfnh tfch cue, su chii dong cua sinh vien. - Huy dong sir tu hoc cao cua sinh vien.

- Gan nhung kien thirc ma sinh vien da dugc trang bi d trudng vao thuc te hanh ngh£, nang cao kha nang thu thap, phan tfch, tong hop, xir ly cac thong tin, va qua do tir thuc tidn nam vung va nang cao dugc kien thirc, tinh thong dugc nghe nghiep.

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- Sinh vien tham gia vao hoat dong true tiep phuc vu ngudi benh, tiep xuc va hgp tac vdi dong nghiep y va benh nhan, nen tu tin han, tranh bd nga va tu ti. - Qua qua trinh hoc tap, sinh vien phai tu danh gia ket qua hoc tap cua ban than, thay ro cac diem mdc ma sinh vien phai dat, vuot.

H Ơ

- Giang vien la ngudi tao dieu kien thuan lgi cho sinh vien hoc tap.

- Dam bao su su dung thuoc dugc hop ly, an toan va cd hieu qua.

4.2. Muc tieu cua hoat dong thong tin thuoc tai benh vien

TP .Q U

- Dam bao lien he giua cac hoat dong qui che, dieu hanh vdi thuc hanh dieu tri, giira y va dugc.

thieu khoa hoc.

4.3. Vai tro cua dugc si trong thong tin thuoc tai benh vien

ẠO

- Giao due benh nhan tranh lam dung thuoc men va tranh tu chira benh bang thuoc

ẦN

To chire Yte The gidi va nhieu nude thira nhan vai tro then chdt cua dugc si trong viec sirdung thuoc hgp ly, an toan va ft ton kem. Da la dugc si, trudc het phai nam vung kien thtic ve su dung thuoc hop ly va truyen dat kien thtic do cho dong nghiep, cho benh nhan, cho quan chung nhan dan de cham sdc va bao ve sue khoe; ndi each khac, dugc si ndi chung va dugc si lam viec tai cac ca sd kham benh va dieu tri ndi rieng phai cung cap thong tin thuoc cho :

- Cac thay thuoc ke don.

Benh nhan.

Ó A

- Cac nhan vien y te, dieu dudng cham sdc benh nhan.

- Cac can bo quan ly lien quan den thuoc.

Í-

- Cho quang dai quan chung nhan dan.

-L

Tir do thay rang, dugc si phai la mot chuyen gia gidi ve thuoc. De lam dugc nhiem vu nay, dugc si phai dugc dao tao day du ve dugc ly, dugc dong hoc va ca nhung kien

ÁN

thirc lien quan den sinh ly, benh hoc...

4.4. Cac doi tuong can thong tin thuoc

D IỄ

Đ ÀN

4.4J. Thong tin thuoc cho thay thuoc dieu tri ke dan

Moi thong tin lien quan den thuoc giup cho viec ra quyet dinh dieu tri ke dan cua y bac si deu phai dugc cung cap.

- Cac thong tin chung ve thuoc: Cac each phan loai thuoc (danh muc thuoc thiet yeu, thuoc khong can dan (OTC), thuoc phai cd dan, ma phan loai giai phau-dieu tri-hoa hoc (ATC), danh muc cac ten thuoc gdc,ten thuang mai, thuoc dugc phep luu hanh, sd dang ky,...

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- Ca che tac dung cua thuoc.

- Tfnh dugc dong hoc: Do hap thu, phan bd, chuyen hoa, thai trtr cua thuoc. - Cac chi dinh, chdng chi dinh. - Doc tfnh, bieu hien ngo doc, xir tri.

H Ơ

- Tuang tac cua thuoc (Thuoc vdi thuoc, thuoc vdi thuc pham, vdi nude udng,

- Cac phan ung phu cd the xay ra.

tuang ky..)

TP .Q U

- Cach dung, lieu lugng . - Thang bac gia ca...

ẠO

Ndi chung, nhung thong tin can cho thay thuoc ke dan biet thuoc de chon thuoc cho dung benh, dung ngudi,dung each dung de cd hieu qua toi uu. Cac thuoc cd san d trong nude, thudng dugc ghi day du trong cudn Dugc thu qudc gia do ca quan cd tham quyen ciia Nha nude bien soan, phat hanh va pho bien rong rai cho cac nhan vien y te.

4.4.2. Thong tin thuoc cho benh nhan

ẦN

Benh nhan la khau cudi cung thuc hien cac y do sir dung thuoc de dat hieu qua cao va an toan. Neu benh nhan khong thuc hien dung y lenh thi moi dieu cd gang ciia y bac

si, dugc si, y ta... deu khong cd hieu qua va trd thanh vo fch. Mudn thuc hien dung va tham gia dong gdp tfch cue vao qua trinh dieu tri, benh nhan phai dugc hieu ro lgi fch,

tac hai cua thuoc tranh cac bieu hien sai lech, khong chfnh xac hay cd hai. Viec thong

tin-giao duc-truyen thong ve thuoc den ngudi benh la rat quan trong can dugc cac bac si,

dugc si tien hanh khi tiep xuc rieng le hoac tap the.

Ó A

Ngudi dung thuoc ngoai tru cung can dugc cac bac si, dugc si quan tam hudng din dung thuoc theo dan da ke, tu theo doi phat hien va bao cao tac dung hieu qua dieu tri va nhat la cac phan ung phu neu cd. Mot sd nude cd dich vu giai dap thac mac ve thuoc cho

-L

Í-

dan. Dich vu nay phai dugc to chircthan trong, tranh nhirng mau thuan nay sinh trong nhung giai thfeh.

ÁN

Noi dung thong tin thuoc cho benh nhan bao gom:

- Ten thuoc (ten gdc, ten biet dugc).

Đ ÀN

- Tac dung mong mudn. - Dang dung, lieu dung, each dung.

D IỄ

- Hudng d^n sir dung cac dang bao che dac biet.

- Hudng dan quan sat, theo doi cac trieu chung khac la trong dung thuoc (nhd ky de theo doi tiep cho nhung Ian dung thuoc sau).

- Nhirng trieu chirng cua phan ung khong mong mudn , each xu tri. - Ky nang tir theo doi tac dung ciia thuoc trong qua trinh dieu tri.

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Tuang tac thuoc (Thuoc - thuoc, Thuoc - thuc pham, Thuoc - nude udng) Cach bao quan lugng thuoc da mua, dugc cap. 4.4.3. Cach giao tiep de thu thap thong tin tu: benh nhan

PfiMflXVOTRlfdNGTOfiN *

Duac si den vi sue khoe benh nhan.

H Ơ

THU VIEN

Dugc si den khong lam phien.

Ngon tir dan gian, ro rang, dan da, dl hieu; tranh dung thuat ngir khoa hoc khd

TP .Q U

Thai do, tac phong, each tiep xiic va ung xu (khoa hoc hanh vi): hieu, thuat ngu dia phuang. Ldi ndi nhe nhang, an can, quan tam.

An mac gon gang, nghiem tiic nhung tranh diem dua qua gay khd gan.

Khoang each ngdi ndi chuyen khong tao cam giac xa each.

Dia diem ndi chuyen rieng biet de d6 dang trinh bay, khong tai ngai ngan.

Quan tam den hoan canh khd khan dac biet.

ẠO

ẦN

- Khi tham hoi theo doi tai ho gia dinh, can tim hieu hoan canh gia dinh, nhung tranh di sau vao nhirng dieu tham km ma ngudi benh khong tu nguyen ndi.

4.5. Noi dung hoat dong thong tin thuoc tai benh vien

Ó A

- Tat ca cac van de ve quan ly va khoa hoc ky thuat lien quan den thuoc nhu: Cac chfnh sach qui che, qui dinh, quyet dinh cua Nganh, thi du: Che do thuoc ddc, nghien, che do dung thuoc an toan hgp ly, danh muc thuoc thiet yeu, dudng ldi su dung thuoc khang sinh, che do ke dan thuoc, quyet dinh ve thuoc dugc phep luu hanh, hoac quyet

dinh cam luu hanh mot sd thuoc v.v...

ÁN

-L

Í-

- Cac thong tin lien quan den thuoc nhu: Ten thuoc, nguon gdc thuoc, tfnh chat, tac dung dugc ly (dugc luc, dugc dong hoc), sinh dugc hoc, chi dinh, chdng chi dinh, tac dung khong mong mudn, tai bien, tuang ky - tuang tac, lieu va each diing, xu tri khi qua lieu, dang thuoc, tinh hinh kha nang thi trudng, gia thuoc va gia thanh dieu tri.

Đ ÀN

Dac biet cac thong tin ve thuoc tren lien quan mat thiet doi vdi mot benh nhan cu the ma cac yeu to nhu gidi tfnh, tuoi, nghe nghiep, the trong, tinh trang benh ly - tam sinh ly, tien str benh, tap quan sinh hoat, thdi quen dung thuoc... cd anh hudng nhieu tdi

D IỄ

viec dung thuoc.

4.6. Cong viec cu the va each thurc tien hanh

Trong thai gian thuc tap tai cac khoa phong dieu tri, sinh vien can ren luyen nhirng ky nang giao tiep de cd the dat dugc nhirng yeu cau sau:

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4.6.1. Thu thap cac thong tin ve noi dunghoatdong ciia benh vien vd khoa duac (noi sinh vien thuc tap)

Nhiem vu nay thudng dugc tien hanh trong 2-3 tuan 16 dau cua dot thuc tap dugc

H Ơ

- Tfnh chat nhiem vu, qui mo hoat dong cua benh vien (benh vien tuyen nao, benh vien da khoa hay chuyen khoa) to chute cua benh vien (sd khoa-phdng, bien che-

lam sang. Sinh vien den hoc can tim hieu:

nhan su: tren dai hoc, dai hoc, so cap...), quan he cong tac, ne nep quan ly cua

benh vien, trang thiet bi chuyen mon ky thuat - quan ly hanh chfnh, sd giudng

TP .Q U

benh, sd Ian kham benh, sd ngay nam dieu tri, cac sd lieu thong ke cd phan tfch

ve benh tat (ty le mac benh, ty le tu vong, sd ca dai, trung, tieu phau, sd ca cap ciru hoi stic vi benh, vi tai nan, vi nhiem doc.)

ẠO

- Tfnh chat nhiem vu, qui mo hoat dong ciia Khoa dugc benh vien: To clitic khoa, bien che, nhan su, cd pha che khong? pha che nhirng gi?

- Vi tri va quan he ciia khoa, lanh dao true tiep cua giam doc va quan he cong tac

vdi cac khoa khac.

- Bien che cua khoa so vdi bien che cua toan benh vien, sd dugc si so vdi sd bac si.

ẦN

- Cd to chtic Hoi dong thuoc khong?

- Cd theo doi tac dung cd hai do thuoc hay khong?

- Nguon nhap thuoc, gia tri nhap, cong tac bao quan, to clitic cap phat thuoc cho noi tru (hang ngay hay nhieu ngay, phieu tap hgp toan khoa hay cap phat cho tung benh nhan...) cd cap phat thuoc ngoai tru khong?

Ó A

- Cac bien phap quan ly kinh te dugc (kinh phf, bao hiem xa hoi, benh nhan tra tien thuoc? gia thuoc va gia thanh dieu tri, cac bien phap de ha gia thanh dieu

tri...).

-L

Í-

- Hoat dong thong tin nghien ciru khoa hoc ky thuat ciia Khoa dugc.

ÁN

Vdi cac thong tin thu thap dugc, sinh vien se doi chieu vdi cac qui che che do, qui dinh cua Nganh da ban hanh, tim hieu su dung-sai, lgi-hai.

4.6.2. Tiep can lam sang

Đ ÀN

Sinh vien can thu thap va trao doi thong tin vdi:

D IỄ

- Thay thuoc - Nhan vien y te

- Benh nhan, ngudi nha benh nhan.

Cong viec nay dugc tien hanh tai cac khoa cd giudng benh. Tai do, sinh vien se lam quen vdi cac cong viec sau:

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- Tim hieu lich su diing thuoc cua benh nhan.

- Nghien ciru mot sd ca lam sang (theo doi qua trinh dieu tri).

- Giai dap cac cau hdi ve thuoc cua thay thuoc va nhan vien y te. •

Lam nhu the nao va lam gi tai benh phong ?

H Ơ

+ Phuang phap va thai do trong giao tiep:

Sinh vien den lam sang can phai xac dinh dung vi tri cua minh la de hoc lam chtic nang chuyen gia ve thuoc, nen phai:

Thuc su cau thi.

- Chu dao, than trong, y thtic dugc trach nhiem ciia minh.

ẠO

TP .Q U

- Khiem ton, hoa minh vao tap the lam sang, vdi benh nhan.

- Tu tin, manh dan chu dong, khdc phuc tu tudng tu ti, e ngai.

- Cd phuang phap giao tiep tot (hdi han, ghi chep, tham khao tai lieu, tham khao y

kien cua thay hudng din ve y va dugc...).

- Va quan trong nhat la lam thay thuoc va benh nhan hieu cong viec minh lam la

vi "Lgi fch cua benh nhan".

ẦN

+ Tim hieu lich sir dung thuoc cua benh nhan:

La cong viec tap hgp cac thong tin thu thap dugc d benh nhan ve qua trinh tri lieu trudc va trong khi dang nam vien, la budc dau tien cua viec tiep can lam sang, vdi muc dfch:

- Sinh vien dugc tiep xtic, thu thap va xu ly thong tin vdi mot benh nhan .

- Cd bien phap thfch hop trong giao tiep de chon loc cac thong tin tir benh nhan, tir

Ó A

qua trinh tri lieu.

- Nang cao kien thtic ve "su* dung thuoc hop ly-an toan" va tren ca sd do, cd kha

Í-

nang tdng hgp, phan tfch, chuyen giao thong tin cho thay thuoc va benh nhan.

ÁN

-L

Trong qua trinh thuc hanh dugc lam sang, dudi su hudng dan cua thay thuoc (y va dugc) chon loc mot sd ca tieu bieu, hoi tu nhieu yeu to nhu: Cac ca benh nang, benh di£n bien phtic tap, benh nhan da dung nhieu thude (do tu chua benh), khong dap ting dieu tri, cd tac dung khong mong mudn, cd tuang tac bat lgi v.v... de tap phan tfch.

Đ ÀN

• Khi tien hanh sinh vien cd the gap mot sd khd khan:

Benh nhan khong hop tac vdi sinh vien: Coi thudng sinh vien, cho la cong viec vo bo.

D IỄ

Mot sd benh nhan do benh ly qua met mdi, trang thai tram cam, tir chdi tiep xtic. Benh nhan khong mudn ndi that vi nhieu ly do: - Ngugng do tu chua benh sai, do thieu kien thtic, do nhirng muc tieu tham km.

Thf du: Benh nhan nam cd tuoi tu dung androgen vdi muc tieu trang kien! dan den bat thudng ve tuyen ti£n liet.

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- Benh nhan tu chira benh ngay trong qua trinh dieu tri tai benh vien, dau thay thude va nhan vien y te, tu dung cac thuoc mang d nha vao.

H Ơ

doan la bi cam sot nen da tu diing den lgam aspirin, va bi tai bien chay mau duong tieu hoa tram trong vi chfnh la benh nhan bi sot xuat huyet.

Thf du: Benh nhan mdi nhap vien vi bi con dau da day, nay tu dung them aspirin de tri chting dau khdp man tfnh, din den tai bien chay mau da day; hoac benh nhan tu chan

Benh nhan tai bien do diing thude- nhung nhat quyet dau thude da dung, dau ten thay thude - luang y da ke dan vi y nghl "an tinh".

TP .Q U

Do vay, trudc khi tiep xtic vdi benh nhan, sinh vien can cd su chuan bi chu dao nhu: Thu thap day du cac thong tin ve benh nhan, cac dac diem can quan tam - va khi tiep xtic can cd phuang phap va thai do dting muc.

ẠO

+ Lam phieu "Lich sirdung thuoc cua benh nhan" (theo m5u sd 2):

De khai thac dugc nhung thong tin cd tfnh khach quan, trung thuc va chfnh xac tir

phfa benh nhan, thai do tac phong giao tiep cua sinh vien vdi benh nhan la rat quan

trong (xem phan tren).

Lich su dung thude chfnh xac se gitip cho ngudi th£y thuoc tranh dugc cac tuong tac sau nay khi ke don, gdp phan vao chan doan va dieu tri.

ẦN

+ Thu thap va tra ldi cac cau hdi ve thuoc:

Trong khi thuc hanh dugc lam sang, mdi sinh vien cd nhiem vu phai thu thap va giai dap cac cau hdi cua thay thuoc va nhan vien y te, cua benh nhan lien quan den thude va viec dung thuoc. Day la ca hoi de sinh vien phat huy dugc tfnh tfch cue chu dong hoc tap, d<§ dang hoa nhap vao tap the doi ngii dieu tri, san sdc benh nhan, nam bat dugc thuc

Ó A

te lam sang, dua dugc kien thtic da dugc hoc va dugc .bo sung vao thuc hanh, tong hop cd phan tfch, ly giai mot van de trong trudng hop cu the.

Í-

Cau hdi cd the la d£, nhung trong moi trudng hgp can can nhac, than trong, cd tham khao tai lieu, kien thtic va kinh nghiem cua thay hudng din, dam bao tra ldi nghiem tuc,

ÁN

-L

dung, theo yeu cau hop ly an toan. De tra ldi cac cau hdi cua benh nhan, nhieu khi sinh vien phai tham khao y kien ciia thay thuoc dieu tri de tranh viec benh nhan cd the suy doan ra hudng chan doan va dieu tri, ma thay thuoc cho la chua phai la thdi diem can cho benh nhan biet.

CACH TRA LCil CAU HOI CUA THAY THUOC

D IỄ

Đ ÀN

+ Mot sd thi du ve tinh hudng cu the :

Cau hoi ve qui che ke dan :

Nhirng qui dinh nao can phai thuc hien trong viec ke don Skenan 30 (vien morphin 30mg - cd tac dung keo dai)?

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Tra ldi :

- Skenan 30 la vien morphin sulfat 30mg dang vi nang, cd tac dung giai phong

H Ơ

thanh 7 chuong). Tai benh vien chti y chuong "ke dan su dung" de ting dung vao cau hdi nay.

thude keo dai; la che pham cd chtia morphin, nen phai thuc hien nghiem ttic "qui che quan ly thude gay nghien" (QD 939/BYT-QD ngay 06/06/1995 qui dinh

- Chi ke dan Skenan cho cac trudng hop dau nang, ma cac thuoc chdng dau khac

TP .Q U

khong cd tac dung (Bac thang cudi cua thang chdng dau cua To chtic Y te The gidi, dac biet dung cho dau do ung thu). - Phieu linh thuoc doc, thuoc gay nghien cho benh nhan noi tru phai ghi ten ho va sd giudng benh nhan - lieu lugng dung (ghi bang chu).

ẠO

- Dan cho benh nhan ngoai tru phai ghi day du theo che do dan doc-nghien, kem

theo d dong chan doan. Vi du "ung thu giai doan cudi". Phai ton trong Luat 7

ngay trong ke don thude A nghien.

- Chu y: Lieu tdi da tiem dudi da va bap thit cho 1 ldn cua morphin la 0,05g

trong 24 gid. Skenan la dang nang cd do giai phong hoat chat keo dai, nen tuy

udng mot luc 30mg - nhung khong cham phai lieu tdi da va nguang doc vi

ẦN

thuoc dugc giai phong tir tti.

Cau hdi ve chat lugng thuoc:

Tai sao insulin dang tiem dung cho benh nhan X (40 dan vi/ngay) da cho dung 2

ngay nhung ham lugng dudng/mau khong xudng ma lai tang cao han? Thuoc hong?

Thuoc qua han?

Ó A

•- Tra ldi : Day la 1 khieu nai cua thay thuoc, nghi van ve chat lugng insulin .

Mot sd viec phai lam:

-L

Í-

- Xem ngay lo insulin dang dung thay: Dung loai; Dung sd 16 Khoa dugc dang cap phat; han dung con dai.

ÁN

- Loai va sd 16 do dang dugc dung cho cac benh nhan noi tru tai cac khoa, tac dung tot.

D IỄ

Đ ÀN

- Xem benh an: Benh nhan 56 tuoi, phat hien dudng mau cao, da dung cac su Ifam id ha dudng huyet khong cd ket qua. Benh nhan khong thuoc nhom dai thao dudng typ 1 (phu thuoc insulin) cung khong thuoc nhom khang insulin.

- De nghi vdi thay thude: Ngung insulin, cho dung Glibenclamid (Daonil, Maninil) phoi hop vdi Metformin (Glucophage) vdi lap luan: Glibenclamid kfch thfch tuyen tuy tiet insulin, Metformin cd tac dung tang su dung glucose d te bao, cai thien mdi lien he insulin vdi thu the, tic che tan tao glucose d gan, giam hap thu glucose d ruot.

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- Dong thdi cung cap cho thay thude cac thong tin day du ve dugc hoc cua Glibenclamid va Metformin de thay thuoc chi dinh.

Ket qua dieu tri dugc danh gia la rat tot, benh nhan khong phai tiem insulin.

H Ơ

Cac cau hdi cua nhan vien y te thudng tap trung hdi ve ten thude, each tfnh lieu

CACH TRA LCJI CAU HOI CUA NHAN VIEN Y TE

lugng va each dung. Yta la ngudi true tiep thuc hien menh lenh dieu tri cua thay thude

TP .Q U

nen can than trong vi neu sai thi cd the gay tai bien ngay cho benh nhan. Dong thdi nhieu khi thay thude cd can nhac, tfnh toan trong chi dinh, nen can thong qua thay thude cac cau tra ldi nhat la khi tra ldi ngugc vdi chi dinh cua thay thude hoac ngay ca khi phat hien sai nham trong chi dinh cuathay thude.

ẠO

Cau hdi ve each dung thuoc:

1. Efferalgan la gi? Tai sao vien thude phai pha vao ede nude, khong udng thang dugc?

Tra ldi:

- Efferalgan la vien paracetamol 500mg sui bot nen khi udng phai pha vao 1 ede

nude. Vien cd kfch thude ldn, khong dugc udng thang.

ẦN

2. Trong y lenh thay thude chi dinh aspirin bao tan trong ruot 250mg each 1 ngay udng 1 vien. Khoa dugc chi cd aspirin pH 8 mdi vien 500mg. Vay cd the cat doi vien

thude dugc khong?

Tra ldi:

Khong dugc vi vien aspirin pH 8, cd vd bao khong tan trong da day, chi tan trong phan cudi cua ruot ta trd xudng. Neu cat doi vien thude thi ta da pha va phan vd bao,

-L

Í-

Ó A

lam mat tac dung khong tan trong da day. Trudng hop nay cd the de nghi keo dai khoang each dung thude. Vi du, each 2 ngay udng 1 vien aspirin pH 8- 500mg) vi de chdng ket tap tieu cau chi can lieu nhd va thdi gian ban thai cua aspirin pH 8 cao han cac loai aspirin thudng khac nen van dam bao ndng do cd tac dung trong mau. Cau hdi ve xu tri khi gap di ting thude:

Đ ÀN

ÁN

Tai sao gan day tiem tinh mach vitamin C-0,5g, phai cd hop cap ctiu chdng choang phan ve? Neu dung dng vitamin C ngoai thi cd can thiet nhutren khong? Tra ldi: Phan ldn cac che pham vitamin C tiem (ca noi Ian ngoai) chtia mudi natri cua cac loai sulfit (Bisulfit, Metabisulfit...) la tac nhan cd the gay choang phan ve, tuy

D IỄ

hiem nhung da gap; do vay, phai cd san phuang tien chdng choang. CACH TRA LCJI CAC CAU HOI CUA BENH NHAN

Cac cau hdi cua benh nhan (hoac ngudi nha benh nhan) rat da dang. Sinh vien cd thuan lgi la d<§ gan han, benh nhan cd the trinh bay cac thac mac mot each thoai mai han

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(vdi dieu kien la sinh vien cd phuong phap tiep xtic tot, gay dugc long tin cua benh nhan). Viec giai dap cho benh nhan can luu y:

H Ơ

kha nang (ve nhieu mat) cua benh vien. Cac giai dap ngugc vdi chi dinh cua thay thude nhat thiet phai thong qua va dugc su dong y cua thay thuoc dieu tri va thay hudng dSn.

- Can nh^c de y kien giai dap khong ngugc vdi y do di&u tri cua thay thude, vdi

TP .Q U

- Xac dinh ro gidi han cua viec chuyen giao thong tin cho benh nhan, theo dting yeu cau dung thude "hop ly- an toan" (tranh de benh nhan suy doan ve benh tat, tu chua benh thieu kien thtic, lam dung thude, tam ly thieu tin tudng va thieu cong tac vdi thay thude). Mot sd thi du ve cau hdi ciia benh nhan:

ẠO

1. Benh nhan Y: Cung nam dieu tri trong mot phong benh ma benh nhan X dugc truyen dung dich dam, con toi lai khong dugc truyen?

ẦN

Qua xem benh an va y kien cua thay thude dieu tri dugc biet benh nhan X can tang dinh dudng nhung dudng ruot cd thuang ton, khong hap thu dugc - phai nuoi dudng ngoai dudng tieu hoa con benh nhan Y thi dudng tieu hoa tot - khong can truyen - chi truyen dich khi bat d&c di, vi qua dudng truyen cd the gap tai bien, hoac do cd chdng chi

dinh vdi benh nhan Y (suy tim mat bu).

Tra ldi benh nhan Y nen giai thfch la: Do benh nhan Y tim dang yeu, khong nen

truyen...

2. Benh nhan Z: Toi bi loet da day, trudc vln dugc dung Tagamet ngay 2 vien (sang

va tdi). Nay bac si doi thuoc, nghe ndi cung loai, nhung chi dugc udng mdi 1 vien vao

Ó A

buoi tdi. Tai sao?

-L

Í-

Xem lai benh an thi thay: Trudc la Tagamet vien 400mg - loai thude do het. Hien nay dang dung Cimetidin 800mg. Nhu vay la dting thude, dting lieu va dting each dung.

ÁN

3. Benh nhan ngoai trti X hdi: Toi bi thudng xuyen nhtic dau rat khd chiu, da dung aspirin, paracetamol khong dd, vay nay nen dung thti thude nao?

D IỄ

Đ ÀN

Cau hdi mdi nghe tudng dl - nhung tra ldi benh nhan thi can than trong, vi nhtic dau la trieu chting cua nhieu benh (do dau 1/2 dau, do huyet ap cao, sau chan thuang, do bi mot chting benh ve mat - tai mui hgng, do xtic dong, do cang ca, do tam than, do viem

tinh mach noi so, do khdi u hoac di can so nao v.v...). Trong trudng hop nay nen khuyen benh nhan den mot bac si noi khoa kham de cd chan doan va chi dinh dting. 4.7. Nghien ciru ca lam sang

Trong khi tien hanh thong tin va truyen thong (lam lich sir dung thude cua benh nhan, tra ldi cac cau hdi cua thay thuoc, cua benh nhan...), vdi su hudng dan cua thay

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(dugc, y) sinh vien chon mot sd ca cd tinh trang benh nang, cap ciru, phtic tap ve sinh ly benh, khd khan trong dugc tri lieu, hgi tu nhieu van de quan he vdi dung thude hgp

H Ơ

Viec nay doi hdi sinh vien phai thu thap nhieu thong tin ve lam sang, can lam sang, dugc hoc, gitip sinh vien cd ca hoi thuc tap phan tfch, tong hoa kien thtic da dang trong mot ca cu the, tao cho sinh vien chu dong chon lua phuang phap hoc va hanh tot.

ly-an toan-hieu qua, de nghien ctiu sau ve "ca lam sang".

Thi du:

TP .Q U

De tra ldi cau hdi cua thay thude: Benh nhan X dung Digoxin 0,25mg x lvien/ngay, mdi dung trong 2 ngay nhung da xuat hien trieu chting "nhi6m doc Digital", tai sao?

De tra ldi cau hdi nay sinh vien phai lam nhirng viec sau day: - Nghien ctiu ho so benh an cua benh nhan :

ẠO

+ Benh nhan X, 73 tudi, suy tim do 3, ca the suy kiet, can nang 39kg.

+ Xet nghiem mau: Protein toan phan thap (50g/l), creatinin mau cao (105

jumol/1), ure mau cao (10 mmol/1), K+ mau thap (3,4mmol/l).

+ Benh nhan da dugc dieu tri: Furosemid 40mg 1 vien x 2 Ian/ ngay trong 7

ngay trudc khi vao benh vien.

ẦN

+ Tir horn nhap vien: Digoxin 0,25mg 1 vien/ngay trong 2 ngay lien tiep; tdi ngay thti ba xuat hien cac trieu chting nhu: Rdi loan tieu hoa (non, ia long), nhtic dau, chdng mat, loan nhip, nhip tim cham (56 lan/phtit).

- Tir cac thong tin tren, sinh vien thu thap cac thong tin dugc ly, dugc dong hoc

chfnh ve Digoxin va Furosemid:

Ó A

+ Digoxin gan protein huyet tuong 29%, phan tu do cao (80%) nen tac dung nhanh, manh, chuyen hoa tai gan ft (10%) dao thai chu yeu qua than, thdi gian

ban thai trong huyet tuang la 36 gid.

-L

Í-

+ Furosemid: Lgi nieu (loai bai nieu mudi), tac dong chu yeu d quai Henle, tic che tai hap thu Na+ va CL. Tac dung bai nieu mudi nhanh va keo dai 7-8 gid.

ÁN

- Phan tfch va tong hop cac thong tin tren, sinh vien cd the ket luan:

+ Dung la benh nhan bi nhi6m doc digital.

Đ ÀN

Nguyen nhan nhiSm doc cd the do:

# Benh nhan gia yeu nen cd the chtic nang than bi suy giam.

# Cd the benh nhan bi suy kiet, protein mau thap din den hau qua tang phan

D IỄ

Digoxin tu do .

# Benh nhan lai cd suy chtic nang than (creatinin, ure mau cao), da dung lgi tieu nhieu ngay lam ndng do kali mau giam. - Suy than va kali mau thap la nhan to thuc day va lam tram trong them tinh trang "nhi6m doc Digital".

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Sau ket luan, sinh vien cd the de nghi vdi thay thude dieu tri:

- Tam ngimg Digoxin 2-3 ngay, sau do neu thay thude xet thay can thi nen chi dinh vdi lieu thap (bang 1/3 den 1/2 lieu thong dung).

H Ơ

- Bo sung kali, gidi thieu cac dang thude mudi kali ma Khoa dugc cd, vf du: Dung dich kali clorid 3%, vien kali clorid 0,6 (biet dugc la Diffu K) vien kali tartrat 0,5 (biet dugc la Natri K)... de thay thude chgn lira thti thfch hgp, lieu lugng thfch hop

ma chi dinh.

4.8. Theo doi bao cao phan ung cd hai nghi do thuoc

ẠO

TP .Q U

Trong nam hoc dugc lam sang, trudc cac hien tugng cd nghi van ve tac dung cd hai (Adverse Drugs Reactions) hay con goi la tac dung khong mong mudn cua thude, sinh vien can thu thap, ghi chep, phan tfch va bao cao. Viec nay tao cho sinh vien tap hgp kien thtic ve cac mat trai cua thude, thuc tap va lam tot "canh giac thude"

(pharmacovigilance).

Xem chuong " Canh giac thude".

4.9. Bao cao "khuyet tat ve chat lugng thuoc"

ẦN

Thu thap thong tin tir benh phong ve chat lugng cua thuoc dieu tri de phan anh kip thdi ve Khoa dugc cung la mot nhiem vu quan trong, giup cho dugc si xu ly kip thdi nhung trudng hgp thuoc khong bao dam chat lugng, tranh dugc nhung tai bien dang tiec va gdp phan nang cao chat lugng dieu tri. Day cung la mot mang cua hoat dong thong tin thuoc tai benh phong, giup cho bac si dieu tri danh gia chfnh xac han cac phan ting bat lgi (neu gap) va quyet dinh xu ly kip thdi. (Xem m&u sd 3 "Bao cao khuyet tat ve

D IỄ

Đ ÀN

ÁN

-L

Í-

Ó A

chat lugng thuoc" - phan phu luc).

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Mau so 1

Ngay.

thang

nam.

Benh vien

H Ơ

Khoa

Phong

2. Tra ldi sau

Theo yeu cau cua:

Thay thude

•

• hg ten

•

ho ten

Benh nhan

ẠO

Sinh vien • hg ten Y ta • hgten Nhan vien khac • hg ten

TP .Q U

PHIEU THONG TIN VE THUOC

Cac ngudi khac • ho ten Lap tai:

• • • •

ẦN

- Tu tim tai lieu de tra ldi

- Tai lieu do thay chi din

B 10 Ó A

H Í-L

thang

ÁN

...gid, ngay

1. Tra ldi ngay

•

(ghi ten tai lieu)

Noi dung cau hdi

Trd ldi

•

(ghi ten tai lieu)

Khi tham benh phong Tai phong kham Qua dien thoai Qua thu

Can cti vao:

- Cac nguon khac

•

Cach tra ldi :

Ndi

•

Qua dien thoai

•

Viet

•

Noi dung cau tra ldi...

nam

•

Đ ÀN

Noi dung cau tra ldi

- Ten sinh vien

- Kien thtic hoc d trudng • - Kien thtic hoc d lam sang •

- Thay hudng dan - Danh gia chat lugng thong tin:

- Cac tai lieu khac

dung du • dung - thieu • sai •

D IỄ

Can cti de tra ldi:

•

(ghi ten tai lieu)

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Mau so 2

PHIEU THONG TIN

VE LICH SlTDUNG THUOC

Phong

Ngay... thang... nam Sinh vien Khoa

Tuoi

Lap

Ly do vao vien (ghi ro chting, benh chfnh va kem theo).

H-

Thdi quen sinh hoat:

TP .Q U

Nam-Nu

H Ơ

Khoa

Benh nhan

Thude la: cd • khong • ;

Rugu: cd • khong •

Trudc khi vao vien cd dung thude Q khong dung thuoc D

HI-

ẠO

An; udng:

Neu cd dung thude gi?; lieu lugng, each dung:

ẦN

)

IV.

Thudng xuyen • thinh thoang • Neu thudng xuyen: Tren 1 thang • (may thang? Tren 1 nam • (may nam? )

Do chi dinh cua thay thude •

Ó A

Thay thude benh vien • - ca sd y te • - thay thude tu •

Thude gi? (ghi sd thude dmuc III)

Do tu ydung thude • - Thude gi? (ghi sd thude d muc III

ÁN

V-

-L

Í-

Theo dting chi dinh cua thay thude • - khong • Neu khong can ghi ro (vf du: Tu y tang lieu • - giam lieu • - ngting thude •)

)

Do khuyen bao cua ngudi khac • - Thuoc gi ? (ghi sd thude d muc III

Neu cd thi la thude gi? Mo ta phan ting Phan ting thude: cd • - khong •

Đ ÀN

VI.

)

Mo ta phan ting

D IỄ

Neu cd thi la thude gi ?

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VII. Thude dung tti khi vao vien, lieu lugng, each dung? la

lb lc

Hieu qua, hau qua:

IX.

Xu ly cac thong tin, nhan xet va bien luan cua sinh vien:

Y kien cua thay hudng dan

D IỄ

Đ ÀN

ÁN

-L

Í-

Ó A

ẦN

ẠO

TP .Q U

H Ơ

VIII.

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Mau so 3

Sd:

BAO CAO NHUNG THUOC

Don vi:

H Ơ

CO KHUYET TAT VE CHAT LUONG

Ten thude:

Han dung...

L6 sd

Loai bao bi.

ẠO

Ngay san xuat

TP .Q U

Nguon gdc (Cong ty, Xf nghiep):

Cd tim dugc mau khong:

1.Mo ta khuyet tat:

2. Sd lugng da sir dung:

ẦN

3. Hau qua:

4. De nghi:

•

- Dugc si

•

Í-

- Benh nhan

Ó A

5. Ai phat hien ra khuyet tat:

•

Đ ÀN

ÁN

-L

-Yta

D IỄ

Chu nhiem khoa Ky ten

Ngay

thang

nam

Ngudi bao cao Hg va ten: Khoa:

Sddien thoai

Chuky

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Chirong II

CAC KHI SLT DUNG TRONG BENH VIEN

H Ơ

I. MCI DAU

TP .Q U

Trong chuong nay, chting toi xin gidi han trong pham vi mot sd chat d the khi trong tu nhien dugc su dung nhieu trong benh vien (goi tat la chat khf dung trong benh vien) Mot sd chat khi sir dung cung d the khf nhu cac thude me la dan xuat halogen, cac chat sat trung thang hoa... khong thuoc pham vi chuong nay.

ẠO

Trong sd khf nay dugc dung pho bien nhat la oxy de hd trg ho hap. Khf carbonic va nita ft dugc dung trong nude nhung lai can de tao hdn hop thd khi ngudi benh can phai

sir dung keo dai.

ẦN

Cac chat khf dung trong benh vien la mot loai thude thiet yeu nhung lai la loai thude ft dugc cac dugc si quan tam day du. Nhung kien thtic sau day hy vong gdp phan vao viec nang cao kien thtic cho dugc si trong linh vuc su dung va dam bao an toan khi quan ly cac loai khf nen nham thuc hien muc tieu su dung thude "Hgp ly va An toan".

2.1. Oxy

II. CAC LOAI KHI THONG DUNG

2.1.1. Vai tro ciia oxy trong qua trinh sinh ly ciia ngudi

Ó A

Oxy la mot nguyen to rat pho bien trong thien nhien d dang hgp chat oxyt. Trong khf quyen, oxy tu do chiem tdi 20,95%. Trong ca the con ngudi, oxy a dang hop chat

cung chiem tdi 6,5%.

Í-

Nam 1774, Priestley da tim ra khf nay rdi Lavoisier da kham pha ra cac tfnh chat

-L

chfnh.

ÁN

Oxy dugc che tao bang phuang phap hoa long khong khf rdi cat phan doan de tach

rieng ra va tir day lai dugc nen hay hoa long trd lai de chuyen tdi noi su dung.

Đ ÀN

Ngay nay, chting ta deu biet oxy la mot chat thiet yeu cho sir song tren trai dat. No la yeu to khong the thieu trong cac chu trinh chuyen hoa va tao nang lugng trong hoat dong cua mdi te bao, cua mgi ca the sinh vat.

D IỄ

Oxy la mot nhan to thiet yeu cho qua trinh oxy hoa trong cac ca the song de tao ra nang lugng cho moi hoat dong sinh hoc. Vdi ngudi va dong vat, oxy tti moi trudng dugc hap thu qua cac ca quan ho hap rdi van chuyen theo mau tdi tan tung te bao. Oxy trong khong khf chiem khoang 21% theo the tfch, cd ap suat rieng phan khoang 150 mmHg . Oxy dugc hit vao tdi cac phe nang qua dudng ho hap, tai day se xay ra qua 30

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trinh trao doi khf. Tai phe nang luon con do 1/3 the tfch dgng nen ap suat rieng phan cua

oxy chi khoang 101 mmHg, tuy nhien ap suat nay v5n ldn han ap suat rieng phan trong dong mach phoi nen oxy dugc hoa tan vao mau. Ngugc lai vdi qua trinh ciia oxy, khi carbonic hoa tan trong mau cd ap luc rieng phan ldn han trong khong khf cua phe nang,

H Ơ

Vdi ngudi binh thudng, he sd trao doi khf dugc tfnh bang ty le giua the tfch khf carbonic thai ra chia cho the tfch oxy hap thu trong mot dan vi thdi gian (thudng la

nhd do qua trinh thai khf nay vao khong khf di6n ra.

phut), trung binh bang 0,8.

TP .Q U

QR = V C02 thai / V 02 hap thu = 0,8

He sd nay giam con 0,7 khi chuyen hoa lipid va tang len 1,0 khi chuyen hoa cac hydrat carbon. 90

120 150 180

%oxy/khi thd

Ó A

ẦN

ẠO

P02(mmHg)

Hinh 2.1. Tuong quan Po2 - Pco2.

-L

Í-

Hinh 1 la do thi bieu hien tuang quan giua ap luc rieng phan cua oxy (P02) va khf carbonic (PC02). Khi hit vao vdi khong khf binh thudng, P02 =150 mmHg con

ÁN

khi tang ndng do oxy len 35%, P02 = 250 mmHg. Theo suy luan nay, khi P02 tang len trong khf thd thi ndng do oxy trong mau cung tang theo nhung chi cd the tdi bao

D IỄ

Đ ÀN

hoa 100%, tuang ung vdi ndng do 19,5%.

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10 -i

40 50

80 90 100 100

w;//////;//A'////////&^ . >

90 80 70

60 £

H Ơ

sol

O en 4

,8 40 * o

TP .Q U

ẠO

Hinh 2.2.Do thi ve sir phan giai 02 theo tuang quan Po2, ty le bao hoa va nong do

02 trong khong khi.

P02(mmHg)

2 3 4 5 6 7 8 » 10 U 12 13

-L

Í-

Ó A

ẦN

10 20 30 40 50 60 70 80 90 100

POjtkPa)

ÁN

Hinh 2.3. Do thi ve su phan ly oxy theo ty le cua khi nay trong hon hop tha. Tir so do nay co the thay viec tang ty le oxy len qua cao la vo ich.

Đ ÀN

Nhu cau oxy 6* con ngirdi binh thudng la 6 khoang 3 - 4 ml/kg the trgng, vi vay neu

D IỄ

cho thd 5 lit oxy/phut nhir thiromg dung da la qua thira. 2.1.2. Tieu chuan oxy y te

Oxy la mot chat khi khong mau, khong mui vakhong vi. Theo Dugc dien Viet Nam, xuat ban Ian thur 1, tieu chuan cua oxy y te phai dam bao do tinh khiet it nhat la 98,5%. Tieu chuan nay da t6n tai tir hon 30 nam qua.

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Theo nhieu Dugc dien cua cac nude nhu Anh, Phap, My, Qudc te, oxy y te phai cd ham lugng nguyen chat ft nhat la 99,5% . Trong cac tai lieu nay con cd mot sd chi tieu cu the ve gidi han tap chat cho phep nhu do am, hoi acid hay kiem, chat khu hay oxy hoa, oxyt carbon...

2.1.3. Sudung oxy trong y te

H Ơ

2.1.3.1. Cac dp dung thudng gap

TP .Q U

Oxy dugc cho thd bu d nhung ngudi benh trong trang thai thieu oxy do bi thieu nang ho hap va trong dieu kien thieu ham lugng oxy trong khong khi nhu d do cao ldn. Oxy rat quan trgng trong cap ciru do bi ngo doc carbon mono oxyt. Ngoai ra, oxy dugc dung de thd cho nhung ngudi phai lam viec d chd cd ap suat cao de lam giam nong do nito hit vao. Trong ngoai khoa, oxy dugc dung lam khi dan hoa loang cac thuoc me bde hoi hay

ẠO

d the khi.

Oxy d nong do cao dugc dung trong ngo doc carbon mono oxyt va tri lieu can den

oxy cao ap.

Sau day la mot sd trudng hgp cu the:

- Dieu tri bang oxy cao ap:

Ó A

ẦN

Viec tri lieu nay gom cd viec cho thd lien tuc oxy 100% dudi ap suat ldn hon 1 atm. Trong dieu tri tac mach do bgt khi, no cd tac dung do co che lam giam kich thude bgt khi trong mau nhd ap lire moi trudng gia tang va ap lire oxy trong dieu kien nay dugc dung tir 2 tdi 6 atm. Day cung la mot phuong phap bo trg de chua hoai thu sinh hoi (do Clostridium): khi dung sdm, phuong phap nay ure che san xuat doc to a do cac vi khuan ky khi tao ra, qua do giup cho ngudi benh chiu dung phSu thuat tot hon va phan biet dugc ro rang cac to enure song hay da hoai tir. Oxy cao ap cung giup cho tri lieu mot sd vet thuong do lam giam phu ne, gay co mach nhu khi bi bong nhiet, bong do burc xa.

- Dieu tri thieu nang ho hap:

ÁN

-L

Í-

Tinh trang thieu nang ho hap xay ra khi ap sua't rieng phan cua oxy (Pa02) va cua khf carbonic (PaC02) trong huyet tuong dong mach khong duy tri dugc trong gidi han sinh ly binh thudng. Thieu nang ho hap dugc chia thanh 2 cap va deu cd dac diem la Pa02 thap. Trong thieu nang cap I, PaC02 binh thudng hay thap con trong cap II lien quan den sir thieu thong khf, PaC02 tang cao. Viec chua thieu nang ho hap cap I can cho

D IỄ

Đ ÀN

thd oxy vdi ndng do cao, su dung dng dan vao mui hay mat na thd de tao dugc ndng do tu 60% trd len theo yeu cau (nhu 100% khi dung mat na gay me km hay dng noi khi quan). Vdi thieu nang cap II, tuy theo nhu cau ma dieu chinh ndng do.

Vdi ngudi bi hen nang, oxy thudng dugc cho thd d ndng do cao tu* 40 den 60%. Ndng do oxy thap 24 - 28% dugc dung cho ngudi benh bi rdi loan ho ha'p man tfnh nhu nghen dudng ho hap vdi muc tieu cai thien thieu oxy ma khong tang PaC02 va nhiem

acid ho ha'p.

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- Trong gay me:

Oxy dugc su dung de duy tri su song cho co the, dong thdi cung vira lam khf hoa loang cac hoi thude me.

H Ơ

Oxy thudng dugc cung cap cho ngudi benh bang dng dan vao mui hay mot mat na thd, vdi ndng do tdi 60%. Khi cho thd qua mat na gay me km hay dng noi khf quan, leu oxy, ndng do oxy cd the dat tdi 100%, luu lugng khoang 4 den 6 lft/phut.

2.1.3.2. Lieu luang va each dung:

Nguon cung cap thudng la cac chai thep cd chu*a oxy bi nen d ap luc cao hay cac

TP .Q U

bdn chiu ap luc cd chira oxy hoa long.

Khi bi suy ho hap khong phoi hop vdi u dgng khf carbonic nhu trong benh viem phdi, phu phoi hay benh bui phoi, oxy cd the dugc cho thdd ndng do cao (tu40 den 100%).

ẠO

Ndng do 40 den 60% se dugc dung trong cac con hen nang khi lugng carbon dioxyd u dong tang len vdi tinh trang cua ngudi benh xau di. Ndng do oxy cao phai ha cang sdm cang tot, tdi ndng do thap nhat can thiet nham tranh cac hien tugng ngo doc oxy, trong

do cd viec tang lugng carbonic u dgng.

ẦN

Trong thieu nang ho hap ket hgp vdi cac dieu kien nghet thd man tfnh nhu viem phe quan man tfnh, oxy thudng dugc cho thd d ndng do tdi 28%.

Oxy d ap xuat ldn hon 1 atm dung vdi ngudi benh trong nhirng budng km cao ap de

Ó A

chua thieu oxy do ngo doc carbon mono oxyt, trong benh nhi£m trung ky khf nang (hoai tu sinh hoi), trong chua chdng mat do giam ap va tac mach do bgt khf. Oxy dugc cung cap vdi luu lugng khoang 5 lit/phut va ap suat cao hon khf quyen do 5 mmHg vdi ngudi khong cd benh ve ho hap. Oxy dugc sue qua nude am 55 - 60°C de khi vao he ho hap cua ngudi thi cd nhiet do 32 den 37°C va do am tuong ddi dat 70 -

75% (oxy nguon gan nhu kho kiet).

-L

Í-

Khong nen cho thd keo dai oxy nguyen chat vi cd the lam kich umg phoi, lam giam dich phe nang dan den viem va co that. Thd oxy nguyen chat keo dai con cd the lam cac

ÁN

men cd gdc -SH bi oxy hoa trd nen vo hoat dan den co giat. De tao cac hdn hop khf thd, ngudi ta thudng pha lan 5% khf carbonic (thudng ggi la Carbogene) va mot phan nito

thfch hop.

Đ ÀN

2.2. Carbon dioxyd hay khi carbonic

Khf carbonic da dugc Paracelse va Van Helmont phat hien tir the ky 16 va nay da cd

D IỄ

trong Dugc dien Anh 1993, My 23, Phap IX...

Carbon dioxyd la mot chat khf khong mau, khong mui va khong duy tri su chay. Khf nay thudng dugc cung ca'p d dang hoa long dudi ap suat trong cac chai thep. Khf carbonic cd the hoa tan trong nude vdi ty le 1/1 theo the tfch, tao thanh dung

dich cd tfnh acid yeu.

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- Cong dung trong y te:

Trong phau thuat noi soi, khf carbonic dugc dung de bom cang khoang bung.

H Ơ

Carbon dioxyd dugc cho them vao oxy d mot sd loai may thd nham duy tri ndng do khf carbonic trong mau, mot sd yeu to kich thfch trung tam ho ha'p. Carbon dioxyd cd tfnh chat kfch thfch ho ha'p nhung khong dugc dung rieng vi muc dfch nay ma chi them vao oxy (carbogene).

:u the ky 18, 19, mot sd tac gia da su dung nhu mot thude te tai chd. Cho tdi dau the ky 20, no dugc phoi hgp vdi clorua etyl de gay me (Carbo - Kelene).

TP .Q U

Ngoai d the khf, carbon dioxyd con d the ran hay "nude da kho" cd nhiet do thang hoa -80°C, dugc dung de dieu tri bang dong lanh hay de bao quan thuoc va vat pham trong khi van chuyen.

Trong nganh van tai thuy, khf carbonic dugc dung de diet chuot va con trung trong

ẠO

tau, thuyen.

2.3. Nita

Nito la mot chat khf khong mau, khong mui va khong vi, khong chay dugc va khong

duy tri sir chay.

Do nito la mot chat khong phat hien dugc bang cam quan nen chi su dung d noi cd

ẦN

dieu kien thong gid tot.

Khf nay thudng dugc cung cap dudi ap luc cao trong cac chai thep hay d dang hoa long, cd tieu chuan ghi trong Dugc dien Anh 1993, My 23 va Phap IX...

Cong dung trong y te:

Ó A

- Nito dugc dung de hoa loang oxy cho benh nhan thd va tao moi trudng khf tro trong mot sd phau thuat dudng tieu hoa hay thu thuat khac.

- Nito long dugc dung lam mot tac nhan trong tri lieu bang dong lanh, de bao quan cac to churc bang nhiet do cue thap.

-L

Í-

- Do tinh chat tro, nito hay dugc dung trong bao che de the chd khong khi (cd chu*a oxy) nham bao quan cac chat dd bi oxy hoa trong thanh phan cua thuoc tiem nhu

ÁN

epinephrine, phytomenadion, acid ascorbic...

Đ ÀN

III. NHUNG DIEM QUI DINH VE AN TOAN TRONG SLT DUNG

D IỄ

Cac loai khf dung trong benh vien deu dugc cap dudi dang cd ap luc va do tinh khiet cao. Hai dac diem nay dan den viec phai tuan theo nhung quy dinh trong Quy pham ve an toan lao dong Viet Nam (QPVN 02/1975 - phu luc) va nhirng bien phap ky thuat de thfch u*ng vdi ngudi benh va yeu cdu ky thuat khi su dung.

- He thong binh chira, dudng din, van dieu tiet, dong hd do ap lire va van an toan phai dugc kiem tra dinh ky va cap chumg chi cho phep su dung bdi co quan cd tham quyen.

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- Cac binh chura phai cd du bg phan bao hiem (chup bao ve van, dai dem chdng va dap) va son mau dung quy che.

- Khong dugc cd nguon nhiet nang trong pham vi an toan quy dinh vdi cac binh chira hay de anh nang chieu true tiep vao.

- Khi su dung hay van chuyen cac binh chu'a, phai cd phuong tien de cd dinh tranh

H Ơ

bi trugt hay do, roi.

- Phai giu ve sinh binh chu'a va he thdng dan truyen, tranh dgng bui ban hay phu

TP .Q U

khan len tren.

Van an toan

^Luu lugng ke

ẠO

*+ Van su dung

Lgc

£H)Bh,h lftnl flm

Van didu ap

Dieu nhiet

ẦN

Van gdc

Nguon

Hinh 2.4: So do nguyen tac lap dat

* Nguon cap tu cac chai thep cd ap luc tdi 150kg/cm2 nen khong the cap thang vao he thdng din truyen ma phai giam va dieu hoa ap lire xudng qua mot bo van dieu

Ó A

ap.

* Mot van an toan trudc noi sir dung la mot su can thiet bat buoc de loai tru* mgi

-L

viec su dung.

Í-

nguy co tang ap sua't dot ngot tren he thdng dan truyen va dam bao an toan cho * Mang lgc de loai trir mgi can ban do dudng dan truyen cd the nha ra trong qua

ÁN

trinh su dung, tranh nguy co cho cac trang thiet bi su dung nguon khf va cho

nguoi benh.

Đ ÀN

* He thdng lam am va dieu nhiet de tranh tac hai len phoi cua ngudi benh do cac khf gan nhu kho tuyet ddi va cd nhiet do thap (ha nhiet do khi gian nd tir ap suat cao

D IỄ

xudng).

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Chirong III

VE SINH BENH VIEN

H Ơ

Cong tac ve sinh trong benh vien la mot cong viec quan trgng va rong khap, trong do sat trung, tay trung va tiet trung la trgng tam.

i. m6 dau

Ve sinh benh vien la cong tac chdng nhi£m trung cheo giua cac hoat dong trong

TP .Q U

benh vien va giua benh vien vdi xa hoi ben ngoai.

ẠO

Do nhiem vu cua minh, benh vien trd nen mot noi tap trung nhieu mam benh nhat ciia toan xa hoi, do do doi hdi phai cd mot yeu cau rat cao cho cong tac ve sinh ma trgng tam la hai viec chfnh: loai tru* vi khuan va ngan lay lan. Ve sinh trong benh vien con bao gom rat nhieu viec khac, tu* ve sinh mgi nguon vao, xu ly mgi chat thai va chdng nhiem cheo trong noi bo.

Thuc pham

II. CAC MAM BENH CUA BENH VIEN

ẦN

Day la mot viec chung cua toan benh vien va can cd quy dinh, quy trinh cu the cho mdi mot cong viec, mdi thao tac hay thu thuat chuyen mon. Ngudi dugc sy cd mot vai trd quan trgng vi da dugc trang bi cac kien thirc ve thude, cac cha't sat trung, cac phuong phap tiet trung.

Ó A

BENH VIEN

-L

Í-

Ngudi benh Nhan vien y te Ngudi den tham Chat thai benh pham

ÁN

Chat thai sinh hoat

D IỄ

Đ ÀN

Chat thai hoa hoc

Chat thai sinh hoat

Chat thai benh pham (Hum hinh, Vd hinh)

Chat thai hoa chat

Hinh 3.1. So do kha n^ng trao doi mam benh ben trong va ben ngoai benh vien

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Cac mam benh trong benh vien thuoc ve nhieu chung loai, nhieu nguon gdc nhung cd the phan thanh hai nguon chfnh la con ngudi va cac vat pham.

H Ơ

Trong benh vien, con ngudi dugc xac dinh la nguon mang mam benh quan trgng nhat. Do la ngudi benh, cung cd the la cac nhan vien hay khach qua lai cd mang mam benh. Vdi su tien bo cua cac ky thuat phat hien vi sinh, ngudi ta da biet ve cac tap hgp vi trung.thudng gap tren cac khu vuc co the khac nhau cua ngudi lanh. Cd hang chuc loai (ca gay benh lln lanh tfnh) thudng cd mat d ngoai da, trong mieng, trong ruot.. va chung

2.1. Con nguoi

TP .Q U

se gay benh khi cd dieu kien thuan lgi. 2.1.1. Ngudi benh

Ngudi benh thudng dugc coi la nguy co chfnh cho su lan truyen mam benh. Hg den

ẠO

benh vien vi mot sir ba't on nao do ve sure khoe. Su ba't binh thudng nay cd the do nhiem khuan hay nhi6m virus, vi nam; cung cd the do nhieu nguyen nhan khac nhu su

thay doi trang thai sinh ly, tam than, chan thuong hoac dan thu£n chi de kiem tra

ẦN

sure khoe. Ngudi benh cd the mang theo mam benh tiem an nhu HIV, viem gan do virus, benh ve gen, ve than kinh... ma khong phai co sd y te nao cung cd kha nang phat hien. Mdi mot ngudi den de chua benh con cd mot tinh trang ve sinh ca nhan rat khac nhau nua. Nhu vay, ngudi benh dugc coi la nguyen nhan chfnh cua nguy co lay benh trong benh vien, nhung khong phai la mot nhan dinh luon luon dung.

2.7.2. Nhan vien ciia benh vien

Trong benh vien cd nhi6u loai nhan vien nhung dang luu y nhat la nhan vien y te bao gom thay thuoc, y ta, ho ly, thuc tapsinh hay cacky thuat vien thao tac mayy te... Theo quy

Ó A

dinh chung, hg phai khong cd benh truyen nhi6m, ngudi tham gia phau thuat phai khong

ÁN

trinh do nua.

-L

Í-

cd vet thuong hd d tay. Tuy the, hg cung la mot con ngudi nen khong the loai tru" kha nang la hg mang theo nguon benh tiem an, hg cd nhung dieu kien ve sinh ca nhan rieng va ca viec chap hanh cac quy dinh ve sinh nghiep vu hay trinh do cua chfnh cac quy

Mot vf du don gian la viec rua tay trudc khi kham benh hay cham sdc benh nhan. Ngay

Đ ÀN

d cac benh vien da cd quy dinh nay nhung v5n cd the gap sai sot nhu nude may khong dat tieu chuan nude udng dugc hay khong cd gia'y lau dung mot lan hoac may say kho (da bi loai tru d cac nude tien tien) lam cho quy dinh rua tay ma't di nhieu phan tac dung.

D IỄ

Cac nhan vien mac ao choang, doi mu de each ly vdi ngudi benh nhung neu nhieu ngay khong thay thi chung se lai la mot co chat mang mam benh den vdi mgi ngudi.

Chie'c khau trang khong khft mat cung ma't di nhieu tac dung lgc khong khf cho chfnh ngudi mang no. Con neu chi che mieng thi ta thay ngay la ludng thd ra cd the tung vao khong khf vo van vi co.

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Mgi nhan vat hoat dgng quanh ngudi benh deu cd the la mot nguon lay lan tiem an. Mat do ngudi trong mdi khu vuc deu cd the anh hudng tdi ngudi benh nen trong cac budng mo va da de, sd ngudi can dugc han che tdi mirc tdi thieu vdi quy dinh ve sinh ca nhan nghiem ngat.

TP .Q U

H Ơ

Benh vien la mot dia diem cong cong nen ngudi den do cung het sure da dang : hg la ngudi den kham benh, la ngudi den tham benh nhan hay la ngudi den vi cong viec lien quan. Khi den, hg cd the mang san nhieu mam benh tir ben ngoai tren trang phuc va vat dung hoac tai chfnh co the cua hg va cac mam benh nay cd the se lan toa vo tinh trong benh vien. Ngugc lai, hg cung thu dong tiep thu cac mam benh san cd trong benh vien qua tiep xuc hay ho ha'p de rdi lai vo tinh lam lan toa ra ngoai xa hoi.

2.1.3. Khdch qua lai

ẠO

Viec han che sd ngudi tdi benh vien hoac di lai tu do giua cac khu vuc trong benh vien, dac biet la cac khu vuc c£n tuyet ddi vo trung se dam bao an toan, hieu qua cho viec chua benh, dong thdi la an toan cho ca ngudi den tham.

2.2. Nhirng vat dung dim vao benh vien

2.2.1. Vdttuyte

ẦN

Day la mot nhom vat pham neu khong dugc tay trung tot se la cac vat trung gian

truyen benh vi vi khuan tir day cd dieu kien dl dang vugt qua cac hang rao bao ve tu

nhien cua co the : bong, gae tiep xuc vdi da bi thuong ton, dung cu tiem truyen tiep xuc true tiep vao mau benh nhan; dung cu phau thuat hoac cac loai dng soi hay dan luu con tiep xuc sau hon nua.

ÁN

-L

Í-

Ó A

Ngay nay, viec xuat hien cac vat tu dung mot lan duy nhat nhu bom tiem, dng dan luu.. da gan loai tru* het nguy co lay benh qua trung gian nay. Tuy vay, van con nhieu loai vat tu va thiet bi phai dung cho nhieu ngudi nhu cac may X quang, may soi hay giudng benh, trang bi cua budng mo, may thd.. Cac trang thiet bi nay cd ket cau phifc tap, nhieu khi da dang v£ vat lieu va rat tinh vi nen phai cd cac quy trinh tay trung thfch ung rieng ma van khong the dam bao tuyet ddi dugc.

2.2.2. Do vdi

D IỄ

Đ ÀN

Do vai trong benh vien cd the coi la mot vat tu vdi khdi lugng ldn va dung rong khap. Do la trang phuc cua thay thuoc va cua ngudi benh, la chan man, dem va ca bong, bang, gae. Vdi ban chat xdp va tiep xuc true tiep vdi mam benh nen chung cd kha nang tfch tu rdi lay lan cac mam benh nay. Mot phan do vai ngay nay da dugc the bang nhung do dung mot lan bang cac loai

gia'y dac biet nhu trang phuc cho nhom phau thuat, khan md hay khan lau tay; sau mdi lan su dung, chung dugc dem dot nen da loai tru* dugc mot phan nguy co nhiSm khuan

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ngi vien. Tuy vay, van con mot phan bong bang dugc sir dung khong qua tiet trung hoac da tiet trung nhung bi tai nhiSm van can dugc quan tam.

Day la mot loai vat lieu dugc dua vao benh vien vdi mot the tfch khong Id. Neu mdi giudng benh can khoang 200 lit nude mdi ngay thi mot benh vien nhd cd 200 giudng da

H Ơ

tieu ton het 40m3 va khdi nude nay khong phai da dat tieu chuan nude udng dugc. Ngay

2.2.3. Nude

tai H* Noi, chi tieu sd E.coli/lit luon vugt gidi han cho phep.

TP .Q U

Nude trong benh vien gom nhieu loai theo nhung yeu cau chat lugng khac nhau.

- Nude udng dugc (thudng ggi la nude may) dugc dung rong rai d mgi noi de rua sach cho benh nhan va nhan vien, eg rua dung cu da su dung va nha cua...

ẠO

- Nude mem lam dung mdi dan nhiet (Nude khu khoang neu cd di6u kien).

- Nude da tiet trung de rua tay cho phau thuat vien hay trang rua cac dung cu da qua thude sat trung, de lam am trong cac may ho ha'p, de tham phan than,..

- Nude cat cho cac phong xet nghiem, cho pha thude, cho dan luu rua cac khoang

co the, cho phau thuat noi soi,..

ẦN

Cho den nay tai cac benh vien, va'n d& nude chua dugc quan tam va quan ly dung vdi tam quan trgng ciia no. Xu ly nude de dat tieu chuan theo mdi loai can cd nhirng hieu biet chuyen nganh kem theo nhung thiet bi (cong vdi quy trinh sir dung chat che) va

dudng dan chuyen dung.

2.2.4. Thuc pham

Ó A

Ngudi benh va nhan vien can dugc nuoi dudng hang ngay nen khong the cd benh vien nao lai khong nhap thuc pham vao. Cac thuc pham tuoi song du la loai chat lugng cao van mang nhieu vi khuan lanh tfnh, doi khi ca nhung mam benh tiem an.

Đ ÀN

ÁN

-L

Í-

Thuc pham ngay nay da cd nhirng loai dung dich bom vao dudng tieu hoa de nuoi dudng nhung benh nhan khong tu an udng dugc. Thuc te, day la nhung dung dich cd yeu cau ky thuat nhu cac thude nude nhung lai do ngudi nha benh nhan tu thao tac lay trong nhirng dieu kien rat tam bg. Tai cac nude da sur dung lau nam loai dich dinh dudng theo dudng tieu hoa nay (enteral nutrition), chung dugc coi nhu thude va do khoa dugc pha rdi cap phat theo don.

2.2.5. Nhung vat pham khac

D IỄ

Benh vien con phai nhap vao hang nghin loai vat pham khac nhau theo yeu cau cua cong viec va phuc vu cho sinh hoat. Chung deu cd kha nang mang theo them cac mam benh vao trong benh vien. Ngudi ta da phat hien ra vi co song ngay ca trong thuoc sat

trung. Duy nhat chi cd con idt la giu dugc vo trung trong mgi hoan canh.

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Rdi day, theo su phat trien cua ky thuat y hgc hien dai, chung ta se con tha'y dua vao nhieu loai mdi nhu cac bo phan ca the nhan tao, cac vat cay.. Mdi loai nay lai cd nhung ddi hdi rieng de dam bao ve sinh, vo trung nhung vSn giu nguyen cac tfnh nang du kien. 2.3. Cac chat thai trong benh vien

Cd the chia cha't thai cua benh vien thanh 3 loai: cha't thai sinh hoat, chat thai long

H Ơ

va chat thai ran cd nguy co sinh hgc (Huu hinh va vo hinh).

2.3.1. Chat thdi sinh hoat

TP .Q U

Cac cha't thai sinh hoat cua benh vien bao gom: cac bao bi, cac gia'y td van phong phe thai, cac thuc pham thira, do vai cu rach, cac dd dung sinh hoat bd di.. Do la thai ra tir benh vien nen chung cd the bi nhiSm cac mam benh nhung van dugc xir ly nhu rac

ẠO

sinh hoat ngoai xa hoi.

2.3.2. Cac chat thdi the long

Cha't thai long cua benh vien gom cd nude thai sinh hoat va phan nguy hiem hon la cac benh pham long, cac hoa chat da qua su dung... do dd chu'a dung nhieu nguy co

nhiSm trung hon chat thai sinh hoat. Su lay nhi£m cac chat thai nay cd the gay benh

ẦN

nhung d£ gap nhat la cac benh dudng tieu hoa, tiet nieu, ngoai da.

De dam bao ve sinh moi trudng ngoai xa hoi, cac chat thai long cua benh vien phai

qua XU ly rdi mdi hoa vao he thdng cong cua cong dong. Cho den nay, phan ldn cac co sd chua benh trong nude chua cd he thdng xu ly nay ma van thai true tiep vao cong cua

thanh phd.

2.3.3. Cac chat thdi cd nguy ca ve sinh hoc

ÁN

-L

Í-

Ó A

Day la mot cha't thai khong kem phan nguy hiem ma Bo Y te mdi cd chi thi phai phan loai rieng tir 1999. Chung gom cac vat dung y te da su dung nhu bom, kirn tiem, bong, bang, gae, dng dan luu, tui chu'a, cac chat thai trir cua co the va cac bo phan co the bi cat bd hoac la cac vat tu da dung cua cac phong xet nghiem. Chung la cac khdi huu hinh cd nguy co truyen benh rat cao. Theo quy dinh cua Bo Y te, chung phai dugc

Đ ÀN

phan loai rieng, cho vao cac tui cd mau quy dinh rdi dua di thieu thanh tro rdi mdi do ra bai rac cong cong.

D IỄ

III. NHUNG PHUONG THlfC TRUYEN BENH TRONG CO SCJ DIEU TRI

Khi cd nguon benh va ngudi cd the lay benh phai cd mot phuong thurc lan truyen thi mdi xay ra dich benh. Chung ta can hieu biet ve cac phuong thuc nay thi mdi cd dugc tinh trang ve sinh huu hieu.

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MOI TRl/CJNG BENH VIEN - Nha va do dung

- Khong khf - Nude

- Do vai

H Ơ

- Ngudi de'n tire thdi - Cac chat thai

TP .Q U

y/L

NGUOI BENH

ẠO

- Nguy co nhiem

Cong tac dieu tri va

khuan cao.

san sdc

- Benh hgc.

ẦN

- The luc ban than.

- Tuoi, gidi tfnh.

Ó A

NHAN VIEN BENH VIEN

vien

Í-

Hinh 3.2: So do nguy co nhi£m khuan trong benh

-L

3.1. Truyen benh qua khong khi

ÁN

Con dudng truyen benh qua khong khf da dugc biet tir hang nghin nam qua va da dugc chumg minh ia cd that. Khi nghien cuti ve nhiem trung cheo noi vien (nosocomial infection), cd tac gia da danh gia tdi 10% cac trudng hop la theo dudng khong khf, nhat

Đ ÀN

la d cac budng benh dong ngudi kieu cu.

Bui chura cac vat the ran va nude nhiem bfo chfnh la nguon lay truyen benh qua

khong khf. Cac hat bui nhd hon 0,2|am cd the mang theo virus con tir 0,5jnm cd the7

D IỄ

mang theo vi khuan va bao tu.

Tiec thay, khong khf la mdi trudng song cua mgi chung ta, no tham nhap dugc tdi mgi noi va ngan chan dugc su tham nhap cua khong khf bi nhiem chi that su huu hieu vdi nhung phuong thirc dong bd, hien dai va rat ton kem.

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H Ơ

Con ngudi hit thd khong khf chung nhau, tiep xuc vdi nhau, san sdc lln nhau do dd lam lay benh sang nhau ma ban tay la mot tram trung chuyen ldn nhat. Bd mon vi sinh cua Dai hgc Y khoa Ha Ndi da dieu tra va thay tren ban tay mod rira xa phong thdng thudng con cd tdi hon 40 loai vi sinh vat ca lanh tfnh lan gay benh. Vao giua the' ky 19, bac sy Schemeillweizt ngudi Hungary da de ra viec tay trung tay ciia ngudi da de nen da ha ty le nhiem trung hau san tu 45% xudng chi con 15%. Qua 2 vf du nay, chiing ta thay

3.2. Truyen benh gitfa nguoi vol ngudi

ban tay la mot cau ndi lay benh chfnh.

Ban tay cam, nam cd the bi dfnh them vi khuan rdi lam lan toa ra noi khac. Trong

TP .Q U

cac co sd y te', nhan vien di gang di each ly la mot sir can thiet khi phai tiep xuc vdi

ẠO

ngudi benh hay benh pham. Cac cura di cua khu vuc cd yeu cau ve sinh cao can thay tay nam bang mot co ca'u md khac, cac vdi nude khong dung tay van la nhirng dieu giup cho ban tay ft phai tiep xuc.

Con ngudi ta song trong mdi trudng tu nhien da luon cd cac mam benh va trong co sd dieu tri, sd mam benh con tap trung hon; tuy nhien chiing phai xam nhap vao co the thi mdi gay benh dugc. Dudng xam nhap cua mam benh vao co the ngudi cd the la:

3.2.1. Nhung vet thuang ha

ẦN

Da va niem mac la mot hang rao bao ve bao phu khap be mat cua co the. Khi hang rao nay bi thung cd nghla la bi mot ton thuong, mam benh se xam nhap de dang. Trong vet thuong ho, ngudi ta da may nhieu loai mam benh nhung chu yeu la cac tu cau va true khuan. Ddi khi, ngudi ta gap ca vi trung yem khf.

3.2.2. Du&ng ho hap

-L

Í-

Ó A

Niem mac dxxcfng ho ha'p cd churc nang ngan can cac van bui trong khong khf hit vao qua dd giu cho he ho hap dudi dugc vd khuan. Chuc nang nay dugc thuc hien bdi cac nhung mao va te' bao tiet ra dich nhay. Churc nang nay khong dugc dam bao khi su xam nhap vugt qua gidi han hay bi lam ton thuong trong mot sd thu thuat nhu hut ddm, dat dng ndi khf quan hoac cho thd oxy nguyen cha't keo dai.

ÁN

3.2.3. Dudng qua da

Khi tiem truyen hay rach da, ldp bao ve nay bi pha thung, ta cd the coi nhu mot ve't

Đ ÀN

thuong hd nhd va mam benh tir dung cu tiem truyen khong dugc khu trung tot cd dieu

D IỄ

kien de xam nhap cac to chire ben trong.

Viec su dung cac dung cu tiem truyen da tiet trung san va chi dung mot lan da lam giam dang ke ty le nhiem trung d day. Tai bien nhiem trung chi con xay ra do thao tac khong diing. Nhiem trung do dat dng dan luu van con. Nguyen nhan ciia tai bien nay phan nhieu do lan toa cua vi khuan d gan diem dat. Mot dieu can nhd la ngudi benh khong con sire de khang tu nhien nhu ngudi lanh nen de bi ton thuong do hau qua cua cong tac ve sinh tdi. 43

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IV. CHIEN LI/0C CONG TAC VE SINH BENH VIEN

Cong tac ve sinh benh vien la mot cudc dau tranh lien tuc chdng nhiem trung cheo trong ndi bd va chdng nhiem trung giua benh vien vdi mdi trudng xung quanh.

ngudi nam vien bi nhiem trung benh vien mac du dieu kien ve sinh cua hg tot hon d

H Ơ

chiing ta nhieu.

6 nhieu nude tien tien, nhieu tac gia da nghien curu va dua ra con sd dang sg la 10%

Cudi nam 1999, Bd Y te da cd chi thi cho cac benh vien thanh lap phong chdng

nhiem trung. Do la mot budc tien dau tien de the che hoa cong tac ve sinh benh vien. De

TP .Q U

lam tot cong viec nay, mdi co so dieu tri can cd mot chien luge lau dai. Cd the' nhu sau:

4.1. Tang ctfcmg huan luyen, giao due nhung hieu biet ve ve sinh va y thirc giOr gin ve sinh chung cho moi nguoi trong benh vien

ẦN

ẠO

Viec huan luyen va giao due la mot bien phap cd the ap dung d mgi co" sd dieu tri theo dinh ky va nhat la vdi cac nhan vien mdi. Dieu nay cd ve la thira vi cac nhan vien y te deu da dugc hgc ve ve sinh dich te co ban nhung trong benh vien con nhieu ngudi lam nhieu nghe khac. Ban than nhan vien y te cung quen di kha nhieu kien thtic va mdi co sd, mdi cong viec lai cd mot yeu cau ve sinh rieng. Khi cd hieu biet hon, mdi ngudi se xu sir cd y thirc hon, tu tranh cho minh bi lay benh va tranh lam lay benh hay vay ban ra

xung quanh.

4.2. Xay dung cac quy trinh ve sinh cho moi khau trong benh vien va kiem tra viec

ap dung chung

Mdi co sd, mdi khau cong tac cd cac dieu kien va yeu cau ve sinh kha da dang. Xay

Ó A

dung cac quy trinh ve sinh cho tung noi, tirng viec la the hien cac cong viec va yeu cau ve ve sinh cu the nhu ve sinh tay cho y ta khi thay bang, ve sinh budng benh, ve sinh budng mo, ve sinh dudng giao thdng trong benh vien.. Budc dau, cac quy trinh se dugc

Í-

vie't theo dieu kien vat chat cu the7 vdi y thirc trach nhiem va hieu biet cao nhat. Sau mot

-L

thdi gian ap dung, chiing se dugc soat xet lai va nang cao theo dieu kien mdi.

ÁN

Quy trinh ve sinh la mot van ban hudng dan thuc hien de dat mot ke't qua theo du

kien. Vf du nhu quy trinh lau san budng benh can neu ro tirng budc cong viec de dat ket

Đ ÀN

qua vdi each kiem tra thfch hop. Viec lam ve sinh theo mot quy trinh da dinh se tranh dugc sai sot do tuy tien va cd dugc mot ket qua dong deu. Vdi cac thiet bi, dung cu dugc dung cho nhieu ngudi thi dieu nay cang quan trgng de tranh hien tugng lay benh cheo

D IỄ

giua cac ngudi benh dugc dung chung.

4.3. Cai thien tirng budc dieu kien vat chat va trang bi ky thuat de cong tac ve sinh benh vien ngay mot tot hon

Dieu kien vat chat va ky thuat la mot khd khan rat ldn. Mudn lam tot cong tac ve sinh benh vien, cd mot sd yeu cdu ma hien van la nhirng ton tai rat ldn. 44

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4.3.1. Nhd dieu tri

H Ơ

kien true, ngoai yeu cau nhu mot budng d, no con cd cac yeu cau rieng de cd the9 ve sinh

Cac co sd dieu tri d nude ta phan ldn da xay dung tu* qua lau, theo mot md hinh quy hoach da bi loai trir. Cac budng benh van con chira qua nhieu benh nhan va thieu cac phuong tien ve sinh ca nhan la mot dieu kien lam cho de bi nhiem trung cheo ndi vien. Mot budng benh hien dai chi gianh cho 1 - 2 giudng vdi cac trang bi ve sinh lien ke. Ve va tay trung de dang nhu tudng va san cd be mat chiu dugc thude sat trung. Yeu cau nay

con kem theo sir dong bo tir hanh lang, cua vdi giudng benh de van chuyen benh nhan de

TP .Q U

dang. Cac do dung bang gd cung bi loai tru* do be mat de bi tha'm.

Trong benh vien, cd mot sd khu vuc cd yeu cau rat cao ve xay dung nhu khu md, do

ẠO

de, xet nghiem vi sinh, X quang.. Mdi khu nay cd mot yeu cau rieng de each ly theo phan cap sach hay tranh anh hudng ra ben ngoai. Yeu cau ve kien true nay con lien quan chat che vdi viec lap dat cac trang thiet bi lam viec va bien phap dam bao ve sinh, tay trung.

4.3.2. Cac trang thiet bi ve sinh vd khvctrung

Cac benh vien phai cd mot khu vuc xu ly chat thai ran va long rdi mdi dua vao he thdng cong cong ngoai xa hdi.

ẦN

Day la nhung trang thiet bi can thiet de lam tot cong tac ve sinh nhung cung tranh viec lay lan mam benh, dong thdi cai thien dieu kien lao dong cua ho ly. Do la cac may hiit bui, may eg rua san thay cho each dung choi va khan lau con kha pho bien hien nay; may rua dung cu, ngoai cac ndi hap, tu sa'y ... da cd. Cong tac ve sinh trong benh vien con can den nhieu trang thiet bi chuyen dung khac nhu may xdng hay phun thud'c sat trung, tu tiet trung bang etylen oxyd, cac trang bi kiem soat mdi trudng...

Ó A

4.3.3. Cac chat sat trung vd tay trung

Tuy noi, tuy chd, chiing ta can cd cac cha't sat trung va tay trung thfch hgp. Viec su

ÁN

-L

Í-

dung chiing sao cho hop ly va hieu qua can van dung nhieu den su hieu biet ve hoa dugc de tranh hien tugng khang thude cua cac vi co theo quy luat quay vdng hay ket hop.

V. M0T SO CAC KY THUAT CHINH VE VE SINH BENH VIEN

D IỄ

Đ ÀN

Cong tac ve sinh benh vien la mot cong viec ldn, hien dien trong mgi hoat dgng. No ddi hdi nhung kien thtic sau rong, nhirngphuong tien chuyen dung cho tdi nhung thao tac rat thdng dung nhu lau, quet trong ddi song thudng ngay. Nhung ky thuat nay dugc chia thanh 4 nhom chfnh.

5,1. Loai bui va rac

Day la ky thuat don gian nha't nhu van lam trong ddi song thudng nhat. Viec quet cd muc dich la loai trtr cac bui va rac bam tren cac be mat, tap hop chiing lai rdi do den chd

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quy dinh. Ky thuat nay chi loai dugc cac bui ldn nhung lai lam van len cac bui nhd va khong tac dong dugc tdi cac khe, ngach.

Trong khi chiing ta van con phai quet, can chgn loai choi thfch hgp, quet nhe tay di

han che tung bui va quet nuong theo chieu gid. Day la mot ky thuat can loai tru* va thay dan bang cac may hut bui hull hieu hon.

H Ơ

5.2. Lau

Lau la mot thao tac nham loai ban khdi mot be mat. Cd the' dung mot vat xdp khd

TP .Q U

hay tam mot chat long thfch hop de lau.

ẠO

Yeu cau ciia thao tac lau la loai het ban nhung dong thdi khong di ban tir chd nay sang chd khac. De dat yeu cau nay, can lau theo mot chieu. Vdi cac vat ldn, phai lau tir tpen xudng, tir trong ra ngoai. Lau tren co the' (sat trung da, lau vet thuong) thi phai lau theo dudng xodn de tirtam lau dan ra ngoai.

H ẦN TR Cach lauxo^ndc

Hinh 3.3. Cach lau

Í-

Ó A

Cach lau song song

ÁN

-L

Tuy theo muc dfch lau, ta cd the tham vao khan, gae hay bong cac cha't long thfch hop nhu cac dung mdi nude hay huu ca, chat sat trung hay tay trung. Cac chat long giup lam sach hoac diet khuan tuy loai sir dung. 5.3. Rira

D IỄ

Đ ÀN

Rua la mot thao tac lau, quet ket hop vdi mot dong chat long de keo di cac chat ban. Cung co the dung mot vdi phun nude cd ap luc de tang hieu lire rira. Nude cung la cha't long thudng dung nhat de rua tir nha cira, xe curu thuong cho tdi cac do vat nhd khac vdi yeu cau la loai het di cac cha't ban du kien. 5.4. Tiet trung

Chiing ta van thudng hie'u tiet trung la mot qua trinh nham diet net cac vi co song trong mot pham vi nhat dinh. Vdi nhirng phat hien mdi ve vi sinh, muc dfch nay rat khd

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dat dugc. Thuc te, To chirc Y te' The' gidi (WHO) da cho mot khai niem thay doi "la sir bat hoat hoac giam thieu cac vi sinh vat song tdi mure cd the chap nhan dugc bang mot qua trinh thfch hgp."

H Ơ

sir xam nhap cua mSm benh vao co the mot each vd tinh nhung day cung lai la mot khau con ton tai nhieu so hd ma chiing ta se khac phuc dan vdi nhirng thanh tuu mdi ve khoa hgc va ky thuat. Ky thuat xet nghiem vi khuan con nhieu so hd, khd khan nhu phai chd

Ky thuat tiet trung la mot khau quan trgng trong quy trinh chua benh nham loai trir

nhieu ngay mdi cd ket qua va khong the thu cho mgi vat pham trong me tiet trung.

TP .Q U

Trudc mat, chiing ta can xay dung cac quy trinh tiet trung theo het kha nang va triet de' tuan thu chiing de dam bao cac ke't qua da dugc tham dinh. 5.4.1. Ngdm

ẠO

La thao tac de ngap dd vat vao mot dung dich sat trung theo thdi gian quy dinh.

Trudc khi ngam, cac do vat phai dugc rua sach va lam khd. Sau thdi gian ngam, chiing phai dugc trang he't dung dich sat trung bang nude vd khuan, lam khd trong dieu kien vd khuan rdi mdi dong gdi, bao quan chd sir dung.

ẦN

5.4.2. Phun

La thao tac rai len be mat can tay trung mot ldp rat mong dung dich sat trung. Mudn phun deu va nhanh, can dung cac bom phun de dinh hudng cac giot dung dich len cac be mat nhu tudng, san, khoang benh nhan cua xe ciru thuong...

5.4.3. Xdng

La thao tac lam bde hoi mot chat sat trung sao cho lap day mot the tfch can tay

Ó A

trimg trong mot thdi gian theo yeu cau.

Day la mot ky thuat da ap dung tir thdi lich sir co dai va chi cd the ap dung cho cac

-L

Í-

khoang km de giir dugc ndng do thude sat trung trong thdi gian can thiet. Ky thuat nay cho phep tiep can vao mgi ngdc ngach nhd nhat nhung can luu y den tuong tac cua chat

ÁN

sat trung va cac dd vat.

Đ ÀN

Ky thuat nay hien da phat trien va md rong ra cho cac vat tu y te' su dung mot lan. Gang, bom tiem, dng dan luu, vat lieu thay the'., deu dugc xdng etylen oxyd do khong sir dung nhiet nang va tiet trung dugc cac vat tu nay trong cac tui dong san chd sir dung.

D IỄ

5.4.4. Bite xa

Trong cac co sd dieu tri, mot sd noi con dung buc xa tia cue tim (U.V.) trong pham vi rat hep va khong bi vat can theo dudng thang tir nguon. Tia gamma cd tac dung ra't tot do kha nang dam xuyen cac vat lieu phi kim loai nhung khd ap dung do ddi hdi cac thiet bi phat tia va phuong tien bao ve cho xung quanh. Do vay, day la mot phuong phap chi thay trong cac co sd cong nghiep.

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5.4.5. Tiet trung bang nhiet ndng

Dung nhiet nang de tieu diet cac vi ca la mot phuang thurc dugc biet tir lau va chi ap dung dugc cho cac vat lieu chiu dugc nhiet do can thiet.

Nggn lira den con cd the dat 400 - 450 °C va no la phuong tien tiet trung don gian

H Ơ

nhat nhung cung nhieu nguy co pha hong nhat. Dot tiet trung thudng dung cho cac vat

5.4.5.1. Dot

dung nhd bang kim loai hay thuy tinh.

TP .Q U

Day cung la mot phuong phap rat triet de vdi cac chat thai cd nguy ca sinh hgc cua benh vien nhung can lam trong cac Id thieu cd kha nang dat tren 1000 °C. Ld thieu la mot phuang tien tiet trung rat can thiet cho benh vien de chan durng mot con dudng lay

ẠO

benh ra ngoai xa hdi. 5.4.5.2. Say

Ngay tir 100°C, oxy cua khf trdi da oxy hoa manh protein cua vi sinh vat lam cho chiing bi diet nhung de dat hieu qua cao, can say dnhiet do tren 160°C.

ẦN

- Nhiet dd tren 140°C trong ft nhat la 4 gid.

Mirc say tiet trung dugc quy dinh nhu sau:

- Nhiet do tren 160°C trong ft nhat la 2 gid 30 phut. - Nhiet do tren 180°C trong ft nhat la 0 gid 30 phut.

Khi say, chiing ta can nhd la khong khf truyen nhiet rat kem nen chi tfnh thdi gian khi vat say dat nhiet do quy dinh va dong gdi trong cac vat lieu cho phep thdng khf qua. Say la phuang phap tiet trung bang nhiet khd va thudng ap dung tren cac do vat

Ó A

bang thuy tinh khong can do chfnh xac cao.

5.4.5.3. Hap

-L

Í-

La phuang phap tiet trung bang nhiet do ket hop vdi do am bao hoa. Day la mot qua trinh hoa hgc phdrc tap lam thuy phan va bien tfnh protein ciia cac vi ca song

Nhiet do (°C )

21°C

125°C

Thdi gian ly thuyet (phut)

Thdi gian thirc te (phut)

134°C 0,5 10

D IỄ

Đ ÀN

ÁN

Bang 3.1: Tuang quan giua nhiet do vd thdi gian hap (phut)

Hap la mot phuang phap tiet trung dugc ap dung rong rai va mudn thuc hien thi can cd mot ndi hap. Thao tac hap can xay dung nhung quy trinh rieng cho tirng loai vat lieu,

each sap xep va tai trgng mdi me hap. Mdi quy trinh rieng deu dugc xay dung tren ca sd thuc nghiem sao cho dam bao cac yeu cau sau:

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Xa het khong khf ton dgng trong budng hap de dam bao chi sd cua ap suat la tuang duang vdi nhiet do.

Thdi gian va tdc do tiep nhiet: phai cd bien phap de khang dinh vat ha'p da dat nhiet do quy dinh d mgi khu vuc trong budng hap. Thdi gian duy tri nhiet do tiet trimg (tdi thieu la 121°C trong 10 phut).

H Ơ

Thdi gian va phuong thirc say khd vat hap.

Cach lay vat hap ra, de ngudi ma van dam bao khong bi cac vi co tai xam nhap.

TP .Q U

Phie'u ghi tien trinh hap la mot chumg tir quan trgng de9 danh gia chat lugng me ha'p cung vdi xet nghiem do vd trung cua vat ha'p (Tin cay nha't la phie'u tu ghi cua ndi ha'p theo lap trinh).

Phuang

Phuang tien

Thai gian

Nhiet do

Chuy

Vat lieu

Bat lai

> 400 °C

Say

> 160°C

> 150 phut

Kim loai

Th6"i

>180°C

> 30 phut

Thuy tinh

nhiet do

Kim loai

Thieu dot

phap Nhiet kho

ẠO

Bang 3.2: Tom tat ve cac phuang phap tiet trung.

Ha'p

ẦN > 10 phut

>121°C

> 5 phut

x6ng

Tia gamma

thuoc

thira

Khong diet bao

Kim loai, vai, -Xa het khong khi

virus

thuy tinh, cao ton dong.

Nhieu

cac

loai - Thdi

chiu nhiet do

tir

quy

gian dat trinh,

nhiet do.

- Say kho.

phai

say ky, de tai

nhiem

khi lay ra 4-8gio r6i xa

Vat lieu khong

Dong

> 50 gia

chiu nhiet

PE han kin.

tui Khi doc, thoi

gian dai.

Chi a quy

Vat lieu phi kim loai, kh6ng chiu nhi6t

vao

mo lan .

Đ ÀN

ÁN

Bite xa

-L

etylen oxyd

Tuy

the tfch cua

Khong

Ó A H

Buong

Í-

Xong

dat

nhan

su,

>134°C

gian

vat sa'y

100 °C

Luoc

Nhiet &m

Thuy tinh

VI. CAC CHAT SAT TRUNG VA TAY TRUNG

D IỄ

Theo To chirc Y te' The' gidi (WHO), sat trung la mot thao tac vdi ke't qua turc thdi loai trir, tieu diet hay tire che cac vi co song tren be mat mot co the song con khir trimg la thuc hien tren be mat cac co cha't tro. Tir khai niem co ban nay, chiing ta se chgn lua nhung cha't thich hop theo muc dich sir dung.

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Bang 3.3: Mot so chat tay trung chinh Nong do toi thieu ire che (mg/1) Pseudomonas

pneumoniae

aeruginosa

aureus

Klebsiella

Escherichia coli

1250

2500-5000

2500

Chlorocresol

625

1250

625

a-phenylphenol

100

1000

500

Hexachorophen

0,5

250

12,5

Triclosan

0,1

>300

Hexetidin

0,4-12,5

100-300

64-125

Chlorhexidin

0,5-1

5-60

Chlorure de benzalkoni

0,5

250

Cetrimid

64-128

Thiomersal

0,2

Nitrat phenyl mercuric

0;1

1-5

N Ư

N Y

TP .Q U

ẠO

>10000

5-10 32 16

0,5

ẦN

H Ơ

Alcool phenylethylic

Staphylococcus

Chat tay trung

6.1. Cac hop chat phenol

Cac hop chat phenol dugc dung de sat trung va khu trung bdi I. Lister tir 1867 tai Anh. Chiing tac dung bang each lam bie'n tfnh protein va mang nguyen sinh cua cac vi co. Tuy theo ndng do, chiing cd tac dung diet trung hay can trung. O cac ndng do rat tha'p, chiing

Ó A

chi lire che cac he thdng men con tur tren 0,5% thi mdi cd tac dung diet trung.

Í-

Hop chat phenol la nhung chat it tan trong nude va thudng phd'i hop vdi cac xa phdng kiem. Chiing it bi anh hudng bdi su cd mat cua protein nhung lai chiu anh hudng

-L

nhieu cua pH (cd tac dung manh nhat d pH thap hon hay bang vdi pKa).

ÁN

Trong mot sd Dugc dien da cd cac hgp cha't phenolic va din xua't nhu: cresylol, phenol, etyl parahydroxybenzoat, metyl parahydroxybenzoat, propyl parahydroxybenzoat, gaiacol,

para-chloro metacrelol, diclorophen ..

Đ ÀN

6.2. Cac hop chat biguamid

D IỄ

Chat dien hinh cho nhom nay la chlorhexidin cd tac dung trung hoa cac dien tfch am rdi lam dao dau dien tfch tren be mat cac vi co. Su ha'p thu cua no len te' bao dien ra

nhanh va tuy thude vao ndng do su dung. No lam bien tfnh mang te" bao rdi phan huy kem theo nhirng thay ddi ve tfnh ky nude cua vi khuan. O ndng do thap (20-50 mg/lft), chlorhexidin gay ton thuong mang te' bao keo theo thoat cac thanh phan cua nguyen sinh chat nhung khi d ndng do cao (>100 mg/lft), nguyen sinh chat bi ke't vdn.

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Chlorhexidin dugc dung ra't rong rai de sat trung tren co the, tir rua tay cho phau thuat vien hay tam cho ngudi benh cho tdi xiic mieng nhung khong dung tren niem mac khac va cho phep dung lam chat bao quan d ndng do tdi da la 0,3%.

H Ơ

Cac anilid la cac chat sat trung cd cau triic phenyl carbamid rdi dugc halogen hoa de tang tac dung , tuy nhien do van chua biet ro co che' tac dung nen ra't ft dung cho ngudi.

6.3. Cac anilid

6.4. Cac hop chat amon bac 4

Cac amdn bac 4 la mot nhom cac phan tir cd tfnh cha't sinh hoc ra't khac nhau va

TP .Q U

trong pham vi chuong nay, chiing ta chi de cap den cac hop chat cd tfnh chat khang trung.

ẠO

Ngay tu* dau the' ky 20, cac hop cha't nay da dugc Einhorn nghien ciru ve tfnh chat sat trung. Chiing la nhung hop chat ludng cue. Cue duong than nude cho phep chiing hap phu len cac be mat tro va mot cue ky nude cationic. Tap hop hinh thai nay tao ra cac

tfnh chat dien hoat cationic va sat khuan.

ẦN

Gidng nhu cac chat sat khuan cationic, cac amdn bac 4 ha'p phu len be mat cac te' bao mang dien tfch am, lam trung hoa dien tfch, din den thay doi do tha'm cua mang nguyen sinh rdi nut ra, giai phdng cac chat cd trgng lugng phan tu tha'p cua te' bao lam cho vd hoat cac men hd hap, bien tfnh va ket tua cac protein va acid nucleic. Tfnh chat sat khuan cua chiing chiu anh hudng cua pH mdi trudng (vd hoat d pH < 3,5, tot nhat d pH trung tfnh hay hoi kiem). Chiing bi ire che' tac dung bdi cac chat huu co va nude cting.

Ó A

Tac dung sat trung cua cac amdn bac 4 dugc urng dung ra't rong rai tu* sat trung tren co the, sat trung cac dung cu, nha cua, xir ly nude, lam chat bao quan. Cung chfnh do tfnh da dung va hoat pho lai hep nen viec su dung chiing bi thu hep dan trong cac benh vien.

D IỄ

Đ ÀN

ÁN

-L

Í-

Cac cha't amdn bac 4 hay dugc su dung nha't la cetrimid, chlorua benzalkonium, bromua cethexonium, chlorua cetylpyridinium va mot sd din xua't polyme hoa.

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Bang 3.4:So sdnh nongdp toi thieu diet khuan (MBC) cua Benzaikonium clorid(mgiml) (MBC: Mininal Bactericide Concentration)

^^^^^^

250

125

62,5

31,3

15,6

Tong

102

209

E.coli

Citrobacter spp

Salmonella spp P.mirabilis

Providencia spp

Pseudomonas spp

ẦN

P. aeruginosa

E.coli CIP 54127**

Aeromonas spp

11 1

Achoromobacter spp

Ó A

P.aeruginosaCIPA22**

1 1

00 10

Acinetobacter spp

Proteus indol +

Serratia spp

TP .Q U

ẠO

Enterobacter spp

Klebsiella spp

-•

^^^—^.

H Ơ

Chung*

MBC

17 2

Ghi chii: *: Sd chiing nghien curu

-L

Í-

**: Sd chiing thir nghiem

ÁN

6.5. Cac hgp chat cua clor

Clor va cac hgp chat da dugc biet va dung de sat trung tir cudi theky 18. Nam 1789,

Đ ÀN

Bertholet da tao ra nude Javel rdi vao 1809, A. Labarraque tao ra dung dich mang ten dng. Tai Anh, tir 1827, J. Alcock de nghi dung nude clo de khu trung benh vien, tau thuyen, cd'ng ranh , chuong gia siic va ca tren co the ngudi. Nam 1908, chlorua vdi dugc

D IỄ

dung de khu trung cho nude may d Chicago. Va cudi cung la khi nha du hanh vu tru N. Armstrong dat chan len mat trang trd ve da dung mot dung dich hypoclorid va

iodophore de7 diet cac tac nhan nhiem khuan cd the mang ve tir vu tru.

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Chen nh6m -NH2

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en co

Acid undecylenicGlutaraidehyt

Bie'n tinh mang nguyen smh

03-C2H202-

Hg-Kim loai n3ng

Chen nh6m -SH

03-Isothiazolon

Aldehyt -C2H202

D IỄ

TO ÁN

10 ẦN

Chlorhexidin dac Phenolic d5c Acid va kiem manh

Carbanilamid

Salicylamid Hexetidin

Phenolic

D6ng v<3n n6i nguyen sinh Formol loang

Ó A

Bat hap nang lutmg.

Í-

-L

Vi khuan (+)

TP .Q U

Oxy hoa

Chlorhexidin loang

Alcolnhan thorn

Phenolic-

Am6n 4 va dien hoat-

Bien tinh mang nguyen sinh

ẠO

C: Chitin

A.G. Arabinogalactan G: Glycon M: Mucopeptid O: Oligosaccarit

H Ơ

F.P: Dong luc proton P: Porin E.P: Khoang ngoai nguyen sinh

M.P: Protein don

M.E: Mang ngoai

A.T: Acid teichoic

A.M: Acid mycolic

Chu thich:

Glutaraldehyt

Hinh 3.4: Dich tac dung cua cac chat sat khuan len vi ca

Đ ÀN

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H ++CI"

ẠO

TP .Q U

H Ơ

HOCI

Hinh 3.5: Anh hirdng cua pH len ty le HCIO va CIO

ẦN

Cac hop chat clor sat trung cd the9 la vd co nhu hypochlorid va cd the7 la hihi co nhu*

cac chloramin. Khi d trong dung dich, chung deu tao ra mot phan acid hypocloro , clo nguyen to, ion hypoclorid va tap hop nay duoc goi la clor hoat tinh.

Ó A

Co che tac dung cua chiing tren te bao chua duoc biet ro va theo ke't qua diet khuan, nhieu tac gia cho rang chung tac dung true tiep len nguyen sinh chat va he thdng men, vd ken bi huy hoai. Chiing cd tac dung tdi uu d khoang pH = 5. Tac dung cua chung tang theo nhiet do (tang 2 lan khi nhiet do tang them 10 °C). Chung bi han che tac dung

Í-

bdi amoniac, nitrat, nitrit va cac chat huu co.

-L

Cac hop chat vd co cua clor hay dung la: khf clor, nude clor, cac hypoclorit (dung dich Javel, Labarraque, Dakin..). Khf clor duoc dung nhieu de sat trung nude may vdi

ÁN

ham luong du dudi 0,2 ppm.

D IỄ

Đ ÀN

Cac hop chat huu co cua clor hay dung la cac chloramin, Dichloramin, Halazon.

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Bang 3.5: Nong dp vd thdi gian tiep xuc vdi nu&c Javel a cac dp pha loang khac nhau

1/100- 1/200

5- 10

1/50

5- 10

1/3- 1/10

10- 15

1/20

Khu trung san nha benh vien +

Bon rira, bdn ve sinh

1/10- 1/20

Khu virus (HIV, viem gan)

1/8- 1/20 1/4-1/1

15-20 >20

ẠO

Khu trung san nha d

12° Clor

chat hiru ca

Thdi gian de tiep xuc (phut)

H Ơ

Do pha loang

Nhiem nhieu

TP .Q U

Muc dich

6.6. Iod va cac dlin xuat

Iod duoc tim thay tir dau the ky XIX va den giua the' ky nay ngudi ta da dung cac dung dich Lugol, con iodde sat trung. Sang the' ky XX tac dung sat trung ngoai da cua chung da duoc khang dinh. Nhung phai tdi 1950 khi polyvinylpirolidone iod ra ddi mdi

ẦN

tao duoc budc nhay vot trong su dung .

He sd hoat tinh khu* trung

cua dung dich

Yeu to khur

Ó A

40 Yeu to khu

Í-L

ÁN

Tac dung khu trunj 30

D IỄ

Đ ÀN

0,1

0,5

2,5

Hinh 3.6: Lien quan giua yeu to khu cua S.aureus va tac dung khu trung (DACS: Disinfection Activity Coefficient) ciia dung dich PVP-I theo nong do

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H Ơ

tac dung len cac men hd ha'p va cac protein, chen su van chuyen dien tir, gay ra cac ton thuong khong phuc hdi cho cac vi co. Co che tac dung tuy vay, van chua dugc biet ro mac du nhan xet thay tac dung diet khuan dien ra rat nhanh. Cac che pham iod vd co sat trung hay dung la: Con iod, dung dich Lugol... Che pham iod huu co sat trung dugc dung rong rai nhat hien nay la polyvinyl pyrolidon iod (PVP-I). Che pham nay dugc su dung d dang dung dich, xa phdng, vien

Iod chi cd tac dung sat trung d dang tu do. Chung tha'm rat nhanh vao mang te' bao,

dat phu khoa, thude md. PVP-I cd tac dung tot nhat d ndng do 0,1 den 1% iod ket hop va dugc dung rong khap co the': da lanh hay ton thuong (nhat la vet bong), niem mac (rua

TP .Q U

cac khoang cua co the nhung khong dugc dung tren tre dudi 10 thang tudi, phu nu cd thai hay dang cho con bu).

Co tac dung vdi

Uc che do

Dung thuc te

Nhan xet

Nude oxy gia

Hop chat chlor

Dung dich

+ +

Tiet trung

+ +

Tay trung Sat trung

Dung dich lugol

PVP-I

Dan xuat

ÁN +

Sat trung

H ±

Đ ÀN

Tay trung

N D IỄ

Ethanol, Propanol

Tay trung

Cho khoang kin, Ngam dung cu

pH tdi uu 7 +

Tay trung

Thuong de dot

Sat trung

Dung rieng hay nhu dung moi.

pH tdi uu 5-7

Phenol

Di, Tri-cloro

de bi an mon,

Con

Methanol

Tac dung oxy hoa

pH tdi uu 7

Glutaraldehyd

clor

pH tdi uu 5-7 +

Í+

12°

38,04g/l 1,5°clor- 5g/l

Sat trung be mat

pH tdi uu 5-7

Ó A

Con Iod

-L

Hop chat Iod

t°<100°C

Rua

Dakin

Formol

Niroc Javel

ẦN

Oxyd etylen

Chat oxv hoa

aldehyd

Ten chat

ẠO

Bang 3.6. Cac chat khu: trung thdng dung

Tay trung

Thuong + dien hoat

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Biguamid

pH tdi uu 5-7

Chlorhexidin

Tay trung

Thuong + dien hoat

Lam thorn

Phoi phenol

hop

H Ơ

Cac loai

Tinh dau

* Ghi chu:

1: Vi khuan gram duong 2: Vi khuan gram am

6: Virus

3: B.koch

7: Nude cumg

4: Bao tu

8: Chat huu co

ẠO

TP .Q U

5: Vi nam

ẦN

VII. KET LUAN

Ve sinh la mot hanh vi ban nang cua the gidi dong vat. Ngudi ta da biet lam ve sinh tu* thdi thugng co. Qua rut kinh nghiem rdi tim ra mot sd ky thuat co ban va vdi su tien bd cua khoa hoc va ky thuat, chung ta hieu dan ve can nguyen, ve co che', tim ra cac

Í-

Ó A

phuong tien de cong tac ve sinh cd hieu qua hon. Trong benh vien, mot noi tap trung cac mam benh ldn nhat cua xa hdi, cong tac ve sinh gdp mot tac dung rat ldn vao ket qua dieu tri. Ve sinh khong don thuan la quet don, lau rua. Ve sinh la mot cong viec cd y nghia bao trum len moi hoat dong cua benh vien tu* phdng ngira sir xam nhap cua mam benh tir ngoai vao, ngan ngura su lay lan cheo trong ndi bd nham dam bao an toan sinh hoc cho moi ngudi tham gia trong hoat dong cua benh vien va ngan ngira su lay lan tir

-L

benh vien ra xa hdi ben ngoai.

ÁN

Trong chuong nay, chung ta khong thay cac sd lieu thdng ke ve tac hai cua ve sinh

D IỄ

Đ ÀN

kem do chua cd dugc. Chung ta cung khong thay mot md hinh, mot tieu chuan hay mot quy trinh mSu nao mac du da cd benh vien thuc hanh tot. Chung ta chi thay cac nguyen ly, nhirng quan diem va ky thuat chinh de tijf do suy nghi va tu dat ra nhirng bien phap, nhung quy dinh va quy trinh thich hop nhat. Cong tac ve sinh benh vien la mot viec lam hien dien trong moi hoat dong cua moi co sd dieu tri va la mot su can thiet trong mdi thao tac. Su thanh cong cua no le thude vao y thuc va su hie'u biet cua mdi ngudi.

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Chiromg IV

DICH TIEM TRUYEN TINH MACH

H Ơ

MCJDAU

Dich truyen la danh tir chung dung de chi cac dang dich the (dung dich, nhu dich) cd dung tfch ldn, thudng dung de dua vao tinh mach, do do con goi lathude tiem lieu ldn.

TP .Q U

Cd nhieu loai dich dugc sirdung de truyen tinh mach vdi nhieu muc dfch khac nhau. Trong chuyen de nay chung tdi chi de cap den 2 loai thdng dung sau:

* Loai dung de bdi phu the tfch dich luu hanh d mach mau nham phuc hdi luu lugng

ẠO

tuan hoan khi bi mat mau, bdng nang, tut huyet ap do gay me, do sdc, do suy tim cap hoac de pha loang mau vdi nhung muc dfch khac nhau.

* Loai dung de cung cap cac hop phan dinh dudng co ban trong nuoi dudng nhan

tao cho benh nhan dm nang khong an udng dugc.

ẦN

Muc dfch chfnh cua chuong nay nham cung cap nhung kien thirc co ban ve mot sd dang dich truyen thdng dung, giup cho cac dugc si cd co sd trong lira chon thude theo dung muc dfch su dung ma khong di sau vao hudng dan su dung vi phan sau nay thude

phan kien thirc cua cac nganh chuyen sau.

I. CAC DUNG DICH DE BU DAP DICH THE LUtJ HANH

Ó A

Khi lugng dich the luu hanh trong long mach khong du se dan den hau qua tut huyet ap va qua trinh van chuyen oxy den cac to chirc bi ngung tre . Do cung chfnh la nguyen

nhan din den tir vong neu khong phuc hdi kip thdi luu lugng tuan hoan.

Í-

Viec quyet dinh lua chon loai dich truyen nao phai can cu* theo tinh trang thay ddi

Đ ÀN

ÁN

-L

huyet dong hoc. Cac loai dich truyen dung cho nhung trudng hgp nay cd the la cac dung dich dien giai hoac dung dich keo de giu can bang ap suat tham tha'u va ap luc keo cho mau. Cac dung dich chira don ddc glucose khong dugc dung vdi muc dfch nay vi glucose phan tan tu do trong tat ca cac khu vuc nude cua co the ca ndi va ngoai bao, di qua thanh mach de dang nen khong giu dugc lau trong long mach.

D IỄ

Cd hai nhom dich hay dung nhat la cac loai dung dich chua mudi khoang (hay con goi la cac dung dich tinh the) va cac dung dich keo (tu nhien va nhan tao). 1.1. Cac dung dich mudi khoang

Cac dung dich loai nay chu yeu bu nude va mot sd cha't dien giai nhu Na+, K+, Ca++, CI...

Cd 5 loai hay dung dugc neu trong bang sau:

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Bdng 4.1. Cac loai dung dich tinh the debit dap dich luu hanh

Ca++

NaCl 0,9%

154

Ringer

147

156

Ringer- lactat

130

112

1,82

154

1.709

NaCl 20%

3.419

5,7

308

309

280

5,1

3.418

6.836

ẠO

NaCl 10%

mOsm/1

TP .Q U

Lactat

K+

Na+

ASTT

dung dich

H Ơ

Nong do ( mmol/I)

Loai

Ghi chu : ASTT la ap suat tham tha'u ( mOsm/ 1) 1 g NaCl = 17 mmol Na+ = 400 mg Na+

1.1.1. Cac loai dung dich dang truang

ẦN

Natri clorid 0,9%

Day la loai dung dich pho bien va re tien nhat, thudng dugc dung de bdi phu nude va trong trudng hop nay thudng phd'i hop vdi glucose 5% (dung dich man ngot dang truong), ngoai ra con dung lam dung mdi pha loang thude khi truyen tinh mach. Dung dich nay re

Ó A

tien nhung nhugc diem la de gay toan mau do lugng ion CI ldn. Nhugc die'm cua dung dich nay la khi truyen qua nhieu hoac qua nhanh de dan de'n ur nude ngoai bao va phu phoi cap; do thieu mot sd chat dien giai nhu Ca++ va K+ nen khong dung de bu dien giai khi rdi

loan; nhung trudng hgp nay thudng dung dung dich Ringer hoac Ringer lactat.

Í-

Ringer lactat (dung dich Hartman)

ÁN

-L

Trong thanh phan cua dung dich nay cd lactat; khi vao co the, lactat se chuyen thanh bicarbonat (neu chirc nang gan tot) va cd tac dung kiem hoa mau khi cd rdi loan toan mau. Ca Ringer va Ringer lactat deu cd chura K+ va Ca++ nen dung tot cho nhirng trudng hgp rdi loan can bang ion.

Đ ÀN

Kha nang phat trien the tfch luu hanh (PTTTLH) nhd: Truyen 1 lit se tang dugc tir 200 den 250 ml, neu mat dich nhieu cd the tang dugc 300 ml; nhu vay can truyen mot lugng gap

D IỄ

3 den 3,5 lan the tfch bi mat. Hon nua the7 tfch tang khong giu dugc lau nen phai truyen lien tuc va dieu nay dan de'n lam phat mudi- nude d khu vuc gian bao, gay phu va nang

hon cd the' gay tang ap luc dong mach phoi ; vi vay chi dung cac dung djch nay de bu cho nhung trudng hop giam the tfch luu hanh ( TTLH ) khong ldn 1dm ( < 1 lit).

Lugng dich can truyen dugc xac dinh theo tinh trang mat nude va dien giai nhung

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tong lugng truyen tdi da khong qua 3-4 lft/24 gid (vdi ngudi ldn) tuc la tuong duong vdi the tfch bi mat « 1 lit.

1.1.2. Cac dung dich uu truang

nhu bdng nang, mat mau tram trong.

H Ơ

Dung dich NaCl uu truong cd kha nang PTTTLH ldn tuong duong vdi dung dich keo khi dua cung the tfch nen bu nhanh dugc the tfch dich bi mat nhung nhugc diem la ap

NaCl uu truong dugc dung de bu CI va bu dap TTLH khi bi mat mot lugng dich ldn

suat tham thau qua cao, de gay phu va tang nguy cochay mau do giam ket tap tie'u cau.

TP .Q U

Cd nhieu mirc ndng do : 1,2 - 1,8 - 3,6 - 7,5 - 10 va 20%.

ẠO

Cac loai dung djch thudng dugc dung de bdi phu TTLH khi bdng hoac mat mau do phau thuat la loai 1,2 - 1,8%. Khi dung nhung dung dich loai nay se giam dugc khoang 1/3 the tfch can truyen so vdi loai dang truong. Tren thi trudng cd san loai 10% va 20%

(ddng dng 10 hoac 20 ml), khi dung pha loang vdi dung dich glucose 5% cho den ndng

do mong mudn.

Dung dich 7,5% dugc dung nhieu hon ca va thudng dung de bu TTLH trong sdc

chan thuong (pha vdi dextran 70).

ẦN

Cac dung dich uu truong cd tac dung gian mach mot sd co quan ndi tang nhu than, tim, tang cirong co bdp co tim, lam giam dugc ty le phu nao va tang ap luc ndi so tot hon

so vdi cac dung dich keo.

Cac dung dich loai nay gay tang nguy co chay mau nen chi dung khi kie'm soat dugc

chay mau va phai than trong vdi benh nhan cd benh tim- phoi.

Ó A

1.2.Cac dung dich keo

Cd hai loai dung dich keo :

Í-

- Loai tu nhien bao gom Albumin

ÁN

-L

Loai nay cd nguon gdc tu* huyet tuong ngudi hoac tir mau rau thai. Truyen che pham nay khong chi tao do keo cho mau ma con cung cap albumin- mot thanh to quan trong

giup chuye'n tai thude va mot sd chat chuye'n hoa cua co the'. Tac dung bu dap TTLH tot nhung rat dat va hiem.

Đ ÀN

- Loai nhan tao bao gom mot so polymer nhu dextran, gelatin hoac HEA.

D IỄ

Nhirng dung dich loai nay cd trong lugng, kich thude va hinh dang phan tir rat khac nhau, nguon gdc cung khac nhau nhung deu cd dac diem chung la cd do keo cao hon nude nen cd the lam tang do keo (do quanh) cua mau, giup giu nude lai trong long mach va duy tri dugc the tfch dich the luu hanh, bao dam cho hoat ddng cua he tuan hoan.

Dac tfnh cua cac dung dich keo la cd trong lugng phan tu (ky hieu PMp) ra't dao

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ddng, do dd cdn goi la dung dich da phan tan. Ky hieu trong lugng phan tu dugc viet ngay sau ten hoat chat de nhan dien dung dich . Thi du :

- Dextran 40 de chi dextran cd PMp = 40.000 daltons.

- HEA 200 de chi HEA cd PMp = 200.000 daltons...

H Ơ

Kha nang lam tang do keo cua mau phu thude cac yeu to sau :

TP .Q U

HEA. Loai mach thang cho do keo ndi tai ldn hon loai hinh cau.

- Hinh dang phan tu: Cd loai cau tao mach thang nhu dextran, cd loai hinh cau nhu

- Trgng lugng phan tu : PMp cang ldn thi kha nang di qua mang (thanh mao mach, cau than) cang khd khan, nhu vay se giu dugc do keo lau hon.

- Dudng kinh phan tu (cp ): cp< 35 Athi phan tu de di qua cau than va nhanh chdng bi

ẠO

dao thai ra ngoai nen kha nang giu ap luc keo ngan.

- Dien tfch cua phan tu : Nhirng phan tu cd mang dien tfch thi khong qua dugc mang lgc d cau than trong khi cac phan tu trung hoa dien lai de qua mang.

ẦN

- Ndng do cua dung dich : Ndng do dung dich cao thi sd phan tu trong mot don vi the' tfch se ldn va do do kha nang giuap luc keo cang ldn. Kha nang lam tang va kha nang duy tri do keo cua mau phai la tong hgp cua cac ye'u

to tren.

Thi du :

- Dextran 40 (D 40) - 10% cd kha nang PTTT tuan hoan ldn hon D 40 - 3,5%

- Dextran 70 (D70) cd trong lugng phan tir ldn hon dextran 40 nhung dung dich

Ó A

D 70 - 6% lai cd kha nang PTTT tuan hoan kem hon D 40 - 10%.

- Dextran 70 - 6% cd kha nang PTTT tuan hoan tuong duong HEA 450 - 6% vi tuy HEA cd trong lugng phan tu ldn hon dextran nhieu nhung ap luc keo ndi tai do

-L

Í-

dextran (mach thang) lai ldn hon HEA (hinh cau).

ÁN

- Kha nang giu ap luc keo cua albumin keo dai hon cac phan tu khac la do albumin mang dien tfch (-) nen khong bi loc qua cau than; su dao thai albumin ra ngoai co

the' phai trai qua giai doan phan huy.

Đ ÀN

Nhung dung dich cd kha nang PTTT nhanh thudng chdng bi dao thai nghla la thdi gian ban thai ra khdi huyet tuong (t 1/2 ) ngan. Thf du : D 40 - 10% cd kha nang PTTT

D IỄ

len tdi 180% nhung bi dao thai 50% sau 2 gid cdn D 70 -6% chi cd kha nang PTTT khoang 1,2% nhung sau 24 gid chi bi dao thai 6%.

Tat ca nhirng dieu tren day cho thay rang viec lira chon che pham rat phire tap va ddi hdi ngudi su dung phai cd kinh nghiem.

Tac dung phu chung nhat thudng gap vdi loai phan tu nay la kha nang gay sdc qua man va di ung.

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1.2.1. Cac dung dich keo thien nhien - Albumin

Nguon gdc cua albumin dugc bao che tir huyet tuong ngudi, sau dd dugc say d +60°C trong vdng 10 gid de diet virus (virus viem gan va HIV). Loai che ttr mau rau thai Albumin cd tir 575 den 600 acid amin vdi trong lugng phan tir (PMp) khoang 56.000

H Ơ

den 69.000 daltons. Dudng kinh phan tir la 35 A; phan tir mang dien tfch (-) nen thdi

cd do tinh khiet cao hon.

gian ban thai dai -1 1/2 ~ 20 gid.

Kha nang PTTT cua albumin ldn so vdi cac loai dung dich khac: Truyen lg

TP .Q U

albumin lam tang dugc 15 den 20 ml TTLH.

ẠO

Loai dung dich 25% (cdn ggi la albumin dam dac) cd ap suat tham tha'u gap 5 lan so vdi huyet tuong binh thudng nen kha nang lam tang the tfch rat ldn - tdi 350% (3,5 lan), loai nay thudng dugc truyen trong trudng hgp mat mau nang hoac bdng nang. Loai dung dich 5% (cdn goi la albumin loang) cd ap suat tham tha'u xap xi huyet

Dang trinh bay cua 2 mure ndng do nhu sau :

lan) va dugc dung de thay the huyet tuong ddng the tfch.

tuong cua ngudi binh thudng nen kha nang PTTT nhd hon loai dam dac (khoang 0,8 - 1,0

ẦN

Biet dugc Albutein 25%, chai 50 va 100 ml - pH = 6,9 ± 0,5. Biet dugc Albutein 5%, chai 250 va 500 ml - pH = 6,9 ± 0,5

Ca 2 loai deu chira 130 - 160 mEq Na+/1.

Ó A

Ngoai chi dinh bdi phu the tfch tuan hoan trong sdc do giam the tfch, giam albumin mau tram trgng, phu trg cho nhung trudng hop phai sir dung tuan hoan ngoai cathe nhu chay than nhan tao hay mot sd loai phau thuat, albumin cdn dugc dung de truyen cho tre

so sinh mdc benh tan mau nham tang thai tru* bilirubin, tranh hien tugng vang da va benh

Í-

Kernicter (vang da nhan).

-L

7.2.2. Cac dung dich keo nhan tao

ÁN

* Dextran

Dextran la polyme cua cac glucose, cau tao mach thang, thudng dugc pha trong

Đ ÀN

dung dich dien giai. Phan tu dextran cd trong lugng rat daoddng . Cd 2 loai hay dugc su* dung la:

D IỄ

- D 40 cd PMp= 40.000 daltons vdi ndng do 3,5% va 10% .

- D 60 (hoac D 70) cd PMp = 60.000 (hoac 70.000 daltons) vdi ndng do 6%. Thdi gian ban thai (ton tai trong ndi mach) khoang 4 gid. Mot so dac diem cua cac dung dich nay dugc torn tat trong bang sau :

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Loai dung dich

D 40-3,5%

D60-6%

Rheomacrodex

Plasmaclair

Hemodex

315

275

300

gap 3,5-4 lan

gap 1,2 lan

gap 1,5 lan

120- 180%

100%

100-120%

mOsm/1

Ap luc keo so vdi huyet tuong

Kha nang PTTT

H Ơ

Ten biet dugc

D40-10%

Bdng 4.2. Mot so loai dextran thudng diing

TP .Q U

Ngoai 3 loai neu trong bang cdn cd dextran phan tir lugng tha'p (PMp= 1.000

daltons) ky hieu la DI (biet dugc Promit) dugc dung de7 ngan ngira phan ting sdc phan ve

ẠO

khi truyen cac loai dextran do tfnh chat hapten cua phan tir nay: Phurc hgp DI-protein ddng vai trd khang nguyen se lien ke't vdi cac khang the cd san trong mau, nhd dd giam dugc cac tai bien khi truyen cac loai dextran cd phan tu lugng ldn.

Do kha nang PTTT qua ldn cua D 40 10% nen neu truyen lieu cao keo dai se de gay suy than cap; trudng hop nay chi gap khi dung D 40 10% - truyen tir 500 de'n 1.000 ml trong nhieu ngay vdi muc dfch chdng ddng mau. Tuy nhien, neu chi thay the' < 10% the tfch luu hanh thi it cd kha nang anh hudng den thdi gian ddng mau.

ẦN

Cac loai dextran deu chdng chi dinh vdi phu nu cd thai do cac tai bien sdc phan ve

nghiem trgng cho ca me va thai nhi. * Gelatin

Gelatin la mot loai keo nhan tao do thuy phan collagen cua xuong hoac da ddng vat, tao thanh cac peptid cua gelatin. Cac dung dich loai nay cd trgng lugng phan tu ~ 35.000

daltons. Gelatin long cd the bd sung ca mot sd chat dien giai vdi thanh phan tuong tu voti

Ó A

dich the ngoai te' bao, dung de tang the tfch tuan hoan khi bi sdc do giam the tfch huyet tuong khi bi bdng hoac ma't mau do chay mau trong chan thuong, tut huyet ap khi gay me...

-L

Í-

Bdng 4.3. Mot so dac diem cua dung dich Gelatin thdng dung Gelatin co cau ndi ure

Biet dugc

Gelafundin

Haemaccel

35.000

30.000

3,5%

Do keo tuong ddi

1,7-1,8

1,7- 1,8

Ap sua't tham tha'u

285 mOsm/1

300 mOsm /l

7,0

7-7,6

ÁN

Gelatin long cai tien

Thong sd

PMp (daltons)

D IỄ

Đ ÀN

Ndng do

Do pH cua dung dich

T 1/2 tir huyet tuong Kha nang PTTT

4-5 gior 100%

2 - 5 gid 100%

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H Ơ

Uu diem cua dung dich gelatin la on dinh dugc the tfch mau sau khi truyen, khong gay gian no qua mure nen it gay qua tai tuan hoan (kha nang PTTT 100%). Kha nang PTTT cua gelatin long chi tuong duomg vdi dextran 40 - 3,5% va thap hon dextran 60 6% va HEA 450 - 6%. Dung dich nay rat ft gay rdi loan ddng mau (chay mau) nhu dextran 40, khong gay suy than nhu dextran nhung lam tang thdi gian mau lang sau khi truyen nen can phai phan loai nhom mau va tfnh tdc do lang mau trudc khi truyen.

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TP .Q U

Cac dung dich nay ft gay tai bien cho phu nu mang thai hon so vdi dextran va tai bien chu yeu ve phfa ngudi me nen khong cd chdng chi dinh vdi phu nu cd thai nhu vdi dextran. Tuy nhien, dung dich gelatin gay phan irng theo kieu phan ve ldn hon nhieu so vdi dextran va HEA, dac biet la cac phan ung d da (nhat la Haemaccel). * Dan chat cua Amidon - HEA

ẠO

HEA la Hydroxy- Etyl- Amidon, cd khi goi la HES (Hydroxy- Etyl- Starch). Day la nhung san pham dieu che tir amidon cd thanh phan la amylopectin- mot phan tu cd nhieu nhanh, chudi day dac, hinh cau. Vao co the chat nay bi men a-amylase cua huyet

tuong thuy phan va ma't hoat tfnh.

ẦN

Do thay the phan tir (DS = Degre de Substitution) la sd gdc hydroxy gan vao cac don vi glucose; thf du DS 0,7 nghla la 7 gdc -OH gan vao 10 don vi glucose. Do thay the cang ldn thi phan tir cang lau bi thuy phan va do dd duy tri ap luc keo keo dai hon (t 1/2

dai).

Trong lugng phan tu cua dung dich rat phan tan: Tir 200.000 den 450.000 daltons. Ndng do dung dich su dung tir 6 - 10%. Loai 10% cd do keo cao nhat nhung tat ca deu thap hon dextran 40 va gelatin cd cung ndng do.

Ó A

Mot sd dac diem cua HEA dugc torn tat trong bang 4.4.

Í-

Bdng 4.4. Mot so dac tinh cua cac dung dich HEA Kha nang

Nong do

T,/2 (gior)

HEA 450

0,7

>24

3,5-7

100

HEA 250

0,5

10%

12-24

4,5- 5,5

150-170

Elohes

HEA 200

0,65

5,7

110-120

HAES-steril

HEA 200

0,5

6% - 10%

3,5-6

100-140

-L

Ky hieu

PTTT(%)

D IỄ

Đ ÀN

Lomol

Hespan

ÁN

Biet dirge

II. CAC DICH THE DUNG TRONG NUOI DUONG NHAN TAO

Co 7 hop phan dinh duong quan trong cdn cung cap cho co thi la glucid, protid, lipid, chat khoang, cac nguyen to' vi luang , vitamin va niroc. Vi&c bu nuac thuang dung 64

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cac loai dung dich tinh the dang truong da neu d phan 1.1. Trong phdn nay chung tdi trinh bay cac loai dich the chura 6 hgp phan ca ban cdn lai. 2.1. Glucid

H Ơ

Glucose la nguon cung ca'p glucid de ddng hoa, re tien nhung nhugc diem la nang lugng do glucose cung ca'p thudng khong du dap umg nhu cau chuyen hoa, dac biet la

100 g glucose cho khoang 400 calo.

loai dang truong. Thf du nhu cau ciia ngudi binh thudng tir 20-30 calo/kg the trong cdn vdi benh nhan mac benh nang thi can tdi 50 calo/kg. The nhung mdi lit glucose 5%

ẠO

TP .Q U

chi cung ca'p dugc 200 calo. Neu dua tdi 3 lft/ngay (the tfch tdi da cho phep) thi cung chi cung ca'p dugc chua day 1/2 nhu cau co sd va 1/5 nhu cau cho benh nhan nang. Vi vay trong nuoi dudng nhan tao thudng phai dung loai uu truong dua vao tinh mach trung tam neu thuc hien nuoi dudng nhan tao toan phan (Total Parateral Nutrition = TPN) . Ngudi ta khong dung glucose cho nuoi dudng qua dudng tieu hoa vi hay gay ia chay.

Luang calo cung cap

Nong do

(calo/1)

Ap suat tham tha'u ( mOsm/1) 280

200

10%

400

15%

600

840

20%

800

1.120

1.200

1.680

2.000

2.800

30 %

Ó A

50 %

560

ẦN

5 %

Glucose

Bdng 4.5. Cac dung dich glucose thdng dung

Chi dinh :

Dung dich dang truong ( 5 % ):

Í-

•

-L

Bdi phu the tfch khi mat nude. Dung dich uu truong :

•

ÁN

Lam dung mdi cho mot sd thude tiem truyen tinh mach.

Đ ÀN

Nuoi dudng nhan tao theo dudng tinh mach

Cap ciru khi ha dudng huyet.

D IỄ

Chdng chi dinh :

Cac dang phu. Tac dung phu :

Vdi dung dich dang truong: Truyen qua nhieu hoac qua nhanh cd the gay ur nude nhugc truong neu benh nhan suy giam churc nang than.

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Vdi dung dich uu truong (ap suat tham tha'u > 800 mOsm/1): Cd the gay hoai tu md neu truyen ra ngoai mach, gay viem tinh mach neu truyen keo dai d cac tinh mach be mat.

Gay giam K+ va Na7 mau .

Ha dudng huyet neu ngumg truyen dot ngdt sau mot thdi gian truyen keo dai.

Nhirng dung dich cd ap suat tha'm tha'u cao, neu dung keo dai phai dua vao tinh

H Ơ

Cach diing:

TP .Q U

mach trung tam qua catheter.

Khong dung nhung dung dich nay cho benh nhan udng vi ap sua't tham tha'u cao cd the gay ia chay.

Neu benh nhan khong dung nap tdt glucose hoac lugng truy6n qua nhieu, cd the them insulin bang each trdn insulin vao dung dich truyen hoac tiem dudi da.

Muc dudng huyet nen duy tri khoang 2g/l . Khi kie'm tra dudng huyet c£n luu y

ẠO

den mot sd thud'c cd the can trd su do glucose trong mau (nhu cac

Cd the phd'i hop them KC1 vdi lugng 0,75 - 3 g/1, dac biet khi cd phd'i hop them

ẦN

cephalosporin..)

insulin.

Tuong ky: Mau toan phan, khdi hong cau, vitamin B12.

- Khi sudung di nuoi benh nhan keo dai, khong nen dung don doc ma nen phd'i hgp

vdi cac hgp phan dinh dudng khac nhu protid, lipid, dac biet la vitamin nhdm B nhu

Ó A

Ngoai viec dung glucose cho nuoi dudng ngoai dudng tieu hoa, cd the' thay bang sorbitol (5%,10%) hoac levulose (5%-10%). Chi dinh va chdng chi dinh gidng

B^PP...

Vdi nuoi dudng qua dudng tieu hoa, cd the7 su dung disaccharid nhu maltose,

-L

Í-

vdi dung dich glucose.

ÁN

sucrose hoac polysaccharid nhu maltodextrin.

2.2. Protid

Protid cd vai trd cung cap cac acid amin di xay dung co the'. Protid cung cd the7 la

Đ ÀN

nguon nang lugng khi can thiet. Nhu cau hang ngay cua benh nhan phu thuoc vao mure

D IỄ

do nang nhe cua benh.

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Bdng 4.6: Nhu cau hang ngay ve protid doi vdi benh nhan Lugng protid can cung cap

Tinh ra nita

g/ kg/ 24 giof

Tre em

2,5

400

Stress nhe

1,2

160

Stress trung binh

1,5

240

> 2,0

320

Stress nang

H Ơ

150

0,8

TP .Q U

Ngudi binh thudng

mg/ kg/ 24 gior

Ddi tugng

- Thudng ngudi ta tfnh lugng protid theo sd gam nito (azot):

ẠO

1 g nito cd trong 6,25 g protid va « 30 g thit

1 g protid cung cap 4 calo.

ẦN

- De cho viec su dung nito cd hieu qua, cdn phai cd mot ty le thfch dang giua mure nang lugng do cac nguon dinh dudng khong phai protein cung cap (tam goi la nang lugng phi protein = NPP) va sd gam nito. Ty le nay la 150 : 1 d ngudi binh thudng cdn d ngudi bi cac stress la 100 : 1, co nghia la khi gap nhung trang thai ba't lgi (cac stress nhu chan thuong, phau thuat...) thi nhu cau protein tang ro ret.

- Cac dang cung cap protid dung cho dung dich nuoi dudng ngoai dudng tieu hda (dua theo dudng tiem truyen, TPN) la cac dung dich acid amin ket tinh hoac tong hgp. Cac dung dich thuy phan protein nhu casein ngay cang it dung vi gay nhieu

tai bien.

Ó A

Ty le giua acid amin can thiet (essential) va acid amin cd the thay the' dugc (nonessential) thudng bat chudc ty le cua cac hop phan protid tu nhien nhu trumg,

Í-

sua... trong dd acid amin can thiet tir 40-50% cdn loai thay the dugc la tu 50-60%. Ndng dd cac acid amin trong dung dich tir 3 de'n 10% va ham lugng tung acid amin khac nhau

-L

tuy theo cong thuc cua cac hang bao che.

ÁN

Nhu cau thdng thudng can tu 150 - 400mg N/kg/24gid - trong dd 40% phai d dang

acid amin khong thay the.

Đ ÀN

Chon che pham :

- Trong suy than cap tfnh: Cd the chon cac cong thuc chi chua cac acid amin can thiet

D IỄ

(essential). Tuy nhien, chua cd bang chung day du ve su uu viet cua cong thtic nay

so vdi cac cong thtic cd ca acid amin thay the' dugc (nonessential).

- Vdi benh nhan cd ton thuong gan: Ngudi ta cho rang cac benh nhan nay cd su tang mtic acid amin thorn nhu tyrosin, phenylalanin trong huyet thanh; cac acid amin nay cung vdi octopamin trd thanh cac chat trung gian dan truyen than kinh

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(neurotransmitteur) gia trong nao. Ben canh dd, lugng acid amin cd mach nhanh nhu valin, leucin, isoleucin lai thap. Do do vdi cac ddi tugng nay nen chon cac hdn

hop acid amin cd ty le acid amin thorn tha'p cdn acid amin nhanh cao. Cac cong thtic loai nay thudng dat hon cac loai binh thudng.

- Trong nuoi dudng qua dudng tieu hda, cd the7 sudung cac hdn hgp acid amin hoac

H Ơ

dich thuy phan protein, cac polypeptid va tham chi ca protein.

- Can luu y den thdng sd ve ap suat tham thau cd ghi tren nhan mdi dung dich. Chi

TP .Q U

dugc dua qua tinh mach ngoai vi nhirng dung dich cd ap suat tham thau < 800 mOsm/1. Nhung dung dich cd ap suat tham thau cao hon phai dua vao tinh mach trung tam qua catheter.

ẠO

- Trong mot sd dung dich acid amin, ngudi ta cd dua them cac chat dien giai nhu Na\ K\ Mg++. Can tinh den lugng nay khi dieu tri de tranh thira cac chat dien giai.

Chu y :

- Khong nen trdn cac thud'c vdi cac dung dich acid amin vi trong da sd trucmg hop

deu xay ra tuong ky.

Tac dung phu :

ẦN

- Neu dua qua lieu acid amin cd the' gay ra nhiem toan do rdi loan chuyen hda

(metabolic - acidosis) hoac tang nito mau d ngudi suy giam chtic nang than.

- M5n cam, di ting hoac sdc qua man .

- Gay tang dudng huyet hoac danieu do tang apluc tham tha'u, dac biet khi phdi hop vcti

dung dich glucose. De7 tranh hien tugng nay, cd the phdi hopthem insulin va kali.

Ó A

Bdng 4.7: Cac acid amin

Í-

Cac acid amin can thiet

Alanin

Leucin

Asparagin

-L

Isoleucin

ÁN TO Đ ÀN N D IỄ

Cac acid amin co the thay the dugc

Lysin

Acid aspartic

Methionin

Cystein

Phenylalanin

Acid glutamic

Threonin

Glycin

Tryphotophan

Hydroxyprolin

Valin

Serin

Histidin*

Tyrosin Arginin

* acid amin can thiet vdi tre em

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Lieu luang:

- Ngudi ldn: 0,10 - 0,45 g nito/ kg/ 24 gid - Tre em: 0,23 - 0,53 g nito/ kg/ 24 gid

H Ơ

Lipid la nguon cung cap va du tru nang lugng quan trong cho co the, la mot hop

2.3. Lipid

phan cau tao cua mang te' bao.

1 g lipid cung cap 9-11 calo.

TP .Q U

Trong nuoi dudng nhan tao qua dudng tiem truyen, phai cd mot lugng chat beo de dam bao ft nhat la 5% tong sd nang lugng cua co the ddi hdi trong mot tuan. Thudng thi mdi benh nhan mdi tuan nen truyen khoang 1.500 ml loai nhu dich 10%. Neu nguon

ẠO

nang lugng chi dugc lay tir glucose bang each truyen lien tuc thi co the se phan ting lai bang each tic che viec giai phdng chat beo, gay trieu chting thieu cac acid beo can thiet (essential) vdi cac bieu hien nhu khd da, tang tinh tham thanh mach, vet thuong cham

ẦN

lanh, giam sure de khang cua co the, tang kha nang nhiem khuan, giam tieu cau... Neu benh nhan cd the su dung nuoi dudng nhan tao qua dudng tieu hda thi viec su dung lipid trong cac hgp phan can dua don gian hon nhieu so vdi dua qua dudng tiem truyen. Trong trudng hgp nay, cd the dung cac chat beo mach dai va trung binh. Neu

dubng tieu hda hoat ddng tot thi cd the sudung chat beo di cung cap tti 20 den 40% sd calo can thiet trong tong sd calo se dua cho benh nhan.

De dua chat beo qua dudng tiem truyen, can cd dang nhu dich (emulsion), trong do

kich thude tieu phan chat beo khoang 0,3 |am (300 nm).

Ó A

Nguon lipid thudng dung la dau dau tuong, lecithin long dd trting tinh khiet, glycerol, trong do acid linoleic chiem ty le ldn (50-60%) va dugc coi la nguon cung cap

cac acid beo va nang lugng chu yeu.

-L

Í-

Nhu cau hang ngay ve lipid ddi vdi ngudi ldn la 0,5-lg/kg. Nguon nang lugng (calo) dugc lay tu chat beo chi nen chiem khoang 10 den 40% (tdi da la 60%) lugng calo

ÁN

phi protein, lugng cdn lai lay tu glucid. Trong tong lugng dd phai cd tdi thieu 10% lay tir

acid beo khong thay the dugc (essential).

Đ ÀN

Ndng do chat beo trong nhu dich thudng tti 10den 20%. Lieu binh thudng cho ngudi ldn la 0,5 - 1 g/ kg/ ngay; tdi da la 2,5 g/ kg/ ngay. Lieu

D IỄ

nay dugc truyen lien tuc trong 24 gid vdi tdc do truyen tuy theo ndng do nhu dich. Loai 10% cd the truyen vdi tdc do tdi da la 125 ml/ h cdn loai 20% thi truyen vdi tdc

dd 60 ml/ gid.

Nhu dich cha't beo dugc dang truong hda bang glycerin va dugc truyen vao tinh

mach ngoai vi. Loai ndng do 10% cti 1ml cung ca'p dugc 1,1 kcal cdn loai 20% thi 1 ml cho ~ 2 kcal.

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Do tfnh chat vat ly cua nhu dich, het sure tranh viec trdn cac dung dich khac vao vi se pha vd dd ben vung cua cac tieu phan cha't beo. Cac kim loai da hda tri nhu Ca++,

Mg++.. de lam cac hat chat beo ke't tu lai vdi nhau va do do gay tang kich thude tie'u phan, gay nguy hiem khi truyen vao mach.

H Ơ

thtic pha che san cd 3 hop phan nay. Khi khong cd loai do ma phai phdi hgp, chi dugc

Neu mudn truyen hdn hop lipid vdi glucid va protid, tot nha't la sir dung cac cong

Than trong :

TP .Q U

Can luu y la cac tieu phan cha't beo khong qua dugc mang loc.

pha trdn ngay khi su dung vdi each truyen qua nhanh chu Y: Hdn hop cua dung dich glucose va acid amin truyen d 1 nhanh cdn nhu dich lipid truyen rieng d nhanh thur 2.

- Can giam sat mtic acid beo tu do va triglycerid trong qua trinh truyen.

ẠO

- Kiem soat tuong ky.

Chdng chi dinh :

- Tang lipid mau nang.

ẦN

- Di ting vdi lecithin cua trting.

- Viem tuy cap tfnh cd kem tang lipid mau.

- Suy gan tram trgng.

Tdc dung phu :

- Khi mdi truyen: Toat md hdi, dau dau, dn lanh, met mdi, cd the gap ban da.

- Khi dieu tri keo dai: Tang nhe phosphatase-kiem, transaminase, bilirubin/mau.

- Giam tieu cdu vtia phai d ngudi ldn va tram trgng d tre em.

Ó A

- Cd mot sd trudng hop bi to gan va vang da.

Chi dinh :

-L

Í-

- Bo sung nang lugng trong nuoi dudng nhan tao.

ÁN

- Cung cap nguon acid beo khong thay the'. Lieu luang:

- Ngudi ldn: 0,5 - 2,5g lipid/ kg/ 24 gid

0,5 - 4 g lipid/ kg/ 24 gid

Đ ÀN

- Tre em :

D IỄ

Cach tinh toe dp truyen :

Dung dich 10% : 1 g lipid = 10 ml = 200 giot. Dung dich 20% : 1 g lipid = 5 ml = 100 giot.

Chu y : Lieu khdi dau thudng nhd, truyen tdc do cham, sau dd cti 10 de'n 20 phut lai tang dan tdc do den mtic c£n thiet. Thi du:

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- Dung dich 10%, trong 10 phut d£u truyen 10-20 gigt/phut, sau dd trong 20 phut tiep theo truyen 30 - 40 gigt/phut rdi tang dan tdi 40 - 60 gigt/phut. 2.4. Cac chat dien giai

Na+

K+

150

Ca++

Ngoai te bao (huyet tirong)

2,5

ẠO

100

HCQ3

Phosphat/ sulfat

2 1

ẦN

Mg++

H Ơ

141

Trong te bao

TP .Q U

Cac chat dien giai

Bdng 4.8: Thanh phan cac chat dien gidi trong dich long cua ca the (mmol/l)

2.4.1. Vai trd cua cac chat dien gidi vdi cathe

Cac chat dien giai ddng mot vai trd quan trgng trong viec duy tri su hang dinh cua

ap suat tham thau: Cac ion K+, Mg++, phosphat la thanh phan quan trgng vdi dich long trong te' bao, cdn cac ion Na\ CI, HC03 lai la hgp phan khong the thieu dugc cua huyet

tuong.

Ó A

Su ma't dien giai qua than, qua phan, do ndn.. anh hudng trudc tien de'n mtic dien giai trong huyet tuong, do do viec phan tfch ham lugng dien giai la viec can lam trudc khi lua chgn mot dung dich thfch hop cho tirng trang thai benh ly.

-L

Í-

Tuy nhien, tinh trang chtic nang cua cac co quan nhu gan, than, tim mach cung la dieu rat dang quan tam khi bu dich.

ÁN

Cac chat dien giai trong te' bao nhu kali, phosphat, magnesi...dac biet quan trong vi no thudng lien ket vdi nito trong cac md cua te' bao hoac gitip cho su van chuyen glucose qua mang. Vi vay nhu cau cac hop phan nay ddi hdi cao trong giai doan dau nudi dudng

Đ ÀN

cac benh nhan suy dinh dudng.

Ngugc lai, cac ion Na+, CI lai rat can khi ma't nude va dien giai ngoai te' bao nhu ia

D IỄ

chay, ndn.

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Bdng 4.9: Cac chat dien gidi dien hinh can trong nudi duong qua dudng tinh mach Nhu cau/ 24 gift ( cho nguoi ldn )

Na+

60-150 mEq

K+

70- 180 mEq

Mg++

10-30 mEq

Ca++

4-30 mEq

Acetat

25- 160 mEq

Phosphat

7- 10 mmol/1000 kcal.

TP .Q U

H Ơ

Thanh phan

ẠO

Lugng dien giai ghi trong bang la nhu cau ddi vdi nhung benh nhan dugc truyen mdi

ngay 2000 den 3000 ml chat dinh dudng.

Can nhd rang trong cac dung dich acid amin va mot sd dang dung dich dextrose (glucose) thudng cd mot lugng nhat dinh chat dien giai va phai tfnh ca sd lugng nay de

tranh dua vao qua thira.

ẦN

Ndi chung ty le Na7 CI nen duy tri d mtic 1:1. Trong trudng hop cd rdi loan chuye'n hda nhu nhiem kiem hoac tang CI , ty le nay phai thay doi. Khi tang CI /mau hoac bi nhiem toan do chuye'n hda thi lugng Na+, K+ nen cung cap dudi dang acetat chti khong nen dung mudi clorid vi acetat de chuyen thanh bicarbonat lam thuan lgi cho chuye'n hda hon.

Ó A

Nhung benh nhan cd chtic nang gan, than, tim-mach binh thudng thi cd the dung cac cong thtic san cd. Trudng hop bi suy giam chtic nang cua cac co quan nay thi lugng dien

giai trong dich truyen phai pha che' tuy thuoc su rdi loan dien giai d benh nhan cu the'.

-L

Í-

Bd sung chat dien giai qua dudng tieu hda don gian hon va cd the dung cac cong thtic pha che' san va pha che' theo don.

ÁN

2.4.2. Cac loai dung dich dien gidi thudng diing

Di bu dap cac chat dien giai trong nudi dudng nhan tao, cac dung dich dien giai

dung trong bdi phu the' tfch dich luu hanh da trinh bay trong phan 1.1. deu thfch hop cho

Đ ÀN

trudng hop nay. Cac loai thudng su* dung nhu sau:

D IỄ

* Dung dich NaCl 0,9%

* Dung dich Ringer lactat (xem phan 1.1) Chi dinh :

Hai loai dung dich tren dung de bdi phu nude va cac chat dien giai qua dudng tiem khi bi ma't nude ngoai te' bao, giam the tfch mau.

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Chu y : Khong su dung trong trudng hgp cd ti tre mudi nude nhu suy than, thieu nang tim, xo gan.

Dung dich Ringer lactat khong dung trong trudng hop nhiem kiem hoac ti tre

H Ơ

acid lactic. •

* Cac dung dich chat khoang khac:

- Dung dich K+:

TP .Q U

Cac dung dich kali dugc dung dudi dang uu truong 7,46%, 15%, 20%, ddng dng 10 ml tfnh ra mmol K+/10 ml tuong ting la 10, 20, 26,8. Khi dung pha loang den mtic ndng do can thiet.

ẠO

- Dung dich Ca" :

Cd nhieu loai dung dich dang luu hanh, thf du:

• Calci- Sandoz cd 1,12 mmol Ca+7 5ml.

• Calci gluconat lavoisier cung cd 1,12 mmol Ca+75ml.

Cac loai dung dich nay deu dugc dua true tiep vao tinh mach.

ẦN

- Dung dich Phospho:

- Dung dich Magnesi:

lg ~ 32 mmol, dugc pha dudi dang glucose 1 - phosphat disodic. 4H20 cd ham lugng 125,4 g/lit, trong dd cd phospho dudi dang phosphat 330 mmol/lit, glucose 330 mmol/lft va Na+ 660 mmol/lit, pha loang den ndng do c£n thiet khi sir dung.

Ó A

lg ~ 42 mmol, pha dudi dang MgS04, dng 10 ml cd l,2g MgS04 (~ 118 mg Mg++).

Tiem tinh mach cham.

Í-

Viec su dung chat khoang dudi dang don le chi thfch hop de' dieu tri nhirng trang

ÁN

-L

thai lien quan den thieu nguyen to dd. Neu can bu dien giai thi nhung loai dung dich nay khong thfch hop ma nen dung cac dang hdn hgp vdi ty le tuong tu vdi ty le cua thanh

phdn dien giai cd trong co the' nhu Ringer hoac Ringer lactat 2.5. Cac nguyen to vi lugng

Đ ÀN

Cd 7 nguyen to vi lugng can thiet cho ddi song hang ngay la Zn, Cu, Fe, Cr, Mn, I2

D IỄ

va Se.

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Bdng 4.10: Nhu cau hang ngay ve nguyen tovi luang Nhu cau hang ngay

Ten nguyen to

(vdi ngudi ldn)

Sat

(Fe)

H Ơ

1,5 mg

Iod

120 ug

(I2)

120

Selen (Se)

Crom (Cr)

Dong (Cu)

TP .Q U

Mangan (Mn)

3 -6mg

Kem (Zn)

jag

ẠO

2 ug

Cac nguyen to nay tuy nhu cau hang ngay ft nhung cd vai trd quan trgng ddi vdi co the. Chiing tham gia vao thanh phan cua cofactor trong cac he men chuyen hoa cac chat

ẦN

sinh hgc cd hoat tfnh cao. Binh thudng thi lugng nay cd du trong thuc pham va neu khong cd nhung rdi loan ve benh ly thi khong bao gid thieu. Trong che do nudi dudng nhan tao qua dudng tieu hoa cung ft khi can bo sung chat nay. Tuy nhien trong nudi dudng nhan tao ngoai dudng tieu hoa, do dac tfnh ve do tinh khiet cao cua cac hop chat

khi dua vao mach mau, cac nguyen to nay thudng khong cd mat trong cac dich truyen va vi vay neu can nudi dudng benh nhan keo dai thi can bo sung them.

Ó A

vdi dich truyen khi su dung.

Cac che pham loai nay thudng dugc ddng dng 10 ml, 40 ml va phai pha loang cung

Viec chon dung dich phai can cti vao trang thai benh ly cua benh nhan. Cac stress do chuyen hoa hoac ia chay, ndn... lam mat 1 lugng ldn kem qua

-L

Í-

Thf du :

phan, dich ndn...

ÁN

Kem, crom, selen dugc bai tiet qua than, cdn mangan, ddng, lai dugc bai tiet qua mat, do do can luu y neu benh nhan bi suy than, tac mat gay ti tre sir thai trti cac nguyen to nay. Cac cong thtic nudi dudng trong trudng hop nay nen giam ham

Đ ÀN

lugng cac nguyen to tren.

D IỄ

Selen bi giam nhieir a benh nhan bdng, chting suy giam mien dich mac phai (AIDS) hoac thieu nang gan. Trudng hgp nay lugng selen can dugc uu tien.

2.6. Vitamin

Cung nhu cac nguyen to vi lugng khac, vitamin cd san trong thuc pham, do dd vdi ngudi khoe manh, cd che dd an can ddi thi khong phai bo sung vitamin. Che do nudi

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dudng nhan tao qua dudng tieu hoa cung it gay thieu vitamin va neu cdn cd the9 bd sung qua dudng udng mot each de dang. Khi sir dung che do nudi dudng ngoai dudng tieu hoa keo dai, viec bo sung vitamin la bat budc, neu khdng se gay nhung rdi loan nghiem trgng trong co the7.

Cac vitamin can thiet cho co the' bao gdm:

- 9 vitamin tan trong nude: B,, B2, B3, B5, B6, B12, C, acid folic va biotin.

H Ơ

- 3 vitamin tan trong dau: A,D,E

TP .Q U

Bdng 4.11:Nhu cau hang ngay ve vitamin khi nudi duong qua dudng tfnh mach keo ddi (lieu tfnh cho nguoi ldn) Vitamin tan trong dau

Thiamin (BI) 5000 UI

3,0 mg

Riboflavin (B2)

3,6 mg

Retinol (A)

trong nude

ẠO

Vitamin tan

A. Pantothenic (B5)

Tocoferol (E) 10 mg

Niacin (PP)

Calciferol (D) 500 UI

40 mg 4,0 mg

A. Folic

400 ug

ẦN

Pyridoxin (B6)

15 mg

60 jug

Biotin

Cyanocobalamin (B12)

300 mg

A. Ascorbic (C)

5pg

-L

Í-

Ó A

Mudi hai loai vitamin tren rat hay gap trong cac dang polyvitamin di udng hoac tiem. Rieng vitamin K khdng dugc phdi hgp vi de tranh tai bien cho nhirng benh nhan dang dieu tri cac thud'c chdng ddng mau nhu warfarin. Vdi nhung benh nhan khdng dieu tri bang cac thud'c chdng ddng mau dang udng, cd the bd sung vitamin K theo dubng

ÁN

tiem 1 mg/1 ngay hoac 5-10 mg/1 tuan.

Trong thuc te khdng phai luc nao cung cdn bd sung du 13 loai vitamin tren,do dd

Đ ÀN

cac dang thuong mai thudng gap cd the chi chtia 9 vitamin (A, D, E, B„ B2, PP, B5 B6, C) hoac hdn hop rieng re cua nhdm vitamin tan trong dau, cua nhdm vitamin tan trong

D IỄ

nude, hoac chi chtia mot vitamin don doc.

Cac cong thtic phd'i hop cang nhieu cha't thi cang dat tien vi ddi hdi ky thuat bao che phtic tap, do do nen can nhac ve nhu cau cu the' trong tung trudng hop ma lua chon. Thf du :

- Vdi benh nhan truyen nhieu glucose thi can hdn hop vitamin nhdm B.

- Benh nhan suy giam mien dich, suy dinh dudng nang thi nen bd sung dang 75

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polyvitamin, trong do lugng vitamin A va C can nhieu hon cac loai khac. Cac loai vitamin nay cd the dugc trdn vao cac dung dich tiem truyen nhung khdng dugc pha lin vao mau hoac huyet tuong. 2.7. Mot sd diem can luu y khi six dung cac loai dich nuoi dudng nhan tao qua

H Ơ

ducmg tinh mach

2.7.1. Cach pha che cac hop phan dinh duong qua tiem truyen

Viec chgn lua cong thtic can phu hop vdi nhu cau benh ly. Trong da sd trucmg hop, su dung hdn hgp cua 3 thanh phan glucid, lipid, protid la ly tudng nhat. Tuy nhien, thudng khdng ton tai nhung cong thtic san cd ca 3 hgp phan, do dd mudn sir dung can phai cd sir hd trg cua cac dugc si trong khau pha trdn. Cac giai doan nay phai thuc hien trong phdng pha che vd khuan. Khd khan nhat la them lipid

TP .Q U

ẠO

vao thanh phan hdn hgp vi de pha vd dd ben cua nhu dich. De7 giai quyet dieu

nay cd the cd 2 each:

Thuc hien trinh tu pha che' diing: Trudc tien nen trdn dung djch glucose (dextrose) vdi dung dich acid amin. Neu can them nguyen to vi lugng va vitamin

ẦN

thi nen them vao giai doan nay, sau dd them tti tti vao dung dich da pha che' nhu dich lipid. Neu pha che'dung nguyen tdc thi hdn hop cd do on dinh trong vdng 48 gid. Can luu y han che' tdi da lugng cac cation hda tri 2 vi no se tac dung vdi cac chat nhu hoa anion trong nhu dich lipid dan den giam do ben.

Viec trdn them nhu dich lipid tot nhat la dugc thuc hien qua nhanh chu Y: Nhu

dich lipid dugc dua rieng re qua 1 nhanh, nhanh cdn lai bao gom hdn hop cac

Ó A

hop phan nhu da neu tren, tuy theo trudng hop cu the.

2.7.2. Nhiing tuong ky cdn tranh

Í-

Khdng nen them albumin vao hdn hop cac chat dinh duong.

-L

Khdng them sat vao nhu dich cha't beo.

ÁN

Vdi da sd cac thud'c, viec them vao hdn hgp nudi dudng phai he't sure han che'. Cac thdng tin lien quan den viec trdn thud'c vao dich truyen cd the tham khao trong don chi dan each dung thud'c hoac cac sach chuyen khao.

D IỄ

Đ ÀN

Do on dinh cua dung dich phu thude nhieu vao cac mudi bicarbonat, calci, phosphat. Trong dich truyen, nen thay bicarbonat bang citrat hoac lactat thi se tranh dugc tuong tac vdi mudi calci, magnesi hoac vdi cac dung dich acid.

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Chuong V

MAU VA CAC CHE PHAM TI/ MAU

H Ơ

I. KHAI NIEM CHUNG VE MAU

1.1. Mau la gi ?

Mau la mot to chtic long leo, cd mat d hau het cac vi tri khac nhau cua co the, dugc

TP .Q U

cau tao tti hai thanh phan chfnh:

Thanh phan te' bao (huu hinh) bao gom cd hong cau, bach cau, tieu cau.

ẠO

Thanh phan huyet tuong (vd hinh) bao gom cac yeu to ddng mau, ndi tiet to, cac mudi khoang, cac protein (albumin va y globulin)... va nude.

Trong 2 thanh phan dd, hong cau cd sd lugng cao nhat, lai chtia huyet sdc to nen

mau cd mau dd.

1.1.1. Cac thanh phan tebdo

ẦN

- Hong cau: Chtia huyet sac to lam nhiem vu van chuyen oxy cho hd ha'p te' bao, tao nang lugng cho co the hoat ddng.

Bach cau cd nhieu loai:

+ Bach cau hat trung tfnh lam nhiem vu tieu diet vi trung, tham gia co che'

bao ve khdng dac hieu.

Ó A

+ Bach cau don nhan va dai thuc bao lam nhiem vu thuc bao vat ldn, trinh dien

khang nguyen, san xuat cytokin.

Í-

+ Bach cau lympho tham gia tao mien dich dac hieu va san xuat cac cytokin.

-L

+ Bach cau ai toan, ai kiem tham gia phan ting di ting.

ÁN

- Tie'u cau: Tham gia vao co che c£m mau. Khi chay mau, tieu cau tu tap tao thanh

"nut" cam mau. Ngoai ra tieu cau cdn tham gia vao co che tang tha'm manh bdi cac hoat chat cd hoat tfnh sinh ly cua chung (vasoactive reagent).

D IỄ

Đ ÀN

- Sd lugng hdng cau: nam 5 - 5,5 T/ 1ft. nu 4,2 - 4,5 T/lft.

(T/lit = Tera/lit = 1012 hong cau trong 1 lit mau) - Sd lugng bach cau: + Bach cau hat:

3 - 6 G/lft.

+ Bach cau lympho: 1,2 - 2,2 G/lft.

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- So lugng tieu cau: 200 - 400 G/lft.

(G/lit = Giga/lit = 109 bach cau hoac tieu cau trong 1 lit mau)

H Ơ

va tieu huy. Ngudi ta tfnh rang mdi ngay cd 200 ty hong cau mdi sinh ra va cung cd khoang 200 ty hong cau tieu di. Dieu do cd nghia rang neu ta khdng cho mau thi hong cau vin cti bi tieu huy d lach va cac to chtic lien vdng khac nhu mot chu trinh lien tuc va

Di duy tri cac chi so ndi tren, co the cd co che'dieu hoa giua hai qua trinh san xuat

khep kfn.

TP .Q U

Co the dieu hoa can bang cac chi so mau bang cac co che' sau day:

Co che thieu oxy: Su thieu oxy se kfch thfch tuye'n thugng than tiet ra cha't kfch thfch sinh hong cau (erythropoietin), chat nay kfch thfch tuy xuong san xuat va tang

ẠO

qua trinh trudng thanh cua hong cau.

Co che' tic che' ngugc (feed - back): Khi vugt sd lugng binh thudng, sd lugng nay se tic che' ngugc lai tuy xuong lam giam sinh hong cau.

Do cac chat kfch thfch sinh mau:

+ Ddi vdi hong cau cd erythropoietin.

ẦN

+ Ddi vdi tieu cau cd thrombopoietin.

+ Ddi vdi bach cau cd GM-CSF, G-CSF, M-CSF.

Do phan ting bao ve cua co the:

+ Chung cho ca 3 ddng cd 11-3,11-6 va cac yeu to tang trudng khac.

+ Sot va nhiem trung deu gay tang bach cau.

Ó A

1.1.2. Thanh phan huyet tuong

-L

Í-

Thanh phan huyet tuong bao gom cac protein, glucose, lipid, mudi khoang, cac men va ndi tiet to, cac chat ddng mau, cac globulin mien dich. Cac ye'u to nay cua huyet tuong deu la cac thanh phan tham gia vao nhieu chtic nang quan trgng cua co the nhu

ÁN

ddng mau, chdng nhiem trung, chuyen hoa, dinh dudng, giu can bang ndi mdi...

Cd the ndi mau rat can thiet cho su song cua co the'. Khi ma't mau (>25% khdi lugng mau), bat dau cd cac rdi loan ve cac chtic nang cua co the nhu: Chtic nang than kinh, hd

Đ ÀN

hap, tim mach, tiet nieu...

D IỄ

1.2. Mot so dac diem sinh ly cua mau * San xuat te bao mau:

Te bao mau dugc san xua't tti tuy xuong. Hang ngay tuy xuong cd the san xuat va dua ra ngoai mau khoang 200 ty hong cau, 120 ty bach c£u hat, 20 ty lympho, 150 ty tieu cau va hang ngay cung cd chting dd cac te' bao mau bi tieu huy.

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* Ddi song cua te bao mau:

O co the' binh thudng, te' bao mau cd tudi thg nhu sau: -

Hong cau song trung binh 120 ngay.

- Bach cau hat song 5-7 ngay nhung thdi gian ton tai a mau rat ngan (khoang 5-10 Tieu c£u song 7-10 ngay.

H Ơ

gid).

TP .Q U

Bach cau don nhan bao gom ca lympho va dai thuc bao, bach cau don nhan to song trung binh 50-70 ngay hoac cung cd the hon nua.

* Dieu hod cdn bang tebdo mau:

Te bao mau luon luon dugc sinh ra, nhung sd lugng trong mau lai luon hang dinh,

ẠO

cu the nhu sau:

- The7 tfch mau toan phan d ngudi ldn: 77ml/kg ddi vdi nam va 66ml/kg ddi vdi nu. - The7 tfch khdi te bao - hong cau: 33ml/kg ddi vdi nam va 22 ml/kg ddi vdi nu. - The7 tfch huyet tuong: 41 ml/kg ddi vdi nam va 40ml/kg ddi vdi nu.

* Kha nang lay nhiem mau cd the bi nhiem mot sd benh nhiem trung, va tti day

ẦN

chting cd the7 truyen sang nhung ngudi khac khi hg nhan mau bi nhiem trung.

* Cd the tach duoc cac thanh phan mau rieng biet

Hien nay bang cac ky thuat mdi, ta cd the' tach rieng dugc cac thanh ph5n sau day:

Cac thanh phan te' bao:

+ Khdi hong cau (parked red cells).

Ó A

+ Khdi tie'u cau (concentrated platelets ).

+ Khdi bach cau hat (concentrated granulocytes).

Í-

+ (Tti "Khdi hong cau", "Khdi bach cau", "Khdi tieu cau" dung de chi phan

ÁN

-L

hdng ceiu, bach cfiu, tie'u clu dam dac sau khi dugc tach ra ttimau toan phan). + Te' bao nguon tao mau (hemopoietic stem cells): CD34+

+ Huyet tuong.

+ Huyet tuong toan phSn- huyet tuong tuoi ddng lanh bao tdn cac yeu to ddng

Đ ÀN

mau.

D IỄ

Tti huyet tuong ta lai cd the tach dugc cac thanh ph£n sau day: + Cac ye'u to ddng mau:

* Tua lanh yeu to VIII dung dieu tri benh chay mau di truyen Hemophilia A . * Cac yeu to ddng mau khac: II, III, V, VII, IX... + Gamma globulin +

Albumin

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Nhd cac ket qua ve ky thuat ndi tren nen cd the su dung bien phap truyen mau tirng phan, vtia an toan vtia cd hieu qua kinh te. II. CHUAN BI CAC SAN PHAM MAU

Dugc tien hanh theo cac budc sau day:

H Ơ

2.1. Tim nguon cho mau

TP .Q U

Van ddng ngudi cho mau tu nguyen tai co sd, biet ro sinh hoat cua hg, giai thfch ro cho mgi ngudi hieu rang khdng cho mau neu cd cac yeu to lien quan den HIV va cac benh nhiem trung khac, duy tri nguon ngudi cho mau an toan. Neu ngudi nao da cho

mau an toan thi nen cho mau 3-4 lan/nam, mdi lan each nhau 3-4 thang. Cach cho nay hoan toan khdng cd hai va bao dam chat lugng mau.

ẠO

2.2. Lay mau

Ngudi chau Au cd the lay 350-450ml/lan vdi ngudi tren 50kg, mot nam cd the lay 3-

5 lan.

Ngudi Viet Nam neu trgng lugng co the tti 40-50kg cd the lay 250-350ml/lan, mdi

ẦN

nam cd the lay 3-5 lan. Ngudi nang tren 50kg cd the lay 300-400ml/lan. Nhin chung cd the lay khoang 5-10% khdi lugng mau co the va khdng nen lay qua

10% khdi lugng nay.

2.3. Tien hanh xet nghiem an toan truyen mau

- Dinh nhdm mau: Nhdm mau phai dugc xac dinh bang huyet thanh mau va hong

cau mlu chuan, ket qua dugc ghi ro tren ttii mau.

- Phat hien khang the bat thudng: Ngoai nhdm khang nguyen hong cau (ABO), tung

Ó A

budc cdn phai dinh ca nhdm mau he Rh va he HLA.

ÁN

-L

Í-

- Phat hien cac yeu to benh nguyen nhiem trung qua dudng truyen mau: Cd nhieu benh nhiem trung truyen qua dudng truyen mau can phai sang lgc, song do dieu kien kinh te hien nay ta mdi chi tien hanh dugc cac thu nghiem sau: Tim anti HIV1/2, HBsAg, anti -HCV, giang mai, sot ret.

2.4. Tach cac thanh phan mau

Đ ÀN

Ta cd the tach cac thanh phan mau tti tui mau lay tti ngudi cho mau trong vdng 6-12

gid bang each su dung may ly tam. Bang each nay cd the7 cd cac thanh phan mau sau day: Khdi hong cau ngheo bach cau, khdi tieu cau ngheo bach cau, huyet tuong, huyet

D IỄ

tuong tuoi ddng lanh, tua lanh yeu to VIII.

Bang each sir dung may tu ddng (Cell auto separator), ta cd the7 tach dugc cac thanh phan mau hoan hao ma ft lan cac thanh phan khac. Ngoai ra cd the dung may nay de tach te bao nguon tao mau CD34, hoac sir dung cho dieu tri nhu trao doi huyet tuong, hoac loai bd bach cau, hong cau, tieu cau...

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2.5. Bao quan mau

Thdi gian bao quan mau phu thude vao chat chdng ddng va dung cu bao quan. Mau toan phan neu su dung tui cd chat chdng ddng la CPD - A, cd the bao quan

H Ơ

Bach cau hat bao quan dugc 24 gid d nhiet do 2- 6°C. Huyet tuong bao quan dugc 1 nam d nhiet do am 30°C.

dugc 42 ngay d nhiet do 2-6°C. Tieu cau bao quan dugc 5 ngay d nhiet do 20 - 22°C trong may lac lien tuc.

TP .Q U

2.6. Phan phdi mau

Mau da dugc chgn lgc va bao quan trong kho mau cd the phan phdi cho cac benh vien theo yeu cau qua khoa huyet hgc - truyen mau cua benh vien hoac phat true tiep

ẠO

cho phdng benh. Trong trudng hop nay, can thiet phai dinh lai nhdm mau ciia benh nhan va nhdm mau cua tui mau du kien phat. Phai su dung hai phuong phap (hong cau mSu va

huyet thanh mau) de dinh lai nhdm mau cho that chfnh xac. Sau do mdi hoan tat cac thu

tuc hanh chfnh de phat mau cho benh phdng.

III. CHI DINH DUNG CAC SAN PHAM MAU TREN LAM SANG

ẦN

3.1. Nguyen tac

- Nam chac muc dfch truyen mau: La tang kha nang cung ca'p oxy bang hong cau, tang tuan hoan (mau toan phan, huyet tuong), tang tieu cau, tang bach cau, tang yeu to

ddng mau (yeu to VE).

Ó A

- Phai chi «dinh dung truyen mau: Can thi truyen, khdng can khdng truyen, thieu gi truyen nay, han che' tdi da truyen mau toan phan.

- Theo ddi hau qua truyen mau: Hau qua trudc mat va hau qua lau dai.

Í-

3.2. Cac thanh phan cua mau duoc su dung

-L

* Dan vi tinh: 1 don vi mau la lugng mau toan phan trong mot tui mau (thudng =

ÁN

250ml)

1 don vi hong cau, 1 don vi bach cau, 1 don vi tieu cau la lugng hong cau, bach cau,

tieu cau tach ra tti mot don vi mau.

Đ ÀN

3.2.1. Mau toan phan

D IỄ

Gom du cac thanh phan mau, tuy nhien trong qua trinh bao quan, cac yeu to ddng mau bi phan huy cho nen khdng dung mau toan phan cho muc dfch cung cap yeu to ddng mau. Dong thdi trong qua trinh bao quan, bach cau va tieu cau thudng bi phan huy nen khdng dung cho muc dfch tang bach cau va tang tieu cau.

Mau toan phan dung tot nhat trong cac trudng hop ma't mau (>30%) de' tang the' tfch mau tuan hoan hoac thay mau (exchange transfusion).

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Can chu y: Mau toan phan bao quan dai ngay (>21 ngay) cd the gay phan ting sot, di ting, sdc do cac san pham cua bach cau, tieu cau giai phdng ra. Neu dung dich bao quan cd adenin thi thdi gian bao quan cd the7 dat 42 ngay.

H Ơ

Khdi hong cau dat yeu cau gom cac thanh phan sau: Sd lugng khoang 150-200ml, hematocrit (the tfch khdi hong cau): 50-60%, sd lugng hong cau mat di dudi 15% trong

3.2.2. Khdi hong cau

mot don vi mau, sd lugng bach cau cdn lai dudi l,2xl09/ don vi mau.

TP .Q U

Khdi hong cau dugc ap dung cho tat ca cac benh nhan thieu mau, dac biet thieu mau man tfnh. Khi su dung can dua vao lugng huyet sac td (HST): HST tren 80% la du nhu cau cung ca'p oxy cho co the.

ẠO

Vdi benh nhan mat mau nang, cd the7 truyen khdi hong cau, nhung neu mat >30% khdi lugng mau thi khdng nen su dung khdi hong cau.

3.2.3. Khdi tieu cau

Can chu y yeu td bat ddng HLA. Tieu cau cd HLA-A va HLA-B, rat ft khang nguyen he ABO va cac HLA khac; cd khang nguyen tieu cau.

Cd 2 loai:

ẦN

3.2.3.1. Khoi tieu cau ti( ngudi cho ngau nhien (Random donor)

* Khdi tie?u cau dat yeu cau gom cac thanh phan sau: Lugng: 50-70ml.

Sd lugng tieu cau 5,5x1010/ don vi tie'u cau.

Sd lugng bach cau <0,12x 109/don vi

Sd lugng hong cau <1,2x 109/don vi

Ó A

Khi can sd lugng ldn cd the tap trung tti 5-6 ca the cd cung nhdm mau.

-L

Í-

Khdi tieu cau lac lien tuc cd the bao quan 3-5 ngay. * Chi dinh:

ÁN

Phong xua't huyet cho nhirng benh nhan cd sd lugng tieu cau 15-20x 109/lft,. Cac benh nhan cd sd lugng tie'u cau giam nang (<10xl09/lft) cd bie'u hien xuat

Đ ÀN

huyet nang.

Du phdng chay mau cho cac phau thuat ldn.

D IỄ

Benh nhan phau thuat cd rdi loan chtic nang tieu cau.

* Chong chi dinh: -

Phong xuat huyet d cac benh nhan bi xuat huyet giam tieu cau vd can.

Trong cac benh cd rdi loan chtic nang tieu cau do nguyen nhan ngoai sinh nhu ure huyet cao, benh Von-Willebrand.

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3.2.3.2. Khoi tieu cau phu hgp HLA

H Ơ

Xac dinh nhdm bach cau HLA giua ngudi nhan va cho de tim ngudi cd HLA tuong ddng vdi benh nhan.

Dung phuong phap tach tieu cau bang may tu ddng tti mot ngudi cho mau, cd the7 thu hoach mot lugng tieu cau kha cao, khoang 3-5xlOn tieu cau cho 1 don vi tieu cau, tuong duong vdi 3-5 don vi tieu cau tti ngudn ngudi cho ngSu nhien.

* Chi dinh:

TP .Q U

Su dung cho dieu tri benh nhan xuat huye't giam tieu cau nhay vdi phan ting tieu cau tti ngudi cho ngau nhien khac nhdm HLA. Trong trudng hop nay can danh gia dap ting vdi truyen tieu cau. Cong thtic danh gia:

—

J—

ẠO

Sd luong tieu cau sau truyen - Sd luong tieu cau trudc truyen

'-^

-— x Dien tich co the

Sd lugng tieu cau truyen x 10

Hieuqua =

3.2.4. Khdi bach cau

Tti 1 ngudi cd the' tach dugc: 1 don vi bach cau chtia 10x10'° bach cau hat, mot ft

lympho, tieu cau va hong cau trong khdi lugng 150-200ml.

ẦN

Khdi bach cau chi dugc bao quan trong24 gid sau khi lay mau.

* Chi dinh:

Truyen cho cac benh nhan giam bach cau ca'p tfnh, nhiem trung nang, khang thud'c,

suytuycd bach cau < 0,5 x 109/ lit.

Truyen 4-6 ngay lien, mdi ngay 1 don vi.

Ó A

Khdng dung khdi bach cau cho dieu tri du phdng.

3.2.5. Huyet tuong tuoi ddng lanh (Fresh Frozen Plasma = FFP)

-L

Í-

Huyet tuong tuoi tach tti mau tuoi trong 6 gid dau sau khi lay mau va dugc bao quan d nhiet do tti -20°C den -30°C trong thdi gian 6 thang.

ÁN

Thanh phan: Ngoai nude va dien giai cdn cd albumin, globulin, ye'u td ddng mau. Ngudi ta tfnh rang cti 1ml huye't tuong tuoi ddng lanh chtia 1 don vi hoat tfnh cac yeu td ddng mau.

D IỄ

Đ ÀN

Huyet tuong tuoi ddng lanh ap dung dieu tri cho cac benh nhan bi benh gan thieu cac yeu td ddng mau, benh nhan bi rdi loan ddng mau rai rac ndi mach (DIC), cac trang thai thieu yeu td ddng mau khac nhu mat mau nhieu phai truyen dich (mau bi hoa loang), benh gan cd PT (thdi gian prothrombin) va TPT (thdf gian thromboplastin) keo dai, benh Hemophilia B... Lieu dung dua vao thdi gian prothrombin va thdi gian thromboplastin de dieu chinh, luc dau cd the dung lieu 15ml/kg can nang.

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Khdng nen dung di dieu tri chay mau don thuan hoac cho muc dfch cung cap globulin mien dich.

Cac thanh phan bo the trong che pham nay bi bat hoat hoac giam nhieu trong qua trinh bao quan.

H Ơ

Tua lanh yeu td VIII dugc dieu che bang each lam tan huyet tuong tuoi ddng lanh d

2.2.6. Tua lanh yeu to VIII

4°C, ly tam d 4°C, tua dugc hoa tan trong 10-15ml huyet tuong. 6 dang nay, tua lanh

chtia khoang 80-120 don vi yeu td VIE, 200mg fibrinogen, 40-70% yeu td V.Willebrand, 20-

TP .Q U

30% yeu td VIE. * Chi dinh:

ẠO

Su dung tua lanh dieu tri benh thieu yeu td VIII, benh Von-Willebrand, benh giam fibrinogen huyet tuong, rdi loan ddng mau ndi mach rai rac hoac de dieu tri du phdng

chay mau d benh nhan Hemophili A.

* Cach dung:

Lugng yeu td VIII dugc tfnh bang % so vdi mtic binh thudng (thf du 50% tuong

duong 0,5U/ ml).

ẦN

The tfch HT x[ Luong can (U/ml) -Luong ban dau(U/ml) ] :

'•

—;—:———

80U yeu td VIII / Mot d on vi tua lanh (mot tui tua lanh)

. ,. , ,v 4..

Sd tui can dung dieu tri =

* Lieu dung dugc tfnh nhu sau:

(HT : huyet tuong; U=unit: don vi)

Neu dung cho muc dfch tang fibrinogen thi su dung 200ml fibrinogen/ ttii. Trong

Ó A

trudng hgp cap ctiu, cd the7 dung 10 tui tuong duong khoang 2g fibrinogen de7 dat yeu

Í-

cau cam mau. Cung cd the dung lieu lugng tti 2 - 3ml huyet tuong/ kg trgng lugng co the7, hieu qua cam mau cd the dat khoang 4 tuan cho benh nhan thieu yeu td VIII.

-L

3.2.7. Yeu to VIII cd dac

Yeu td VIII cd dac dugc dieu che bang each chiet tach tti huyet tuong tuoi ddng

ÁN

lanh.

1 don vi qudc te yeu td VIII la lugng yeu td VIII trong 1ml huyet tuong binh thudng.

1 don vi yeu td VIII co dac bang lugng yeu td VIII trong mot ttii huye't tuong yeii to

Đ ÀN

VIII cd dac.

D IỄ

Thdi gian ban huy 12-18 gid. * Chi dinh:

Su dung yeu td VIII cd dac cho cac trudng hop sau:

- Benh nhan Hemophili A do thieu yeu td VIII bam sinh. - Benh nhan cd yeu td tic che' yeu td VIII.

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* Lieu dung dugc tfnh nhu sau:

0 . ,. The tfch HT xf Luong can dung (U/ml) - Luong ban dau (U/ml)

So tui =

—

Sd lugng yeu td VIII / Mot d on vi (mot tui) yeu td VIII cd d ac

H Ơ

Yeu td IX cd dac dugc dieu che' tti huyet tuong cd chtia ye'u td IX va mot sd ye'u td

3.2.8. Yeu to IX cd dac

ddng mau khac (II, VII, X, XI).

* Chi dinh:

TP .Q U

Sir dung yeu td IX cd dac di dieu tri benh thie'u yeu td IX (Hemophilia B), benh thieu yeu td VII, X bam sinh.

ẠO

* Khdng nen dung cho benh nhan bi benh gan. 3.2.9. Albumin

Albumin dugc san xua't tti huyet tuong, thudng d dang dung dich cd ham lugng tti 50 - 250 g/ ml va dugc bao quan d nhiet do - 85°C trong thdi gian dai.

* Chi dinh:

ẦN

Bu the tfch tuan hoan, giam ap luc keo do mat albumin man tfnh nhu suy dinh dudng, suy gan, thay the' lau dai trong bdng dien rong, thay the' huyet tuong trong trudng hop lay huyet tuong nhieu.

* Khdng dung cho muc dfch lam lanh vet thuong hoac cung ca'p chat dinh dudng.

Ó A

3.2.10. Globulin mien dich

* Lieu dung: Tuy thude tinh trang benh.

Dugc cd dac tti huyet tuong d dang ddng khd hoac dung dich vdi ham lugng 0,5- lOg

Í-

protein, dugc dung tiem tinh mach hoac tiem bap.

-L

Thanh phan : Cd 90% la IgG, cdn lai la IgA va IgM.

ÁN

Thdi gian ban huy tti 18-30 ngay.

Bao quan d nhiet do -85°C. * Chi dinh:

Đ ÀN

Tinh trang thie'u hut mien dich the dich, thieu hut mien dich hdn hgp, hgi chting

D IỄ

Wiskott Aldrich, dieu tri benh tu mien, nhat la xuat huyet giam tieu cau vd can, giam yglobulin trong AIDS, bo sung y-globulin binh thudng cho benh nhan bi benh da u tuy (multiplemyeloma), dung sau dieu tri hoa cha't.

* Khdng nen dung cho benh nhan cd trang thai di ting.

* Lieu dung tuy thuoc vao chi dinh.

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3.2.11. Globulin mien dich Rh(D)

La dung dich dam dac chtia anti-Rh (D) IgG, dugc san xuat tti huyet tuong cua ngudi da m5n cam vdi khang nguyen Rh (D).

Mot lieu anti-Rh(D) chtia khoang 300mg du de khang lai 15ml hong cau Rh(+)

H Ơ

hoac 30ml mau toan phan.

Bao quan d nhiet do lanh 2 - 8°C.

* Chi dinh:

Sau khi de d ba me Rh(-) ma dtia tre la Rh(+).

Trudc sinh d tuoi thai tuan thur 28 cho me Rh(-) chua man cam.

TP .Q U

Sau cactrudng hopnghi cd trao doi Rh me - connhusaythai, sot rau, vd di non, thai lac

ẠO

chd,...

Du phdng cho phu nu Rh(-) chua man cam vdi Rh(+) d tuoi sinh de da tiep xtic

vdi hong cau, tieu cau, bach cau cua ngudi Rh(+).

* Lieu dung: 30mg trong 72 gid trudc hoac sau khi ba me tiep xuc vdi hong cau Rh(+) hoac nghi ngd cd trao doi giua me Rh(-) vdi con Rh(+).

ẦN

* Khdng dung cho phu nu Rh(+), me Rh(-) sinh con Rh(-) hoac me Rh(-) da man

cam (da cd anti Rh(D))...

IV. HAU QUA KHONG MONG MUON DO TRUYEN MAU VA CACH XLTLY

4.1. Cac tai bien do bat dong mien dich

Ó A

4.1.1. Phan itng tan mau cap tinh

Xay ra nhanh, ngay trong khi dang truyen mau.

* Benh sinh: Chu yeu do bat ddng nhdm mau ABO. Phan ting khang nguyen (hong

-L

Í-

cau ngudi cho) vdi khang the (huye't tuong ngudi nhan) va vdi su cd mat cua bd the, gay

ÁN

tan mau, trong dd khang the khang A khang B typIgG ddng vai trd quan trong.

* Lam sang: Tfnh cap dien rat ro ret vdi bieu hien sot dot ngdt, lanh, run, dau nguc, dau lung, ndn mira, khd thd, dai ra huyet sac to, vd nieu, xuat huyet, ha huyet ap, sdc...

Đ ÀN

tuy mtic do cua phan ting.

* Xti ly:

D IỄ

Ngting truyen mau, giu nguyen hien trang, mdi can bd nhan vien phdng truyen mau de'n giudng benh xti ly.

Hdi sure tfch cue, nang huyet ap va tang chtic nang lgc cua than, chdng di ting,... -

Thu hdi va lam lai nhdm mau tren cac vat pham hien cd va kiem tra cac thu tuc phat mau, truyen mau, lap bien ban.

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Lam cac xet nghiem: Coombs true tiep, dinh lugng LDH, hematocrit, bilirubin tu do, lugng haptoglobin tu do,...

H Ơ

Tan mau xay ra mudn do bat ddng khang nguyen hong cau bdi cac nhdm mau hie'm nhu: Kell, Duffy, Kidd, Rh. Benh nhan dugc man cam trudc bdi cac lan cho mau trudc do, lan nay truyen mau se tiep tuc man cam tao ra khang the (typ IgG) va mtic khang the

4.1.2. Phan itng tan mau man tinh

TP .Q U

tang len nhanh chdng, lam giam ddi song hong cau, tan mau nhe; benh nhan cd sot, ret run, vang da nhe,...xet nghiem Coombs true tiep duong tfnh. Vi dien bie'n nhe nen khdng can xti ly gi. 4.1.3. Phan itng di ung

Phan ting di ting xay ra cd the gap d hai mtic do:

ẠO

4.1.3.1. Ngua man, noi may day, khong sot

Gap d cac benh nhan cd tien su di ting va thudng gap sau khi truyen mau, nha't la truyen hong ca\i, tieu cau, mau toan phan cd nhieu bach cau. Cac san pham nay tao ra histamin va cac chat gay hoat mach khac tti cac te'bao cd gan IgG, IgE be mat.

ẦN

Dieu tri: Khdng can thiet, song neu keo dai va nang cd the cho khang histamin, hoac cho du phdng khang histamin trudc khi truyen mau, nhat la ddi vdi cac ca the cd co dia di ting.

4.1.3.2. Phan ve

Phan ve trong truyen mau hiem gap; neu cd thudng tha'y d cac benh nhan bi thieu

hut IgA.

Khi truyen mau lam tang khang the7 IgA (anti IgA). Ddi vdi trucmg hop nay chi nen truyen mau lay tti ngudi thieu IgA hoac truyen hong cau rira loai bd huye't tuong.

Ó A

Xti ly: Khi gap sdc phan ve, can ngting ngay truyen mau, ddng thdi tang cudng hdi stic, nang huyet ap, tang sure lgc cAu than.

-L

Í-

4.1.4. Phan itng mien dich dong loai sau truyen mau

Truyen mau, dac biet la truyen mau cd nhieu bach cau va tieu cau (truyen mau toan

ÁN

phan) cd the gay phan ting mien dich ddng loai do khang nguyen tuong ddng to chtic HLA cd mat tren cac te' bao lympho va tieu cau hoac do khang nguyen hong cdu (khdng phai khang nguyen A va khang nguyen B).

Đ ÀN

4.1.4.1. Mien dich chong hong cau

D IỄ

Cac khang nguyen ngoai A, B ciia hong cdu dong loai, cd the gay dap ting mien dich tao khang the chdng hong cau. Khi truyen mau, hong cau cd khang nguyen tuong tu se gay phan ting dac hieu lam tan mau hoac ngung ket.

Xti ly cac benh nhan nay gidng nhu cac trudng hop truyen mau khac. Cd the7 dieu tri du phdng bang each phat hien va xac dinh tfnh khang the. Khi phat mau, can lam ky cac

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phan ting cheo di tim don vi mau phu hop nhat, ddng thdi chi dinh truyen cac thanh phan mau nhu khdi hong cau hoac hong cau rira, khdi tieu cau phu hop vdi cac ca the nhay cam hoac cd the dung corticoid. 4.1.4.2. Dong miin dich chdng tieu cau

H Ơ

ngudi cho va ngudi nhan; thudng gap d benh nhan truyen mau nhieu lan do nguon mau tti nhieu ca the khac nhau nen gay ra phan ting mien dich tao khang the chdng tieu cau trong co the nhan; nhirng lan truyen tieu cau sau khdng cd hieu luc nhat la d cac benh

Dong mien dich chdng tieu cau do sukhdc nhau ve khdng nguyen he HLA giua tie'u cau

TP .Q U

nhan Leukemia, xuat huyet giam tieu cau, suy tuy, ung thu.

Dong mien dich chong tieu cau do khdng nguyen dac hieu tieu cau (P„ A,) thudng gap a nhirng benh nhan khdng cd khang nguyen tieu cau, hoac me khdng cd khang

ẠO

nguyen tieu cau.

Cac trudng hop bat ddng khang nguyen HLA tieu cau hoac khang nguyen tieu cau ke tren khi truyen mau hoac truyen tieu cau nhieu lan se gay phan ting mien dich dac

hieu lam tan tieu cau, giam tie'u c5u nghiem trgng vdi cac bieu hien xua't huye't nang ke7

ca xuat huyet nao; xet nghiem thay sd lugng tieu cdu giam nang hon trudc khi truyen

tieu cau. Cac dau hieu xuat huyet nang thudng gap trong 24 gid dau sau khi truyen mau.

4.1.4.3. Dong mien dich chong bach cau

ẦN

Xti ly: Cd the' dung ky thuat thay the huyet tuong de loai bdt khang the, truyen hong cau rua, tim ca the tuong ddng khang nguyen tieu cau de cung captie'u caucho benh nhan.

Tuong tu nhu ddng mien dich chdng tie'u cau do khac nhau ve HLA, ve khang nguyen dac hieu bach cau. Trong cac trudng hop truyen mau nhieu lan cd lan bach cau

Ó A

se gay dap ting mien dich tao khang the chdng bach cau trong co the nhan. Khang the7 nay cd the chdng lai bach cau cua ban than (nhu tu khang the) lam giam bach ca\i, nhat

Í-

la bach cau hat sau khi truyen mau.

-L

Xti ly: Truyen mau tirng phan, lgc bach cau.

ÁN

4.1.5. Benh md ghep chdng vat chu do truyen mau

(Graft-Versus-Host-Disease = GVHD)

Benh md ghep chdng vat chu do truyen mau khac vdi benh md ghep chdng vat chu do

Đ ÀN

truyen tuy: GVHD do truyen mau la do cac te'bao lympho T cd tham quyen mien dich cua mau

D IỄ

ngudi cho truyen vao co the ngudi nhan bi suy giam mien dich nghiem trgng. Cac lympho nay phan ting vdi khang nguyen tuong ddng to chtic (MHC-HLA) cua ngudi nhan, tao thanh cac lympho doc (cytotoxic T lymphocytes) hoac hoat hoa T-CD4 tao ra cac cytokin.

Ca hai thanhphan nay tac ddng lam huy hoai td chtic cua co the nhan, gay GVHD. Benh GVHD gap trong cac trudng hop truyen mau toan phan khdi lugng ldn, truyen bach cau hat, truyen khdi tieu c£u, khdi hong cau.

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Cac bieu hien lam sang thudng gap: Sot, ia chay, u hat da, ban xuat huyet. Xet nghiem thay 3 ddng te' bao mau deu giam. Benh xuat hien trong thdi gian ngan, khoang

H Ơ

Xu ly: Dieu tri GVHD do truyen mau khd dem lai ke't qua: thudng dung corticoid, khang the chdng lympho T, cyclosporin A, hoac cac hoa cha't khac. Cd the han che' benh md ghep chdng vat chu do truyen mau bang each chie'u xa tui mau nham ba't hoat lympho T trudc khi truyen cho benh nhan. Day la bien phap huu hieu nhat phdng GVHD

30 ngay sau truyen mau.

trong truyen mau.

TP .Q U

4.1.6. Phan itng sot khdng do tan mau sau truyen mau

ẠO

Nguyen nhan gay sot do truyen mau cd the do phan ting tan mau, nhung cung cd the7 do khang nguyen bach cau, tieu call d mau ngudi cho phan ting vdi khang the' dac hieu cd mat trong mau cua ca the nhan. Xua't hien trong mau ngudi nhan khang the7 chdng

bach c£u, tie'u cau, thudng ggi la cac ngung ket td. Cac ngung ke't to nay cd the' dac hieu

vdi HLA hoac dac hieu vdi khang nguyen khac ngoai he HLA cua bach cau. Khang the7 nay xuat hien d nhung ca the truyen mau nhieu lan bao gom truyen mau toan phan, truyen khdi hong cau, khdi bach cau hat, khdi tie'u cau. Nhirng lan truyen mau sau se

ẦN

xuat hien phan ting khang nguyen khang the7 vdi su cd mat cua bo the giai phdng ra cac cha't gay sot.

Lam sang: Sot, ret run sau truyen mau, ddi khi xay ra ngay khi dang truyen mau. Trudng hop nay cd the' phai ngting truyen mau.

Xti ly: Bang each xac dinh chic chan nhung phan ting tuong ddng trudc khi truyen

mau. Thuc hien trao doi huyet tuong de loai bdt khang the, lgc bach cau, tie'u cau trudc

Ó A

khi truyen cac san pham cua mau, ngoai ra can kie'm tra tinh trang nhiem trung bao gom

lien cau, tu cau hoac cac virus viem gan...

-L

Í-

4.1.7. Phii phoi cap do truyen mau

Thu pham chfnh gay tinh trang nay la cac khang the ddng loai dac hieu bach cau,

ÁN

tieu cau. Cac khang the nay cd the cd san trong mau cua ngudi cho hoac ngudi nhan. Thudng gap d phu numang thai nhieu lan hoac benh nhan truyen mau nhieu lan. Do tuong tac khang nguyen - khang the' lam cho bach cau, tieu cau ngung tap d he vi mach phoi,

Đ ÀN

tti day giai phdng ra cac chat gay hoat mach, lam tang tha'm mach, thoat huyet tuong va te baomau lam cac thanhphan nay tran vaophe' nanggay phu phdi.

D IỄ

Xti ly:

Lgc bach cau, truyen mau tting phan, neu khang the nay d ngudi cho thi can truyen hong cau rua.

Khi cd bieu hien phu phdi: Ngting truyen mau, cho corticoid lieu cao, dieu tri con phu phoi ca'p.

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4.2. Mac cac benh nhiem trung do truyen mau

Mac cac benh nhiem trung qua dudng truyen mau cd the do cac nguyen nhan

TP .Q U

H Ơ

- Mau lay ra bi nhiem do thao tac trong qua trinh lay mau, tach cac thanh phan mau, bao quan mau va khi truyen mau cho benh nhan. Trong trudng hop nay cd the nhiem vi trung bao gom tu cau, lien cau... hoac nam. Nguyen nhan nay hien nay ft gap do dieu kien tiet trung tot hon, cac phuong tien lay mau hien dai hon (dung tui chat deo lay mau, tach cac thanh phan mau va truyen mau deu dugc thuc hien trong vdng km). Tuy nhien van cdn nguy co lay nhiem, nen can dugc chu y.

- Mau ngudi cho bi nhiem ngay trong co the cua hg ma cac ky thuat sang lgc khdng

phat hien dugc, hoac lay mau trong giai doan ctia sd chua cd chuye'n doi huyet thanh nen xet nghiem khdng phat hien dugc benh nguyen. Bang dudng nay cd the'

ẠO

gap lay do ky sinh trung sot ret, xoan trung giang mai, virus HIV, HCV, HBV.

Sau day se gidi thieu cac benh nguyen chfnh:

4.2.1. Do nhiem cac virus truyen qua dudng mau

4.2.1.1. Cac virus viem gan

ẦN

- Nhiem virus viem gan C (HCV): Day la virus truyen qua dudng truyen mau, cd tdi tren 90% viem gan sau truyen mau la do virus nay. Bieu hien lam sang ra't Id md: Khoang 25% cd trieu chting vang da, sot, cdn chu ye'u la cac bieu hien am tham nhu met mdi, chan an. Xet nghiem thay tang men gan. Neu sau truyen mau tren 2 tuan le thay benh nhan cd bieu hien met mdi, chan an thi can lam xet nghiem tim anti

HCV va men gan.

Ó A

- Nhiem virus viem gan B (HBV): It gap viem gan B do truyen mau so vdi viem gan

ÁN

-L

Í-

C. Tuy cd sang lgc huyet thanh nhung van cd the lay do lay mau d giai doan ctia so. Thdi gian u benh dai: 6-11 tuan. Bieu hien lam sang ra't ft, cd tdi 60% trudng hop khdng cd dau hieu lam sang. Sau truyen mau neu nghi bi nhiem HBV can lam cac xet nghiem tim cac dau an viem gan d huye't thanh nhu HBsAg, HBeAg, antiHBc, anti-HBs, anti- HBe.

D IỄ

Đ ÀN

- Nhiem virus viem gan D (HDV): Day la loai virus nhiem phdi hgp (coinfection) vdi HBV, vi ldi cua chting thuoc nhdm ARN, vd HBsAg, ndn thudng kem theo viem gan B va lam sang bieu hien la mot viem gan nang. Khi nghi ngd viem gan B sau truyen mau, can lam xet nghiem sang lgc, su dung HBsAg, neu HBsAg (+) thi lam xet nghiem tim anti- HDV-IgM.

- Nhiem virus viem gan G (HGV): Day la mot virus mdi phat hien truyen qua dudng

truyen mau. Nhung virus HGV cd phai la virus gay viem gan khdng thi cdn dang ban cai song ve nguon gdc chting thuoc hg Flavivirideae. Khi nghi ngd can lam xet nghiem tim anti -HGV trong huyet thanh. 90

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- Nhiem virus TTV (Transfusion Transmitted Virus): Day la virus mdi gay viem gan, cd nhan la ADN, truyen quaducfng truyen mau. CJ Viet Nam chua xacdinh cd hay khdng. 4.2.1.2. Nhiem HIV1,HIV2

H Ơ

Day la nguy co ldn do truyen mau. Mau ngudi bi nhiem HIV nhung chua cd chuye'n doi huyet thanh (nghia la chua cd cac dau an dac biet HIV trong huye't thanh cd the' phat hien dugc) hoac da cd chuye'n doi huyet thanh nhung ky thuat chua du nhay, hoac chua cd ky thuat phat hien do vay khi sang lgc huyet thanh cho ket qua am tfnh (-). Mau nay truyen cho benh nhan se bi lay nhiem HIV, lay nhiem nay dugc ggi la nhiem trung ctia

TP .Q U

so (window infection).

De han che' lay nhiem HIV do truyen mau c£n: Tim nguon ngudi cho mau an toan,

gidi thieu cac yeu td nguy co de hg tu sang lgc, kham tuye'n chgn ngudi cho mau ky

ẠO

cang, bo sung cac xet nghiem cd do nhay, do dac hieu cao de rut ngdn thdi gian ctia so huyet thanh, tien hanh truyen mau tting phain, han che' truyen mau toan phan, su dung cac ky thuat lgc bach cau, truyen mau tu than. Cd van dung tong hop cac bien phap tren mdi cd co hdi han che' tdi da lay nhiem HIV qua dudng truyen mau - mot nguy co lay

nhiem rat dang tiec, gay nhieu bat hanh va du luan xa hdi.

ẦN

4.2.1.3. Nhiem HTLV1-2 (Human T lympho Leukemia virus)

HTLV1 la virus cd the gay Leukemia va u lympho d ngudi. Tai Nhat Ban, virus nay

da gay thanh dich. 6 nude ta ty le nhiem HTLV rat thap, tuy nhien vi sd lugng nghien

ctiu cdn ft nen cung can cd dieu tra d nhieu vung vdi sd lugng nhieu hon neu cd ty le

nhiem cao thi phai dua vao sang lgc ngudi cho mau.

Ó A

4.2.1.4. Cac virus thuoc nhom Herpes

Í-

Trong nhdm nay cd CMV (Cytomegalovirus) va EBV (Epstein-Bar virus) cd the7 truyen qua dudng truyen mau. Qua dieu tra thay d nude ta ty le ngudi khoe manh cd

-L

khang the7 cua hai virus nay kha cao (60-70%), mat khac qua theo ddi truyen mau lam sang thay hiem gap benh nhan bi CMV, EBV do truyen mau, cd the7 vi phan ldn benh

ÁN

nhan da cd khang the chdng CMV, EBV, do dd viec sang lgc ngudi cho mau cd nhiem 2 virus nay chua can thiet. Tuy nhien ddi vdi ghep tuy, ghep than, ghep gan thi sang lgc

Đ ÀN

cac virus nay la can thiet. 4.2.2. Do nhiem cac vi khuan

D IỄ

Mot trong cac vi khuan lay qua dudng truyen mau la xoan khuan giang mai (Treponema pallidum). Lay nhiem qua truyen mau lay tti ngudi cho mau bi giang mai; lay do khdng sang lgc hoac cd sang lgc nhung d giai doan ctia sd khdng phat hien dugc. Du phdng lay nhiem giang mai cd 2 bien phap: - Sang lgc huyet thanh can than vdi kit cd do nhay, do dac hieu cao.

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- Bao quan mau dai ngay d nhiet dd thap (4-6°C). Cach nay khdng phu hop vdi khdi tieu cau va khdi bach c£u vi hai san pham nay can truyen ngay va nhiet do bao

quan cao nen khdng du giet dugc xoan khuan. Vi vay de du phdng lay nhiem giang mai van phai dua vao su tu nguyen cua ngudi cho mau va sang lgc huyet

thanh hoac truyen mau tu than.

H Ơ

4.2.3. Nhiim ky sinh triing

Cac ky sinh trung truyen qua dudng truyen mau cd the ke: Sot ret, giun chi,

Trypanosoma, Schistosoma.^ nude ta nen dac biet chti y ky sinh trung sot ret vi dich

TP .Q U

sot ret cdn luu hanh, ngudi mang trung lanh cdn cao, do dd van cd nhieu nguy co lay qua dudng truyen mau.

ẠO

Ve lam sang: Thudng sau truyen mau 1-3 ngay, benh nhan bi sot, mac du khdng cd bang chting dich te nhung chung ta van phai xet nghiem tim ky sinh trung sot ret, lam xet nghiem ngay trong con sot, phai tim ky tren lam kfnh de chan doan. Du phdng: Phai xet nghiem sang lgc ky ngudi cho mau. Ngoai ky thuat tren lam kfnh, phai tim ky sinh trung sot ret tti50-100 vi trudng cho mot mau xet nghiem. Cd the dung ky thuat tap trung ky sinh trung sot ret (QBC), ky thuat nay gia thanh khoang

ẦN

1USD/mau xet nghiem.

4.3. Cac bien chirng do truyen mau khdi lugng ldn

Truyen mau khdi lugng ldn la thay mot khdi lugng mau bang che' pham mau trong 24 gid. Thudng ap dung trong chan thuong, phau thuat mach mau, phau thuat ghep gan...Truyen mau khdi lugng ldn cd the xay ra cac tai bien ma cac tai bien do khdng

Ó A

gap trong truyen mau khdi lugng nhd.

4.3.1. Rdi loan huyet tuong

Í-

Nguyen nhan rdi loan huyet tuong do truyen mau khdi lugng ldn:

-L

- Truyen mau toan phan hoac khdi hong cau cd ft tieu cdu. Mau nay pha loang vdi

ÁN

mau cua ngudi nhan, do vay tieu cau va chat ddng mau bi pha loang trong tuan hoan lam cho de chay mau hoac tang chay mau.

- Do giam cung cap mau d to chtic va do rdi loan ddng mau, ddng mau ndi mach

Đ ÀN

lam giam tieu cau va cac cha't ddng mau.

Xti ly: Can dua vao ket qua xet nghiem ddng mau bao gom xet nghiem tie'u cau va

D IỄ

cac yeu td ddng mau.

4.3.2. Nhiem doc citrat

Nguyen nhan nhiem doc citrat la do truyen nhieu mau kem theo cha't chdng ddng cd citrat lam tang lugng citrat trong mau benh nhan, gay rdi loan chtic nang tim do giam calci mau.

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Xti ly: Cho tiem calci clorid, calci gluconat. 4.3.3. Ha than nhiet

Nguyen nhan: Lugng ldn mau bao quan nen khi truyen vao co the9 sd lugng nay se thu nhiet lam giam than nhiet. Viec ha than nhiet cd the7 lam giam calci mau, tang lien ket cua phan tti Hb vdi oxy, lam giam trao doi oxy td chtic, gay rdi loan nhip tim tien

H Ơ

lugng xa'u.

4.3.4. Mat cdn bdngkiem toan

TP .Q U

Truyen mau khdi lugng ldn cd the7 gay nhiem toan chuyen hoa do thieu oxy to chtic vi cung cap mau cho td chtic bi giam do tang lien ke't HST-02. Cung cd the7 bi nhiem kiem vi tang cudng sinh bicarbonat tti citrat va lactat.

ẠO

Xti ly: chu ye'u phuc hdi tuan hoan, nang huye't ap de du ap luc tudi mau cho td chtic lam giam rdi loan chuye'n hoa cac chat, tao dieu kien duy tri thang bang kiem toan.

4.3.5. Mat cdn bdngkali

Cd the gap hai chieu hudng:

- Tang kali do mau truyen vao da cd kali trong huye't tuong hoac trong hong cau.

ẦN

- Giam kali mau gay nhiem kiem chuyen hoa thti phat do chuyen citrat thanh

bicarbonat.

4.3.6. Chan thuong hong cau

Ó A

4.3.7. Nhiem hemosiderin

Nguyen nhan do bom hut mau, do lam am mau khdng dung qui each.

KET LUAN

ÁN

-L

Í-

Mdi khdi hong cau chtia khoang 200mg sat. Cac benh nhan phai truyen mau thudng xuyen, nhieu lan (d benh nhan Thalassemia) thi tinh trang nhiem hemosiderin la khd tranh. Can lgc bdt bang each sir dung deferoxamin.

Đ ÀN

Truyen mau la mot phuong phap dieu tri hd trg cho cac trudng hop thieu mau hoac thie'u cac thanh phan mau. Tuy nhien, neu truyen mau ma khdng dam bao an toan ve mien dich va nhiem trung thi hau qua gay ra se vd cung nguy hiem.

D IỄ

Truyen mau chi cd hieu qua thuc su neu cd chi dinh diing; mau dugc truyen cd cha't lugng bao dam va trong dieu kien bao quan dung quy dinh.

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TP .Q U

H Ơ

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ẠO

Phan II

SU DUNG THUOC

•

D IỄ

Đ ÀN

ÁN

-L

Í-

Ó A

ẦN

TRONG DIEU TRI

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Chirong VI

SIT DUNG THUOC TRONG DIEU TRI

H Ơ

CAC BENH VE MAT

I. NHUNG NGUYEN TAC DIEU TRI CHUNG TRONG KHOA MAT

TP .Q U

Tren lam sang, cac ton thuong mat rat da dang bao gdm tti cac tdn thuong nhe nhung gay kfch thich khd chiu nhu viem ket mac di ting, khd mat den nhung tdn thuong

nang nhu nhiem trung nang de doa thi luc. Mot sd trudng hgp cd the dugc dieu tri vdi cac che pham thud'c thdng thudng hoac tu qua khdi nhung phan nhieu cac ton thuong khac ddi hdi su dieu tri tfch cue, thudng xuyen, phdi hgp thud'c bang nhieu dudng vdi su

ẠO

hieu biet thau dao ve tac dung ciia cac thud'c

Dieu tri hoc trong nhan khoa cd nhiem vu sir dung thud'c de phuc hdi dugc hoat ddng ciia nhung ton thuong benh ly ciia md mat. Thud'c dung trong khoa mat dugc dua

vao co the theo nhieu dudng dua thud'c khac nhau: Tai chd hoac toan than. Sau khi vao co the, thuoc vao mau qua nhirng hang rao tu nhien nhu niem mac rudt-da day ( neu dua dudng udng) hoac true tiep vao thang mau (neu tiem tinh mach), sau dd chiing ket hop

ẦN

vdi protein ciia mau va ton tai trong huyet tuong dudi dang hda tan rdi thud'c ngam vao

cac md, trong do cd md va cac mdi trudng cua mat, qua ndi md cua mao mach. De tien hanh dieu tri cac benh d mat mot each diing dan, can chu y mot sd van de

- Sir ngam thuoc vao md cua mat.

- Sir phan bd thud'c trong md cua mat.

-L

cua mat.

Í-

Ó A

- Thdi gian duy tri thud'c trong md mat va tdc do bai xuat cua thudc(dugc ddng hgc). - Sir bien ddi ciia thud'c trong md mat (su trao ddi chat). - Sir anh hudng cua thud'c len nhung qua trinh sinh ly, hoa hgc... cua md va te bao

ÁN

- Su tuong tac ciia cac thud'c khi dung ddng thdi. Trong dieu tri can chii y rang viec dieu tri khdng cd ket qua cd the do: - Chon thud'c khdng diing.

Đ ÀN

- Dung thud'c khdng du ndng do d trong mau, md va te" bao cua mat. - Giam tac dung cua thud'c do sirdung qua dai ngay gay nhdn thud'c.

D IỄ

Trong viec lira chon thud'c dieu tri thfch hop, can chii y den nhirng mtic do bieu hien cua tdn thuong: Ton thuong nhe thi dung thud'c d ndng do nhe; ton thuong nang thi dung thud'c d ndng do va lieu lugng cao hon va luc nay can chu y vi cd the gay doc.

Do cau tao giai phau dac biet cua mat (hinh 6.1) nen trong dieu tri nhung benh d mat, viec dieu tri tai chd la chu yeu: Vf du dieu tri nhung benh cua phan phu mat va benh cua

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phdn trudc nhan cau. Viec dieu tri toan than phai tuy theo tting chi dinh rieng biet. Cac

thud'c sirdung tai chd (tac dung true tiep den te'bao va md bi ton thuong) cd nhieu ndng do va d nhieu dang bao che khac nhau : Dung dich, dich treo, mang thud'c, thud'c mo, Nhirng thud'c sir dung tai chd cung khdng tham vao md va te' bao nhu nhau, thf du cac hoat chat vtia than nude, vtia than lipid cd mtic do ion hoa vtia phai thi de dang tha'm qua

D IỄ

Đ ÀN

ÁN

-L

Í-

Ó A

ẦN

ẠO

TP .Q U

H Ơ

giac mac.

tiem dudi ket mac, dua thud'c vao bao Tenon, hau nhan cau, tien phdng hay dich kfnh.

1- Gdc tien phdng. 2- Tien phdng.

12- Day than kinh thi giac

3- Mach the mi trudc.

14- Hau phdng.

4- Giac mac.

15- Mach the mi sau.

5- The mi.

6- Hac mac.

16- Pars plana. 17- V5ng mac.

7- Ke't mac nhan cau.

18-Co true.

13- Oraserrata.

8- 6ng Schlemm.

19- Cung mac.

9- Hoang diem. 10- Mong mat. 11-The thuy tinh.

20- Mo dudi ket mac. 21-Dich kfnh.

22- Day chang Zinn

Hinh 6.1. Thiet do cat doc nhan cau

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Ngudi ta tha'y rang viec dua thud'c vao mat bang dien di hoac dung song sieu am dat hieu qua cao hon ca. Thud'c dieu tri tai chd (thud'c tra) se tham vao ket mac, giac mac va nhanh chdng vao he tuan hoan rdi dugc toa di khap co the. Thud'c theo dudng tiem se tham vao mat qua hang rao mau-mat (hinh 6.2). MAU

k& VM

^wmwM^:^i^ Ghi chu:

H Ơ

MAU

»»»>}»»»»M

TP: tien phdng VM: vdng mac HP: hau phdng —» chieu di chuyen

TP .Q U

ẦN

ẠO

cua thud'c

Hinh 6.2. So do tuan hoan tai mat va hang rao mau-mdt.

Ó A

Trong dieu tri nhirng benh cua mach mac (mang bd dao), vdng mac, than kinh thi giac... nen phdi hop dieu tri tai chd (tra, tiem hau nhan cau) va dieu tri toan than. Viec phdi hop la phuong phap tdi uu. Tuy vay gin day cac bac si nhan khoa thudng hay nhan thay nhung phan ting am tfnh trong dieu tri. Nguyen nhan cd nhieu song mot trong nhirng nguyen nhan do la viec sirdung phdi hop thud'c khdng dting.

Í-

Nhirng yeu td quyet dinh trong viec tang hieu qua cua dieu tri nhirng benh

-L

nhan khoa la:

ÁN

1- Chan doan dting va kip thdi.

2- Chgn thud'c thfch hgp.

3- Xac dinh dting lieu va chgn dugc dudng dua thud'c thfch hop.

Đ ÀN

4- Dieu tri phdi hop kip thdi va thdi gian sir dung dung.

5- Khi can cd the phdi hop dung dan vdi cac phuong phap dieu tri khac (vat ly tri

D IỄ

lieu, laze, lanh ddng, phau thuat.. .).

Thud'c sau khi dua vao mat khdng phai chi cd tac dung tai chd tren mat ma cdn gay tac dung toan than. Cac phan tti thud'c (ndi chung) de dang chuyen ddng tti mot vung

cua mat den vung khac hoac vao ddng mau bang each tha'm tha'u thu ddng nhd cac ye'u td sau:

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- Tinh trang cua to chtic mat: Su tdn hai cua to chtic cho phep chuye'n giao cac phan tti thud'c vd'n khdng the tham vao mot td chtic lanh manh binh thudng. Thf du nhu viem nhiem luon lam tang su tham tha'u thud'c vao viing chiu tac dung.

H Ơ

- Tuoi tac anh hudng den che tiet nude mat: 6 tuoi gia, su giam che tiet nude mat,

- Khi mat cuong tu dd, su din truyen thud'c tang len dan den tang ha'p thu toan than che' pham thud'c nhan khoa va do dd tac dung phu toan than tang len.

tui le lao hda ... dugc cho la cd anh hudng de'n hap thu va phan bd thud'c. Tuoi rat tre va rat gia cd xu hudng de hap thu thud'c tra mat hon nen de dang gap tac dung

TP .Q U

phu toan than hon.

Nhung cau true mat dugc coi la phan trudc gom cac to chtic trudc the7 thuy tinh (I'll) nhu ket mac, cung mac, giac mac, md'ng mat, the mi va thuy dich (hinh 6.1)dugc cac thud'c xuyen qua rat tot. Tuy vay cac thud'c nay hiem khi xuyen qua phan trudc nhan

ẠO

cau du de' de'n dugc phan sau (dich kfnh va vdng mac). Cac thud'c toan than vao mat qua

ddng tuan hoan. Hac mac va vdng mac la cau trtic giau mach nen nhan dugc su cung ca'p thud'c ldn nhat tti dudng nay. Cac thud'c toan than cung cd the' de'n dugc cac vung khac ciia mat bang tham tha'u tti cac mach mau khac quanh mat.

ẦN

Thdi gian keo dai tac dung thud'c phu thuoc nhieu vao dang bao che; thf du: Thanh phan hoat tfnh trong thud'c tra mat dugc ha'p thu tot khi d dang nude hon dich treo, thud'c md mat hap thu kem hon hai dang kia nhung lai cd tac dung keo dai nha't. Cac hat thud'c dugc tim may trong dich treo nude hoac dau bi thai dan khi chung hoa tan trong nude mat.

II. CAC THUOC THONG THUtJNG TRONG KHOA MAT

-L

Í-

Ó A

Cac ton thuong tai mat ra't da dang va phtic tap. Mdi benh ddi hdi mot su dieu tri rieng biet vdi cac thud'c khac nhau va bang nhieu dudng phdi hop. Cac che' pham thud'c dung tai mat cd rat nhieu. Chuong nay se de cap den nhirng loai thud'c thudng dung trong nhieu benh mat khac nhau va cac ggi y chung cho dieu tri.

ÁN

2.1. Cac che pham khang sinh

Trong cac ton thuong tai mat, viem cd kem nhiem trung la qua trinh pho bie'n hon

Đ ÀN

ca. Cac ton thuong loai nay phln ldn la cac trudng hop nhiem trung true tiep; mot phan nhd la cac qua trinh viem khdng do nhiem trung true tiep ma do cac co che'mien dich-di ting, sau do bdi nhiem; do dd khang sinh la thud'c dugc su dung ra't pho bien trong nhan

D IỄ

khoa.

Cac khang sinh diet khuan hien dugc sir dung ca dudng udng va dudng tiem la cac penicilin (bao gom ca cac penicilin ban tong hop), cac cephalosporin, cac aminozid (streptomycin, kanamycin, gentamicin, tobramycin va amikacin), vancomycin. Khang sinh diet khuzin chi dung tai chd ( nhd va tra mat) la bacitracin, neomycin va polimyxin B.

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Cac khang sinh kirn khuan hien dugc sir dung bao gom tetracyclin, chloramphenicol, erythromycin, clindamycin va cac sulfonamid, dugc dung trong nhan khoa theo ca 2 dudng-

H Ơ

Gidng nhu dieu tri khang sinh toan than, viec sir dung khang sinh tai mat cung cd the7 gap nhung nguy hiem nhu: Man cam hoac dac ting vdi thud'c, ton hai do doc tfnh cua thud'c, khang thud'c va thay doi can bang vi sinh vat tai mat. Su thay doi vi khuan chf d ket mac thudng xay ra sau khi sirdung khang sinh tra mat keo dai lam tang sinh nam d

tai chd va toan than.

tui ket mac.

TP .Q U

2.1.1. Lua chon khdng sinh

Viec lua chgn va sirdung khang sinh phu thude vao nhung yeu td sau:

- Ban chat cua tac nhan gay benh (vi khuan) va su nhay cam cua chung vdi khang

ẠO

sinh.

- Ban chat cua benh, do tram trgng va vi tri bi benh.

- Stic khoe chung cua benh nhan, dac tfnh man cam di ting cua benh nhan.

ẦN

Viec phan lap vi khuan gay benh va lam khang sinh do ra't quan trgng va cd lgi. Tuy nhien do phai chd ket qua xet nghiem nen cd the gay tri hoan viec dieu tri mot each dang ke. Bdi vay, viec dieu tri bang khang sinh thudng bat ddu theo kinh nghiem. Nhirng trudng hop nhiem trung nhe tai chd nhu viem bd mi, viem ket mac khdng dang phai ton kem cho xet nghiem nudi cay vi khuan va lam khang sinh do. Bang viec dieu tri theo kinh nghiem, ngudi ta cd the chua khdi benh trudc khi cd day du xet nghiem. Viec phan lap tac nhan gay benh chi can thiet khi dieu tri cac nhiem trung mat nang nhu loet giac mac, viem to chtic hoc mat, viem ndi nhan...Nhung trudng hop nay chi dieu tri theo kinh

Ó A

nghiem khi khdng the' lam dugc khang sinh dd.

De dieu tri tai chd cd the7 sirdung cac khang sinh cd hoat tfnh manh nhung do doc tfnh

ÁN

-L

Í-

cao nen ft dugc dung dudng toan than nhu neomycin, bacitracin (hoac gramicidin) va polymixin B. Thud'c nhd mat gentamicin va tobramycin cd hieu qua tot trong dieu tri cac nhiem trung nang do vi khuan Gram am. Cac khang sinh dua tai chd phai khdng gay kfch ting. Thf du: tetracyclin, cloramphenicol, gentamicin, sulfacetamid va sulfamethoxazol la

nhung thud'c cd hieu qua tot va hay dugc dung; neomycin cd kha nang diet khu&n tot nhung

Đ ÀN

lai thudng gay ra phan ting man cam tai chd.

D IỄ

Cd 2 chi dan de giup cho viec dieu tri theo kinh nghiem dat ket qua tot, dd la:

- Can nam vung mdi quan he giua vi tri nhiem khufo va tac nhan gay benh.

Thf du: Nhiem khuan ndi nhan sau mo thudng gay ra bdi tu cau hoac true khuan Gram am; cac loet giac mac trung tam thudng do phe'cdu, lien call hoac true khuan Gram duong. - Theo ddi chat che dap ting lam sang cua benh nhan sau khi dung thud'c. Neu sau

100

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48-72gid dieu tri bang khang sinh vdi lieu vtia du ma khdng thay bien chuyen tot hon thi nen chuyen sang khang sinh khac.

TP .Q U

H Ơ

Khi phai dieu tri khang sinh toan than, viec ke don rieng re cd le phu hop hon la cac thuong pham phdi hop san vi chgn dugc lieu thfch hgp vdi ca the tuy theo mtic do nang nhe ciia benh. Ddi vdi thud'c tra mat thi trai lai, cac khang sinh phd'i hop dang thuong pham ra't cd hieu qua.

Trong trudng hop nhiem khuan nang chua cd xet nghiem , cd the ap dung khang sinh pho rong hoac phdi hop khang sinh, thf du mot khang sinh nhdm aminoglycosid va mot cephalosporin tiem dudi ket mac ket hop tra tai mat.

ẠO

Trudc day, hau het cac nhiem trung d mat chu ye'u la do vi khuan; cdn nhiem virus va nam hiem gap hon. Vai nam gan day do viec sir dung khang sinh manh va corticoid mot each btia bai, nhiem trung mat do nam (dac biet nhiem nam giac mac) trd nen pho bien hon va tram trgng hon, de dga thi luc cua nhieu benh nhan. Do vay mgi khuyen cao dp dung cho khdng sinh toan than cung dung cho khdng sinh tai mat. Viec sir dung

ẦN

2.7.2. Dudng dua thuoc trong dieu tri nhan khoa

khdng tien lugng trudc dugc.

khdng than trgng cd the7 dan de'n tac hai hoac cd the7 gap hien tugng man cam do thud'c

Khang sinh cd the dugc sir dung tai chd, dudi ket mac, trong tien phdng hay toan

than de dieu tri cac tdn thuong mat.

Thud'c tra mat thudng la du de dieu tri hau he't cac viem ket mac va loet giac mac ndng. Dudng toan than can thiet trong dieu tri nhirng nhiem trung ndi nhan, hoc mat va cung cd the cd gia tri trong dieu tri viem ket mac nang nhu viem ket mac do lau cau hay

Ó A

loet giac mac nang. Tiem dudi ke't mac phdi hop toan than chi dinh trong nhiem trung

ndi nhan nang va mot sd loet giac mac.

ÁN

-L

Í-

Tiem khang sinh vao budng dich kfnh ngay nay dugc chi dinh nhieu hon trong dieu tri viem ndi nhan do vi khuan; lugng khang sinh dugc dung chi ra't nhd (0,1-0,2ml) vdi ndng do thap vi ndng dd cao se rat doc cho the thuy tinh va vdng mac. Thud'c dieu tri ton

tai dugc trong dich kfnh 72- 96 gid.

Đ ÀN

Khi da chgn lua dugc khang sinh va dudng dua thud'c tot nha't, cdn phai tfnh den dd tham thau cua thud'c vao to chtic bi nhiem trung. Dieu nay dac biet can thie't trong cac

D IỄ

nhiem trung ndi nhan vi nhieu loai khang sinh khdng xuyen qua dugc hang rao mauthuy dich khi dung dang tra hoac toan than. Cloramphenicol, ampicillin, cephazolin, sulfonamid va khang sinh nhdm quinolon la nhung khang sinh cd the tham xuyen vao thuy dich tot sau khi dung toan than.

Can luu y lad ben mat nhiem trung thi hang rao mau- mat bi pha vd va vi vay do tap trung cua khang sinh trong thuy dich tang dang ke.

101

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H Ơ

Khang sinh dua bang dudng tiem dudi ket mac xam nhap giac mac va tien phdng bang each tham thau don gian qua cung mac hoac vung ria. Dung ky thuat tiem dudi ket mac cd the dua khang sinh vao mat tot hon dudng toan than. Cd the7 dat dugc ndng do khang sinh rat cao trong thuy dich bang each nay va mtic thud'c du dieu tri thudng duy tri dugc 6-8 gid. Ndng do khang sinh dieu tri duy tri d giac mac trong vdng 24 gid sau tiem dudi ket mac. Tuy nhien sd lugng cac mui tiem dudi ket mac cdn phai dugc han che. Kha nang kfch ting gay dau khi tiem tuy theo loai khang sinh, vf du cephazolin hau

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nhu khdng dau trong khi neomycin lai gay dau. Ban than viec tiem cung gay ra phan ting viem. Hon nua, ket mac cd the bi mun do tiem lap lai nhieu lan. Tuy nhien viec dieu

TP .Q U

tri nay cung da giir dugc thi luc cho nhieu mat bi nhiem trung giac mac va phdn trudc nhan cau. Khang sinh tiem dudi ket mac cung dugc nhieu phau thuat vien ap dung ngay khi ket thtic cudc mo de chdng viem ndi nhan.

ẠO

2.1.3. Cac khdng sinh thudng diing trong nhan khoa

Bdng 6.1: Cac che pham khdng sinh thudng dung trong nhan khoa.

Nong do

Ten thuoc

0,3%

Tobramycin

0,3%

Cac cephalosporin

0,25g,0,5g,lg

Chloramphenicol

0,04-0,05% 0,16%, 0,5%, 1%

Nude, md

Tiem, udng. Nude Md Md

500 dv/1 g

0,3%

Nude

0,3%

Nude

10%,15%,30%

Nude

10%

Sulfisoxazol

Nude, md

Chlortetracyclin

Oxytetracyclin

Nude, md

0,5%

Erythromycin

ẦN

Gentamicin

Dang che pham

Ó A

Bacitracin

Norfloxacin

ÁN

-L

Sulfacetamid

Í-

Ciprofloxacin

D IỄ

Đ ÀN

Tetracyclin

* Cac che' pham phdi hop khang sinh:

- Neomycin 0,35% + polymyxin B 10.000 dv/g + bacitracin 500dv/g

-Polymyxin lO.OOOdv/g hoac dv/ml + neomycin 0,35% - nude, md 102

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-Oxytetracyclin 0,5% + polymyxin B 10.000 dv/g -

-Trimethoprim 0,1% + polymyxin B 10.000 dv/g -

H Ơ

thi than kinh. Cac sulfamid cung la nhung thud'c khang khuan tot, thudng dung trong nhiem cac loai vi khu^n Gram (+) va Gram (-) va dac biet trong dieu tri benh mat hot.

Dung khang sinh nhdm aminoglycosid cdn than trgng vi chung gay ddc cho than va tai. Khdng chi dinh dung trong nhung benh cua thi thdn kinh vi no cd tac dung xau len

2.2. Cac che pham khang virus

Nhiem virus mat la ton thuong thudng gap trong nhan khoa. Tuy theo tting trudng

TP .Q U

hop ma virus cd the gay ton thuong tti cac td chtic phan trudc nhan c£u (ke't-giac mac,

ẠO

mang bd dao) de'n cac to chtic phan sau (mang bd dao sau, vdng mac). Cd nhieu loai virus gay benh tren mat nhung thudng gap hon ca la Herpes simplex (gay viem loet giac mac tai phat hoac nang hon cd the gay viem phan trudc nhan cau), Adenovirus (gay viem ket mac thanh dich), Herpes zoster (cdn ggi la benh zona). Viec dieu tri ton thuong do virus kha khd khan do benh thudng xuyen tai phat va viec dung khang sinh chi cd tac dung phdng bdi nhiem vi khuan ma khdng chdng dugc virus.

ẦN

Bdng 6.2: Cac che pham chong virus hien cd Lieu dung

Dang thuoc

Ten thuoc

Nude 0,1%

Cach 1 gid/lan vao ban ngay,

(IDU)

Md0,5%-1%

2 gid/lan vao ban dem

Idoxuridin

trong 10-21 ngay 5 lan/ngay x 14-21 ngay

Md3%

Ó A

Vidarabin

Nude 1%

9 lan/ngay x 14 ngay

Md3%

5 lan/ngay x 10-21 ngay

Vien 200mg,400 mg

5 mg/ kg trong lugng co the x 3

Í-

Trifluorothymidin

(Ara A)

ÁN

Acyclovir

-L

(TFT)

lan/ ngay.

Đ ÀN

(Zovirax)

Vi cac thud'c tren cd co che' tic che tong hop ADN cua virus nen cung tac ddng len te' bao chu. May man la lugng thud'c du cd tac dung chdng virus thap hon nhieu so vdi

D IỄ

ngudng ddc tfnh len te bao. Trong cac loai thud'c tren, IDU, Ara A va TFT cd the gay ddc cho phdn trudc cua mat ne'u dung keo dai. Cac ton thuong do ddc tfnh cua thud'c khi dung keo dai la viem ket mac cd hot, phu ke't mac nhan cau, co chft diem le hoac le

quan, viem giac mac cha'm ndng bi^u md, giam che' tiet nude mat. Acyclovir ft gay ddc cho te' bao chu hon cac loai tren vi co che' true tie'p chdng su sao chep cua ADN virus.

103

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2.3. Cac thuoc chdng nam Trong nhan khoa, nhiem nam la nguyen nhan dting hang thti hai sau vi khuan gay

tdn thuong tren giac mac. Nhung nam gan day, sd lugng benh nhan nhiem nam giac mac tang len va mtic do ton thuong trdm trgng hon do viec sir dung mot each btia bai thud'c

H Ơ

thuong tren giac mac khi bieu md giac mac bi pha vo d mot vi tri nao dd do chan thuong (la lua, que, cgng rom...) hoac benh ly khac. Cac ton thuong nguyen phat do na'm thudng

khang sinh va nhat la cac thud'c tra cd corticoid. Nam thudng phat trien va gay tdn

la 6 loet phat trien cham, ft kfch thfch. Qua trinh viem nhiem chi bung len du ddi sau khi

TP .Q U

dieu tri "tfch cue" vdi khang sinh manh va corticoid. Ton thuong se lan rong va vao sau

trong be day giac mac tao 6 ap-xe va mu tien phdng. Ne'u khdng dugc dieu tri kip thdi va

ẠO

tfch cue, nam se lan vao sau gay nhiem nam toan nhan, hoai tti cac to chtic ndi nhan va gay mu vinh vien.

Bdng 6.3: Cac che pham khdng nam

Natacin

Lieu dung

10-15 lan/ngay x 3-4 ngay

Dich treo 5%

Natamycin

Dang thud'c

Biet dugc

Ten thuoc

ẦN

sau dd 8 lan/ngay x 14-21 ngay

Sporal

Vien nang lOOmg

Itraconazol

Ong tiem 500mg,

Amphotericin B

Miconazol

vien 250mg

Dung dich lg

Daktarin

Ketoconazol

D/dich 1-5%

6-8 vien/ngay x 15-20 ngay

Tinh mach lg/ngay; ngudi ldn 8v/ngay

Tra l-2gid/ldn x 3-4 ngay

Vien nen 200 mg

2v/ngay x 14-21 ngay.

-L

Í-

0,1-lmg/kg/ngay - tinh mach

sau do 8 ldn/ ngay x14-21 ngay

Nizoral

Ó A

Vien nen 125mg

2v/ngay x 10-21 ngay

ÁN

Cac chung nam thudng gay benh tren giac mac la Aspergillus, Fusarium, Cephalosporium, nam soi. Hien nay cd nhieu loai che' pham khang nam song chi mot sd ft

Đ ÀN

cd tac dung tren cac chung nam tren, do vay khi dieu tri phai tuy thuoc vao tac nhan gay benh di chgn thud'c thfch hgp.

D IỄ

2.4. Cac che pham corticoid dung trong nhan khoa

Corticoid da dugc su dung de dieu tri cac benh a mat khoang 50 nam nay. Ngudi ta thay rang hieu qua cua corticoid trong dieu tri cac ton thuong viem va di ting tai mat ky dieu hon bat ky chuyen khoa nao khac. Trong nhan khoa, cac thud'c cd corticoid dugc sir dung kha pho bien, thudng xuyen va td ra la mdt vu khf rat lgi hai trong dieu tri cac

104

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H Ơ

benh mat. Tuy nhien mat trai cua thud'c nay la gay nhieu tac dung phu nguy hiem cho toan than cung nhu tai mat, tham chf dan de'n mu loa do dung khdng dung chi dinh hoac thie'u than trgng. Ngoai cac bien chting toan than khi sir dung keo dai nhu hdi chting Cushing, tang huyet ap, xdp xuong, cham lien vet thuong, rdi loan kinh nguyet, tang dudng mau..., tai bien tai mat thudng gap nhat la lam giam kha nang de khang cua mat vdi nhiem trung nen de mac benh, nhat la nhiem nam va virus, cham lien vet thuong,

due the7 thuy tinh. Dac biet khi tra corticoid keo dai se gay ra tang nhan ap (glaucome do

TP .Q U

corticoid), mot trong nhirng nguyen nhan hang diu gay mu loa. Mtic do gay tang nhan ap khac nhau tuy tirng san pham corticoid, vf du cac che' pham nhu dexamethason hoac betamethasongay tang nhan ap nhieu hon nhung loai khac.

Cac thud'c dung trong nhan khoa dugc bao che' dudi dang nude, md, dich treo d dang

ẠO

gom corticoid don le hoac phdi hop vdi khang sinh hoac sulfamid.

Bdng 6.4: Cac thuoc corticoid don ddc vd phdi hop dung trong nhan khoa. Dang thuoc

Ten thuoc

* Cac corticoid dang dan ddc:

Dung dich 0,5%, 1%

ẦN

Prednisolon

Dich treo 0,12%, 1%.

Djch treo 0,1%

Dexamethason

Hydrocortison

Ó A

Fluorometholon

Dung dich 0,1% Md0,05%

Dich treo 0,1 %,1%. Md

Í-

* Cac thuoc corticoid phdi hop:

-L

Prednisolon acetat

ÁN

+ Atropin sulfat Hydrocortison

0,25%

Dung dich

1% 0,5%

Dung dich

D IỄ

Đ ÀN

+ Cloromycetin 2,5% Hydrocortison 0,5%

Cloramphenicol 0,1 %

PolymicinB

10.000 dv/g

Hydrocortison 0,5%

Neomycin

0,35%

Hydrocortison

Polymycin

10.000 dv/mg

Dung dich

Dich treo, md

105

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Bacitracin

4000 dv/gr

Neomycin

0,3%

Prednisolon

0,2%

Dung dich, md

0,35%

Polymycin B

10.000 dv/ml

Prednisolon

Gentamicin

0,3%

Neomycin

0,5%

H Ơ

Dich treo

Prednisolon

TP .Q U

Dich treo

ẠO

Dich treo, Md

Dexamethason 0,1%

0,35% Dich treo, md.

Polymicin

lO.OOOdv/ml

0,35%

Neomycin

Dexamethason 0,1%

Dich treo, md.

ẦN

Dexamethason 0,1%

0,3%

Tobramycin

Neomycin

Sulfacetamid 10%

2.5. Cac thuoc chdng viem khong steroid

Í-

Ó A

Day la mot trong 2 nhdm thud'c chdng viem, trudc day thudng chi dinh trong nhung trudng hop viem nhe cua mang bd dao hoac viem thugng cung mac, ngay nay dugc su dung pho bien hon trong cac viem nhiem phdn trudc nhan cau cd xua't tiet nhieu. Dac biet tti khi phat hien ra co che tang tiet prostaglandin tai md viem, cac che pham chdng viem khdng steroid cang dugc sir dung nhieu nham tic che su che tiet prostaglandin

-L

trong md bi viem, nhat la sau phau thuat.

ÁN

Bdng 6.5: Cac thuoc chdng viem khdng steroid

Đ ÀN

Ten thuoc

Indometacin

D IỄ

Diclofenac

Dang thuoc

Lieu dung

Indocollyre

Vien nang 25, 50, 75 mg Dung dich tra 1%

100-150mg/ngay tra 46 lan/ ngay

Voltarene

Vien lOOmg

300-600 mg/ngay

Naclof

Dung dichl%

tra 4 -6 lan/ ngay.

Biet dugc Indocid,

106

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2.6. Cac thuoc tac dgng len he than kinh thuc vat

Than kinh thuc vat gom hai he thdng : Giao cam (adrenergic) va ddi giao cam (cholinergic), cd vai trd quan trgng trong hoat ddng cua mat. Cac thud'c tac ddng len he than kinh thuc vat dung trong nhan khoa chu yeu vdi muc dfch co co md'ng mat hoac the mi, tti do dat muc dfch co, gian ddng tti hoac dieu chinh nhan ap. Cac thud'c nay dugc

H Ơ

chia thanh cac nhdm sau:

2.6.1. Cac thuoc cudng ddi giao cam

Tac dung co ddng tti, co co the mi, gian cac mach mau ket mac va mdng mat, tang

TP .Q U

cudng luu thdng thuy dich.

Cac che' pham loai nay dugc dung de' co co the7 mi va dieu tri glaucome. * Cac thud'c cudng ddi giao cam theo co che'true tiep bao gom:

ẠO

- Pilocarpin: Dung dich tti 0,5%-6%, tra 2-6 lan/ ngay, cd the dung keo dai hang thang, hau nhu khdng cd phan ting phu. Tuy vay, tren nhirng benh nhan dung

thud'c keo dai cd the xua't hien mot day hot d cung do kie'u di ting.

ẦN

- Carbachol: Dung dich 0,75%- 3% , tra 1-4 lan/ ngay, dung di dieu tri glaucome gdc md. Vi kha nang tha'm qua giac mac kem nen thudng pha them vdi benzalkonium chlorid. Vdi ndng dd bang nhau, carbachol cd tac dung co co manh hon pilocarpin nen dugc ap dung cho nhung benh nhan dieu tri pilocarpin khdng hieu qua. Dung dich carbachol 0,01% cdn dung de bom vao tien phdng sau mo due thuy tinh the' (cataract) de co ddng tti.

* Cac thud'c cudng ddi giao cam theo co che gian tiep (hay cac thud'c tic che' men

cholinesterase):

-L

Í-

Ó A

Cac thud'c thuoc nhdm nay gay co that co that mdng mat va co the mi, gian mach ket mac va md'ng mat, tang cudng ddng thuy dich d hau he't cac mat, dugc sir dung dieu tri glaucome gdc md, khdng dung dieu tri glaucome gdc hep vi chung cd the' gay sung huyet va phu mdng mat va to chtic be (trabeculum). Vi cac che'ph^m nay tac dung gian tiep bang tic che' men cholinesterase va lam keo dai tac dung cua acetylcholin tu nhien

ÁN

nen chung khdng cd tac dung co co.

Cac thud'c dugc dung la:

Đ ÀN

Neostigmin : Dung dich 5% tra 2-6 lan/ ngay

Floropryl: Dung dich 0,1% tra 1-2 lan/ ngay.

D IỄ

2.6.2. Cac thuoc cudng giao cam

Thudng dugc dung vdi tac dung gian ddng tti trong cac phau thuat nhan cSu nhu mo lay the thuy tinh due, cat dich kfnh... Tuy vay can than trgng tren benh nhan cd benh tim mach va cao huyet ap. Chting cung dugc dung vdi muc dfch co mach, giam trieu chting trong phan ting di ting va sung huye't ket mac. 107

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Cac thud'c thudng dugc dung la:

- Epinephrin: Dung dich 0,5% - 2%, 1-2 lan/ ngay, thudng dugc dung de dieu tri glaucome gdc md hoac dung phdi hop vdi pilocarpin trong glaucome gdc ddng cap tfnh de ha nhan ap tam thdi chd phau thuat. Epinephrin tac ddng den nhan

H Ơ

- Phenylephrin hydrochlorid: Dung dich 1%-10%. Loai dung dich 2,5% dung cung vdi tropicamid (mydriacyl) de gian ddng tti, dac biet d tre em va benh nhan

ap thdng qua viec kfch thfch ca alpha va beta receptor

cd cao huyet ap.

TP .Q U

2.6.3. Cac thuoc itc che doi giao cam

Cd tac dung gian ddng tti va liet dieu tiet, thudng dugc sudung de chdng dfnh ddng tti

trong viem mang bd dao trudc (gian ddng tti, giam xuat tiet) hoac gay liet dieu tiet di do

ẠO

khtic xa a tre em. Cac thud'c nhdm nay cd the gay tang nhan ap d nhirng benh nhan cd

glaucome gdc ddng tiem tang do gian ddng tti manh gay bft gdc tien phdng, thuy dich khdng luu thdng dan den tang nhan ap cap tfnh. Ngoai tac dung chung da neu, atropin cung dugc dung dieu tri glaucome ac tfnh do nghen the mi (xem phan dieu tri glaucome).

Cac thud'c thudng dung :

Atropin : Dung dich 0,5%- 4%, md 1%, tra 1-2 lan/ ngay.

Gian ddng tti keo dai 14 ngay, liet dieu tiet 12 ngay.

ẦN

Tac dung phu : Phan ting toan than nhu khd mieng, khat nude, dd do gian mach va

Scopolamin : Dung dich 0,25% , tra 1-3 lan/ ngay.

tang nhiet do, di ting tiep xtic.

nhan man cam vdi atropin.

Ó A

Tac dung keo dai 5-7 ngay, ft cd phan ting toan than, thudng dugc dung khi benh

Í-

Homatropin: Dung dich 2%-5%.

-L

Tac dung liet dieu tiet 48 gid, ft cd phan ting phu.

Cyclopentolat (cyclogyl): Dung dich 0,5% -l%xl-2 ngay. Tropicamid (mydriacyl): Dung dich 0,5%- 1%?. Tac dung ngan.

ÁN

Liet dieu tiet ngan (2-4 gid), dugc dung phdi hop vdi phenylephrin 10%? de gian ddng tti.

D IỄ

Đ ÀN

2.6.4. Cac thuoc chen giao cam

Cac dang ngay cang dugc sir dung nhieu trong nhan khoa nhu: - Thymoxamin: 0,5% dieu tri glaucome gdc md. - Timolol: Dung dich 0,25% - 0,5%c dieu tri glaucome, giam tiet thuy dich, cd the cd tac dung phu nhu viem giac mac ndng, khd mat. - Betaxolol hydrochlorid : Dung dich 0,25%? - 0,5%. Hieu qua ha nhan ap nhu timolol nhung dung an toan hon d nhung benh nhan cd benh co that phe quan.

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2.7. Cac thuoc im truong va tic che men carbonic anhydrase (CA)

TP .Q U

H Ơ

Men carbonic anhydrase (CA.) cd mat d nhieu co quan trong co the bao gom cac te' bao hong cau, tuy, than, he than kinh trung uong va dich vi. Tai mat, no cd d mang bd dao, vdng mac, dich kfnh va the thuy tinh. Khi dung thud'c tic che' men CA. , huye't ap giam, dich vi va dich tuy giam. Tai mat se lam giam nhan ap d nhung mat glaucome do tic che tiet thuy dich. Trong nhan khoa, cac chat tic che' men CA. dung trong mgi hinh thai glaucome. Trong glaucome nguyen phat, chting dugc dung phdi hop vdi thud'c liet co the mi hoac corticoid tra (khi cd viem mang bd dao trudc). Thudng chi dung mot thdi gian ngan, neu dung keo dai cd the cd tac dung phu hoac quen thud'c hoac hap thu thud'c kem.

2.7.1. Cac chat itc che men CA

* Che' pham va lieu dung:

ẠO

- Acetazolamid (Diamox, Diuramide, Fonurit):

Vien nen 125mg, 250mg, udng 1 vien/ l£n x 2- 4 vien/ ngay.

2.7.2. Cac thuoc uu truong

ẦN

Cd tac dung tang tham thau dich ngoai te' bao; trong nhan khoa dugc ap dung de dieu tri cac dang glaucome cap tfnh, ngoai ra cdn dugc dung lam thud'c ha nhan ap trudc mo va giam the tfch dich kfnh, sau mo dung de tao do sau tien phdng va tranh tiep xuc dich kfnh vdi ndi md giac mac.

* Cac che' pham thudng dung:

- Mannitol dung dich tiem tinh mach 10%, 20%.

Lieu dung:

Ó A

• Ngudi ldn - dung dich 20% truyen tinh mach , 1,5- 2g/ kg the trgng vdi tdc do truyen 40-60 gigt/phtit.

• Tre em - dung dich 10% truyen tinh mach , l,5g/ kg the trgng, tdc do truyen

Í-

40-60 giot/ phut

-L

- Glycerin (glycerol): Dung dich 50%, udng: 1- l,5g/ kg the trgng/ ngay.

ÁN

2.8. Thuoc te

D IỄ

Đ ÀN

Thud'c te dung trong khoa mat cd the dugc dua bang dudng tiem tai chd hoac nhd mat.

109

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2.8.1. Dudng tiem

Ten thuoc

Dang thuoc

Lieu tdi da

Thdi gian bat dau tac dung

Keo dai

Doc tinh

Procain

Dung dich

10-15

Nhanh

30' - 1 gid

Non, u tai,

l%-2%

mg/kg 10-20

Tetracain

Dung dich 0,05-0,15%.

1,5 mg/kg

Dung dich

3-4 mg/kg

3 - 6 gid

-i-Epinephrin

7 mg/kg

2 - 3 gid

5-30'

0,5-2%

H Ơ

Hon me

co giat Hon me

co giat

Dung dich 1-

5-30'

Dudi

700mg

2 - 3 gid

(Citanest)

ẦN

1/200.000 Prilocain

2 gid

5-30'

Dung dich

Hon me

co giat

0,5-3%

(Xylocain) Lidocain

15'-45'

It ddc

l%-2%

Lidocain

lgid

TP .Q U

(Nesacain)

(Pontocain)

Rat nhanh

mg/kg

Dung dich

Chloroprocain

co giat.

ẠO

(Novocain)

Bdng 6.6: Cdc thuoc te dudng tiem dung trong khoa mat

2.8.2. Dudng nhd mat

Ó A

Vai loai thud'c te tiem cung cd tac dung te be mat nhu tetracain va lidocain, tuy nhien cd nhung thud'c nhu procain lai khdng cd hieu qua gay te be mat. Tac dung phu

dung theo dudng nay ft, cac tac dung phu bao gom di ting ket mac, mi, phu giac mac,

Í-

cam giac kfch thfch khd chiu

-L

Cac thud'c thudng dung la :

ÁN

- Tetracain 0,5%

- Cocain 0,5%) - 2%.

Đ ÀN

III. DIEU TRI CAC BENH MAT THONG THl/ClNG

3.1. Cac benh mi mat thuong gap

D IỄ

3.1.1. Di itng mi

Bao gom cac phan ting di ting do tiep xuc (my pham, dau gdi dau, md tra mat). Cung cd khi do thud'c udng hoac thtic an (khang sinh, aspirin, thud'c ngu, ca, torn...). Trieu chting thudng gap la dd mat, ngtia, phu mi.

110

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Dieu tri phai tim can nguyen, chu yeu de9 loai trti nguon di nguyen. Thud'c chu yeu dung la cac loai khang histamin toan than hoac tai chd. Corticoid thudng dugc dung tra

tai chd di lam diu phan ting ttic thi. 3.1.2. Nhiim triing mi

Cd the7 rat nhe hoac ra't nang. Thudng hon ca la viem nang long mi do tu c5u gay

H Ơ

trieu chting ngtia hoac bdng rat mi.

Dieu tri: Trong cac trudng hop viem nhe chu yeu dung khang sinh tai chd:

Bacitracin phdi hop dung dich sat trung rua bd mi. Nang hon, cd the' phdi hop khang

TP .Q U

sinh toan than. 3.1.3. Leo

La nhiim trung tu cau cua nang long mi va tuyen Zeiz bd mi: Sung dd khu trti d

ẠO

mot diem bd mi, cd the sung tay, dau nhtic.

Dieu tri tai chd bang mo khang sinh. Neu leo thanh ap-xe mu thi can chfch trudc khi

ap-xe vd.

3.1.4. Viem mi do virus (do Herpes hoac Zona)

ẦN

Thudng bie'u hien bang mun phdng da quanh mi. Cac mun phdng nay ban dau chtia nude trong, sau due dan tao mu va vd tao 6 loet. Ton thuong do virus Herpes cd the' xua't hien d ba't ky vi tri nao (quanh mi mat, mep mdi...) nhung tdn thuong da do virus Zona

bao gid cung khu trti theo vung phan bd cua day than kinh V va benh nhan cd trieu

chting dau nhtic rat du ddi.

3.1.5. Nhiim nam bdmi

Dieu tri bang cac che' pham chdng virus.

Í-

Ó A

Nhiem nam be mat da mi mat bieu hien bang cac vay da khd hoac sting hoa, ngtia va thudng dugc dieu tri tot vdi griseofulvin. Trudng hop viem sau phai phdi hop cac loai thud'c chdng nam toan than nhdm ketoconazol hoac miconazol. Nhiim nam bd mi

-L

thudng gay rung long mi, ngtia va tao v^y bd mi.

ÁN

Dieu tri keo dai bang ve sinh, sat trung bd mi va dung cac che' pham chdng nam.

3.1.6. Chap

D IỄ

Đ ÀN

La viem vd trung cua tuyen Meibomius thude mi mat nhung cung cd the la do bi nhiem trung thur phat. Dieu tri d giai doan dau bang chudm ndng, ne'u cd bdi nhiem phai dung khang sinh tai mat. Ne'u chudm ndng khdng cd ket qua, chap khu tru tao vd xa thi can chfch va nao sach long chap. Trudng hop vd xa qua day can mo la'y ca bgc de tranh tai phat.

Ill

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3.2. Cac benh ke't mac

3.2.1. Viem ket mac di itng

Xuat hien do nhieu can nguyen khac nhau nhu tiep xuc vdi di nguyen (bui, nam

mdc, phan hoa, long sue vat, thud'c, hoa chat, my pham...) hoac ddc td vi khuan tti mot 6

nhiem triing trong co the... Trieu chting chung la ngtia mat nhieu, ket mac sung huyet,

H Ơ

mat kfch thfch dd. Trong trudng hop cap tfnh, mi va ket mac phu mgng.

Dieu tri: Bang cac thud'c khang histamin toan than va tai chd, cac thud'c co mach,

cac corticoid tai chd . Dieu tri tot nhat la loai trti di nguyen.

TP .Q U

3.2.2. Viem ket mac do vi khuan

Cac vi khuan thudng gay viem ket mac la tu cau, lien cau, Moraxella...

Trieu chting: Mat com, sung dd, tiet td nhieu va ban, ket mac dd cuong tu manh.

ẠO

Dieu tri: Thud'c tra tai chd la chu yeu, rat ft khi dung toan than. Neomycin,

ẦN

bacitracin va polymyxin B cho ket qua tot. Sulfacetamid ft tac dung phu nhung lai ft cd hieu qua. Erythromycin (md 0,5%c) cd tac dung tot vdi vi khuan Gram duong nhung tu cau nhanh khang thud'c. Cloramphenicol ft kfch thfch nhung pho khang khuan hep. Dung dich gentamicin hoac tobramycin dung trong trudng hop khang cac thud'c tren. Khang sinh toan than dung khi cd nhiem khuan nang: Do nhiem vi khuan bach hau,

lau, lao... 3.2.3. Benh mat hot

Tac nhan gay benh la Chlamydia trachomatis.

Dac diem: Hot tren ket mac sun va cung do, mang mau giac mac, seo ket mac...

Ó A

Dieu tri: Toan than va tai chd bang khang sinh loai tetracyclin, erythromycin,

Í-

sulfonamid. Nhdm tetracyclin dugc diing nhieu nhat, cd the7 dieu tri lieu trinh 2 tuan bang dudng udng. Tre em dudi 9 tuoi hoac phu nu cd thai: Udng erythromycin hoac

-L

sulfonamid thay cho tetracyclin.

ÁN

Neu chi dieu tri tra khang sinh tai chd cung khdi benh nhung thdi gian dieu tri se keo dai hon: Tetracyclin 1% (md) tra 2 lan/ ngay x 6 ngay/ tuan x 10 tuan. 3.2.4. Viem ket mac mua xudn

Đ ÀN

La mot the7 viem ke't mac di ting tai dien theo mua vdi trieu chting ngtia du ddi, chdi

com, chay nude mat va nhieu nhu gai to tren ket mac sun. Xet nghiem te' bao hgc tiet td

D IỄ

ket mac sun cd mat bach cau ai toan.

Dieu tri so bd bang corticoid tra tai mat nhung vi benh ddi hdi dieu tri keo dai nen neu duy tri dieu tri steroid lau dai se tang nguy co due the thuy tinh va tang nhan ap.

Hien nay, mot sd thud'c khac nhucromolyn natri 4%, alomid tra 4-6 ldn/ ngay cd the han che' dugc trieu chting.

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3.3. Chan thuong mat 3.3.1. Di vat a mat

La dang rat thudng gap, trieu chting chfnh la com va dau trong mat. Ne'u xti tri lay di vat khdng tot cd the gay tdn thuong thti phat d mat do thay thud'c, nhiem trung thur phat

H Ơ

Di vat ndng nhu bui, cdn trung vao mat cd the lay di bang each ddi cac thuoc sat trung thdng thudng hoac nude mat nhan tao, nude mudi hoac tham chf nude may.

vamu.

Di vat giac mac: Can cd dung cu lay va thud'c gay te be mat

Neu thay khd khan can chuyen ngay den co sd chuyen khoa.

TP .Q U

Di vat d tui ke't mac: Cd the dung bdng cudn gat.

ẠO

3.3.2. Chan thuong dung dap phan trudc nhan cau ("dau hieu mat den")

Khi bi mot vat dap true tiep vao mat (que, vgt bdng, qua bdng...) cd the' gay ton

thuong phtic tap bao gom di lech TTT, dtit chan mdng mat, viem mdng mat chan

thuong, chay mau tien phdng. Benh nhan can dugc chuye'n den phdng kham chuyen

khoa.

ẦN

Dieu tri : Neu tu mau, can chudm lanh trong 24 gid dau de7 han che sung. Ngay thti

hai chudm ndng de tieu mau.

Neu cd xuat huye't tien phdng: Bang ep ba't ddng mat, udng nude nhieu va dung cac thud'c gitip tieu mau va chdng chay mau.

3.3. 3. Bong mat

Ó A

Bdng hoa chat ke't mac va giac mac can phai dieu tri ttic thi bang each rtia manh bang tia nude (nude sach hoac nude mudi) trong 5-30 phtit de loai bd he't hda chat. Ne'u

khdng cd nude vd trung cd the' dung nude nguon (nude may, vdi nude udng...). Mi mat

ÁN

-L

Í-

nen dugc tach ra de phun rtia vao mat lien tuc 5 phtit . Sau dd benh nhan can dugc dua den co so nhan khoa va rtia tiep tuc, ft nhat benh nhan can dugc rtia 2000 ml nude mudi 0,9% trong lgid den khi giay pH trd ve binh thudng (giua 7,3-7,7). Sau 5-10 phut thti lai de bao dam rang pH khdng thay doi.

Đ ÀN

Sau khi rtia, benh nhan can dugc tra khang sinh (gentamicin, tobramycin hoac erythromycin) de tranh nhiem trung thti phat.

D IỄ

Neu nhan ap tang do chan thuong, nen dung thud'c tic che' men CA. Phong viem dinh mdng mat vao TTT (dfnh sau): Chat gay liet co the mi va gian

ddng tti (atropin) dugc dung tai chd. Sau khi dieu tri so ctiu, bang mat va tiep tuc dung khang sinh 2-5 ngay.

113

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3.4. Benh cua he thdng nude m&t (chay nirdc mat)

Benn cd the7 do che' tiet qua nhieu nude mat hoac khdng dan luu dugc nude mat. Ca che thti nhat do kfch thfch giac mac khi cd di vat hoac chan thuong.

Co che' thti hai do cac nguyen nhan gay chft hep hoac tac dudng dan nude mat d cac

H Ơ

tui le) cd the se qua khdi. Neu khdng khdi can phai bom rtia le dao va thdng, nong le dao nhung can than trgng khi chi dinh va phai do thay thud'c chuyen khoa tien hanh vi

vi tri khac nhau. 0 tre so sinh, sau khi tra thud'c khang sinh nhe va day gdc mui (vung

de gay ra ton thuong dudng le vlnh vien.

TP .Q U

3.5. Benh cua giac mac

La viem nhiem xay ra tren giac mac. Vi giac mac khdng cd mach mau nen viem bieu hien bang phu, tham lau giac mac bdi bach cau, dd quanh ria giac mac, dau nhtic

ẠO

do tdn thuong than kinh cam giac.

Nguyen nhan viem giac mac thudng do nhiem triing (vi khuan, virus, nam hoac do amip) hoac vd trung (do deo kfnh tiep xtic cting) hoac khdng nham km mat.

3.5.1. Viem giac mac do nhiem trung

Thudng xay ra sau mot chan thuong nhe (bui, di vat vao giac mac). Tac nhan gay

ẦN

benh cd the7 do cac loai tu cau, lien cau, true khuan mu xanh... Benh nhan cd loet giac

mac vi khuan thudng cd cam giac khd chiu, com mat nhu cd di vat, chdi dau, tang tiet

dich. Kham thay cuong tu dd quanh ria giac mac va d loet trang tren giac mac. Thi luc giam neu 6 loet d trung tam giac mac.

-L

Í-

Ó A

Dieu tri chu yeu bang khang sinh tra tai mat hoac phdi hop udng khang sinh neu tdn thuong nang. Nen dieu tri dua tren ket qua xet nghiem vi khuan tti cha't nao giac mac. Khi chua cd ket qua nudi cay nen diing cac khang sinh pho rong hoac cac thud'c cd phdi hop nhieu loai khang sinh nhu neosporin, cebemycin... Khdng nen bang kfn mat di tranh tao dieu kien cho vi khuan ye'm khf phat trien. Cac trudng hop viem loet giac mac

ÁN

nen dugc chuyen den co sd nhan khoa. 3.5.2. Viem loet giac mac do nam

Đ ÀN

O nude ta do su lam dung khang sinh va corticoid ndn benh nay ngay cang gap nhieu va cang nang. Trieu chting chu quan gan gidng nhu d benh nhan loet do vi khuan

nhung nhe nhang hon. Tien trie'n cua viem loet giac mac do nam cham va lang le hon

D IỄ

song neu dung corticoid benh se nang len rat nhanh chdng.

Dieu tri bang cac thud'c khang sinh chdng nam tai chd la chu yeu va ket hop thud'c

chdng nam toan than neu tdn thuong sau va nang. Neu cd loet rong, cd the phdi hop cac lieu phap khac nhu cham dung dichLugol 5% vao be mat 6 loet (saukhi da gay te giac mac).

114

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3.5.3. Viem giac mac do virus

Thudng do virus Herpes hoac Zona, trong do viem do Herpesthudng gap hon ca. Benh nhan cam thay dau mat, chdi com va dd mat. Benh thudng xuat hien d mot mat. Nhudm giac mac bang fluorescein se cd hinh anh vet loet bat mau hinh canh cay,

H Ơ

V gay dau du ddi theo vung phan bd than kinh. Tai mat cd the gay viem, loet giac mac

ban dd hoac loet rong neu cd nhiem trung thti phat. Virus Zona tan cong day than kinh

hoac ca mang bd dao.

Dieu tri cd the tuy theo tdn thuong dung mot trong cac loai thud'c chdng virus nhu

TP .Q U

acyclovir, IDU, trifluorothimidin, vidarabin... tra tai mat. Trudng hop cd viem sau hoac viem mang bd dao can dung phdi hop acyclovir toan than.

Viec sir dung steroid can dugc can nhac than trgng.

ẠO

Khac vdi virus Herpes, viem giac mac do virus Zona lai cd chi dinh dung steroid tra

de phdng viem keo dai va dau than kinh. Thf du dung dung dich dexamethason0,1% tra 4

lan/ ngay phdi hop vdi thud'c gian ddng tti (atropin 1%) va thud'c chdng virus (acyclovir

udng 800-1000mg/ ngay x 10ngay) cho ket qua tot.

3.6. Ton thuong cua mang bo dao

ẦN

Mang bd dao bao gom mdng mat, the mi va hac mac. Cac phan nay cd the bi viem

nhiem rieng le hoac ddng thdi.

Viem mang bd dao trudc la tti de7 chi viem cua md'ng mat va the mi, cdn viem mang

bd dao sau la ttide chi viem ciia hac mac hoac hac-vdng mac.

Nguyen nhan viem mang bd dao hien nay cdn chua dugc biet d&y du nhung chung

Ó A

cd lien quan vdi mot sd tinh trang viem khac nhu lao, khdp, sarcoidosis...

Benh nhan bi viem mang bd dao d giai doan dau thudng de bi chan doan nham vdi

-L

Í-

viem ket mac vi trieu chting dd mat nhe nhung thi luc chua giam. Nan tay len nhan cau se cd cam giac dau. Ddi khi benh nhan cam thay chdi sang hoac chay nude mat. Mudn hon, mat ngay cang dd, dau hon va thi luc giam. Kham ky mat se thay ddng tti mat dau

ÁN

nhd hon mat kia va cd the phan xa yeu hoac mat, nhieu tua nhd d mat sau giac mac va

van due thuy dich.

Đ ÀN

Se khdng cd dieu tri dac hieu ne'u nguyen nhan khdng dugc tim ra.

D IỄ

Bien phap dieu tri khdng dac hieu gom: Gian ddng ttibang atropin l%-4% de chdng dinh vao mat trudc the thuy tinh. Corticoid lam giam phan ting viem rat cd hieu qua . Thud'c tra tai chd cd tac dung tot vdi viem mang bd dao trudc nhung khdng cd tac dung vdi viem mang bd dao sau. Lieu lugng tuy thuoc vao do nang cua benh va cd the phai

dung toan than neu benh nhan khdng dap ting vdi thud'c tra.

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H Ơ

Day la tdn thuong thoai hoa gay due thuy tinh the (TTT). Due TTT bam sinh xuat hien tti luc mdi sinh phat trien cham va gay mat thi luc dan, nguyen nhan cd the do di thudng nhiem sac the. Due TTT mac phai cd the do tudi gia, tia phdng xa, benh toan than, sau chan thuong hoac dung thud'c keo dai (nhu corticosteoid). Benh nhan thay mat md dan, khdng dau nhtic, mtic dd mdtuy thude vi tri due va do lan rong cua vung due.

3.7 Due the thuy tinh (cataract)

Dieu tri triet de chi la phau thuat lay bd TTT due, sau do deo kfnh hdi tu cong suat

ldn hoac lap TTT nhan tao vao nhan cau thay the.

TP .Q U

Mot sd loai thud'c hien dugc su dung nham lam cham qua trinh phat trien cua due TTT nhu catalin, vitaphakol, catastat, catacol.. . song hieu qua chua ro rang. 3.8. Glaucome

ẠO

Glaucome la mot benh mat, trong dd ap luc ndi nhan tang cao qua mtic de cd the duy

tri chtic nang thi giac binh thudng. Viec dieu tri chu yeu nham phdng ngtia su mat thi luc

dan. Dieu tri cd the bang thud'c hoac phau thuat tuy thuoc vao co che tang nhan ap.

Glaucome cd hai the:

ẦN

- The nguyen phat gom 2 loai glaucome gdc md va gdc ddng.

-The thti phat xuat hien sau viem phan trudc nhan cau, chan thuong hoac phau thuat. Du la loai nao thi hau qua cudi cung se la teo thi than kinh va mu vinh vien.

Cac thud'c dugc su dung trong dieu tri glaucome thuoc cac nhdm khac nhau: Co ddng tti, chen giao cam, tic che' men CA. va thud'c uu truong tang cudng tham thau.

Ó A

Cac thud'c tren cd the dung don le hoac phdi hop:

- Nhdm co ddng tti chu yeu dung pilocarpine 0,5%-6%: Dieu tri glaucome gdc md

hoac glaucome gdc ddng ca'p tfnh trong khi chd phau thuat.

-L

Í-

- Thud'c chen beta-adrenergic hien dugc su dung nhieu vdi cac che' pham nhu

ÁN

timolol, betaxalol, timoptol.. . tra tai mat.

- Thud'c tic che men CA. nhu acetazolamid (diamox), fonurid (diuramid) dugc dung

khi nhan ap tang cao va thud'c tra khdng cd hieu qua vdi muc dfch ha nhan ap tam

Đ ÀN

thdi chd phau thuat.

D IỄ

- Cac thud'c uu truong, tang tham thau dich ngoai te bao dugc sirdung vdi muc dfch giam the7 tfch dich kfnh, rut phu giac mac va dich kfnh. Thud'c thudng dung la glycerol 50%?, mannitol 10-20%?.

Ddi vdi glaucome gdc md va glaucome thti phat: Di£u tri budc dau bang thud'c, neu nhan ap khdng dieu chinh mdi phau thuat, trong khi vdi glaucome gdc ddng va glaucome bam sinh bat budc phai dieu tri bang phau thuat sdm.

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Glaucome ac tfnh do nghen the' mi la mot bien chting phau thuat hiem gap vdi dac diem la nhan ap tang cao va xep tien phdng, the7 thuy tinh va dich kfnh nhd ra trudc ep chat vao vdng cung mac, day thuy dich ra sau. Nguyen nhan cd the do sung huye't the mi va xay ra sau phau thuat glaucome, dac biet la sau phau thuat Id rd. Dieu tri chfnh la

H Ơ

lui the thuy tinh ra sau giai phdng dien ddng tti, ket hop vdi thud'c tang cudng tham thau lam giam the tfch dich kfnh. Neu dieu tri nhu tren khdng cd ket qua, can phau thuat hut

gian ddng tti bang thud'c gian co the mi (cycloplegic) nhd dd md rong khe the' mi va day

dich kfnh va bom hoi tien phdng.

TP .Q U

3.9. Viem thi than kinh (viem gai thi)

Viem gai thi la viem cua phan than kinh thi giac cd the7 nhin tha'y dugc bang may soi

ẠO

day mat. Nguyen nhan cdn chua rd rang. Benh thudng xuat hien sau mot benh virus, sau khi dung mot sd loai thud'c, sau tiep xuc vdi mot vai hoa chat nao dd (methanol), viem

mang nao, giang mai. O ngudi gia, mot nguyen nhan quan trgng cd the7 gap la viem ddng

mach tarn thdi. Trieu chting chi la giam hoac mat thi luc.

De dieu tri can tim dugc nguyen nhan.

ẦN

Cd the sir dung corticoid toan than hoac tiem hau nhan cau. Thud'c chdng viem khdng steroid dugc sir dung toan than cung cho ke't qua tot.

IV. KET LUAN

Dieu tri cac tdn thuong mat can phai can cti vao cau true mat bi benh, nguyen nhan va dd nang cua benh. Viec dieu tri phai gom viec hudng dan benh nhan cung nhu ngan ngtia nhung hau qua do lua chgn thud'c khdng dung hoac dung khdng dung phuong

D IỄ

Đ ÀN

ÁN

-L

Í-

Ó A

phap.

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Chuong VII /v'

SU* DUNG THUOC

H Ơ

TRONG DIEU TRI CAC BENH 6 TAI MUI HONG

I. DAI Cl/ONG VE BENH HOC TAI- MUI - HONG (TMH)

TP .Q U

1.1. Dac diem benh hoc TMH

ẠO

Phan nay trinh bay nhirng khai niem co ban chung ve benh TMH. Nam vung dac diem benh hgc TMH khdng chi gitip cho hieu thau dugc nguyen nhan, dien bien va tam quan trgng cua benh hgc TMH ma cung qua dd de cd khai niem, lien he ve vai trd tac

Cac dac diem co ban ve benh hgc TMH cd the neu len la :

dung va each su dung cac thud'c dung trong TMH.

Vi la cac hoc thdng vdi nhau nen benh hgc TMH khdng phai la benh rieng tirng bd phan ma cd lien quan, anh hudng true tiep de'n cac bd phan khac. Thf du :

ẦN

1.1.1. TMH Id cac hoc thdng vdi nhau vd thdng vdi ben ngoai

• Viem hgng se gay nen viem mui, viem thanh quan vi hgng, mui, thanh quan thdng vdi nhau.

• Viem hgng- mui lai thudng la nguyen nhan gay viem xoang (cac xoang deu cd ld, dng thdng vdi mui), viem tai giua - xuong chum (thdng vdi mui hgng qua vdi tai ggi la vdi Eustachi).

•

Ó A

TMH thdng vdi ben ngoai nen benh hgc TMH chu yeu lien quan den mdi trudng vdi 2 yeu td co ban la : Nhiem khuan va di ting

Í-

ÁN

-L

Mui hgng la noi tiep xuc thudng xuyen va chiu tac ddng dau tien ciia cac vi khuan va virus, cac di nguyen; nen benh nhiem khuan va di ting chiem ty le cao va la benh

chu ye'u cua TMH.

• Cac yeu td khac nhu nhiet do, do am.. . cung tac ddng quan trgng de'n TMH.

Đ ÀN

Nude ta khf hau nhiet ddi, nhiet do, do am cao, mua nhieu nen ty le benh TMH ndi

chung cao rd ret.

D IỄ

1.1.2. Lot bdng niem mac dudng hd hap tren

Day la dac diem co ban: Cac hoc tai - mui - xoang - hgng - thanh quan tuy cd thanh la xuong, sun, gan, co khac nhau nhung deu dugc lat mat trong bang ldp niem mac

dudng hd hap tren. Vi vay tti thap ky 70 theo xep loai cua To chtic Y te'The' gidi (OMS) thi viem tai giua cung thuoc nhdm benh dudng hd hap tren.

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Cung can biet tuy ve cau true cd thay doi theo tung bd phan nhung tfnh cha't chung cua niem mac dudng hd hap tren van la he thdng niem mac long nhay: Cac ldp bieu md

cd cac te' bao tru cd long chuye'n ddng dugc cung vdi cac tuyen tiet dich nhay da tao nen mot ldp nhay bao phu be mat niem mac. Cd the7 ndi benh hgc TMH la benh hgc cua he

H Ơ

1.1.3. Giu cac chtic nang quan trongthd - an - nghe - ndi - thdng bang - nguH - vigiac

thdng niem mac long nhay.

Do cd vai trd nhu vay nen neu mac cac benh d TMH thi se anh hudng, tac ddng den cac chtic nang tren; dac biet luu y 2 chtic nang co ban cua ddi song la thd va an vi

TP .Q U

khi bi tac ddng de dua tdi tti vong, cd the' ra't nhanh chdng.

Cac chtic nang tren ne'u bi tdn thuong se gay anh hudng de'n cudc song, thf du nhu bi diec khi cdn be se dua tdi cam, ngudi diec - cam se phai chiu rat nhieu thiet thdi trong

ẠO

cudc song xa hdi va giao tiep.

1.1.4. Giu vai trd quan trong trong he thdng mien dich ciia cathe

ẦN

^>ubw% tiep xtic vdi di nguyen chu ye'u la qua mui, hgng. O hgng cd td chtic lympho quan trgng la vdng Waldeyer vdi cac td chtic amidan. Dac biet niem mac dudng hd hap tren ma dien hinh la d mui - xoang cd vai trd quan trgng khdng chi vdi mien dich te' bao ma ca vdi mien dich dich the. Su hinh thanh cac khang the de bao ve co the7 dugc thuc hien chu yeu d mui - hgng va vi vay benh viem mui di ting la benh di ting thudng gap nhat.

1.1.5. Cd he mach - than kinh rat phong phu

Ve he mach: Tai - mui - hgng dugc chi phdi bdi ca 2 he mach: Canh trong va canh

ngoai. Cac mach d mui rat phong phu: 6 cudn dudi dugc ggi la ho mach vdi lugng mau

Ó A

qua day dieu chinh dugc di dam bao luon giu am va lam am khdng khf d hang sd nhat

Í-

dinh; vach ngan la noi cd vung giao luu mach phong phti va d ndng nhat (vung mach Kisselbach) nen la noi de chay mau do bat ky mot yeu td bat thudng nao. Cung can nhd rang mot phan mach d tai mui hgng cd lien quan de'n cac he mach ndi sg nen cac benh

-L

tfch, tdn thuong d TMH cd the nhanh chdng dua tdi cac bie'n ddng mach d ndi sg.

ÁN

Ve than kinh: Hau he't cac day than kinh sg nao deu di qua TMH va lien quan de'n TMH. Dieu can luu y la TMH cd he thdng than kinh giao cam rat phong phu nen khdng

nhung cd the7 dua tdi cac phan xa, phan ting nguy hie'm ma cdn tac ddng den cac bo phan

Đ ÀN

co quan khac cua co the.

D IỄ

1.1.6. La ciia ngo cua dudng thd, dudng an Y hgc hien nay coi mui hgng la nga tu cua dudng thd, dudng an, la tien don cua bd may hd hap. Cach day nhieu the' ky, Tue Tinh trong "Nam dugc than hieu" da viet:

"Hgng la ctia ra - vao cua hoi thd, dudng len - xudng cua do an, he bi be tac thi song chet trong nhay mat".

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Benh hgc cua TMH vtia cd the anh hudng den cac bd phan, co quan khac, vtia la bie'u hien ton thuong cua bd phan, co quan khac ma rd ret nha't la cua bd may hd hap va tieu hoa.

H Ơ

cua mot bg phan. Benh hgc TMH lien quan chat che vdi nhau va tdi toan than, lien quan mat thiet tdi dieu kien va mdi trudng song, chiu anh hudng va ddng thdi cung tac ddng

Qua nhung dieu da neu d tren cho thay: Benh hgc TMH khdng phai chi la benh hgc

den benh hgc cua cac co quan, bd phan khac cua co the.

TP .Q U

Do do khi su dung thud'c trong TMH, nhung phan ting, hau qua do thud'c gay ra cd the7 nguy hiem ttic thdi de'n tfnh mang, den sinh hoat va cudc song. Thud'c dung trong TMH khdng chi tac ddng den TMH ma cd the tac ddng den toan than va nhieu bd phan, co quan khac.

ẠO

II. CAC BENH TMH THl/ClNG GAP

Cac benh TMH gap trong 4 nhdm co ban la:

- Nhiem khuan .

- Di ting - mien dich .

ẦN

- Rdi loan, tdn thuong chtic nang,

- Khdi u.

Trong dd 2 nhdm nhiem khuan va di ting chiem ty le cao nhat, cd the7 tdi tren 90%.

Di cd khai niem ve benh TMH, trong bai nay chi trinh bay khai quat cac benh thudng gap nhat ve nhiem khuan va di ting.

Ó A

2.1. Nhiem khuan dudng ho ha'p tren

-L

Í-

O nude ta nhiem khuan dudng hd hap tren chiem ty le cao nhat trong benh hgc TMH, dac biet d tre em. Theo tong ket cua chuong trinh NKHHCT cho thay: Trong sd 8620 tre dugc theo ddi trong 2 nam d 23 tinh tren toan qudc thi ty le benh la 70,70%, trong dd tan suat mdc > 5 lan/nam la 20,05% va 3 - 4 ldn/nam la 29,84%. Nhu vay hang nam sd

ÁN

lan tre mac benh len tdi hang chuc trieu

Trong nhiem khuan hd hap tren can luu y:

Đ ÀN

2.1.1. Viem amidan

Thudng gap nhat, d ca ngudi ldn va tre em. Do tuoi tren 7 tuoi chie'm ty le tdi >

D IỄ

34%.

Viem amidan thudng xay ra cac dot viem cap tfnh vdi cac trieu chting: Sot, met mdi; d tre em cd the sot cao.

Dau hgng: Cd cam giac ndng rat, dau nhdi hay ngtia hgng, dau tang khi udng, an. Thudng kem theo: Ho, chay mui, sung dau hgng (d tre em).

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Dgt viem amidan cap tfnh thudng keo dai 5-10 ngay, cd the tu khdi.

O tre nhd viem cd the lan xudng dudng hd ha'p dudi, gay viem khf- phe quan, viem phdi cap tfnh. Xti tri dgt viem amidan cap tfnh chu yeu la: Nghi ngoi, 'giu am (ve mua lanh).

Ve sinh hong mieng tot, siic hgng hang ngay, khf dung hgng.

Theo ddi de phdng cac bie'n chting, viem lan rong.

Chi cho khang sinh, ha nhiet, giam dau khi sot cao, keo dai; cd cac bie'n chting

H Ơ

TP .Q U

viem dudng hd hap dudi.

Van de quan trgng la chi dinh cat amidan dung khi bi viem cap tfnh nhieu lan hoac

ẠO

cd bie'n chting.

2.1.2. V.A

V.A la ggi tat theo tti Vegetation Adenoidite, nay da pho cap trong nhan dan. V.A

la benh thudng gap nhat d tre nude ta. 6 tre 2-4 tudi chiem tdi 55% (theo bao cao cua

chuong trinh NKHHCT). V.A hay bi tai phat nhieu lan vdi cac trieu chting: Sot, quay khdc, bd an, kem ngu; d tre nhd, ye'u cd the sot cao.

Khd thd: Thd khut khit, ha mom de' thd, ngay to, khdng ngam dugc nude lau, de

ẦN

bi sac, trd.

Chay mui: Mui nhay, xanh, chay thudng xuyen ca 2 ben.

Thudng bi ho.

Ó A

Dgt viem V.A cap tfnh thudng keo dai 5-7 ngay, cd the tu khdi nhung rat hay bi lai va de dua tdi bie'n chting:

Chay mu tai: Thudng bi theo dot viem V.A cap tfnh.

V.A anh hudng den phat trien the7 luc (suy dinh dudng, cham phat trie'n) va ca

ÁN

tri tue cua tre.

-L

Í-

Trong dgt viem V.A cap tfnh chu ye'u: Rd mui ngay vai lan sau khi hut sach mui mu.

Cho ha nhiet neu cd sot cao, keo dai.

Cho khang sinh khi cd viem nhiem dudng hd ha'p dudi, viem tai giua.

Co ban la nao V.A khi he't dot viem ca'p tfnh.

D IỄ

Đ ÀN

2.1.3. Viem mui xoang

Viem mQi xoang cung la benh rat thudng gap a ngudi ldn va tre em. Benh cd the7 la

do viem ke' can nhu V.A, amidan hay viem lay do dudng hd ha'p nhu sdi, ho ga gay nen...

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Cac tac nhan kfch thfch nhu d nhiem mdi trudng, hoa chat, thud'c trti sau, lanh - am cung cd vai trd rat quan trgng trong khdi phat benh. Viem mui xoang thudng cd cac trieu chting sau:

Dau hieu nhiem khuan hay virus vdi sot, the trang met mdi.

mau ban, chay lien tuc.

Neu cd dau nhtic vung mat, nhtic dau la da cd dau hieu viem xoang.

TP .Q U

H Ơ

- Ngat mui, cd the tting ben hoac ca 2 ben va phai thd bang mom. - Chay mui: Nude mui luc dau trong, loang sau thanh nhay, dac dan thanh mu, cd

Neu viem mui cap tfnh thong thudng (do virus), dien bien trong khoang 7 ngay cd the tu khdi.

ẠO

Cd the chuyen thanh viem man tfnh vdi dau hieu ngat tac mui, chay nude mui

keo dai. Neu cd nhtic dau, dau ttic vung mat can nghi tdi viem xoang.

Viem mui - xoang man tfnh lam anh hudng tdi sinh hoat, lao ddng. Neu da cd polip to lap hoc mui - xoang thi can phai phau thuat.

ẦN

2.1.4. Viem thanh quan cap tinh

Viem thanh quan cap tfnh thudng gap d tre em, tuy cung gap ca d ngudi ldn. Thanh

quan la noi dudng thd hep nha't nen khi bi viem, phu ne de gay khd thd, cd the din tdi

tac thd gay nguy hiem de'n tfnh mang.

Viem thanh quan cap tfnh thudng bieu hien: Cd dau hieu NKHHCT nhu VA, amidan, mui xoang trudc.

Cd khd thd tang dan vdi dac die'm:

Ó A

Thd cham

•

Khd thd khi thd vao

Í-

•

-L

• Cd tieng rit khi thd vao

Đ ÀN

ÁN

• Khan tieng. Can luu y tdi viem thanh quan ha thanh mon khdng cd khan tieng nhung cd tieng ho nang, dng dng. Dau hieu co keo co hd ha'p, tim tai the hien mtic do cua khd thd.

D IỄ

Vdi viem thanh quan cap tfnh can:

Cho ngudi benh nghi ngoi, giu am.

Cho khang sinh phdi hop vdi corticoid de chdng phu ne thanh quan.

Gui den chuyen khoa hoac theo ddi sat de can thiep kip thdi (dat ndi khf quan, mo khf quan) khi khd thd rd ret.

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2.1.5. Chay mu tai

Benh nay cung thudng gap d nude ta, khoang 3 - 4% d tre em. Chay mu tai gap trong nhieu benh ve tai - xuong chum. Mtic do nang nhe khdng can cti vao chay mu nhieu hay ft ma theo tfnh cha't cua mu.

Mu tai canged mui thdi rd, cang chting td benh tfch da tdi xuong va nguy hie'm.

H Ơ

Neu thdi kham, cd mau trang Ion nhon hay cd vang dng anh can nghi tdi benh

tfch pha huy xuong nhanh, manh ggi la cholesteatom.

Luliy:

TP .Q U

• Chay mu tai keo dai anh hudng nhieu tdi sure nghe.

• Neu cd sot, dau tai, mu nhieu va thdi hon thi can nghi tdi viem tai xuong

chum hdi viem ra't de dua tdi cac bien chting hiem ngheo, tti vong.

ẠO

• Viec dieu tri khang sinh toan than ft tac dung, chu yeu la lam thud'c tai chd hoac can thiep ngoai khoa.

2.2. Di ting - mien dich

2.2.1. Di ting mui xoang

ẦN

Di ting mui xoang hay cdn ggi la viem mui xoang di ting gap nhieu a nude ta; gap mgi ltia tuoi va cd xu hudng ngay cang tang. Theo cac cong trinh nghien ctiu hien cd, d nude ta trong thap ky 90 viem mui di ting chiem khoang 12-25% dan sd, dac biet la d cac thanh phd ldn.

Di ting mui - xoang la phan ting mien dich dac hieu cua niem mac mui xoang trudc su tai xuat hien cua di nguyen dac hieu, the hien qua cac dau hieu dien hinh la:

Ó A

Ngtia mui: La trieu chting bao hieu; ngtia d mui - xoang cd the lan xudng hgng, len mat, mtic do nang nhe tuy tung ngudi.

Í-

Hat hoi tirng hdi, khdng kiem che' dugc. Chay nude mui loang, trong, nhieu sau con hat hoi, ngtia mui.

-L

ÁN

Ngat mui: Cd the' 2 ben hoac 1 ben.

Cac dau hieu tren thudng xuat hien thanh con, tang khi thay doi thdi tiet, yeu met.

Đ ÀN

Ngoai con binh thudng khdng de' lai trieu chting gi khi tham kham.

D IỄ

Theo con di ting ngudi ta chia lam 3 loai:

Viem mui di ting theo mua: Thudng con xuat hien vao mua xuan.

Viem mui di ting quanh nam: Con xuat hien quanh nam, 70% do di nguyen la bui nha.

Viem mui nghe nghiep: Con chi xay ra khi lao ddng; di nguyen cd trong quy trinh san xuat nhu sgi det, long vu, son...

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Xti tri viem mui xoang di ting chu yeu la loai trti di nguyen hoac giam man cam vdi di nguyen dac hieu (neu tim dugc).

Vi rat nhieu thti cd the la di nguyen, khd xac dinh dugc nen dieu tri trieu chting la quan trgng.

Tai chd: Rd, xit hay khf dung bang thud'c co mach + cocticoid hay thud'c tic che

H Ơ

giao cam.

Luu y: Trong benh nay, khang sinh khdng cd tac dung va bat lgi.

2.2.2. Viem mui hong cap tinh a tre nhd

Toan than: Cho khang histamin va corticoid.

TP .Q U

Dieu tri bao gom:

ẠO

Tre tti 6 thang tuoi da het anh hudng mien dich ciia me. Tti dd trd di cho de'n 5, 6 tudi khi tiep xtic lan dau vdi virus hoac vi khuan se cd phan ting de tu tao lap yeu td

mien dich cho su bao ve cua co the khi chung tai xam nhap. Nhu vay thuc ra day khdng phai la mot benh ma la mot phan ting can thiet cho tre.

Sot: Thudng khdng cao trong vdng vai ngay.

ẦN

Thudng thay vdi trieu chting viem dudng hd hap tren bieu hien:

Chay nude mui trong hoac nhay. Ho, ngtia hgng.

DiSn bien trong 3 den 7 ngay rdi tu khdi.

Khi tiep xuc vdi 1 chung virus hoac vi khuan khac lai bi lai.

Ó A

Tuy nhien cd nhung trudng hop phan ting xay ra qua manh: Tre sot cao 39°C - 40°C,

Í-

met mdi nhieu; cung cd khi do benh xay ra d tre suy yeu, co the khdng du sure chdng da va dSn tdi viem lan xudng dudng hd hap dudi gay viem phdi.

ÁN

-L

Binh thudng chi can cho tre nghi ngoi, giu am, rd mui de phdng bdi nhiem. Khdng nen cho khang sinh hay ha nhiet vi lam can trd den qua trinh tao lap mien dich can thiet cho tre sau nay. Can theo ddi tot de phdng ngtia va phat hien bien chting. Chi cho khang

sinh khi cd bien chting.

Đ ÀN

III. THUOC DUNG TRONG TAI MUI HONG

D IỄ

3.1. Nguyen tdc khi six dung thuoc Thud'c dung trong TMH rat da dang, cd the dung theo dudng tai chd hay toan than. Sir dung thud'c trong dieu tri cac benh ve TMH cung tuan theo nhung nguyen tac chung

ve sti dung thud'c trong dieu tri; tuy nhien do nhung dac die'm khac biet ve benh hgc cua TMH nhu da neu tren, sir dung thud'c trong TMH can luu y den nhung diem sau:

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3.1.1. Cac tai bien phan ting toan than

Vi TMH la ctia ngd cua dudng an, dudng thd, cd he mach va than kinh rat phong phti nen luon nhd khi sir dung thud'c, ngay ca chi tai chd cung cd the gay cac tai bie'n, phan ting nguy hiem.

H Ơ

Rd mui cho tre so sinh bang naphazolin l%o da gay tti vong (theo thdng bao cua Vien Nhi) do do lan toa va co mach qua manh cua thud'c lam co that cac mach

Thf du :

Dung corticoid qua dudng xit mui hay khf dung keo dai se gay xuat huyet dudng tieu hoa d nhung ngudi cd loet da day, ta trang, tang tien trien cac benh dudng

TP .Q U

m a u nao.

ẠO

hd hap d nhirng ngudi cd benh dudng hd hap, lao phoi. 3.1.2. Cac tai bien, phan ting phu

Vi TMH cd he thdng thdn kinh giao cam phong phti nen cac phan ting phu thudng

gap deu cd lien quan den TMH nhu chdng mat, ti tai, budn ndn. Cac phan ting phu ciia thud'c nhieu khi khd tranh khdi, neu khdng dugc giai thfch, can dan se cd the? gay hau

qua nghiem trgng.

ẦN

Thf du : Khang histamin (khang U{) thudng dugc dung trong viem mui xoang cd phan ting phu thudng gap la gay budn ngu, neu khdng dugc giai thfch ky ve thdi gian udng cd the gay anh hudng nghiem trgng neu udng xong lai xe, lai tau.

3.1.3. Gay ton thuong chtic nang cua TMH

TMH la co quan giirnhieu chtic nang quan trgng nen can dac biet luu y khi sti dung

Ó A

cac thud'c cd anh hudng xa'u de'n chtic nang cua cac co quan nay.

ÁN

-L

Í-

Trudc het vdi chtic nang nghe: Nhieu trudng hop do dung thud'c dan de'n diec, nguy hai hon neu xay ra vdi ba me mang thai hay d hai nhi dua tdi diec cam. Khang sinh gay tac dung phu loai nay pho bie'n nha't la nhdm aminozid. C£n nhd vdi nhung ngudi cd man cam thi chi vdi lugng nhd nhu rac, nhd vao tai cung gay nen die'c tiep am, khdng cd kha nang hdi phuc.

Chtic nang ngtii: Cac thud'c rd mui cd Hg, As se gay mat ngtii, thudng khdng hdi

Đ ÀN

phuc.

D IỄ

3.1.4. Gay ton hai niem mac

Niem mac mui xoang vdi he thdng long - nhay hoat ddng ra't tinh te'. Khi lam thay ddi pH, nhiet do, do nhdt nhu rd mat ong nguyen chat vao mui se gay ton hai niem mac do do pH va do nhdt cao.

Cac thud'c dung dai ngay cung gay tac hai ldn nhu rd cac thud'c co mach (ephedrin, naphazolin) tuy dting ham lugng nhung nhieu lan, keo dai lien tuc se gay viem mui do 125

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thud'c; nguyen nhan la do te' bao tru cd long chuyen khdng dugc thay the, cac mach bi xa cting...

H Ơ

Nhu da biet vdi tre nhd can tao lap he thdng mien dich. Viec sir dung thud'c khang sinh, ha nhiet trong viem mui hgng cap tfnh thdng thudng lam can trd viec tao he thdng mien dich hoac tao he thdng mien djch khdng hoan chinh. Ngugc lai rd cac loai dich thud'c

3.1.5. Gay anh hudng den he thdng mien dich

chua dugc nghien ctiu ky (cac ddng dugc vdi hoa, la tuoi) cd the se la each vd tinh dua

TP .Q U

cac di nguyen vao co the; neu rd lien tuc thi cac di nguyen nay se tac ddng de'n he thdng mien dich va la nguyen nhan gay cac phan ting di ting sau nay. 3.1.6. Gay kich thich, phan ting tai cho

TMH la cac co quan cd bd phan cam giac rat nhay cam, do dd cac thud'c dung tai

ẠO

chd phai dam bao khdng gay kfch ting de tranh tdn hai niem mac hoac cac phan ting bat

thudng nguy hai den co the.

Thf du:

Rd nude tdi tuoi ep vao mui, hgng de sat khuan se gay ndng, rat, beng, tdn hai

Thud'c rd tai ve mua lanh hay de7 trong tu lanh cd nhiet do dudi 20°C, ne'u rd

ẦN

niem mac.

ngay vao tai se kfch thfch tien dinh gay chdng mat, budn ndn...

3.2. Thuoc thuong dung tai cho va cac phuong phap dua thuoc tai cho

TMH la cac hoc thdng vdi ben ngoai, lot bang ldp niem mac nen cac phuong phap

dieu tri tai chd thudng dugc sirdung va cd tac dung quan trgng.

Ó A

Cac phuong phap dua thud'c tai chd va cac thud'c thdng thudng dung trong dieu tri

bao gom:

-L

Í-

3.2.1. Ro mui

ÁN

Day la dudng dua thud'c pho cap nhat. Tuy nhien can luu y nhung diem sau.. * Cach rd mili:

Trudc khi rd mui can xi hay hut het chat dich nhay, mu ti dgng trong hoc mui thi rd thud'c mdi cd tac dung. Dac biet vdi tre nhd chua biet xi mui, phai dugc hut

Đ ÀN

nhe nhang, dting each bang qua bdng hut mui.

D IỄ

Khi rd mui, tot nhat la de7 tu the' nam ngtia, neu khdng cd dieu kien nam thi phai ngdi, ngtia dau tdi da di thud'c vao dugc trong hoc mui. Hudng dau dng rd ra

phfa ngoai va khdng de cham vao mui, cd gang dua sau trong hoc mui do 1cm rdi rd tti tti vai giot, khdng nen rd qua 5 giot. Sau khi rd, cd the bao benh nhan hit nhe hoac day nhe tren canh mui de thud'c vao dugc sau trong hoc mui

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* Cac thuoc ro mui:

Thud'c co mach: Co mach de tao su thdng thoang cho dudng thd . Cac thud'c co mach thudng dung hien nay la: Ephedrin 1% den 3% (1% cho tre em), naphazolin 0,5%o de'n l%o.

Can luu y: Khdng dung cho tre so sinh, tre dudi 6 thang tudi.

Thud'c sat khuan : Thudng dung argyrol 1% den 3%. Argyrol vtia la thud'c sat khuan, vtia lam san niem mac va chdng xuat tiet nen hay dugc dung cho tre nhd

H Ơ

Vdi tre so sinh, hai nhi nhd cd the dung NaCl 0,9%.

TP .Q U

trong viem V.A, viem mui ca'p tfnh.

ẠO

Luu y: Argyrol la the' pham cua bac nitrat, khi tie'p xuc vdi anh ndng se bi oxy hoa, san pham phan huy lam ton hai den niem mac; do dd argyrol phai dung trong lg, dng thuy tinh cd mau hoac dugc bao bang gia'y den che sang. Khdng nen dung keo dai va

Thud'c khang viem: Vdi cac viem mui, mui - xoang man tfnh, cac thuoc khang viem corticoid cung thudng dung, neu viem kem mu thi nen rd bang cac loai

khdng sir dung thud'c da qua han.

corticoid phdi hgp vdi khang sinh.

ẦN

Luuy :

• Di khdng lam tdn hai niem mac mui, dam bao hoat ddng sinh ly cua he

thdng long nhay, cac thud'c dua vao mui phai dam bao pH = 7 - 9, nhiet do : 23°C - 40°C, do nhdt va ap suat tham thau thfch hop.

• Khdng nen rd khang sinh hay corticoid vdi ndng do qua dam dac vi khdng

Ó A

cd tac dung ma lai gay hai.

• Khi dung cac thud'c rd ddng dugc bang hoa, la, thao mdc tuoi, ngoai cac nguyen Khdng dugc rd cac thud'c co manh nhieu lan trong ngay, keo dai lien tuc nhieu

-L

Í-

tdc tren can dam bao khdng cdnam, vi khuan, di nguyen gay phan ting.

Khdng dung cac thud'c rd cd Hg, As., vi cac cha't nay gay kfch ting qua manh,

ÁN

ngay vi se gay viem mui do thud'c.

ton hai niem mac mui va gay mat ngui.

Đ ÀN

3.2.2. Ro tai

D IỄ

* Cach rd tai:

Trudc khi rd thud'c vao tai, cdn lau, rtia, htit sach cha't dgng trong tai thi thud'c mdi cd tac dung.

Khi rd tai nen de benh nhan nam nghieng, hudng tai bi benh len tren; neu khdng cd dieu kien ndm thi phai ngdi, nghieng dau, hudng tai bi benh len tren.

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Rd tti tti vai gigt, hoi chech dan dng rd de thud'c chay tti thanh dng tai vao trong. Sau khi rd, lay ngdn tay day nhe ndp tai vao ctia dng tai de day thud'c qua Id thiing vao thung tai. Tot nhat la nen dung bdng cao su nhd, dng dau cd ambout dat khft d Id tai, bom nhe trong khi bdp bdng, bao benh nhan nudt vao de md vdi tai cho Dat mot manh bac nhd dgc theo dng tai, nut Id dng tai de thud'c giu dugc lau khdng chay ra ngay khi cti ddng dau co. Sau 1 gid tu bd manh bac di.

H Ơ

thud'c vao khdp thung tai (ngudi benh thay thud'c xudng hgng gay ddng latot).

TP .Q U

Thud'c rd tai nhdm sat khuan, chdng viem, giam xuat tiet, san niem mac.

* Thud'c rd tai :

Cac thud'c thudng dugc dung :

Cdn boric 2% - 5% : Cd tac dung sat khuan, giam xuat tiet. Can luu y neu tai cd xay xudc thi khi rd con se gay dau, xdt rat khd chiu.

Glycerin borat 2% - 5% : Cung cd tac dung sat khuan, giam xuat tiet, giam dau.

Khang sinh: Tren thi trudng hien nay cd nhieu loai. Can luu y den tac dung gay anh hudng den tai trong gay diec, chdng mat...Nhung khang sinh cd tac dung phu loai nay la cac khang sinh nhdm aminosid nhu gentamicin, framycetin,

ẠO

Corticoid: Co tac dung chdng viem. Thud'c thudng dung la hydrocortison, dexamethason...dung don ddc hoac phdi hop vdi khang sinh.

ẦN

nhdm tetracyclin nhu clotetracyclin (aureomycin)...

- Luu y : Nude oxy gia (H202) 6 den 10 don vi the tfch la nude rtia tai, khi rtia xong phai lau that khd. Khdng dugc dung nhu thud'c rd tai vi se gay hai den

Ó A

niem mac cua thung tai.

3.2.3. Phun thuoc tai

-L

Í-

Trong cac trudng hgp chay mu man tfnh, cd mui hdi thudng dugc dieu tri bang each phun thuoc vao tai.

Cung nhu vdi rd tai, trudc khi phun thud'c cung phai lau, rtia sach mu d tai.

ÁN

* Cach phun thuoc tai:

Đ ÀN

- Dung binh phun thud'c tai de bdt thud'c vao dugc deu khdp trong tai. Mdi lan chi phun mot ldp mdng du lang phan trong tai. Khdng nen phun, nha't la rdc qua nhieu bdt thud'c vi gay lap km Id thimg trong tai, bit tdc dudng dan luu , lam tai

D IỄ

bi tdn hai nang hon.

* Thuoc phun tai:

Khang sinh: La loai thud'c dugc dung nhieu nhat, chu yeu dudi dang bdt. Can luu y: Bdt phai min, khdng ddng vdn khi gap mu hoac dich xua't tiet d tai.

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Khdng dugc cao vien khang sinh di rdc vao tai vi bdt khdng min, cd ta dugc ke't dfnh de lam lap Id thung, mat dan luu.

Trong cac trudng hop viem tai xua't tiet cd mu nhay, thudng dung : • Bdt acid boric: Cd tac dung htit nude, sat khuan.

H Ơ

• Bdt phen phi (tan min): Cd tac dung htit nude, giam xua't tiet tot. 3.2.4. Stic hong

TP .Q U

Stic hgng khdng nhung cd tac dung tot trong dieu tri ma cdn de phdng chdng cac viem hgng, amidan cap va man tfnh.

ẠO

* Cach site hong : Ngam 1 ngum nude hay dung dich sue hgng, ngtia cd, ha mieng keu kha.. kha.. kha.. sau do ngam mieng nghi mot lat, lai ngtia co ha mieng keu, lam nhu vay vai ba lan rdi nhd di. Mdi lan lam ba luot.

Luu y : Khdng nen ngam vao rdi nhd ra ngay, nen cd gdng ngam lau tdi da, stic vai

lan, mdi lan vai ba ngum khdng chi de sach cac nhay, mu (ne'u cd) trong hgng ma dam

bao tac dung sat khuan, thay ddi pH cua niem mac hgng. Mdi ngay nen thuc hien stic 1

den 3 lan.

ẦN

* Thuoc site hong:

Theo nguyen ly: Trong cac hoc tu nhien cua co the, khi mdi trudng acid (toan tfnh) thi vi khuan cong sinh trd thanh cd hai, do dd thud'c stic hgng phai cd pH kiem tfnh nhe. Khdng dung do kiem qua cao vi se gay khd, san niem mac.

Cac thud'c sue hgng thudng dung la:

Bdt BBM (gom Na Borat, Na Bicarbonnat va Menthol) gdi lg. Pha vdi nude am

Ó A

(-200 ml), chi pha ngay khi dung vi ne'u de lau mentol bi thang hoa. Cac dung dich kiem nhu kali clorat 1% - 3%.

Di thuan tien cd the7 dung mudn an (NaCl): 1 thia ca phe (5g) pha trong 1 ede

-L

Í-

nude a'm.

ÁN

Luu y : Khdng nen dung nude sue rang- mieng di stic hgng vi cac dung dich nay

thudng cd pH acid.

Đ ÀN

3.2.5. Xit mui - hong

D IỄ

Ngay nay cac thud'c d dang phun mu (aerosol) dung trong TMH kha pho cap d nude ta vdi rat nhieu chung loai va thanh phan khac nhau nhung cd nguyen tdc chung la: Khi bam nut, thud'c se dugc phun ra dudi dang cac hat thud'c nhd li ti, cd kfch thude > 15jam va < lOOum. Cac hat nhd hon 15um se di sau xudng dudng hd hap dudi, cac hat ldn hon lOOum se roi nhanh va khdng vao sau dugc trong hoc mui, hgng.

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Trudc khi xit nen stic hgng hay xi va htit sach mui de thud'c tdi dugc niem mac.

De dau dng xit hudng vao Id mui hay khoang hgng tuy muc dfch dieu tri.

Bam ntit xit de7 luong thud'c phun ra khi hit vao. Thd deu chting 1/2 phut, sau do xit lan thti hai.

TP .Q U

H Ơ

Cd 2 loai binh phun: Loai cd van dinh lieu va loai phun lien tuc. Loai cd van dinh lieu khi bam nut md van, thud'c dugc day ra vdi mot lieu lugng xac dinh va sd lan an nut dugc tfnh theo lieu lugng can dieu tri. Loai khdng cd van dinh lieu khi bam ntit md van, thud'c dugc phun ra lien tuc va chi ngting khi bd tay, nut bam se trd ve vi tri cu va van ddng lai. Tuy nhien, theo quy dinh khdng nen xit lien 4 cai va mdi ngay thuc hien 1 - 4

* Cach dung :

lan la du.

ẠO

Luu y :

• Neu khi xit gay ho, sac, hat hoi thi nen ngting vai phtit rdi hay lam tiep.

• Vdi cac thud'c xit gay co mach, sau khi xit nen chd mot lat cho kip tac dung, khdng nen xit lien tiep ngay nhieu lan. Khdng xit lien tuc nhieu ngay vi cd the gay viem mui do thud'c.

ẦN

• Vdi cac thud'c xit cd corticoid, can nhd mdi lan xit cd the nhan chting 200jig

den 400jLig thud'c (tuy tung loai), do dd khdng xit nhieu lan trong ngay. Ne'u phai xit mot thdi gian lien tuc cung phai theo ddi, can nhdc tdi tac ddng toan

than cua corticoid nhu khi udng hoac tiem.

3.2.6. Xdng hong - mui

Ó A

* Nguyen tdc: Six dung tinh dau hoac cac thud'c bay hoi d nhiet do tha'p, khi cho vao

binh nude am (50°C - 70°C), thud'c se bay hoi cung hoi nude; hting luong hoi dd vao

-L

Í-

hgng hay mui de7 sat khuan, giam dau, phuc hdi niem mac hgng - mui. Xdng tuy don gian nhung cd tac dung rat tot vdi viem mui - hgng ca'p tfnh.

ÁN

* Cach xdng hoi :

Dung binh xdng hoi chuyen dung: Binh dugc dun ndng bdng dien va giu cd dinh

Đ ÀN

d nhiet do 50°C - 60°C. Rd vao binh vai giot tinh dau hay dung dich thud'c bay hoi. Up mui hay hgng hoac ca mui hgng vao mieng pheu ma dau loe dudi tip tren mat binh, thd hit sau de dua hoi nude cd thud'c vao hgng mui.

D IỄ

Thinh thoang cd the thd hit khdng khf thudng cho de chiu. Mdi lan xdng hoi trong khoang 10 phtit. Mdi ngay cd the xdng 2, 3 lan va xdng lien tuc vai ngay.

Neu khdng cd binh xdng hoi chuyen dung, cd the thuc hien don gian bdng 1 ede hay bat dung nude, 1 pheu cudn de vao Id mui hay ngam trong hgng. Khi thay hoi len ft thi phai bo sung hay thay nude cho du do am va rd them thud'c.

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Luu y: Trudc khi xdng hoi mui - xoang can xi, htit het dich mu ti dgng trong

mui, rd thud'c co mach de7 dudng thd thdng thoang tao dieu kien cho viec xdng thud'c phat huy hieu qua.

H Ơ

Dung khf dung la phuong phap dieu tri rat thdng dung va cd ke't qua tot vdi cac loai viem cap va man tfnh d mui - xoang - hgng - thanh quan.

3.2.7. Khi dung (aerosol)

* Nguyen tdc :

TP .Q U

O dang khf dung, thud'c dugc phan tan thanh nhung tieu phan ra't nhd the rdn hoac the7 long trong khdng khf. Cac hat khf nhd nay theo chuyen ddng Brown cd the di sau tdi

ẠO

cac khe ngach cua mui - xoang hay hgng - thanh quan. Cd the them bd phan sieu am de cac hat vao sau trong cac khe, ngach xoang. * Cach khi dung:

Khf dung hgng - thanh quan: Cho ngam dau dng khf dung (khdng nen ngam

ẦN

qua sau, chi can qua rang - mdi la du), mfm mom, thd hit bdng mui. De thud'c vao dugc va cd tac dung tren niem mac hgng - thanh quan nen thd hit du sau, cd thdi gian ngting sau mdi lan thd. Luu y :

• Khdng ngam qua lau, tranh de nude bgt chay vao dng khf dung. Khi cd ho

hoac sac hay ti dgng nude bgt, can bd. dng, nghi mot lat, nhd het nude bgt rdi

mdi lam tiep.

• Vdi tre nhd hay ngudi benh met nang, phai ndm, cd the thay dng khf dung

Ó A

bang mot mat na up tren hgng mui.

- Khf dung mui - xoang:

-L

Í-

• Trudc khi thuc hien khf dung can hut sach dich, mu trong mui - xoang, dat hay rd thud'c co mach de dudng thd thdng thoang tao dieu kien cho thud'c cd tac dung.

ÁN

• Dua hai dau dng khf dung vao qua hai Id mui. Thd hit du manh.

Luu y: Chi dau thi thd vao va cudi thi thd ra thud'c mdi vao dugc xoang.

D IỄ

Đ ÀN

* Cac thuoc:

Nguyen tdc: Cac thud'c sti dung trong khf dung rat da dang, do dd viec lira chgn

thud'c phai tuy theo yeu cau dieu tri. Tuy nhien can dam bao cac nguyen tdc sau: • Thud'c phai khdng gay phan ting di ting, dac biet luu y choang phan ve. Khi dung cac khang sinh cd ty le di ting cao nhu penicilin thi phai hdi benh nhan va neu da cd tien sir man cam vdi thud'c tiem hoac thud'c udng loai nay thi tuyet ddi khdng dugc dung.

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• Phai dam bao do pH = 7 - 9, ndng do thud'c khdng qua cao; neu dam dac thi can pha loang thfch hop trudc khi sir dung.

• Khi dung phdi hop nhieu loai, phai tranh cac tuong ky dugc ly va vat ly. Cac thud'c thudng sirdung de dieu tri viem mui xoang, hgng, thanh quan:

H Ơ

• Thud'c co mach : Naphazolin hay ephedrin.

• Corticoid: Thudng dung hydrocortison, mdi lan khf dung 10-50 mg.

• Khang sinh: Nhieu loai khang sinh dugc sti dung, thf du: Penicilin - mdi lan

D IỄ

Đ ÀN

ÁN

-L

Í-

Ó A

ẦN

ẠO

Lugng dung dich thud'c cho mdi lan khf dung khoang 2 - 3 ml.

TP .Q U

khf dung 50.000 - 100.000 dv.

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