Nghiên cứu biến cố tức thì liên quan đến thủ thuật đặt ống nội khí quản cấp cứu ở trẻ em tại bệnh viện nhi trung ương

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Nghiên cứu biến cố tức thì liên quan đến thủ thuật đặt ống nội khí quản cấp cứu ở trẻ em tại bệnh viện nhi trung ương

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B GIO DC V O TO B Y T TRNG I HC Y H NI THEPNALY XAYSIDA NGHIấN CU BIN C TC THè LIấN QUAN N TH THUT T NG NI KH QUN CP CU TR EM TI BNH VIấN NHI TRUNG NG LUN VN THC S Y HC H NI-2016 B GIO DC V O TO B Y T TRNG I HC Y H NI THEPNALY XAYSIDA NGHIÊN CứU BIếN Cố TứC THì LIÊN QUAN ĐếN THủ THUậT ĐặT ốNG NộI KHí QUảN CấP CứU TRẻ EM TạI BệNH VIÊN NHI TRUNG ƯƠNG Chuyờn ngnh: Nhi khoa Mó s: 60720135 LUN VN THC S Y HC Ngi hng dn khoa hc: PGS.TS Trõ n Minh iờ n TS Phan Hu Phỳc H NI-2016 LI CM N hon thnh lun ny, tụi xin c by t lũng bit n ti: Ban Giỏm hiu, Phũng o to sau i hc, cỏc phũng ban chc nng ca trng i hc Y H Ni ó giỳp v to iu kin thun li cho tụi quỏ trỡnh hc v nghiờn cu Cỏc thy cụ B mụn Nhi ó úng gúp nhiu cụng sc ging dy, o to tụi sut quỏ trỡnh hc cng nh hon thnh lun ny Cỏc thy cụ Hi ng thụng qua cng ó a nhng gúp ý vụ cựng giỏ tr giỳp tụi cú iu chnh hon thnh lun ny c tt hn Ban giỏm c, Phũng K hoch tng hp Bnh vin Nhi Trung ng ó nhit tỡnh giỳp chỳng tụi quỏ trỡnh hon thnh lun vn.Tp th khoa iu tr tớch cc Bnh vin Nhi Trung ng ó to iu kin thun li nht tụi cú th hon thnh lun ny PGS.TS Trõ n Minh iờ n v TS Phan Hu Phỳc, Ngi Thy ht sc tõm huyt, tm gng nhit tỡnh ging dy, o to, ó tn tỡnh ch bo tụi trờn ng nghiờn cu khoa hc, l ngi trc tip hng dn tụi hon thnh lun ny Tụi xin chõn thnh cm n tt c bn bố thõn thit ó ng viờn, c v v giỳp tụi c cuc sng v s nghip nghiờn cu ca mỡnh Cui cựng tụi xin chõn thnh cm n: Gia ỡnh: B, M, chng, l ngun ng viờn ln ó chia s mi khú khn, vui bun, sỏt cỏnh v theo dừi tng bc i ca tụi s nghip hc v phn u ca mỡnh H Ni, ngy 20 thỏng 12 nm 2016 Thepnaly XAYSIDA LI CAM OAN Tụi l Thepnaly XAYSIDA, hc viờn cao hc khúa 23, Trng i hc Y H Ni, chuyờn ngnh Nhi khoa, xin cam oan: õy l lun bn thõn tụi trc tip thc hin di s hng dn ca PGS.TS Trõ n Minh iờ n v TS Phan Hu Phỳc Cụng trỡnh ny khụng trựng lp vi bt k nghiờn cu no khỏc ó c cụng b ti Vit Nam Cỏc s liu v thụng tin nghiờn cu l hon ton chớnh xỏc, trung thc v khỏch quan, ó c xỏc nhn v chp thun ca c s nghiờn cu Tụi xin hon ton chu trỏch nhim trc phỏp lut v nhng cam kt ny H Ni, ngy 20 thỏng 12 nm 2016 Hcviờn Thepnaly XAYSIDA CC CH VIT TT NKQ Ni khớ qun SHH Suy hụ hp SHHC Suy hụ hp cp HSCC Hi sc cp cu NC Nghiờn cu BS Bỏc s T VN Th thut t ng ni khớ qun (NKQ) l mt th thut rt quan trng kim soỏt ng th hi sc cp cu Chớnh s i ca ca th thut ny ó cu sng rt nhiu bnh nhõn thi gian va qua v c ỏp dng thng xuyờn ti cỏc khoa Gõy mờ hi sc, nhng n v hi sc tớch cc nhng trng hp cp cu, cn kim soỏt ng hụ hp Mc dự th thut mang li rt nhiu li ớch cho hi sc bnh nhõn nhng khụng th trỏnh c nhng bin chng cú th xy Trong ú cú th gp bin chng tc thỡnh: chn thng, thiu oxy, chm nhp tim, ngng tim [1],[2], hay bin chng lõu di nh: phự n, khn ting, au hng, hp khớ qun,thm cú th gõy hoi t lp di niờm mc khớ qun, thng sn khớ qun, gõy nhim trựng, hp khớ qun[3],[4],[5].Cỏc mc tai bin v bin chng khỏc t cỏc tn thng t rt nh n tn thng trm trng Nghiờn cu cỏc bin chng tc thỡ t NKQ, Jaber v cng s cho thy cú ti28% bnh nhõn xut hin ớt nht mt bin chng nng nguy him nh ngng tim, sc, suy hụ hp nng[6] cỏc khoa hi sc cp cu nhi, cỏc bin chng ca t ng NKQ cng xut hin vi tn sut cao ti 24%[7], cũn t l t vong th thut gõy thỡ rt ớt ch 0,4%[1] Cỏc bin chng ny cú th nh hng n vic iu tr, thi gian nm vin, chi phớ v cuc sng sau ny ca bnh nhõn gim cỏc bin chng ca th thut cn cú s tham gia ca tt c cỏc thnh phn liờn quan t khõu chun bdng c,nhõn lc, chun b bnh nhõn, cỏch chn li ốn, lachn cỏc phngphỏp vụ cm thớch hp trc t ng NKQ, hn na liu lng ca thuc cng phi phự hp vi tỡnh trng ca bnh nhõn khụng gõy tn thng hoc hn ch bin chng c nhiu nht v mt iu khụng th thiu l k nng ca bỏc s lm cng phi tt Trong ú nhiu nghiờn cu thy rng s thnh cụng ca th thut cũn ph thuc nhiu vo kinh nghim ca bỏc s[8],[9] Trờn th gii, ó cú nhiu nghiờn cu v th thut t ng NKQ cp cu v nhng tai bin ca th thut tr em [1],[2],[4],[5],[6] Vit Nam, t NKQ l mt th thut cp cu rt ph bin, nhng vic la chn cỏc k thut, sdng cỏc thuc an thn, gión c trc lm th thut, cng nh nhng tai bin ca t NKQ cũn cha c cp ti Nhõ n xet qua trinh chun b thu thuõ t t ụ ng nụ i quan, cac bc tiờ n hanh thu thuõ t, qua trin h theo doi va sau thu thuõ t, va xac inh cac biờ n chng tc thi cua thu thuõ t la rõ t quan tro ng, giup cho an toan ngi bờnh va ngi thõ y thuụ c tich luy kinh nghiờ m chuyờn mụn Do vy chỳng tụi thc hin ti:Bin c tc thỡ liờn quan n th thut t ng ni khớ qun cp cu tr em ti Bnh vin Nhi Trung ng, nhm hai mc tiờu: Xỏc nh t l cỏc bin c tc thỡ ca th thut t ng ni khớ qun cp cu tr em Phõn tớch mt s yu t liờn quan n bin c tc thỡ ca th thut t ng ni khớ qun cp cu tr em CHNG TNG QUAN 1.1 Suy hụ hp tr em Suy hụ hp(SHH) l mt hi chng hay gp nhiu nguyờn nhõn gõy nờn v rt nguy him n tớnh mng ca bnh nhõn nu khụng phỏt hin v iu tr kp thi SHH cp l tỡnh trng c quan hụ hp t nhiờn khụng bo m c chc nng trao i khớ, gõy thiu oxy mỏu, cú hoc khụng cú kốm theo tng cacbonic (CO2) mỏu, c biu hin qua kt qu o khớ mỏu ng mch, vi PaO2 < 60 mmHg, PaCO2>50 mmHg th viFiO2 = 21%[10],[11] SHH tr em c bit tr s sinh cú rt nhiu yu t gúp phn vo lm cho tr b suy hụ hp nng lờn v nhanh vỡ c im cu to ng th ca tr cng cú nhiu im khỏc vi ngi ln vỡ cu to cng cha hon thin nh: ng dn khớ nh hn, nhu cu trao i cht li cao m kh nng d tr li thp v c ch bự tr thp hn so vi ngi ln nờn lm cho tr nhanh chúng b SHH v nng,c bit tr s sinh non nguy c ny cng tng lờn cao v nng n 1.1.1 Nguyờn nhõn ca suy hụ hp SHH cú th nhiu nguyờn nhõn khỏc rt phc tp, nhng cú th túm tt thnh nhúm nguyờn nhõn chớnh: - SHH tn thng h hụ hp, lm ri lon quỏ trỡnh trao i khớ phi nh: viờm phi, vim tiu ph qun, hen ph qun, trn dch mng phi, trn khớ mng phi, viờm khớ ph qun, d vt ng th, phự phi, ui nc,[11] - SHH cỏc bnh tim mch v bnh mỏu lm ri lon quỏ trỡnh chuyn O2 c th nh bnh thp tim h hp van lỏ, tim bm sinh, suy tim, thiu mỏu nng, sc,[11] - SHH cỏc bnh h thn kinh lm c ch v ri lon trung tõm hụ hp, nh hng n cỏc c hụ hp, nh viờm nóo- mng nóo, viờm ty, xuthuyt nóo, chn thng ty, bi lit, nhc c, ng c, chn thng u nng,[11] Cỏc nguyờn nhõn gõy t vong hng u tr em di nm tui vo nm 2015 l bin chng v sinh non thỏng, viờm phi, bin chng liờn quan lỳc chuyn d, tiờu chy v nhng bt thng bm sinh T vong s sinh chim 45% tr di tui mt nghiờn cu nm 2015[12] Biu 1.1: Nguyờn nhõn t vong tr di tui nm 2015 theo s liu ca T chc Y t th gii 68 im mnh v hn ch ca nghiờn cu õy l nghiờn cu h thng u tiờnv thc hnh th thut t ng ni khớ qun tr em Vit nam, xỏc nh nhng bin c, cng nh xỏc nh cỏc yu t liờn quan ti bin c ca th thut Quỏ trỡnh chun b v tin hnh th thut, cng nh ghi nhn cỏc bin c c quan sỏt, tin hnh trc tip, ỏnh giỏ khỏch quan bi ngi khụng trc tip tham gia vo thc hin th thut, ú thụng tin v s liu thu nhn c l chớnh xỏc, khỏch quan, v trỏnh c tỡnh trng sai lch t l bin c ớt hn so vi t bỏo cỏo Tuy nhiờn, nghiờn cu cũn mt s hn ch nh s lng bnh nhõn nghiờn cu cha i din cho tt c cỏc khoa phũng vỡ nghiờn cu ch lm khoa hi sc cp cu th thut ny s dng rt nhiu cỏc khoa phũng khỏc nh: cp cu, khoa s sinh, khoa hi sc ngoi v cỏc n v cp cu ca khoa phũng Trong nghiờn cu ny, thụng tin v liu ca cỏc thuc an thn gim au, gión c khụng c thu thp, ú khụng phõn tớch c mi liờn quan gia thuc v liu ti bin c ri lon huyt ng Nghiờn cu cng khụng ỏnh giỏ c kt qu sng- t vong liờn quan ti cỏc bin c t ng NKQ, nhiờn, kt qu iu tr cui cựng ca bnh nhõn cũn ph thuc bi nhiu yu t khỏc 69 KT LUN Nghiờn cu v bin c tc thỡ ca t ni khớ qun trờn 132 bnh nhõn c thc hin 176 ln t ng cp cu ti khoa Hi sc Cp cu Bnh vin Nhi Trung ng, chỳng tụi rỳt mt s kt lun nh sau: - c im nhúm nghiờn cu: ch yu tr nh di tui (68,2%), nguyờn nhõn suy hụ hp ti phi l chớnh (69,7%) - Chun b dng c tt t ni khớ qun l 88,6%, ng ni khớ qun c la chn phự hp l 58,5%, cú 32,4% la chn c ng to v 9,1% la chn c ng nh S dng an thn v/hoc gim au t l 83,5% Ngi thc hin th thut t ng ni khớ qun nhiu nht l bỏc s ni trỳ (51,7%), sau ú l bỏc s khoa HSCC (27,8%), cao hc (10,2%) - S ln n lc thc hin th thut t ng ni khớ qun c ln l 58,5%, tip cn ln thnh cụng l 26,1%, cũn 3,4% tip cn hn ln Trong quỏ trỡnh lm th thut, so sỏnh giỏ tr trung bỡnh SpO2, nhp tim trc v gim cú ý ngha thng kờ (p < 0,05) - Bin c chung l 76/176 trng hp, chim 43,2% Trong ú bin c gim oxy gp 34,1%, chm nhp tim 12,5%, khỏc (xõy xỏt mụi, chy mỏu, kớch thớch, t vo thc qun) l 13,6% - Bin c chung liờn quan n t ng khú khn, bỏc s HSCC (p < 0,05), sau phõn tớch a bin ch cũn yu t c lp liờn quan n bin c chung t ng ni khớ qun l hc viờn t ng(OR: 2,1; 95%CI: 1,1 4,4) v n lc t ng > ln(OR: 2,0; 95%CI: 1,1-3,9) - Bin c gim oxy liờn quan n nguyờn nhõn suy hụ hp ti phi, bỏc s HSCC, ln n lc t (p < 0,05), phõn tớch a bin cũn li yu t nguyờn nhõn suy hụ hp ti phi (OR: 2,7; 95%CI: 1,1 6,7) v hc viờn t ng(OR: 2,3; 95%CI: 1,1-5,3) 70 KIN NGH Giỏm sỏt cht ch quỏ trỡnh t ng ni khớ qun cho cỏc bnh nhõn suy hụ hp, c bit nhúm suy hụ hp nguyờn nhõn ti phi, cung cp ụ xy liu cao trc t nhm gim bt nguy c gim oxy Cn cú trang thit b y c s lng v cht lng Cn o to cho cỏc bỏc s tham gia cụng tỏc cp cu, hi sc nhi khoa cỏc chng trỡnh cp cu c bn, cp cu nhi khoa nõng cao Chỳ trng k nng kim soỏt ng th, ú th thut t ng ni khớ qun l tiờu quan trng Cỏc bỏc s l hc viờn cn c thc hnh trờn mụ hỡnh k trc thc hin trờn ngi bnh Cn cú s giỏm sỏt, tr giỳp ca bỏc s cú kinh nghim cho cỏc bỏc s hc viờn lm th thut t NKQ cho bnh nhõn MC LC T VN CHNG 1:TNG QUAN 1.1 Suy hụ hp tr em 1.1.1 Nguyờn nhõn ca suy hụ hp 1.1.2 Phõn loi suy hụ hp cp 1.1.3 Triu chng lõm sng v xột nghim 1.1.4 X trớ suy hụ hp 1.2 Lch s v s phỏt trin ca ng NKQ 1.3 Th thut t ng NKQ 10 1.3.1 Chun b bnh nhõn 10 1.3.2 Chun b nhõn viờn y t 11 1.3.3 Chun b dng c v thuc 11 1.4 Tin hnh th thut t ng NKQ 19 1.5 Nguyờn nhõn cú th lm tin trin xu trờn lõm sng t ngt 21 1.6 Tai bin t ng ni khớ qun 21 1.6.1 Cỏc tai bin tc thỡ 21 1.6.2 Tai bin quỏ trỡnh th mỏy 23 1.6.3 Tai bin sau rỳt ng ni khớ qun 24 1.7 Mụt s yu t liờn quan n t ng ni khớ qun 25 CHNG 2:I TNG V PHNG PHP NGHIấN CU 26 2.1 i tng nghiờn cu 26 2.1.1 Tiờu chun la chn bnh nhõn 26 2.1.2 Tiờu chun loi tr 26 2.1.3 C mu 26 2.1.4 a im v thi gian nghiờn cu 27 2.2 Phng phỏp nghiờn cu 27 2.2.1 Thit k nghiờn cu 27 2.2.2 Ni dung nghiờn cu 27 2.2.3 Cỏc bin nghiờn cu 28 2.2.4 Phng phỏp thu thp s liu 31 2.2.5 X lý s liu 32 2.3 o c nghiờn cu 32 CHNG 3:KT QU NGHIấN CU 33 3.1 c im ca bnh nhõn nghiờn cu 33 3.2 c im chun b dng c, thuc t ng ni khớ qun 35 3.3 Thy thuc thc hin t ng ni khớ qun 38 3.4 Th thut t ng ni khớ qun 39 3.5 Bin c t ng ni khớ qun 41 3.6 Cỏc yu t liờn quan n bin c 43 3.6.1 Mt s yu t liờn quan n bin c chung 43 3.6.2 Liờn quan cỏc yu t n bin c gim oxy 47 CHNG 4:BN LUN 52 4.1 c im chung ca nhúm nghiờn cu 52 4.2 Chun b dng c v thuc t ng ni khớ qun 54 4.3 Thy thuc thc hin th thut t ng ni khớ qun 57 4.4 Th thut t ng ni khớ qun 58 4.5 Bin c t ng ni khớ qun 59 4.6 Cỏc yu t liờn quan n bin c t ng ni khớ qun 62 KT LUN 69 KIN NGH 70 TI LIU THAM KHO PH LC DANH MC BNG Bng 1.1: C ng NKQ theo tui v cõn nng 12 Bng 1.2 t ng NKQ theo phng phỏp RSI 15 Bng 3.1 Phõn b tui bnh nhõn 33 Bng 3.2 Nguyờn nhõn chớnh gõy suy hụ hp 34 Bng 3.3 c im chun b dng c cỏc ln t ng NKQ 35 Bng 3.4 Phõn b s dng c ng NKQ 36 Bng 3.5 Kiu ng NKQ 37 Bng 3.6 Phõn b bỏc s lm th thut 38 Bng 3.7 S ln ln n lc t ng NKQ trờn mt th thut t ng thnh cụng 39 Bng 3.8 Mt s ch s lõm sng trc, v sau t ng NKQ 40 Bng 3.9 T l cỏc bin c t ng NKQ 41 Bng 3.10 Liờn quan c im bnh nhõn vi bin c chung 43 Bng 3.11 Liờn quan n dng c t ng NKQ v bin c chung 44 Bng 3.12 Liờn quan s dng thuc an thn v bin c chung 45 Bng 3.13 Phõn b liờn quan bỏc s lm th thut v bin c chung 45 Bng 3.14 Liờn quan thc hin th thut v bin c chung 46 Bng 3.15 Phõn tớch hi quy a bin cỏc yu t liờn quan n bin c chung 46 Bng 3.16 Mt s yu t c im bnh nhõn liờn quan vi bin c gim oxy 47 Bng 3.17 c im dng c t ng NKQ liờn quan ti bin c gim oxy 48 Bng 3.18 Liờn quan s dng thuc v bin c gim oxy 49 Bng 3.19 Liờn quan thy thuc lm th thut v bin c thiu oxy 49 Bng 3.20 Liờn quan thc hin th thut v bin c gim oxy 50 Bng 3.21 Phõn tớch a bin cỏc yu t liờn quan n bin c gim oxy 51 DANH MC BIU Biu 1.1: Nguyờn nhõn t vong tr di tui nm 2015 theo s liu ca T chc Y t th gii Biu 3.1: T l gii tớnh 34 Biu 3.2 T l v bnh nhõn b d ng 35 Biu 3.3 T l v li ốn s dng t ng 36 Biu 3.4 T l la chn c ng phự hp 37 Biu 3.5 T ldựng cỏc thuc trc t ng 38 Biu 3.6 T l v ch nh t ng NKQ 39 Biu 3.7 Thi im t ng 40 Biu 3.8 T l bin c chung 41 Biu 3.9 Phõn b s bin c mi ln t NKQ 42 Biu 3.10 Mc gim oxy quỏ trỡnh t 42 Biu 3.11 T l t ng ni khớ qun khú khn 43 DANH MC HèNH Hỡnh 1.1 Li ốn Machintosh, loi cong v thng 11 Hỡnh 1.2 Li Miller 11 Hỡnh 1.3 ng NKQ loi khụng cú búng 13 Hỡnh 1.4 ng NKQ loi cú búng 13 Hỡnh 1.5 Búng búp, mask, tỳi tr oxy 13 Hỡnh 1.6 Dng c li 14 Hỡnh 1.7 ng thụng nũng 14 Hỡnh 1.8 K thut sellick 20 Hỡnh 1.9 T th t ng 20 Hỡnh 1.10 T th tay lỳc t 20 Hỡnh 1.11 Cỏch c nh ng NKQ qua ng ming 21 TI LIU THAM KHO NộlioS., Carvalho, Brunow W (2009) Complications of tracheal intubation in pediatrics.Revista Da Associacao Medica Brasileira Journals 55 (6), 646-65 Akira N, David A, Calvin A, et al (2013) A national emergency airway registry for children Landscape of tracheal intubation in 15 PICUs Critical Care Medicine.41 (3), 874-885 Trn Trung Kiờn (2000), Nghiờn cu bin chng ca t ng ni khớ qun ng ming hi sc cp cu, Lun tt nghip thc s y hc, Trng i hc Y H Ni Divatia J V, Bhowmick K (2005) Complication of endotracheal intubation and other airway management procedures Indian Journal of Anaesthesia 49 (4), 308 318 Colice GL, Stukel TA, Dain B (1989) Laryngeal complications of prolonged intubation Chest 96(4),877-884 Jaber S, Amraoui J, Lefrant JY, et al (2006) Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple center study Critical Care Medicine 34 (9),23552361 Rivera R, Tibballs J (1992) Complications of endotracheal intubation and mechanical ventilation in infants and children CriticalCare Medicine 20(2), 193-199 Leone TA., Rich W., Finer NN (2005) Neonatal intubation: success of pediatric trainees Journal of Pediatrics 146(5), 638641 Ronald C Sanders,Jr, MD, MS, John S.,et al (2013) Level of trainee and tracheal intubation outcomes Pediatrics, 131(3), 821-828 10 Nelson Textbook of Pediatrics (2008) 18th edition 11 GS.TSKH Lờ Nam Tr (2013) Bi ging nhi khoa, Trng i hc Y H Ni, Nh xut bn Y Hc H Ni, tp1, tr420-434 12 WHO database.Availablefrom: http://www.who.int/gho/child_health/mortality/causes/en/ 13 Williams B G., Gouws E., Boschi-Pinto C., et al (2002) Estimates of World wide Distribution of Child Deaths from Acute Respiratory Infections Lancet Infectious Diseases 2(1),2532 14 WHO database Available from: http://www.who.int/mediacentre/factsheets/fs331/en/ 15 Lờ Nam Tr (2013) Bi ging nhi khoa, Trng i hc Y H Ni, Nh xut bn Y Hc H Ni tp2, tr 300-306 16 Erickson S, Schibler A, Numa A, et al (2007) Acute lung injury in pediatric intensive care in Australia and New Zealand: a prospective, multicenter, observational study Pediatric Critical Care Medicine; 8(4), 317323 17 Flori HR, Glidden EV, Rutherford GW, et al (2005) Pediatric acute lung injury: Prospective evaluation of risk factors associated 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Seminars in Perinatology; 31(5), 309-317 71 Ghanta S, Abdol-latif M, Lui K, et al (2007) Propofol compared with the morphine, atropine, and suxamethonium regimen as induction agents for neonatal endotracheal intubation: A randomized, control trial Pediatrics.119(6): 1248-1255 11,13,14,18,20,34-43 3-10,12,15-17,19,21-33,44- ... TRNG I HC Y H NI THEPNALY XAYSIDA NGHIÊN CứU BIếN Cố TứC THì LIÊN QUAN ĐếN THủ THUậT ĐặT ốNG NộI KHí QUảN CấP CứU TRẻ EM TạI BệNH VIÊN NHI TRUNG ƯƠNG Chuyờn ngnh: Nhi khoa Mó s: 60720135 LUN VN... thỡ liờn quan n th thut t ng ni khớ qun cp cu tr em ti Bnh vin Nhi Trung ng, nhm hai mc tiờu: Xỏc nh t l cỏc bin c tc thỡ ca th thut t ng ni khớ qun cp cu tr em Phõn tớch mt s yu t liờn quan n... hn Ban giỏm c, Phũng K hoch tng hp Bnh vin Nhi Trung ng ó nhit tỡnh giỳp chỳng tụi quỏ trỡnh hon thnh lun vn.Tp th khoa iu tr tớch cc Bnh vin Nhi Trung ng ó to iu kin thun li nht tụi cú th

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