TRNG I HC THNG LONG B MễN Y T CễNG CNG TRN TH NHUNG THC TRNG VIấM PHI TH MY V MT S YU T LIấN QUAN N CHM SểC CA IU DNG TI KHOA HI SC CP CU VIN TIM MCH BNH VIN BCH MAI NM 2016 LUN VN THC S Y T CễNG CNG H NI - 2016 TRNG I HC THNG LONG B MễN Y T CễNG CNG TRN TH NHUNG THC TRNG VIấM PHI TH MY V MT S YU T LIấN QUAN N CHM SểC CA IU DNG TI KHOA HI SC CP CU VIN TIM MCH BNH VIN BCH MAI NM 2016 Chuyờn nghnh: Thc s y t cụng cng Mó s: LUN VN THC S Y T CễNG CNG Ngi hng dn khoa hc: PGS.TS T Mnh Cng H NI 2016 CC CH VIT TT BV Bnh vin CDC Trung tõm kim soỏt bnh tt CSNB Chm súc ngi bnh D iu dng HSCC Hi sc cp cu HSTC Hi sc tớch cc NK Nhim khun VPTM Viờm phi th mỏy NKQ Ni khớ qun NT Nhim trựng VPTM Viờm phi th mỏy MC LC TI LIU THAM KHO PH LC DANH MC BNG DANH MC BIU DANH MC HèNH T VN Viờm phi th mỏy (VPTM) hay cũn gi l nhim khun (NK) phi mc phi thi gian nm vin cú ch nh th mỏy khụng xõm nhp v th mỏy cú xõm nhp (thng sau 48 gi), nhim khun ny khụng hin din giai on bnh ti thi im nhp vin [9] Hin nay, t l VPTM cú xu hng tng lờn nhng bnh nhõn (BN) nng cú can thip th mỏy, c bit bnh nhõn nm cỏc khoa Hi sc tớch cc, khoa cp cu, phũng cp cu khoa Nhi, Thn kinh , õy l mt thỏch thc i vi cỏc bỏc s v iu dng (D) trc tip iu tr, chm súc ngi bnh Bnh nhõn vo iu tr ti khoa Hi sc Cp cu (HSCC) hu ht tỡnh trng rt nng, v thng phi can thip nhiu th thut cựng lỳc vỡ vy mc dự D viờn khoa ó thc hin rt tt, ỳng quy trỡnh k thut chm súc ngi bnh (CSNB) nhng t l NK phi cũn rt cao Theo thng kờ ca Trng Anh Th bnh vin Bch Mai 2008, NKBV lờn n 25% v t l nhim viờm phi th mỏy (VPTM) chim cao nht, t l mi mc cao nht thi gian u mi nhp vin l 3%/ ngy ngy u th mỏy, tip theo l 2% /ngy t n 10 ngy, sau ú l 1% /ngy t 10 ngy tr i [20] Thc t ngi bnh nng cú can thip th mỏy nhn thy b nhim khun phi lm cho tỡnh trng bnh nng lờn, kộo di thi gian iu tr, chi phớ cho iu tr tng lờn, tng t l t vong, ngoi cũn lm tng s khỏng thuc khỏng sinh ca ngi bnh VPTM hin ó tr thnh mt thỏch thc mang tớnh thi i v ton cu Tai Hoa Ki, c tinh VPTM lam keo dai thi gian iờu tri lờn ngay, phai chi thờm cho mụi trng hp nhiờm khun la 2100 ụ la, la nguyờn nhõn cua 99000 trng hp chờt mụi nm Hang nm Hoa Ki phai chi ti 5- 10 ti USD cho viờc mua KS va thi gian nm viờn keo dai cac bờnh gõy Hin nay, ti cỏc khoa Cp cu, Khoa iu tr tớch cc nhiu bnh vin ang cú chuyn bin thc hin lm ca t c chm súc ton din, hy vng phn no s lm gim t l nhim khun phi ú cú viờm phi (VP) trờn ngi bnh th mỏy Bờn cch cỏc xột nghim lõm sng v cn lõm sng phỏt hin bnh nhõn cú biu hin VPTM thỡ khụng th khụng tớnh n s theo dừi sỏt tỡnh trng v din bin ca bnh nhõn mt cỏch h thng ỏnh giỏ, ngn nga, khng ch v tỡm nguyờn nhõn gõy VPTM nhm cú bin phỏp phũng nga Nguụn bờnh co thờ t nụi sinh hoc ngoai sinh Tac nhõn nụi sinh xuõt phat t cac quõn thờ sụng hụi sinh da BN, ng tiờu hoa hoc hụ hõp Cac tac nhõn ngoai sinh c lõy truyờn t bờn ngoai vao BN t cac nguụn bờn ngoai sau BN nhõp viờn Nhiờu yờu tụ gop phõn lam tng s nhõy cam vi nhiờm khun BN nm viờn nh cac bờnh lam tụn thng hờ thụng miờn dich, cac thuục c chờ miờn dich, tuụi qua cao hoc qua thõp, cac nguyờn nhõn lam tụn thng hang rao bao vờ cua võt chu: tụn thng da, niờm mac, bong, chõn thng, cac thu thuõt xõm nhõp, cac ụng thụng nụi mach, Khoa HSCC Vin Tim Mch l ni iu tr nhiu bnh nhõn tỡnh trng nng phi th mỏy ó cú rt nhiu nghiờn cu ỏnh giỏ thc trng ny cỏc khoa HSCC bnh vin Bch Mai nhng ti khoa HSCC Vin Tim Mch thỡ cha cú nghiờn cu no ỏnh giỏ tỡnh VPTM cng nh cỏc yu t liờn quan n thc trng ny Vỡ vy, chỳng tụi thc hin ti: Thc trng viờm phi th mỏy v mt s yu t liờn quan n chm súc ca iu dng ti khoa Hi Sc Cp Cu Vin Tim Mch Bnh Vin Bch Mai nm 2016 nhm hai mc tiờu: Mụ t thc trng viờm phi th mỏy ti phũng HSCC Vin Tim mch Bnh vin Bch Mai nm 2016 Xỏc nh yu t liờn quan n viờm phi th mỏy v chm súc ca iu dng Chng TNG QUAN TI LIU 1.1 Gii phu h hụ hp H hụ hp gm h thng dn khớ v h thng trao i khớ gia mỏu v khụng khớ H thng dn khớ gm cú: Mi, hu, qun, khớ qun v ph qun H thng trao i khớ l phi, cha cỏc ph nang l ni trao i khớ gia mỏu v khụng khớ 1.1.1 Mi Mi ngoi li lờn gia mt, cú dng hỡnh thỏp mt m mt nh nht l l mi trc, mt bờn nm bờn Mi ( mi) gm mi cỏch bi vỏch mi, thụng vi bờn ngoi qua l mi trc v thụng vi hu sau qua l mi sau Mi mi cú thnh: trong, ngoi, trờn v di Cú nhiu xoang nm cỏc xng lõn cn, vo mi [6] Niờm mc mi lút mt mi, liờn tc vi niờm mc cỏc xoang, niờm mc hu Niờm mc mi c chia thnh vựng: + Vựng khu giỏc niờm mc cú nhiu u mỳt thn kinh khu giỏc + Vựng hụ hp: Niờm mc cú nhiu mch mỏu, tuyn niờm mc v t chc bch huyt cú chc nng si m, lm m khụng khớ, lc bt bi v sỏt trựng khụngkhớ trc vo phi Cỏc xoang cnh mi Gm cú ụi l: xoang hm trờn, xoang trỏn, xoang sng v xoang bm Bỡnh thng chỳng u rng, thoỏng v khụ rỏo, cha khụng khớ cú nhim v cng hng õm thanh, lm m niờm mc mi, si m khụng khớ v lm nh xng u mt [16] 10 TAI LIấU THAM KHAO TIấNG VIấT Trõn Duy Anh (2004), Tinh hinh nhiờm trung bờnh viờn mụt sụ n vi iờu tri tich cc va ngoai nc, Y hoc Viờt Nam, (4), tr.7-13 Nguyờn Ngoc Bich, Nguyờn Duy Viờt (2004), Khao sat nhiờm khuõn vờt mụ mụt nm tai khoa ngoai Bờnh viờn Bach Mai, Cụng trinh nghiờn cu khoa hoc Bờnh viờn Bach mai, 2, tr.88-93 Nguyờn Gia Binh, Giang Thuc Anh, Vu Vn inh (2006), anh gia s dung khang sinh nhiờm khuõn bờnh viờn tai khoa iờu tri tich cc Bờnh viờn Bach Mai nm 2003-2004, Cụng trinh nghiờn cu khoa hoc Bờnh viờn Bach Mai, 1, tr.138-145 Khu Thi Khanh Dung, Lờ Kiờn Ngai va CS (2005), Ti lờ nhiờm khuõn bờnh viờn va mụt sụ yờu tụ liờn quan tai Bờnh viờn Nhi Trung ng, Tap chi nghiờn cu y hoc, 38(5), tr.206-210 Vo Cụng ụng, Phung Nguyờn Thờ Nguyờn (2005), c iờm nhiờm trung huyờt Klebsiella tai Bờnh viờn Nhi ụng II nm 2000-2003, Y hoc Thanh phụ Hụ Chi Minh, 9(1), tr.29-32 Hoang Hoa Hai, Lờ Thi Anh Th va CS (2001), Tõn suõt nhiờm khuõn vờt mụ va võn s dung khang sinh tai khoa ngoai Bờnh viờn Ch Rõy, Y hoc Thanh Phụ Hụ Chi Minh, 5(20), tr.41-46 Bui Khc Hõu (2007), Xac inh mc ụ khang vi khang sinh cua Pseudomonas aeruginosa nhiờm trung bờnh viờn, Y hoc thc hanh, 375+376(8), tr.9-11 Phan Quục Hoan, Nguyờn Kim Pua men -lactamase phụ rụng, Tap chi khoa hoc tiờu hoa Viờt Nam, 3(10), tr.602-607 Lờ Thi Anh Hụng (2004), Tinh nhay cam khang sinh cua chung Pseudomonas aeruginosa phõn lõp tai mụt sụ bờnh viờn Ha Nụi, Y hoc Viờt Nam, 303(10), tr.1-6 10 Nguyờn Viờt Hung, Trng Anh Th, ao Xuõn Vinh va CS (2007), Tinh hinh nhiờm khuõn bờnh viờn tai khoa iờu tri tich cc Bờnh viờn Bach Mai, Tap chi y dc hoc quõn s, 32(3), tr.33-39 11 Nguyờn Viờt Hung, Trng Anh Th, Nguyờn Gia Binh va CS (2006), Nhiờm khuõn phụi bờnh viờn tai khoa iờu tri tich cc Bờnh viờn Bach Mai: ti lờ, cn nguyờn va cac yờu tụ nguy c, Cụng trinh nghiờn cu khoa hoc Bờnh viờn Bach Mai, 2, tr.167-173 12 Hoang Trong Kim, Nguyờn Hoai Phong (2005), c iờm nhiờm khuõn bờnh viờn tai khoa Hụi sc tng cng Bờnh viờn Nhi ụng I, Y hoc Thanh phụ Hụ Chi Minh, 9(1), tr.147-153 13 Nguyờn Thi Nam Liờn, Nguyờn Vn Hoa, Nguyờn Duy Thng (2006), Nghiờn cu ti lờ mang S aureus va tinh khang khang sinh cua chung can bụ cụng chc tai Bờnh viờn Trung ng va mụt sụ c quan Thanh phụ Huờ, Tap chi dc hoc,(359), tr.19-22 14 Vo Hụng Linh (2001), Khao sat nhiờm khuõn bờnh viờn tai khoa Sn soc c biờt Bờnh viờn Ch Rõy (7/2000 - 12/2000), Tap chi Y hoc Thanh Phụ Hụ Chi Minh, 5(4), tr.19-27 15 Vu Vn Ngo (2000), Nghiờn cu c iờm lõm sang va vi khuõn gõy viờm phụi mc phai sau t ụng nụi quan tre em, Luõn tụt nghiờp bac si chuyờn khoa cõp II, Trng hoc Y Ha Nụi 16 Nguyờn Thi Lờ Thuy, Hoang Trong Kim (2005), anh gia viờm phụi trờn tre c thụng hụ tr tai khoa Hụi sc cõp cu Bờnh viờn Nhi ụng I, Y hoc Thanh Phụ Hụ Chi Minh, 9(1), pp.1-6 17 Lờ Thi Anh Th, Vo Thi Chi Mai, Nguyờn Phuc Tiờn, ng Thi Võn Trang (2008), anh gia s khang thuục cua bờnh nguyờn nhiờm khuõn bờnh viờn, Y hoc thc hanh, 594+595(1), tr.19-24 18 Trng Anh Th, Lờ Thi Thanh Thuy, Nguyờn Viờt Hung va mang li viờn chụng nhiờm khuõn Bờnh viờn Bach Mai (2006), Tinh hinh nhiờm khuõn bờnh viờn hiờn mc tai Bờnh viờn Bach Mai 2005, Cụng trinh nghiờn cu khoa hoc Bờnh viờn Bach Mai, 2, tr.199-208 19 Pham Lờ Tuõn, Nguyờn Viờt Hung, Trng Anh Th va CS (2007), iờu tra tinh hinh nhiờm khuõn bờnh viờn tai mụt sụ bờnh viờn thuục S y tờ Ha Nụi, Tap chi Y hoc thc hanh, 264(2), tr.85-87 20 Ha Manh Tuõn, Hoang Trong Kim (2005), Tõn suõt nhiờm khuõn bờnh viờn tai khoa Hụi sc cõp cu nhi, Y hoc Thanh phụ Hụ Chi Minh, 9(2), tr.78-85 21 Trõn Quục Viờt (2007), anh gia kờt qua theo doi nhiờm khuõn bờnh viờn tai khoa Hụi sc tich cc Bờnh viờn 175, Tap chi Y Dc lõm sang 108, 2(3), tr.26-30 22 Nguyờn Thi Vinh, Nguyờn c Hiờn, oan Mai Phng, Vo Thi Chi Mai, ng Thu Hng va CS (2006), Giam sat s khang khang sinh cua vi khuõn gõy bờnh thng gp Viờt Nam nm 2005, Tap chi nghiờn cu y hoc, 46(6), tr.87-91 23 Nguyờn Minh Vu (2004), Khao sat nhiờm khuõn bờnh viờn tai khoa Sn soc c biờt Bờnh viờn a khoa Cõn Th, Luõn thac si y hoc, Hoc viờn Quõn y TIấNG ANH 24 Akash D, Ghildiyal R et al (2004), Clinical and microbiological profile of nosocomial infections in the pediatric intensive care unit, Indian Pediatric, 41, pp.1238-1256 25 Akira B, 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Annals of Internal Medicine, 145(8), pp 582-592 79 Vincent JL, Bihari DJ, Suter PM et al (1995), The prevalence of nosocomal infection in intensive care units in europe: results of the european prevalence of infection in intensive care study, J Am Med Association, 274(8), pp.639-644 80 Xiao YH, Wang J, Li Y, MOH National Antimicrobial Resistance Investigation Net (2008), Bacterial resistance surveilance in China: a report from Mohnarin 2004-2005, Eur J Microbiol Infect Dis, 27(8), pp.697-708 81 Yhu-Chering H, Yi-Hon C et al (2006), Methicillin-resistant Staphylococcus aureus colonization and its association with infection among infants hospitalized in neonatal intensive care units, Pediatrics, 118, pp.469-474 PH LC MU BấNH AN NGHIấN CU THC TRNG VIấM PHI TH MY V MT S YU T LIấN QUAN N CHM SểC CA IU DNG TI KHOA HI SC CP CU VIN TIM MCH BNH VIN BCH MAI NM 2016 Sụ lu tr: S th t: HANH CHINH Ho va tờn: .Tuụi : Gii tớnh Ngh nghip : Khu vc sng : Ngay vao viờn: Ngay : Sụ iờu tri ti khoa : S ngy th mỏy: Kờt qua iờu tri: T vong/ nng xin vờ chuyờn khoa khoi viờn CHN OAN 2.1.Chõn oan vao khoa HSCC: TBMN/ST Bờnh li thõn kinh trung ng Bờnh li tiờu hoa Bờnh li thõn kinh-c Bờnh huyờt hoc Bờnh li tim mach Bờnh li hụ hõp Bờnh chuyờn hoa Ngụ ục Bờnh li khac CAC TRIấU CHNG LM SANG VA XET NGHIấM CHINH KHI VAO KHOA - Cõn nng : kg - Sụ lng bach cõu: G/l - Th trng : suy kit : Co - ng mau: mmol/l Khụng - Tinh thõn ( anh gia theo thang iờm.( glassgow) : - Mach: .ln/phỳt - Nhiờt ụ: - Huyờt ap trung binh: mmHg - Suy hụ hõp phai t NKQ: Co - Protein: g/l - Albumin: g/l - Procalcitonin : ng/ml - Khớ mỏu M : + PCO2: mmHg Khụng -SpO2 : - X- Quang tim phi : + PH : + Lac : - Xột nghim cy m : m tớnh Dng tớnh ( vi khun ) THI IấM PHAT HIấN NHIấM KHUN PHI ( Sau : nhõp khoa ) 4.1 CAC BIấN ễI LM SANG VA XET NGHIấM CHINH KHI PHAT HIấN NHIấM KHUN PHI - Tinh thõn (anh gia theo thang iờm - Protein: (glassgow) - Mach: lõn/phut - Nhiờt ụ: 0C - Huyờt ap trung binh: mmHg - Albumin : g/l - Procalcitonin : g/l - Khớ mỏu M : - Suy hụ hõp phai t NKQ: Co + PCO2: mmHg Khụng -SpO2 : - X- Quang tim phi : - Sụ lng bach cõu: + PH: + Lac : % - Xột nghim cy m : m tớnh Dng tớnh ( vi khun .) 4.2 Viờm phụi th mỏy - Tng sn sut cỏc cht tit ca ng hụ hp: Co Khụng - Mi xut hin m m: Co Khụng -Thay i tớnh cht ca m: Co Khụng - Ho: Co Khụng Khũ khố : Co Khụng - Ral ngỏy: Co Khụng Ral õm/nụ: Co Khụng + ỏm m mi thõm nhim Co Khụng + Hỡnh nh ụng c Co Khụng + Hang Co Khụng + Hinh anh tran Co Khụng - X- quang phi: viờm phi CAC THU THUT THC HIấN TRấN BấNH NHN 5.1 Th may: Thi gian th may.ngay Co Khụng 5.2 Th khụng xõm nhp Co 5.3 t NKQ: Sụ lõn t NKQ : lõn Khụng Co Tụng thi gian lu ụng NKQ: Co Khụng Co lõn Khụng Khụng > lõn 5.4 t ụng thụng tinh mach trung tõm: Sụ lõn t ụng thụng nụi mach: lõn Tụng thi gian lu ụng thụng nụi mach: 5.5 t thụng tiờu: Sụ lõn t thụng tiờu: 1lõn Tụng thi gian lu ụng thụng tiờu: 5.6 t ng sonde d dy : Co 5.7 t mỏy to nhp : Co Khụng Khụng IấU TRI 6.1 nhng khang sinh trc phat hiờn NK phi : Co Khụng Tờn cac loai KS dung:Rocephin 1g x 2g/ngy Tavanic 50mg /ngy Sụ lng KS dung: KS KS 6.2 nhng KS sau phat hiờn nhim khun phi : Co Tờn cac loai KS dung/ngy : CHM SểC 7.1 TRèNH IU DNG - d i hc - d Cao ng Khụng - d trung cp 7.2 V Rung - T th T th 7.3 Hỳt m - T th T th T th 7.4 S ln hỳt m - ln ln ln 7.5 Chm súc NKQ v v sinh rng ming 24 gi - lõn ln 8.KấT QUA NUễI CY VA KHANG SINH ễ Tờn bờnh phõm:.m ( õm tớnh ) Vi khuõn phõn lõp c: Khang sinh ụ: S: Nhay cam I: Trung gian R: Khang Mc nhay cam KS Nhúm Carbapenems Meronem Tienam Nhúm Quinolon Tavanic Avelox Nhúm Cephalosporine Fortum Nhúm Polymyxin Colistin Nhúm Glycopeptid Vancomycin S Vi khuõn I R S Vi khuõn I R S I 9.Vi khun gõy viờm phi th mỏy VK gõy bờnh Cú Khụng R P.aeruginosa K.pneumoniae Enterobacter cloacae S.aureus Acinetobacter NC Staphylococcus E.coli Pseudomonas sp A.baumanii