B Y T TRNG I HC DC H NI NGUYN TH VN AN KHO ST CCH S DNG KHNG SINH DNG NG TIM BNH VIN PH SN TRUNG NG KHA LUN TT NGHIP DC S H NI 2013 B Y T TRNG I HC DC H NI NGUYN TH VN AN KHO ST CCH S DNG KHNG SINH DNG NG TIM BNH VIN PH SN TRUNG NG KHA LUN TT NGHIP DC S Ngi hng dn: 1. ThS. Cao Th Bch Tho 2. ThS. Thn Th Hi H Ni thc hin 1. B mn Dc lm sng Trng i Hc Dc H Ni 2.Bnh vin Ph sn Trung ng H NI 2013 LI CM N Em xin gi li cm n su sc nht n Thc s Cao Th Bch Tho b mn Dc Lm Sng v Thc s Thn Th Hi H khoa Dc bnh vin Ph sn Trung ng, nhng ngi thy trc tip hng dn ch bo em tn tnh trong sut qu trnh thc hin ti. EmcngxinchnthnhcmnccthycgiotrongbmnDcLm Sng, trng i hc Dc H Ni to iu kin cho em hon thnh kha lun. TicbitcmntpthcnbkhoaDc,tpthiudngtibnh vin Ph sn Trung ng nhng ngi gp phn khng nh cng ti thc hin ti ny. Xin chn thnh cm n gia nh, bn b lun bn ng vin, to mi iu kin cho ti hon thnh kha lun tt nghip. H Ni, thng 5 nm 2013 Sinh vin NGUYN TH VN AN MC LC DANH MC BNG DANH MC HNH DANH MC CH VIT TT T VN ..............................................................................................................1 PHN 1.TNG QUAN...........................................................................................2 1.1.TNG QUAN V CC NG TIM V TRUYN KHNG SINH........2 1.1.1.Tim bp ...................................................................................................2 1.1.2.Tim tnh mch .........................................................................................3 1.1.3.Truyn tnh mch ......................................................................................3 1.2.NHNG VN CN CH TRONG THC HNH TIM TRUYN...5 1.2.1.Nguy c gp tng k ................................................................................5 1.2.2.Th tch gia tng........................................................................................6 1.2.3.Tc tim truyn ....................................................................................6 1.2.4.Hin tng qu ti dch .............................................................................7 1.3. SAI ST LIN QUAN N THUC TRONG THC HNH TIM TRUYN KHNG SINH........................................................................................7 1.3.1.Sai st lin quan n thuc ........................................................................7 1.3.2.Mt s sai st thng gp trong qu trnh thc hin khng sinh ng tim.........................................................................................................11 PHN 2.I TNG V PHNG PHP NGHIN CU............................... 13 2.1.KHO ST VIC THC HIN KHNG SINH NG TIM DA TRN BNH N...................................................................................................13 2.1.1.i tng nghin cu..............................................................................13 2.1.2.Phng php nghin cu .........................................................................13 2.2.KHO ST KIN THC CA IU DNG V VIC THC HIN KHNG SINH NG TIM. ............................................................................14 2.2.1.i tng nghin cu:.............................................................................14 2.2.2.Phng php nghin cu .........................................................................14 2.3.PHNG PHP X L S LIU.............................................................. 15 PHN 3.KT QU............................................................................................... 16 3.1.KHO ST VIC THC HIN KHNG SINH NG TIM DA TRN BNH N...................................................................................................16 3.1.1.c im bnh nhn trong nghin cu..................................................... 16 3.1.2.c im vic thc hin khng sinh ng tim theo ch nh bc s.......17 3.1.3.c im thc hin khng sinh ng tim theo phiu theo di ca iu dng......................................................................................................22 3.2.KHO ST KIN THC CA IU DNG V VIC THC HIN KHNG SINH NG TIM. ............................................................................24 3.2.1.La chn ng dng..............................................................................24 3.2.2.La chn dung mi.................................................................................. 25 3.2.3.La chn thi gian tim truyn................................................................ 26 3.2.4.Nguy c gp tng k gia hai thuc cng ng dng c ch nh cng thi im......................................................................................... 27 PHN 4.BN LUN............................................................................................ 30 4.1.V vic la chn ng dng trong thc hin khng sinh tim...................... 30 4.2.V vic la chn dung mi v th tch dung mi............................................31 4.3.V tc tim, truyn trong thc hin khng sinh tim. ................................ 34 4.4.Nguy c gp tng k khi s dng cc thuc .................................................35 4.5.Hn ch ca nghin cu.................................................................................36 KT LUN XUT TI LIU THAM KHO PH LC DANH MC BNG Bng 3. 1: c im v tui v chn on ca bnh nhn trong nghin cu .......... 16 Bng 3. 2: c im la chn ng dng ca cc khng sinh.............................. 18 Bng 3. 3: La chn dung mi pha long khng sinh dng ng truyn tnh mch.............................................................................................................................. 19 Bng 3. 4: So snh th tch dung mi v tc truyn trong ch nh vi khuyn co.............................................................................................................................. 20 Bng 3. 5: Cc trng hp trong ch nh c nguy c xy ra tng k ................... 21 Bng 3. 6: Mt s vn cn lu trong ch nh khng sinh truyn tnh mch.... 21 Bng 3. 7: Thng tin v dung mi ca cc khng sinh ch nh tim tnh mch trongphiu theo di ca iu dng. .............................................................................. 22 Bng 3. 8: Mt s vn cn lu v thng tin trn phiu theo di ca iu dng trng hp truyn tnh mch khng sinh................................................................ 23 Bng 3. 9: Cc sai st trn phiu theo di ca iu dng ca mi khng sinh truyn tnh mch............................................................................................................... 24 Bng 3. 10: Cc trng hp la chn sai ng dng trong phiu kho st kin thc ca iu dng...................................................................................................... 25 Bng 3. 11 Kt qu la chn dung mi pha khng sinh tim truyn trong phiu theo di ca iu dng ................................................................................................ 26 Bng 3. 12: Cc trng hp la chn dung mi c tng k vi khng sinh .......... 26 Bng 3. 13: Cc trng hp la chn sai thi gian tim truyn trong phiu theo di ca iu dng...................................................................................................... 27 Bng 3. 14: La chn cch tim tnh mch khi 2 thuc c ch nh cng thi im...................................................................................................................... 28 Bng 3. 15: La chn cch truyn tnh mch khi 2 thuc c ch nh cng thi im...................................................................................................................... 29 DANH MC HNH Hnh 3. 1: T l cc khng sinh ng tim c ch nh trong bnh n...... 17 DANH MC CH VIT TT TMTnh mch NCPTNc ct pha tim 1 T VN Knlbcutinvthchinlbccuicngtrongchutrnhs dngthuctrnlm sng. ylccbcc nhhng nhiu nht n hiu qu iu trcathuc.Tuynhin, ycng l bc tim nnhiu nguycsai stnh hng n hiu qu iu tr v an ton ca bnh nhn. Khng sinh l mt trong nhng nhm thuc c dng ph bin nht ti bnh vin.MtnghincuvtnhtrngsdngkhngsinhticcbnhvinVit Namchothytlkhngsinhsdngtrongsnphkhoal84,3%[29].Trong iu tr ni tr, khng sinh c s dng ch yu qua ng tim v truyn. Trong cc nghin cu v sai st lin quan n thuc, t l sai st trong thc hnh lm sng c lin quan n khng sinh trong cc nghin cu dao ng t 5%[8] n 67%[31]. Mc d c s khc bit do c im s dng thuc khc nhau gia cc nghin cu nhng kt qu u cho thykhng sinh l nhm thuc c rt nhiu nguy c sai st trong thc hnh. Tibnhvin PhsnTrungng,khngsinhdngngtimcdng kh ph bin. Ti thi im kho st bnh vin cha c mt hng dn c th thng nht v cch thc hin thuc, c bit cc khng sinh dng ng tim. Khng sinh ng tim ang c s dng nh th no l mt cu hi c t ra cho n v thng tin thuc ca khoa Dc Bnh vin. Xut pht t thc t trn, chng ti tin hnh nghin cu ti:Kho st cch s dng khng sinh dng ng tim bnh vin Ph sn Trung ng. Vi mc tiu:1.Kho st v cch s dngcc khng sinh dng ng tim trn bnh n ca bnh nhn ti bnh vin Ph sn Trung ng. 2.Kho st kin thc ca iu dngv cch s dng khng sinh tim bnh vinPhsnTrungng.2 PHN 1.TNG QUAN 1.1. TNG QUAN V CC NG TIM V TRUYN KHNG SINH ng tim l ng dng quan trng trong thc hnh thuc ti bnh vin v ngycnggiatngvtlsdng.Sovingdngkhc,ngtimcu im: hiu qu iu tr nhanh, d kim sot liu v duytr tt nng thuc trong mu nh c hiu qu iu trlin tc,thch hptrongnhngtrng hpthuc khng hp thu theo ng ung, bnh nhn bt tnh, khng hp tc[15]. Vikhngsinh,ngtimthngcsdngl:timbp,timtnh mch, truyn tnh mch. 1.1.1.Tim bp Tim bp l cch a thuc vo bp c pha di da. Do lng mu n bp ln hn nn tim bp c tc hp thu thuc nhanh hn tim di da, tuy nhin tc dng khi u thng chm. Cc v tr thch hp tim bp l vng i, c mng v i khi vng c delta (t bp tay n vai)[2, 15].Dngbochcakhngsinhtimbpcthldungdchphasnhocbt phatim.Viccchphmdngbtphatimcnchatanvilngdung mi ha tan thch hp. Trong , dung mi ha tan thuc bt pha tim c khuyn co trong cc ti liu hng dn thng l nc ct pha tim. Mt s khng sinh khi sdngngtimbpcthgyau(ampicilin+sulbactam,ceftriaxon).Cc thucnythngcchnhphatimbpcngvidungdchlidocain0,5% hoc 1% hoc 2%[1, 15].Th tch dung dch pha tim bp ph thuc vo v tr tim: ti a cho php l 5 ml cho cc trng hp tim bp i (hoc 4ml trong trng hp s dng cc dng gii phng chm v c th gy kch ng), 2ml cho cc trng hp tim vo c delta [15].Nukhilngdungdchtimbpln hn5mlcthnhhngnhiu qu hp thu ca thuc hoc gy p xe v tr tim [15]. Do , cc trng hp phi s dng lng th tch tim bp ln hn 5 ml thng c khuyn co tim nhiu 3 hn 1 v tr. Nu phi dng nhiu mi tim cng 1 thi im th phi thay i, lun chuyn v tr cc ln tim[15]. Khi s dng ng tim bp cn ch trnh r r thuc vo phn m lin kt. C 2 kthut tim bp l: tim trc tip vo vng c v tim Z track. Trong , vi k thut tim trc tip, mi kim c cm vung gc vi b mt da, sau khi rt timcnnchtvtrtimtrnhrrthuc.Vi kthuttimZtrackda vng c s c dn sang mt pha trc khi tim, phng php nythng c s dng trong trng hp cc thuc gy kch ng m di da[15]. 1.1.2.Tim tnh mch Timtnhmchlcchathuctrctipvotnhmchvithtchdung dch nh,trongkhongthigianngn.Thuccthctimtrctipvotnh mch hoc bm qua dy truyn hoc qua ng thng trn chc truyn[15, 20]. Thtchdungmiphatimtnhmchthngl5mlhocnhhn.Tuy nhin, th tch dung dch cn dng c th ln hn nu thuc c tan km, c kh nng gy kch ng nim mc hoc c khuyn co tim chm[15]. Theo mt s ti liu, th tch dung mi khuyn co thngt 10ml tr ln v khng qu 25ml[20]. Thigiantimtnhmchtheokhuyncothngdi5pht[15,30],tuynhin mtsthuccthyucuthigiantimdihn.Vdampicilin,sulbactam thng c khuyn co thi gian truyn t 10 15 pht [15, 20]. Sau khi tim tnh mch, thuc nhanh chng t c nng cao trong mu. Vvytimtnhmchthngcsdngtrongcctrnghpkhncp,thi gian dng hn ch (v d: trc phu thut), cn nng thuc cao trong mu hoc cc trng hp bnh nhn phi hn ch dch[15]. 1.1.3.Truyn tnh mch Truyn tnh mch l cch a thuc trc tip vo tnh mch vi th tch dung dchlnvtrongthigiandihnngtimtnhmch.Qutrnhtruyntnh mchcthcthchinbngcchcmtrctipkimtruynvingtnh mchhoccsdngthngquachcba(Y-site).C2loingtruyntnh mch l truyn tnh mch ngt qung v truyn tnh mch lin tc. 4 Truyntnhmchngtqung:ltruynthucvotnhmchtrongkhong thigiant 20 pht cho n vigi.Truyn tnh mch c th dngliu n hoc dng lp li nhiu ln[15], nhm m bo duy tr nng nh v y trong khong tiu[20].ylngdngthchhpchocctrnghpihitca thucvocthchm mkhthchinbngngtimtnhmch.Tuynhin, nu s dng nhiuliu c th dnti quti dchtruyn[15].Thtch dchtruyn daongt50mln500ml.Trongthchnhlmsnghuhtccthucu cphavi100mldungmivctruyntrongthigiant20n30 pht[15]. Truyntnhmchlintc:chophpcungcplngthucnnhtrong khongthigiandi,gipduytrnng thuctrongmu.Trongmts trng hp, nhanh t c nng thuc ban u c th a 1 liu ln (loading dose) trckhitruyntnhmchlintc[20].sdngngtruyntnhmch,cn m bo cc thuc c n nh trong dch truyn trong sut thi gian truyn. Khi truyn mtlngln dch c th gyqutidchtruyn vthayiin giica bnh nhn[15, 20]. Qutrnhchunbdungdchthuctrckhitruyntnhmchthngkh phctp.Viccchphmdngbtphatim,trctincnchatanvi lng dung mitng hp.Giai on nycn c gi lgiaion hon nguyn thuc.Saugiai on hon nguyn,thuc s c pha longtrongdung mitng hp truyn tnh mch. Cc ch phm dng dung dch tuy khng cn hon nguyn nhngmtsvnphiphalongtrckhitruyn.Cnphimbodungmi tng hp vi thuc. Dungmiphalongtruyntnhmchthnglccdchtruynng trngvimu,trnhgyvtbomu[1]vdnh:NaCl0,9%,glucose5%, dch truyn natri clorid v glucose, ringer lactat. Ngoi nhim v a thuc cc dch truyn ny cn c th dng b dch hoc in gii[2]. Cn trnh truyn mt th tch ln dch truyn nhc trng, do vy cn cn trng khi s dng nc ct pha tim truyn tnh mch[1]. 5 Loi dung mi pha truyn, th tch dung mi v tc truyn l nhng thng tincbncnxcnhtrckhisdngccthuctheongtruyntnh mch[20]. Ccthngtin nyc thtmthytrong cc hng dnthc hnh vt hngdnsdngcanhsnxut.Tctruyncthctnhtheonv git/pht hoc s ml/pht . Cc n v ny c th quy i theo cng thc sau: Xcnhs git/mllphthucvoloidytruynsdng. Cnhiuloi dy truyn vi bu m git khc nhau : 15 git; 20 git, 30 git hoc 60 git [2].Trong k n, nu ch nh tc theo n v s git/ pht cn ch r s dng trn loidy truyn no.Tt nht trnh nhmln,tc nn ck ntheo s ml/ gi [20].1.2. NHNG VN CN CH TRONG THC HNH TIM TRUYN 1.2.1.Nguy c gp tng k Tngklnhngtngtchahchocvtlkhngmongmuncth xy ra gia thuc v dung mi hoc gia cc thuc vi nhau. Tng kc th xut hinkhiccthucctrncngtrong1bmtim,trongcngmtdungdch truyn tnh mch hoc khi hai thuc c dng cng mt ng truyn[20]. Tng kxyracthlmgimhocmthiulc,tngctnhhoctcdngchi khc ca thuc[1].S thuc bnh nhn phi s dng tng ln ng ngha vi vic tng nguy c tngkgiaccthuc,cbitnhngtrnghpbnhnhncchnh nhiu thuc truyn tnh mch cng thi im, hoc tim tnh mch trc tip qua ng thng trn ng truyn c sn. trnh bt kvn tng kno c th xyra cnmboluntrngdytruyngia2lna2thuckhcnhauquang truyn bng dung mi tng hp vi c hai thuc. Dung mi thng dng l NaCl 0,9% hocglucose 5%.trng ngthngcn 5 10 ml dung mi, trng dy Th tch dung dch truyn (ml) Thi gian truyn (pht) s git/1ml = s git/pht 6 truyn cn 20 ml dung mi[15]. Cc trng hp tim tnh mch qua ng thng cng phi c trng sch kim lun trc v sau khi s dng bng 2 5 ml dch trng. Nhng yu t nh hng n kh nng xy ra tng k gm c: Nng thuc: tng tc ha hc ch c th xy ra khi cc phn t thuc tip xcvinhau.Khinng thuccao,khnngtngtcgiaccphntthuc tng ln do nguy c tng k gia cc thuc cng tng ln[20]. Thi gian tip xc: tng tc gia cc thuc v gia thuc vi dung mi c th xy ra ngay sau vi giy thm ch l vi ngy. Thi gian tip xc cng di cng lm tng nguy c tng k. Do , cc dch truyn nn c pha ngay trc khi dng v nn b i sau 24 n 48 gi[20].pH: cc thuc c gi tr pH khc nhau nu c dng ng thi c th gy ta hoc ngng hot ng ca chng [15]. pH ca dung mi cng c th nh hng n nnhcathuc.Vikhngsinh,khongpHnnhthngt4n8nn khiphalongtrongccdchtruyncbnchtkimcthgyphnhy thuc[20]. 1.2.2.Th tch gia tng Thuc dng bt ng kh cn c hon nguyn trc khi dng. Th tch sau khiphacadungdchtimcthlnhnthtchdungmibanu.Lngth tch ln hn ny gi l th tch gia tng (displacement value). V d trng hp pha tim amoxicilin 250 mg th th tch gia tng l 0,2 ml. Khi tin hnh pha long vi 4,8 ml th dung dch to thnh c th tch l 5ml nn nng thuc l 250mg/5ml. Nu s dng 5 ml dung mi th dung dch to thnh c nng 250mg/5,2 ml. Gi tr nyc nhcntrong hng dnthchnh ca mts thuc.Th tchgiatngkhng nh hng nvic hon nguynca ccthucvtrng hp ton b thuc em pha c s dng mt ln. Tuy nhin, phi ch n gi tr ny tnh liu trong trng hp ch s dng mt phn lng thuc em pha [15]. 1.2.3.Tc tim truyn 7 Tc tim truyn nhanh c th gy sc do nng thuc trong mu tng cao tngtnmcliuc.Timtnhmchlngdngdgyschncc ng dng khc[20]. Cc du hiu nhn bit tnh trng sc gm: au u, hn m, bng mt, tc ngc, co git, ngng tim[20]. 1.2.4.Hin tng qu ti dch Qu ti dch c th xy ra trong cc trng hp truyn tnh mch ngt qung nhiu ln hoc truyn lin tc vi khi lng dch qu ln [15]. Nguyn nhn qu ti dch thng do s lng dch ln vi tc truyn qu nhanh lm tng t ngt th tch tun hon[2, 20].Khi c hin tng qu ti dch, bnh nhn c th gp cc du hiu ca suy tim, tng huyt p, phi c ran, tnh mch c ni v kh th[20]. 1.3.SAISTLINQUANNTHUCTRONGTHCHNHTIM TRUYN KHNG SINH 1.3.1.Sai st lin quan n thuc Saistlinquannthuc(medicationerorrs)theongharngcnh ngha l bt k sai st no xy ra trong qu trnh k n, cp pht, s dng thuc, bt k sai st c dn n hu qu bt li hay khng[21]. Mt trong nhng kh khn cavicnghincusaistthuclskhcnhauvnhngha,phngphp nghin cu, phn loi sai st ca cc nghin cu. Chnh v vy, t l v mc nh hng ca cc sai st thuc gia cc nghin cu c s khc nhau [32]. Trong bo co nm 2004 ca C quan an ton bnh nhn quc gia ca Anh (National Patient Safety Agency Report 2004 (UK)) v bo co nm 2000 ca Vin YKhoaHoaK(InstituteofMedicine-IOM)cnhnmnhrngsaisttrongy khoalnguynnhncatllncccatvongminm.Trong,ccsaist lin quan nthuc lnguynnhn duynhtc th phng nga. Ccbo co ny cng ch rarng phnln ccsaistkhnglin quan n hnhvithiucn trng trong chm sc sc khe, nhng li c lin quan n tc v s phc tp ca cc chu trnh thc hin thuc [32]. 8 Trong mt nghin cu hi cu v t l t vong lin quan n sai st thuc, t l t vong lin quan n thuc tim chim tl cao 49,9%, tl t vong lin quan n nhm khng sinh l 7,5%, ng th 4 so vi cc nhm thuc[23]. Mt chu trnh thc hin thuc c th chia thnh 5 giai on: k n, sao chp kim tra n, pha ch, cp pht v s dng trn bnh nhn [21]. Qu trnh s dng thuc bt u t thi im bc s ra quyt nh k n, vit n thuc, sau dc s chu trch nhim cp pht thuc v kt thc bng vic chun b v s dng thuc cho bnh nhn ca iu dng. Cc sai st c th xut hin trong bt c giai on no vnh hngtivicsdngthucchobnhnhn. Vd:nthuckhng chnh xc v liu lng do ch nh ca bc s, cung cp dng bo ch sai do sai st ca dc s, iu chnh tc truyn khng chnh xc ca iu dng. Cc sai st ny u c th nh hng n vic s dng thuc trn bnh nhn. Mc d qu trnh s dng c s tham gia ca nhiu i tng nhng iu dng l ngi thng phi chutrchnhimchoccsaistxyravhuqucan.Sdngthuclqu trnh c nguy c mc cc sai st cao nht trong thc hnh ca iu dng[16].1.3.1.1. Sai st trong giai on k n Vic k n l trch nhim ca bc s. Cc thng tin trong n cn ghi r gm: tn thuc, liu lng, s ln dng, ng dng, cch s dng, loi dung mi pha truyn v tc truyn [15]. Rt nhiu sai st lin quan n k n khng c pht hin v bo co. Tuy nhin,cc bngchng nghincu n naychothy,saistthuctrongk nl vn thc t rt quan trng. Trong mt phn tch v nh hng ca cc sai st y t viitng tr em xcnh ccsaist chim 24,5% cccanthipy tc ghi nhn,sai st ph bin nhtthucvccsai sttrongk nchim 68,3% cc sai st trong thi gian ny. Sai liu, sai tc tim truyn chim 28% tt c cc sai sttrongk ntrong 44% l qu liu v16% lthiuliu[11].Trongnghin cuny,saisttrongkncnhnghalsthiuthngtintrongkn (thiu ng dng, s ln dng, hm lng); sai thuc, sai liu, sai tc , sai bnh 9 nhn, ch vit tay kh c, n thuc khng r rng, d ng, chng ch nh v cc sai st khc Trongmtnghincuvtlsaistdokntrnbnhnhnngoitr, khngsinh l nhmthuc ctl lin quan n ccsai sttrongk n cao nht 31,22%.Tlsaisttrongk ncnguycgytcdngbtlilin quann khng sinh l 11,18%[14]. Mttng quan h thng ca 65 nghincu c nh gitlv bncht ca cc sai st trn nhm bnh nhn ni tr ch ra cc sai st trong k n xut hin vgynhhng7%(2-14%)trntngsnk,52(8-227)saisttrn100 trnghpnhpvin,v24(6-212)saisttrn1000ngybnhnhnnmvin. Nhm thuc khng sinh l nhm d xy ra sai st nht, v ph bin hn ngi ln (trung v l 18% trn tng s n, 10 nghin cu) so vi tr em (trung v l 4% trn tng s n, 6 nghin cu). ng thi, nghin cu a ra mt nh ngha c th: sai st trong k n l s la chn thuc khng chnh xc so vi cc hng dn, chng ch nh, cc yu t d ng bit, cc thuc hin ang s dng v cc yu t khc. l cc sai st v: liu dng, dng bo ch, s lng, ng dng, hng dn s dng ca thuc trong n hay thm quyn k n ca bc s, khng c c n dn ns dngsaitrnbnh nhn,s dng ccthutng khngchun hoccc ch vit tt [19].Mts yut nh hng ns xuthin caccsaisttrongk n nh: thiu kinh nghim, thiu kin thc, cha nhn thc r vai trca vic k n, mi trng lm vic, khi lng cng vic cao[32]. Ccsaisttrongknnukhngcphthincthgyraccsaist trongthc hnh.Tuynhin, dc sv ytc ththam gia pht hinti70% cc sai st thuc trong n thuc [18]. 1.3.1.2. Sai st trong giai on cp pht thuc Sai st trong giai on cp pht thuc c th xy ra trong bt c giai on no k t lc tip nhn n thuc cho ti khi thuc c a n bnh nhn, t l xut hin l 1 24 %v thng bao gm cc sai st do la chn sai sn phm thuc hay 10 sai hm lng hoc dng bo ch [32]. iu ny thng xy ra do cc thuc c tn hochnhthctngt nhau. Vd:amilorid v amlodipin,Lasix(furosemid) v Losec(omeprazol),nhngtrnghpnynunthuckhngrrngdgy nhm ln vi nhau [32]. Nguynnhngyraccsai sttrongcp phtc cp trong ccnghin cu gm: p lc cng vic (21%) , p lc thi gian (11%), thiu nhn vin (12%), stress(11%),bginontrongqutrnhphachcppht(9,4%),ccthuctn hoc hnh thc gn ging nhau (8,5%) [5] [32] [9].1.3.1.3. Sai st trong qu trnh chun b, thc hin thuc Trong qu trnh dng thuc, cc sai st c th xut hin bt c bc no v ddnnnhngthithinghimtrng,thmchtvonghnccloisaist thuc khc. Qu trnh thc hin thuc t lu gn vi nhng nguy c sai st trong thchnhcaiudng.Ccsaisttrongthchinthngbaogmsaigia thuc m bnh nhn nhn c v cc thuc bnh nhn c k v cc sai st trong kthutthchin,ngdngkhngchnhxchocccchphmquhn [32]. T l mc cc sai st trong qu trnh thc hin thuc trong cc nghin cu kh cao,chim42,1-53%[22],[3],[17].Ktqucamtnghincuvtlsaist trong thc hin thuc: tl sai st trong qu trnh chun b thuc l 13,4%, 86,6% sai st cn li l trong qu trnh thc hin thuc[24]. Cc nghin cu v sai st trong thc hnh s dng thuc thng kho st vic thc hnh thuc dng ng tnh mch. Trong cc nghin cu ny,cc sai st lin quan n thc hin thuc ng tnh mch c nh ngha l nhng sai lch trong qutrnhphach,sdngthucsovichnhcabcs,hngdncabnh vin v nh sn xut [22, 28]. Hu ht cc kt qu nghin cu u cho thy t l cao cc sai st trong thc hnh ng tnh mch: 48%[26], 49%[28], 69,7%[31]. Trong mt nghin cu khc cng cho thy hn mt phn ba cc li trong thc hnh c lin quan n ng dng tnh mch[16].Kthut thc hin thuc phc tp l mt trong cc nguyn nhn dn n cc sai sttrongthc hnhthuc ng tnh mch. Ngoira,thiuthit b,thiu nhn 11 thcvccnguychaynhnvinytthiukinthc,thitbs dngphctp cng l mt trong cc nguyn nhn [32]. Vn kinh nghim ca iu dng cng c cp trong kt qu ca mt s nghin cu. Khi s nm kinh nghim ca iu dngtng dn n 6 nm c sgim ng ktlvmc nghim trng ca cc sai st m h mc phi. Tuy nhin, khi s nm kinh nghim tng trn 6 nm th c th khng c s lin quan ny na. iu nycho thys cn thit phi c mc tiu o to c th cho cc iu dng vin cn thiu kinh nghim [31]. Cc yu t khc cng gp phn lm gia tng s xut hin ca cc sai st trong thc hnh, bao gm:lutrccchphmtngt,gngingnhautrongcngkhuvctrnxe thuc, tht bi trong kim tra cc thng tin ca bnh nhn trc khi s dng thuc, cc yu t mi trng tim n nh: p lc cng vic, thiu nh sng [13].1.3.2.Mt s sai stthng gptrong qutrnhthchinkhngsinhng tim Trongmtnghincuquanstccsaistkhithchinthucngtnh mch ti 3 bnh vin Anh v c, t l cc sai st quan st c giai on chun b thuc l 26%, giai on s dng thuc l 34%. Trong sai tc tim truyn, sailiu vccli do thiu sttrongthc hnhchim tl ln nht.Sai sttc tim, truyn chim t l t 22% n 49%, trong 88% l cc sai st do tim thuc nhanh hntc ckhuyn co.Mts iu dngthngtimthucnhanh, s khc tim chm t t tuy nhin tc vn cha ph hp vi khuyn co. Tng kxyra10%liu dngvthng ccthuccdngcngthiim hoc c a qua dy truyn truyn[33]. Trong mtnghincu khc,sai sttrong phatrn,saithtch dung mi,sai tc tim truyn v tng k c xc nh l 4 sai st chnh chim 91,7% cc sai sttrnlmsng.Tlnhcnlilnhngsaistvtnsutsdng,ng dng v thuc[31].Trong mt nghin cu v bc chun b v thc hin ng tim khc, sai st ph binnhtl saitc timtruyn,chimti73,3%[31]hoc85,1%[22]v thnggpmtsthucnh:cefuroxim,Augmentin(amoxicilin+acid 12 clavulanic),Unasyn(amipicilin +sulbactam) v cefoperazon [22]. Tlsaitc timtrong tim tnh mch cc nghin cu l 39%[26],thm ch 73%[28].Trong hu ht l cc li do tim vi tc nhanh hn tc c khuyn co. (Tc khuyn co thng t 3 5 pht)[10, 28, 32]. S khc nhau v t l sai tc tim tnhmchldoskhcnhauvcimngdngcaccthuctrongmi nghin cu. Nguyn nhn ca cc li sai tc c th do s c tnh vi phm, mc d iu dng c bit v tc chnh xc c khuyn co. L do ca vic khng tun th khuyn co ciu dng a ra l kh khntrongvicxcnhtrn thc t khong thi gian khuyn co ko di nh th no[27]. Tronggiai on phachc thgp ccsaistv dung mi vthtch dung mi. Sai st trong la chn dung mi c th dn n tng k nh hng n n nh ca thuc. Khng phi tt c dung mi pha long thng c s dng trong cc bnh vin nh nc ct pha tim hay NaCl 0,9% u ph hp cho tt c cc loi thuc tim truyn tnh mch. Nhn vin y t cn c cc kin thc, ti liu tham kho m bo s dng thuc an ton [22]. Saistvthtch dung mi c thxyrakhilng dung mi cs dng khng ph hp vi cc khuyn co. V d s dng 10 ml nc ct pha tim thay v sdng20mlhatan1,2gbtco-amoxiclav(amoxicilin+acidclavulanic) [28]. T l sai st th tch dung mi trong mt nghin cu l 33,3%[31]. Liu dng cn c tnh ton trc khi pha ch trnh bt k sai st no v liu lng v th tch dch truyn. Vic s dng lng dung mi sai c th nh hng n tan ca thuc qua nh hng n hiu qu iu tr. . 13 PHN 2.I TNG V PHNG PHP NGHIN CU 2.1.KHOSTVICTHCHINKHNGSINHNGTIMDA TRN BNH N 2.1.1.i tng nghin cu itngnghinculccbnhncabnhnhncsdngkhngsinh ng tim ti bnh vin Ph sn Trung ng trong thi gian t thng 7/2012 n thng 10/2012. 2.1.2.Phng php nghin cu 2.1.2.1. Thit k nghin cu Nghin cu c tin hnh theo phng php m t hi cu ct ngang. 2.1.2.2. Phng php ly mu Phng php ly mu: ly mu thun tin. Cc bnh n c lu tr phng h s bnh n v phn loi theo m bnh. Chng ti chn bnh n trong 5 nhm bnh c s lng bnh nhn ln l: tp bnh, cha ngoi t cung, m , u x t cung, u nang bung trng. Tng s bnh n c a vo nghin cu l 263 bnh n. Phng php thu thp thng tin Thngtin cthuthpt bnh n cghi litrong phiuthuthpthng tinbnhn.Thngtinclytchnhcabcsvphiutheodicaiu dng. Ccch nh ca khng sinhtim cghi litheotngltch nhtrn mi bnh nhn. 1 lt ch nh khng sinh l 1 t 1 khng sinh c dng 1 mc liutrn1ngdng.Misthayivliudnghocngdngcamt khng sinh th c tnh l 1 lt ch nh mi. 2.1.2.3. Ch tiu nghin cu M t c im ca bnh nhn v tui v chn on. M t c im vic thc hin khng sinh ng tim theo ch nh ca bc s. -T l ca cc khng sinh dng ng tim c ch nh. 14 -Tl cc khng sinh c ch nh theo ng tim bp, tim tnh mch v truyn tnh mch. -Tlccloidungmicchnhhatanvphalongkhngsinh ng tim. -Tllachnthtch dung mi vtc timtruyncckhngsinh ph hp v khng ph hp vi th tch khuyn co. -T l cc ch nh c th gy tng k.-Mtsimcnlutrong chnh cthnhhngnqutrnhthc hin khngsinhngtimcaiudng:tlthiuthngtintrongch nh, t l thng tin trong ch nh khng thng nht. Mtcimthc hinkhngsinhngtimtheophiutheodicaiu dng: -Tlthiuthngtintrnphiutheodicaiudngvdungmi,th tch dung mi v tc truyn. -Tlthngtintrnphiutheodicaiudngsailchsovichnh ca bc s. 2.2.KHO ST KIN THC CA IU DNG V VIC THC HIN KHNG SINH NG TIM 2.2.1.i tng nghin cu i tng nghin cu l cc iu dng c mt ti 3 khoa: iu tr t nguyn, sn 2, ph 1 bnh vin Ph sn Trung ng trong 3 ngy 15/10/2012; 16/10/2012 v 17/10/2012. 2.2.2.Phng php nghin cu 2.2.2.1. Thit k nghin cuNghin cu c tin hnh theo phng php m t ct ngang. 2.2.2.2. Phng php thu thp thng tin Thng tin v kin thc ca iu dng c thu thp qua b cu hi. DavosliutkhoaDcbnhvinPhsnTrungngchngtila chnra9khngsinhthngcsdngkhost,gmc:ampicilin+ 15 sulbactam,amoxicilin+acidclavulanic,cefuroxim,cefotaxim,clindamycin, pefloxacin, cefoperazon + sulbactam, ceftriaxon v imipenem + cilastatin. Mi b cu hi phng vn gm 9 phiu nh, trong : 1 phiu hi v cc kin thccbnkhisdng ngthiccthucccng ng dng, 8 phiu hi v c im s dng ca tng cc khng sinh. Thng tin c kho st mikhoatrong 1 ngy.Tt ciu dng c mt tikhoatrongngykho stsnhncbcuhingunhin.Qutrnhpht phiu, tr li v thu li phiu c din ra trong cng 1 ngy. 2.2.2.3. Ch tiu nghin cu T l la chn ng dng khng sinh khng ph hp vi khuyn co.Tllachnsaidungmiiviccthucckhuyncodngng tim bp, tim tnh mch v truyn tnh mch. T l la chn thi gian tim v truyn ph hp v khng ph hp khuyn co. T l la chn cch thc tim v truyn trong trng hp 2 thuc c ch nh cng ng dng (tim bp, tim tnh mch hoc truyn tnh mch) cng thi im. 2.3.PHNG PHP X L S LIU S liu c nhp vo phn mm SPSS 16.0. Lmschsliu:sliuclm schbngphngphpthngkmt. Khi phthinsai st th kimtra lithngtintrongb s liu v sa lithngtin trong phn nhp liu. X l s liu bng phng php thng k m t. CcbinlintccmttheogitrtrungbnhSD(nulphnphi chun) hoc gi tr trung v (khong trung v25% - 75%) (nu khng l phn phi chun). Cc bin phn hng c m t theo tn sut v t l %. 16 PHN 3.KT QU 3.1. KHOSTVICTHCHINKHNGSINHNGTIMDA TRN BNH Nc im bnh nhn trong nghin cucimvtuiv chnon lnhngcimcbncaccbnhnhncchngtithngk trong bng 3.1.Bng 3. 1: cimv tui v chnoncabnhnhntrong nghin cu c im S bnh nhn T l (%) < 2093,4 20 3920477,6 40 -594818,3 6020,8 Tng263100,0 TuiTui trung bnh (n=263)31,6 9,0 Thai nghn khng pht trin3513,3 Cuc 4818,3 Bin chng ca chuyn d v 228,4 Vim nim mc t cung4316,3 Nhim khun sau khc155,7 Bin chng sau T mu vt khu sn khoa31,1 Bnh vim cc c quan vng chu n145,3 Bnh h sinh dc Ri lon khng do vim ng sinh dc7829,7 Khc51,9 Chn on Tng263100,0 Nhn xt:17 Tuitrung bnh ca bnh nhn l 31,6. Phn ln bnh nhn nmtrong nhm tui 20 39 (77,6%). V chn on, bnh nhn c bnh h sinh dc chim t l cao nht (35,0%).3.1.2.c im vic thc hin khng sinh ng tim theo ch nh bc s. 3.1.2.1. La chn khng sinh ng tim C12khngsinhngtimcchnhtrongccbnhn.Tlcc khng sinh ng tim c ch nh trong cc bnh n c trnh by hnh 3. 1. Hnh 3. 1: T l cc khng sinh ng tim c ch nh trong bnh n Nhn xt:Cc khng sinh c t l s dng cao l metronidazol 0,5g/ 100ml (24,5%), sau ampicilin + sulbactam 1,5g (21,5%), pefloxacin 0,4g/5ml (14,5%) v cefuroxim 0,75g (11,3%).3.1.2.2. La chn ng dng ca khng sinh ng dng l thng tin c bn cn c trong ch nh ca bc s. 12 khng sinh trong nghin cu c ch nh theo 3 ng tim l: tim bp, tim tnh mch 18 v truyn tnh mch. c im la chn ng dng ca mi khng sinh c th hin trong bng 3.2 Bng 3. 2: c im la chn ng dng ca cc khng sinh Tim bpTim TMTruyn TMTng Khng sinh Hm lng n (%)n (%)n (%)n ampicilin + sulbactam1,5 g1 (0,9)113(99,1)-114 amoxicilin + acid clavulanic 1,2 g- 11 (100,0)-11 cefuroxim0,75 g- 60 (100,0)-60 cefuroxim1.5 g- 31 (100,0)-31 ceftriaxon1 g- 12 (100,0)-12 cefotaxim1 g 26 (100,0)-26 cefoperazon + sulbactam 1 g-- 13 (100,0)13 piperacilin + tazobactam 4,5 g--2 (100,0)2 imipenem + cilastatin0,5 g-- 22 (100,0)22 clindamycin 0,6 g/ 4 ml 10 (31,2)1 (3,1) 21 (65,6)32 pefloxacin 0,4 g/ 5 ml -- 77 (100,0)77 metronidazol 0,5 g/ 100 ml --130 (100,0)130 Tng11 (2,1)254 (47,9)265 (50,0)530 Nhn xt:C tng cng 530 lt ch nh khng sinh ng tim. Tl s dng ng truyntnhmchlcaonht(50,0%),tiptheolngtimtnhmch(47,9%). Huhtmikhngsinhcchnhtheo1ngdng,ngoitrampicilin+ sulbactam cch nhtheohai ng ltim bp(1ltch nh) vtim tnh mch (113 lt ch nh) v clindamycin c ch nh theo 3 ng: tim bp (10 lt ch nh), tim tnh mch (1 lt ch nh), truyn tnh mch (21 lt ch nh). 19 3.1.2.3. La chn dung mi ha tan v pha long Thngtinvdungmihatanvphalongkhngctrongcctrnghp cchnhtimbpvtimtnhmch,chctrongcctrnghpchnh truyn tnh mch. Trong 265 lt ch nh ng truyn tnh mch, c 130 lt ch nh khngsinh metronidazol l ch phm dng dung dich phasnvi hmlng 0,5 g/100ml, khng cn ch nh dung mi. Trong 135 lt ch nh cn li, chng ti khng tm thy thng tin v dung mi ha tan, ch c thng tin v dung mi pha long l NaCl 0,9% v glucose 5%. c im la chn dung mi pha long ca mi khng sinh truyn tnh mch c trnh by trong bng 3.3 Bng 3. 3: La chn dung mi pha long khng sinh dng ng truyn tnh mch Dung mi pha long truyn tnh mch Khng sinhHm lng NaCl 0,9%Glucose 5% Tng s cefoperazon + sulbactam1 g13013 piperacilin + tazobactam4,5 g202 imipenem + cilastatin0,5 g22022 clindamycin0,6 g/ 4ml02121 pefloxacin0,4 g/ 5mg07777 Tng s 37 (27,4%) 98 (72,6%) 135 (100,0%) Nhn xt:Mikhngsinhucthngnhtlachn1loidungmiphatruyn. Phn ln cc lt ch nh la chn dung mi l glucose 5% (72,6%). 3.1.2.4. La chn th tch dung mi v tc tim truynThngtinvthtchdungmivtctimtruynkhngctmthy trongccchnhtimbpvtimtnhmch.Vi6khngsinhcchnh ng truyn tnh mch, chng ti so snh thng tin v th tch dung mi v tc truyn vi khuyn co. Kt qu c trnh by bng 3.4. 20 Bng 3. 4: So snh th tch dung mi v tc truyn trong ch nh vi khuyn co c im thng tin trong ch nhn (%) Th tch242 (91,3) Ch nh ph hp khuyn co (n=265) Tc truyn256 (96,6) Th tch23 (8,7) Ch nh khng ph hp (n=265) Tc truyn2 (0,8) Thiu thng tin (n=265) Tc truyn7 (2,6) Nhn xt: Trong265ltchnhtruyntnhmch,23trnghpchnhthtch dung mi khng ph hp l: imipenem + cilastatin (20 trng hp) v pefloxacin (3 trnghp),2trnghptctruyncchnhnhanhhnsovikhuyn co. 3.1.2.5. Nguy c gp tng k ca cc thuc trong ch nh Tng k c th xy ra gia thuc vi dung mi hoc gia cc thuc nu c trn chung trong cng xi lanh hoc chai truyn, c bm qua cng dy truyn nu khng trng dy gia cc ln a thuc c cng ng dng. Nguy c xy ra tng k khi cc thuc v dung mi tng k vi nhau c ch nh cng ng dng ti cng thi im. Cc trng hp c nguy c xy ra tng k c trnh by bng 3.521 Bng 3. 5: Cc trng hp trong ch nh c nguy c xy ra tng k Cc trng hp nguy c xy ra tng k (n=530)n (%) Cefoperazon + sulbactam v ringer lactat1 (0,2) Metronidazol v glucose 5%95 (17,9) Metronidazol v ringer lactat14 (2,6) Ampicilin + sulbactam v glucose 5%24 (4,5) Amoxicilin + acid clavulanic v metronidazol2 (0,4) Ceftriaxon v ringer lactat4 (0,8) Tng140 (26,4) Nhn xt: Nguy c tng kxy rach yu gia khng sinh v dung mi. Metronidazol l thuc c nguy c gp tng k cao nht. 3.1.2.6. Mtsimcnlutrongchnhcthnhhngnqutrnh thc hin khng sinh ng tim ca iu dng Trong 265ltch nhkhngsinh ngtruyntnh mch, 64,5%ch nh yvthngnhtthngtinvdungmi,thtchdungmivtctruyn. 35,5% trng hp cn li thiu thng tin hoc thng tin khng thng nht gia cc ln ch nh trn cng bnh nhn, c trnh by bng 3.6. Bng 3. 6: Mt s vn cn lu trong ch nh khng sinh truyn tnh mch Vn cn lu trongch nh khng sinh truyn tnh mch (n=265) S lt ch nh T l (%) Thiu thng tin v tc truyn72,6 Th tch dung mi khng thng nht83,0 Tc truyn khng thng nht7929,8 Tng9435,5 Nhn xt: 22 Vnhaygpnhtlskhngthngnhtvtctruyntrongmtch nh (29,8%). 3.1.3.c im thc hin khng sinh ng tim theo phiu theo di ca iu dng3.1.3.1. Khng sinh c ch nh tim bp Trong 11 lt ch nh khng sinh tim bp c 10 lt ch nh clindamycin, 1 lt ch nh ampicilin + sulbactam. Clindamycin l ch phm pha sn v vy khng cn ch nh dung mi phatim.Vitrng hpampicilin+sulbactam, chngti khng tmthythng tinv dung mi, thtch dung mitrong phiutheo di ca iu dng. 3.1.3.2. Khng sinh c ch nh tim tnh mch Trong 254 trng hp khng sinh c ch nh ng tim tnh mch c 168 trnghp(66,1%)khngcthngtinvdungmivthtchdungmi.86 trnghpcnliusdng10mlncctphatim.cimthngtinv dung mi trn phiu theo di ca cc khng sinh ny c th hin trong bng 3.7 Bng 3. 7: Thng tin v dung mi ca cc khng sinh ch nh tim tnh mch trongphiu theo di ca iu dng. Khng c thng tin v dung mi C thng tin v dung mi Tng s Khng sinh Hm lng %%n amoxicilin + acid clavulanic1,2 g6 (54,5)5 (45,5)11 cefuroxim0,75 g30 (50,0)30 (50,0)60 cefuroxim1,5 g29 (93,5)2 (6,5)31 clindamycin0,6 g/4ml1 (100,0)-1 cefotaxim1 g21 (80,8)5 (19,2)26 ceftriaxon1 g12 (100,0)-12 ampicillin + sulbactam1,5 g69 (61,1)44 (38,9)113 Tng s168 (66,1)86 (33,9)254 Nhn xt:23 Thngtinvdungmivthtchdungmicghiynhtivi cefuroxim(50,0%)vamoxicilin+acidclavulanic(45,5%).Ngcli,100% trnghpceftriaxon,93,5%trnghpcefuroximv80,8%trnghp cefotaxim khng c thng tin v dung mi trong phiu theo di ca iu dng. 3.1.3.3. Khng sinh c ch nh truyn tnh mch Trong 265ltch nhtruyn tnh mch, cim caccthngtinvth tch dung mi v tc truyntrn phiutheo di caiu dng ctrnh by trong bng sau. Bng 3. 8: Mt s vn cn lu v thng tin trn phiu theo di ca iu dng trng hp truyn tnh mch khng sinh Mt s vn cn lu (n=265)N (%) Thiu thng tin v tc truyn16 (6,0) Thiu thng tin v th tch dung mi pha truyn8 (3,0) Sai th tch dung mi so vi ch nh ca bc s10 (3,8) Sai tc truyn so vi ch nh ca bc s153 (57,7) Nhn xt: Trong phiutheo dicaiu dng, vn thnggp nhtlsaitc truyn so vi ch nh ca bc s (57,7%). Tlsaistthngtintrong phiutheo dicaiu dng catng khng sinh c trnh by trong bng 3.9. 24 Bng 3. 9: Cc sai st trn phiu theo di ca iu dng ca mi khng sinh truyn tnh mch Tn sut s dng Sai th tch dung mi Sai tc truyn Khng sinhHm lng n%% cefoperazone, sulbactam1 g133 (23,1)12 (92,3) piperacilin, tazobactam4,5 g21 (50,0)1 (50,0) metronidazole0,5 g/ 100ml130-68 (52,3) clindamycin0,6 g/ 4ml214 (19,0)15 (71,4) pefloxacin0,4 g/ 5ml772 (2,6)38 (49,4) imipenem, cilastatin0,5 g22-19 (86,4) Tng s26510 (3,8)153 (57,7) Nhn xt: Piperacilin + tazobactam c t l sai th tch dung mi so vi ch nh ca bc s cao nht (50,0%). T l sai tc truyn so vi ch nh ca bc s ca mi khng sinh u cao, c bit l cefoperazone, sulbactam (92,3%). 3.2. KHOSTKINTHCCAIUDNGVVICTHCHIN KHNG SINH NG TIM Chng ti kho st kin thc ca 61 iu dng v vic thc hin khng sinh ngtimca9khngsinhcsdngphbinbnhvinPhsnTrung ngl:amoxicilin+acidclavulanic 1,2g,ampicilin+sulbactam 1,5g,cefuroxim 0,75g,cefotaxim1g,cefoperazon+sulbactam1g,ceftriaxon1g,imipenem+ cilastatin 0,5g, clindamycin 0,6g/4mlv pefloxacin 0,4g/5ml. 3.2.1.La chn ng dng Trongs9khngsinhckhost,c3thuckhngckhuynco ngtimbpl:amoxicilin+acidclavulanic,imipenem+cilastatinv pefloxacin.3thuckhngckhuyncotimtnhmchl:imipenem+ 25 cilastatin, clindamycin v pefloxacin. Tt c 9 thuc u c khuyn co truyn tnh mch. Tl iu dng chn sai ng dng ca khng sinh c trnh bytrong bng 3.10 Bng 3. 10: Cc trng hp la chn sai ng dng trong phiu kho st kin thc ca iu dng La chn sai ng dngN (%) Khngla chn tim bp vi nhng thuc c php tim bp (n=295) 92 (31,2) La chn tim bp vi nhng thuc khng c php tim bp (n=136) 61 (44,9) Khngla chn tim tnh mch vi nhng thuc c php tim tnh mch (n=306) 12 (3,9) La chn tim tnh mch vi nhng thuc khng c php tim tnh mch (n=118) 85 (72,0) Khngla chn truyn tnh mch vi nhng thuc c php truyn tnh mch (n=421) 101 (24,0) Nhn xt: nglulcctrnghplachnngdngmthuckhngc khuyn co. 72,0% la chn tim tnh mch vi nhng thuc khng c php tim tnh mch. 44,9% la chn tim bp vi nhng thuc khng c php tim bp. 3.2.2.La chn dung mi Tccphiulachnngngdngchngtitinhnhkhostkin thc la chn dung mi ca iu dng. Cc la chn dung mi c a ra trong phiukhostgmc:ncctphatim,NaCl0,9%,glucose5%,ringerlactat. c im la chn dung mi theo ng dng c trnh by trong bng 3. 11. 26 Bng 3. 11 Kt qu la chn dung mi pha khng sinh tim truyn trong phiu theo di ca iu dng Nhn xt: Vi ng tim bp, 100% la chn nc ct pha tim l dung mi ha tan. Vingtimtnhmch,ncctphatimcngldungmiclachn nhiu nht (80,8%). Vi ng truyn tnh mch, ng lu l c 12,8% la chn ncctphatimldungmiphatruyn.Cctrnghplachndungmic tng k khng sinh c trnh by bng 3.12 Bng 3. 12: Cc trng hp la chn dung mi c tng k vi khng sinh Cc trng hp la chn dung mi c tng k vi khng sinhN (%) Amoxicilin + acid clavulanic v glucose 5%1 (0,3) Ampicilin + sulbactam v glucose 5%2 (0,6) Cefoperazon + sulbactam v ringer lactat6 (1,7) Ceftriaxon v ringer lactat4 (1,1) Tim tnh mch (n=354) Tng 13 (3,7) Amoxicilin + acid clavulanic v glucose 5%10 (2,5) Ampicilin + sulbactam v glucose 5%15 (3,7) Pefloxacin v NaCl 0,9%13 (3,2) Ceftriaxon v ringer lactat12 (2,9) Truyn tnh mch (n=407) Tng50 (12,2) 3.2.3.La chn thi gian tim truyn Nc ct pha tim NaCl 0,9% Glucose 5% Ringer lactat Tng Dung mi %%%%n Tim bp146 (100,0)---146 Tim tnh mch286 (80,8)35 (9,9)4 (1,1)29 (8,2)354 Truyn tnh mch52 (12,8)119 (29,2)114 (28,0)122 (30,0)407 Tng484 (53,4)154 (17,0)118 (13,0)151 (16,6)907 27 Cckhuyncov thigiantimtruynchccpngtim tnh mchvtruyn tnhmch.Vvy,chngtitinhnhkhostkinthcvthi gian tim truyn ca cc phiu c ch nh tim, tnh mch v truyn tnh mch. Kt qu c trnh by trong bng sau: Bng 3. 13: Cc trng hp la chn sai thi gian tim truyn trong phiu theo di ca iu dng ng dngn (%) Thi gian tim tnh mch khng ph hp vi khuyn co (n=279) 172 (62,0) Thi gian truyn tnh mch khng ph hp vi khuyn co (n=301) 23 (7,6) Nhn xt:T l la chn thi gian tim tnh mch khng ph hp vi khuyn co l 62,0%, cao hn t l la chn thi gian truyn tnh khng ph hp vi khuyn co (7,6%). 3.2.4.Nguycgptngkgiahaithuccngngdngcchnh cng thi im kho st kin thc ca iu dng v vn tng k vi cc thuc dng cng,chngtitinhnhphngvniudngbngbcuhivicctrng hp gi nh y lnh c 2 thuc c ch nh cng ng dng ti cng thi im. 3.2.4.1. Tim bp C 3 la chn c c a ra l: trn chung 2 thuc trong cng mt xi lanh ri tim, tim 2 thuc 2 v tr khc nhau. 100,0% la chn l c th trn chung 2 thuc trong cng mt xi lanh ri tim. 3.2.4.2. Tim tnh mch C 5la chn c ara l:trnchung 2thuctrongcng mtxilanhri tim; tim 2 thuc 2 v tr khc nhau, tim ln lt tng thuc qua ng truyn 28 m khng cn trng dy truyn, tim ln lt tng thuc qua ng truyn v trng sch dy truyn gia cc ln a thuc. Kt qu c trnh by trong bng 3.14:Bng 3. 14: La chn cch tim tnh mch khi 2 thuc c ch nh cng thi im La chnTn sutT l (%) Trn chung 2 thuc vo cng bm tim 00,0 Tim 2 thuc 2 v tr khc nhau 46,9 Tim ln lt tng thuc qua ng truyn, khng cn trng dy truyn 1322,4 Tim ln lt tng thuc qua ng truyn v trng sch dy truyn gia cc ln a thuc. 4170,7 Tng58100,0 Nhn xt: Trong 58 phiu trli, as u chn c thtimlnltthucqua ng truyn,trongtllachnctrngschdytruyngiacclnathuc chimtlcaonht(70,7%),nglul22,4%lachnkhngcntrngdy truyn gia 2 ln a thuc. 3.2.4.3. Truyn tnh mch C 4 la chn c a ra: trn chung 2 thuc vo cng chai truyn, truyn 2 thuc cng lc qua chc ba, truyn ln lt tng thuc qua ng truyn m khng cn trng dy truyn, truyn ln lt cc thuc qua ng truyn v trng sch dy truyn gia cc ln a thuc.Kt qu thu c c trnh by bng 3.15: 29 Bng 3. 15: La chn cch truyn tnh mch khi 2 thuc c ch nh cng thi im La chnTn sutT l (%) Trn chung 2 thuc vo cng chai truyn 23,2 Truyn cng lc 2 thuc qua chc ba 1219,4 Truyn ln lt tng thuc qua ng truyn, khng cn trng dy truyn 1930,6 Truyn ln lt tng thuc qua ng truyn v trng sch dy truyn gia cc ln a thuc. 2743,6 kin khc23,2 Tng62100,0 Nhn xt: Phn ln cc la chn l c th truyn ln lt tng thuc qua ng truyn. nglul30,6%lachnkhngcntrngdytruyngiacclna thuc.30 PHN 4.BN LUN 4.1.V vic la chn ng dng trong thc hin khng sinh tim Ch nh trong cc bnh n c kho st lun c y thng tin v ng dng.Tlngtnhmchchimtrn97%,baogmtimtnhmchvtruyn tnh mch.Hu htch nh ng dng u ph hpvikhuyn co.Tuy nhin, c 2 trng hp (0,4%) c sai st trong ch nh ng dng u lin quan n s dng clindamycin: 1 trng hp clindamycin vi c ch nh liu 0,6gtim tnh mch thay v tim bp hoc truyn tnh mch, 1 trng hp khc c ch nh tim bp liu 1,2g. Trong kt qu kho st kin thc iu dng, i vi clindamycin c 22,4%lt la chn caiu dngchorng c th tim tnh mch.Mc dkch ngtichrttkhixyra,nhngmtvitrnghpghinhntimbp clindamycincthgychaicnghocpxevtrtim.Clindamycintimtnh mchcthgyvimtctnhmchvnhngnhhngtrnhtimmchnh: ngngtim,kodikhongQT,xonnh.Ccduhiunysbinmtsaukhi ngngs dngclindamycinvingy.Mtbnh nhn 50tuib ngngtimsau khi tim tnh mch nhanh 600 mg clindamycin [25]. V vy, clindamycin ch c khuyn co tim bp su vi liu 1 ln khng qu 600 mg v truyn tnh mch vi nng 18 mg/ml v truyn vi tc ti a l 30 mg/pht [7, 15, 25, 30]. T l la chn sai ng dng ca iu dng kh cao, 44,9% la chn tim bpvinhngthuckhngckhuyncotimbp,72%lachntimtnh mchvinhngthuckhngckhuyncotimtnhmch.Do,khnng gp ccsaistvlachnngdngtrongthchinthuctrnlmsnghon ton c th xy ra.Ccnghincuvcctrnghpsdngsaingdngvhuquhin naycnt,chyudavoccbococa[6].Trongmtnghincuvtlt vong lin quan n sai st thuc ch ra sai st v ng dng l nguyn nhn ph binthbasauccsaistvthucvliudng.Trongnghincuny,trn57 bnh nhn (9,5 %) c pht hin s dng thuc sai ng dng, trong c 4 bnh 31 nhntvong[23].Tlsaistngdngtrongmtnghincul28,7%[12], trong mt nghin cu khc l 33% [6]. Trong hu ht cc trng hp sai st ukhngxuthin tcdngkhng mong mun (ADR)hocxuthinADRva v nh,tlnhxuthinADRnng(7,7%)vkhngctrnghpnotvong. Trong cc sai st gy ADR nng u do s sutca iu dng trong qu trnh thchin. Ccli sai ng dng c thdo cc nguyn nhn nh:thiukinthc v thuc, mt tp trung hoc thiu quy trnh thc hin c chun ha[24]. Ccnghincutrnuctlsaistlinquannngdngcaohn kho st ca chng ti rt nhiu. Tuy nhin, khng sinh u khng phi l i tng nghin cu chnh trong cc nghin cu . 4.2.V vic la chn dung mi v th tch dung mi 4.2.1.Vi khng sinh tim tnh mch Cc ch nh khngsinhtim tnh mch u khng c thng tinv dung mi ha tan. Vvy,vi ccch phm dng bt phatim,vicla chn dungmi,th tch dung mi ph thuc ch yu vo kinh nghim v thi quen ca iu dng. Trong cc lt ch nh tim tnh mch, 66,1% phiu theo di ca iu dng khngcthngtinvdungmi,thtchdungmi.33,9%phiucnliula chn 10 ml nc ct pha tim. Trong kt qu kho st kin thc iu dng, a s cng la chn dung mi ha tan bt tim khng sinh l nc ct pha tim (80,8%). Viclachn ncctphatim ldung mil ph hpvicckhuyn co.Th tch10mlcngphhpvithtchkhuyn cocaaskhngsinhtim tnh mch. Tuy nhin, mt s khng sinh tim tnh mch c khuyn co ha tan bng th tch dung mi ln hn rt nhiu: ampicilin + sulbactam 1,5 g cn ha tan bng 33 ml nc ct pha tim, amoxicilin + acid clavulanic 1,2 g cn ha tan bng 20 ml nc ct pha tim, cefuroxim 1,5 g cn ha tan bng 15 20 ml nc ct pha tim [15, 20, 30].ng ch , 3 khng sinh ny u c ch nh ch yu qua ng tim tnh mch:ampicilin+sulbactam1,5g(99,1%),amoxicilin+acidclavulanic1,2g (100%) v cefuroxim 1,5 g (100%). 32 Mtnghincuvtlsaistvmcnhhngcaccsaisttrong thc hin thuc ng tnh mch nh gi mc nh hng ca cc sai st ny l t[28]. Trong kho st kin thc ca iu dng, tl la chn dung mi gy tng k vi khng sinh l 3,7%. Cn lu mt s la chn dung mi tim tnh mch nh: ampicilin+sulbactamvamoxicilin+acidclavulanictngkviglucose5%, ceftriaxon v cefoperazon + sulbactam tng k vi ringer lactat. 4.2.2.Vi khng sinh truyn tnh mch a. La chn dung mi trong thc hin khng sinh truyn tnh mch 100% ch nhtruyn tnh mch u c thngtinv dung mi,thtch dung mi phatruyn.NaCl 0,9% vglucose 5% l 2 dung mi c ch nhtrong cc trnghpny.ycnglnhngdungmithngckhuyncos dng[20].Khng c ch nh dung mi no gy tng k vi khng sinh. Thng tin v loi dung mi thu c t phiu theo di ca iu dng u thng nht vi ch nh. Tuynhin,ktqu thu ctkho stkinthciu dngchothytl iudngchndungmikhngthchhpkhcao.lcctrnghpchn ncctphatimldungmitruyntnhmch(12,8%)vcctrnghpchn dungmigytngkvikhngsinh(12,2%):ampicilin+sulbactamv amoxicilin+acidclavulanictngkviglucose5%,ceftriaxontngkvi ringer lactat v pefloxacin tng k vi NaCl 0,9%.Trongcchngdnthchnh,ncctphatimthngcsdng hatanbtthuc.Dungdchsaukhihatanbtthuccphalongvidung mi tng hp. Ngoi tng hp vi thuc, dung mi pha truyn cn tnh nyu t ngtrngvimutrnhgyvhngcu,cbitkhithtchtruyn ln.NaCl 0,9% v glucose 5% l dung dch ngtrngthng c khuyn co trongcchngdnthchnh.Ncctkhngphildungmithchhppha truyn v khng l dung mi ng trng vi mu [15]. 33 Trongmtnghincuvccsaisttrongthchinthuc,saisttrongla chndungmiclinquan nviclachnsaidungmivthtchdung mi cho thy sai st v dung mi ha tan v dung mi pha long thuc tim chim 8,6% cctrnghptimtruyntnhmch.Trong,vancomycin,piperacilin+ sulbactam, imipenem l cc khng sinh thng lin quan n sai st ny[24]. Mtnghincuatrungtmvccsaisttrongqutrnhchunbthuc tim tnh mch ti 3 bnh vin Anh, c v Php cho thy tl sai st lin quan n dung mi c s khc nhau rt nhiu gia cc bnh vin. Bnh vin c c t l sai st lin quan n dung mi ln nht 49%, sau l bnh vin Php 18% v bnh vin Anh 1%[10].S dng dung mi tng k vi thuc c th nh hng n n nh,gytanh hng n tcdng cathuc.iu dngcntham kho thm cc thng tin trn t hng dn s dng c y thng tin v dung mi. Nghin cu cng ch ra tm quan trng ca vic cung cp y thng tin cho iu dng.Nn c bsung cnh bo canhsnxuthocbnhvin bn ngoi bao b thuc, hoc s dng cc bng tra cu nhanh. Ngoi ra vic s dng cc ch phm c sn dung mi cng l bin php gim t l sai st [10]. b. La chn th tch dung mi trong thc hin khng sinh truyn tnh mch Trongnghincucachngti,tlchnhthtchdungmikhngph hpl8,7%.Cctrnghpnyclinquannchnhcaimipenem+ cilastatin(20trng hp)v pefloxacin(3trng hp).ng ch ,trong 22lt ch nh imipenem + cilastatin th c 20 trng hp c ch nh c th tch dung mi nh hn th tch c khuyn co. S dng sai th tch dung mi c th lm gim ha tan ca bt thuc, lm dungdchxuthincctiuphnkhngtannhhngnantoncabnh nhn[10], nh hng n nng thuc trong dung dch. Trong mt nghin cu ghi nhn sai th tch dung mi l 1 trong 4 sai st thng gp, vi t l sai st l 33,3% trong 17,4% l cc li nghim trng [31]. i vi cc ch nh th tch dung mi ph hp vi khuyn co, mt s trng hpthtchdungmicschnhlchkhlngiacclnchnh.Vd:vi 34 clindamycin600mg c ch nh truyn tnh mch, th tch dung mi dao ng trong khong 50 n 250 ml. Cchngdnhinnayucharathtchdungmitithiupha truynm khng c nhnglu nus dnglng dchtruyn ln.Nus dng lng dch truyn qu ln c th gy qu ti dch truyn, nh hng ti bn ca thuc do ko di thi gian truyn [15].4.3.V tc tim, truyn trong thc hin khng sinh tim Sai st trong tc a thuc ng tnh mch chim t l kh cao trong cc sai st khi s dng thuc ng tnh mch. Tl sai st ny trong mt nghin cu chim77,1%[22], mt nghin cu khc chim 88%[33] cc sai st lin quan n thuc.Ccsai st xut hintrongtrng hpthuc dngng tim tnh mchvi t l kh cao. Trong mt nghin cu c nh gi mc nh hng ca cc sai st thc hnh, tl gp sai st trn ng tim tnh mch l 73%, trong 95% l sai stdotimvitc nhanh hntc khuyn co, hn mtnaccsaistny c nh gic mc nh hngva[28].Mt nghincu khcchothytl saisttctimthphn(39%),tuynhinti nghincunyngtim tnh mchtcsdngdokhngckhuynkhch[26].Tc timkhuynco trong cc nghin cu ny l 3 5 pht[26, 28, 32, 33]. Nguyn nhn dn n nhng sai st trong tc tim tnh mch l do: thiu nhn thc v nhng nguy c ri ro, thiu thit b s dng v thiu nhng quytrnh mu[22, 32], hoc nhng kh khn khi p dng cc khuyn co trong thc hnh[27]. Trongchnhvphiutheodicaiudngukhngcthngtinv thi gian tim tnh mch. Thi gian tim tnh mch ca cc thuc trong phn kho stkinthcphnlnuckhuyncotrongt2n5pht,trampicilin +sulbactam c tc khuyn co t 10 n 15 pht. Tuy nhin, kt qu t qu trnh kho st kin thc ca iu dng cho thy 62% la chn tc tim l khng ph hpvikhuynco.51,3%lachnthigiantimt1n2phtv1,8%la chn thi gian tim di 1 pht. Tc tim truyn nhanh c th gy sc do nng 35 thuctrong mutng cao tngt n mc liuc.Tim tnh mch lng dng d gy sock hn cc ng dng khc[20]. Vi ng truyn tnh mch, t l sai st v tc truyn trong nghin cu l 0,8% s lt ch nh truyn tnh mch. Trong mt nghin cu v t l cc li trong thc hin thuc, t l gp sai st tc truyn chim 1,2% lt ch nh truyn tnh mch[24]. Nguyn nhn c a ra l do nhng tnh ton sai v tc truyn. Vn hay gp nht ca cc ch nh trong nghin cu l tc truyn khng thng nhtgiaccln chnhtrn cng1 bnh nhn.n vcatc truyn trong ch nh l git/pht. iu ny c th gy kh khn cho iu dng trong vic xcnh khongthigian thch hp athuc.n vtc truyn thch hp nn l ml/gi[30]. 4.4.Nguy c gp tng k khi s dng cc thuc Nguy c gp tng k ca cc thuc trong ch nh l 26,4%. l cc trng hptngkgiaccthucvtngkgiathucvidungmicchnh cngngtrongmtthiim.Thngtintchnhchothykhngctrng hp no khng sinh c ch nh dung mi ha tan gy tng k. Tuy nhin chng ti ghi nhn c mt t l kh cao tng k c th xy ra gia khng sinh v dung mihatancaccthuckhccchnhcngthiim.Nguyctngk cathucvidungmilRingerlactatv glucose 5%lcaonht(26%).Ngoi mcchhatan,athucvotnhmchycnlnhngdungdchbin gii, b sungthtchtun hon vvyc dng kh phbin.Cnlu mts trngchnhcnglccefoperazon+sulbactam,metronidazolhocceftriaxon viringerlactat,metronidazolhocampicilin+sulbactamviglucose5%.Trong mtsnghincu,tltngkcghinhnl0,8%[31],7,2%[4].Trong piperacilin + tazobactam and imipenem +cilastatin l nhng thuc c ghi nhn hay xy ra tng k c bit vi cc dung dch in gii. Cchthchinccthuccchnhcngthiimkhngccp trong ch nh.Vic thc hinthuctrong cctrng hp nyph thucrt nhiu vokinhnghim,thiquencaiudng.Khichivcchthchincc 36 thuc c ch nh cng ng dng cng thi im, tl iu dng la chn cch thc khng c khuyn co kh cao. 100% cho php trn chung 2 thuc vo bmtimtrongtimbp,22,4%lachntimlnlttngthucquang truyn,khngcntrngdytruyn,70,7%lachntimlnlttngthucqua ng truyn v trng sch dy truyn gia cc ln a thuc. Vic nhn thc cha ng caiu dng c thlmtng nguyctng kgiaccthuc nh hng n an ton ca bnh nhn. 4.5.Hn ch ca nghin cu Khitinhnhtiny,chngtinhnthynghincucn1simhn ch. Th nht, trong phn hi cu bnh n thng tin trong bnh n khng y , v vy khng th phn nh ton b nhng vn trn thc t thc hnh s dng thuc. Th hai, phng php ly mu thun tin, vvykt qu nghin cu cha thc s idin vics dng khngsinhtim cabnhvin.Th ba, nghincu mi ch dng li mc ghi nhn cc sai st trong ch nh, thc hin khng sinh tim, cha nh gi c mc nh hng ca cc sai st nytrn thc hnh. Th t, phn kho st iu dng: hnh thc a b cu hi ch nh gi c nhn thc ca iu dng, cha nh gi c cht lng vic thc hin thuc trn lm sng. 37 KT LUN XUT 1. Kt lun Thng qua kho st nhng thng tin trn bnh n v kin thc ca iu dng v vic thc hin khng sinh tim bnh vin Ph sn Trung ng chng ti a ra cc kt lun nh sau: 1.1. Mt s vn trong ch nh v phiu theo di ca iu dng Phn ln khng sinh c dng theo ng tnh mch (97,9%). Hu ht cc ch nh ng dng ca bc s l ph hp vi khuyn co. Cc thng tin v dung mi, th tch dung mi, tc tim truyn ch c trong cc ch nh truyn tnh mch. NaCl 0,9% hoc glucose 5% l dung mi c ch nh cho khng sinh truyn tnh mch. Nguy c gp tng k trong ch nh l 26,4%. Metronidazol l thuc c nguy c gp tng k cao nht. C8,7%chnhthtchdungmiphatruynv0,8%chnhtc truyn khng ph hpvikhuyn co. Tl khng ph hp haygp nht limipenem + cilastatin. Mt t l ng k (61,5%) phiu theo di ca iu dng c thng tin sai so vi ch nh ca bc s, trong sai tc truyn chim t l ln nht (57,7%). Cn lu th tch pha tim tnh mch vi cc thuc ampicilin + sulbactam 1,5g, amoxicilin + acid clavulanic 1,2g v cefuroxim 1,5g. 1.2. Mtsvnvkinthccaiudnglinquannvicthchin khng sinh ng tim. T l la chn sai ng dng ca iu dng kh cao. 44,9% la chn tim bp vinhngthuckhngcphptimbp,72,0%lachntimtnhmchvi nhng thuc khng c php tim tnh mch. Vn la chn dungmi: 12,8%la chn nc ct phatim ldungmi pha truyn tnh mch, 3,7% la chn dung mi tim tnh mch c nguy c gp tng k 38 vi thuc, 12,2% la chn dung mi truyn tnh mch c nguy c gp tng k vi thuc. V thi gian tim truyn 62% la chn tc tim tnh mch khng ph hp vi khuyn co, 7,6% la chn tc truyn tnh mch khng ph hp.Cchthcthchinkhi2thuctimcch nhcngngdngticng thi im c nhiu im cha ph hp vi khuyn co: trn cc thuc ch nh tim bpvocngbmtim(100%),timlnltccthuctimtnhmchquady truynmkhngcntrng(22,4%),truynlnltccthucquadytruynm khng cn trng (30,6%). 2. xut T kt ca nghin cu chng ti xin a ra 1 s xut nh sau: Cn c 1 ti liu hng dn v thc hin khng sinh ng tim: khuyn co vlachnngdng,dungmi,thtchdungmi,tc truyn bcsv iu dng tham kho khi k n v thc hin thuc. Tphunthmchoiudngvkinthclinquannvicthchin thuc tim, truyn. 40 TI LIU THAM KHO Ting Vit 1.B Y T (2009), Dc th quc gia Vit Nam, pp. 2.Trn Th Thun (2007), iu dng c bn II, Nh xut bn y hc, pp. 298 - 334. Ting Anh 3.AgaluA.,AyeleY.,BedadaW.,WoldieM.(2012),"Medication administrationerrorsinanintensivecareunitinEthiopia",IntArchMed, 5(1), pp. 15. 4.BertscheT.,MayerY.,StahlR.,Hoppe-TichyT.,EnckeJ.,HaefeliW.E. (2008), "Prevention of intravenous drug incompatibilities in an intensive care unit", Am J Health Syst Pharm, 65(19), pp. 1834-40. 5.BesoA.,FranklinB.D.,BarberN.(2005),"Thefrequencyandpotential causes of dispensing errors in a hospital pharmacy", Pharm World Sci, 27(3), pp. 182-90. 6.Bloch-TeitelbaumA.,LudeS.,Rauber-LuthyC.,KupferschmidtH., RussmannS.,Kullak-UblickG.A.,CeschiA.(2013),"Medicationwrong routeadministration:apoisonscenter-basedstudy",ExpertOpinDrugSaf, 12(2), pp. 145-52. 7.BritishMedical Association,RoyalPharmaceuticalSocietyofGreatBritain (2009), British national formulary: 58: September 2009, pp. 288 - 371. 8.CassidyN.,DugganE.,WilliamsD.J.,TraceyJ.A.(2011),"The epidemiology and type of medication errors reported to the National Poisons Information Centre of Ireland", Clin Toxicol (Phila), 49(6), pp. 485-91. 9.Cheung K. C., Bouvy M. L., De Smet P. A. (2009), "Medication errors: the importance of safe dispensing", Br J Clin Pharmacol, 67(6), pp. 676-80. 10.CousinsD.H.,SabatierB.,BegueD.,SchmittC.,Hoppe-TichyT.(2005), "Medicationerrorsinintravenousdrugpreparationandadministration:a 41 multicentreauditintheUK,GermanyandFrance",QualSafHealthCare, 14(3), pp. 190-5. 11.Cunningham K. J. (2012), "Analysis of clinical interventions and the impact ofpediatricpharmacistsonmedicationerrorpreventioninateaching hospital", J Pediatr Pharmacol Ther, 17(4), pp. 365-73. 12.DetersM.,PrasaD.,HentschelH.,SchaperA.(2009),"Iatrogenic intravenousmedicationerrorsreportedtotheGIZ-NordPoisonsCenter Gottingen", Eur J Intern Med, 20(7), pp. 728-31. 13.ElliottM.,LiuY.(2010),"The ninerights ofmedicationadministration:an overview", Br J Nurs, 19(5), pp. 300-5. 14.Gandhi T. K., Weingart S. N., Seger A. C., Borus J., Burdick E., Poon E. G., LeapeL.L.,BatesD.W.(2005),"Outpatientprescribingerrorsandthe impact of computerized prescribing", J Gen Intern Med, 20(9), pp. 837-41. 15.GrayAlistair,WrightJane,GoodeyVincent, BruceLynn(2012),Injectable Drugs Guide December 2012 update, pp. 16.J.Gladstone(1995),"Drugadministrationerrors:astudyintothefactors underlyingtheoccurrenceandreportingofdrugerrorsinadistrictgeneral hospital", pp. 17.Krahenbuhl-Melcher A., Schlienger R., Lampert M., Haschke M., Drewe J., KrahenbuhlS.(2007),"Drug-relatedproblemsinhospitals:areviewofthe recent literature", Drug Saf, 30(5), pp. 379-407. 18.Leape L. L., Bates D. W., Cullen D. J., Cooper J., Demonaco H. J., Gallivan T., HalliseyR.,IvesJ.,LairdN.,LaffelG.,etal. (1995),"Systemsanalysis ofadversedrugevents.ADEPreventionStudyGroup",JAMA,274(1),pp. 35-43. 19.LewisP.J.,DornanT.,TaylorD.,TullyM.P.,WassV.,AshcroftD.M. (2009),"Prevalence,incidenceandnatureofprescribingerrorsinhospital inpatients: a systematic review", Drug Saf, 32(5), pp. 379-89. 20.Lippincott Williams & Wilkins (1998), "Nursing I.V. Drug Handbook", pp. 21.MoyenE.,CamireE.,StelfoxH.T.(2008),"Clinicalreview:medication errors in critical care", Crit Care, 12(2), pp. 208. 42 22.OngW.M.,SubasyiniS.(2013),"Medicationerrorsinintravenousdrug preparation and administration", Med J Malaysia, 68(1), pp. 52-7. 23.Phillips J., Beam S., Brinker A., Holquist C., Honig P., Lee L. Y., Pamer C. (2001),"Retrospectiveanalysisofmortalitiesassociatedwithmedication errors", Am J Health Syst Pharm, 58(19), pp. 1835-41. 24.Rodriguez-GonzalezC.G.,Herranz-AlonsoA.,Martin-BarberoM.L., Duran-GarciaE.,Durango-LimarquezM.I.,Hernandez-SampelayoP., Sanjurjo-Saez M. (2012), "Prevalence of medication administration errors in twomedicalunitswithautomatedprescriptionanddispensing",JAmMed Inform Assoc, 19(1), pp. 72-8. 25.Sweetman.SeanC,BPharm,FRPharmSMartindaleTheCompleteDrug Reference Thirty-sixth edition, Pharmaceutical Press, pp. 158 - 361. 26.TaxisK.,BarberN.(2004),"Incidenceandseverityofintravenousdrug errors in a German hospital", Eur J Clin Pharmacol, 59(11), pp. 815-7. 27.TaxisK.,BarberN.(2003),"Causesofintravenousmedicationerrors:an ethnographic study", Qual Saf Health Care, 12(5), pp. 343-7. 28.Taxis K., Barber N. (2003), "Ethnographic study of incidence and severity of intravenous drug errors", BMJ, 326(7391), pp. 684. 29.Thu T. A., Rahman M., Coffin S., Harun-Or-Rashid M., Sakamoto J., Hung N.V.(2012),"AntibioticuseinVietnamesehospitals:amulticenterpoint-prevalence study", Am J Infect Control, 40(9), pp. 840-4. 30.Trissel Lawrence A. (2012), Handbook on Injectable Drugs, 17th edition, pp. 31.WestbrookJ.I.,RobM.I.,WoodsA.,ParryD.(2011),"Errorsinthe administration of intravenous medications in hospital and the role of correct procedures and nurse experience", BMJ Qual Saf, 20(12), pp. 1027-34. 32.Williams DJP. (2007), "Medication errors", pp. 343 -6. 33.WirtzV.,TaxisK.,BarberN.D.(2003),"Anobservationalstudyof intravenousmedicationerrorsintheUnitedKingdomandinGermany", Pharm World Sci, 25(3), pp. 104-11. 43 PH LC Phiu thu thp thng tin bnh n ti: Kho st cch s dng khng sinh dng ng tim bnh vin Ph sn Trung ngPh lc 1: Mu phiu thu thp thng tin t bnh n I.THNG TIN CHUNG V BNH NHN 1H v tn: 2M bnh n: 3Khoa iu tr 4Tui/ nm sinh 5Ngy nhp vin6Ngy xut vin 7 Bnh chnh: 8 Bnh mc km 9 Tin s d ng 10 Ngy bt u dng khng sinh ng tim 11 Ngy kt thc dng khng sinh ng tim 12 Hiu qu iu tr: Khi Nng hn Chuyn vin Khng thay iT vong 13 n thuc c nh my hay vit tay? nh my Vit tayII.THNG TIN V CCH S DNG KHNG SINH Khng sinh: . 1Tn bit dc 2Tn hot cht 3Hm lng 4Ngy bt u dng 5Ngy kt thc dng6Liu dng1 ln 7Liu dng 24 gi 8S ln dng trong ngy 9ng dng Tim bp Tim tnh mch Truyn tnh mch 10 Dung mi Nc ct Ringer lactate NaCl 0,9 % Glucose 5 % Dung mi khc :. PHIU KHO ST VIC THC HIN KHNG SINH TIM Ti bnh vin Ph sn trung ng (Thng 9/2012) PHN 1. THNG TIN C NHN H v tn (c th in hoc khng):Gii:NamN i tng: iu dngN h sinhK thut vin Trnh : Trung cp Cao ng i hc 11 Th tch dung mi trong 1 ln tim/ truyn (theo n bc s) 12 Th tch dung mi trong 1 ln tim/ truyn (theo phiu theo di ca iu dng) 13 Thi gian tim/truyn (theo n bc s) 14 Thi gian tim truyn (theo phiu theo di ca iu dng). 15 Thuc khc c ch nh cng ng tim/truyn cng thi im. (nu c) 16 Sai lch thng tin gia n thuc v phiu truyn ca iu dng? (ghi r).

Ph lc 2: Mu phiu kho st kin thc ca iu dng. Mu 1: Kho st kin thc khi s dng ng thi cc thuc cng ng dng. Khoa: S nm kinh nghim: PHN 2. PHNG VN Anh/ch vui lng tr li cc cu hi sau bng cch tch (X) vo cc thch hp. (C th la chn nhiu cu tr li nu anh/ch thy ph hp) PHN CU HI CHUNG: Tng k trong qu trnh tim truyn khng sinh 1. Trng hp y lnh c 2 thuc u c ch nh tim bp vo cng mt thi im, anh/ch s: Trn chung 2 thuc trong cng mt xi lanh ri tim Tim 2 thuc 2 v tr khc nhau kin khc (ghi r):.................................... 2. Trng hp y lnh c 2 thuc u c ch nh tim tnh mch vo cng mt thi im, anh/ch s: Trn chung 2 thuc trong cng mt xi lanh ri tim Tim 2 thuc 2 v tr khc nhau. Tim ln lt tng thuc qua ng truyn, khng cn trng dy truyn. Tim ln lt tng thuc qua ng truyn v trng sch dy truyn gia cc ln a thuc. kin khc (ghi r):.................................... 3. Trnghpylnh c 2thuc u c ch nh truyn tnh mchvo cng mt thi im, anh/ch s: Trn chung 2 thuc trong cng 1 chai truyn Truyn ln lt tng thuc, khng cn trng dy truyn Truyn ln lt tng thuc v trng sch dy truyn Truyn2 thuc cng lc qua chc ba. kin khc (ghi r):.................................... BtphatimAUGMENTIN1,2g(amoxicilin1g+acidclavulanic200 mg) A. Theo anh/ch, Augmentin 1,2g c th dng theo ng tim bp khng? PHN CU HI C TH I VI TNG THUC:(Vui lng xem nhng trang sau) Xin trn trng cm n anh/ch! Ph lc 2: Mu phiu kho st kin thc ca iu dng. Mu 2: Cu hi c th i vi tng thuc C u la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn B 1.Theoanh/ch,dungmithchhpdngphadungdchtimbpAugmentin 1,2g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 2.Theo anh/ch, gim au khi tim bp, c th trn Augmentin 1,2gvi lidocain c nng l: Lidocain 0,5% Lidocain 1% Lidocain 2% Khng c trn kin khc (ghi r):.................................... 3.Theoanh/ch,thtchdungmithchhpdngphadungdchtimbp Augmentin 1,2g l: 1-2ml 2-3ml 3-4ml 4-5mlkinkhc(ghi r):.................................... 4. Theo anh/ch, dung dch tim bp Augmentin 1,2g nu cha s dng ngay sau khi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... B.Theoanh/ch,Augmentin1,2gcthdngtheongtimtnhmch khng? C u la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn C 5.Theoanh/ch,dungmithchhpdngphadungdchtimtnhmch Augmentin 1,2g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 6. Theo anh/ch, th tch dung mi thch hp dng pha dung dch tim tnh mch Augmentin 1,2g l: 5 ml 10 ml 20 ml 40 mlkinkhc(ghi r):.................................... 7. Theo anh/ch, thi gian thch hp tim tnh mch Augmentin 1,2g l: Di 1 pht 1-2 pht2-3 pht 3-5 pht 5-10 pht kin khc (ghi r):.................................... 8. Theo anh/ch, dung dch tim tnh mchAugmentin 1,2g nu cha s dngngay sau khi pha th: B i C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... C.Theoanh/chAugmentin1,2gcthdngtheongtruyntnhmch khng? C u la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn C 9.Theoanh/ch,dungmithchhpdngphadungdchtruyntnhmch Augmentin 1,2g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 10.Theoanh/ch,thtchdungmithchhpdngphadungdchtruyntnh mch Augmentin 1,2g l: 50 ml 100 ml 200 ml 500 mlkinkhc(ghi r):.................................... 11. Theo anh/ch, thi gian thch hp truyn tnh mch Augmentin 1,2g l: 15-30 pht 30-60 pht60-120 pht kin khc (ghi r):.................................... 12.Theoanh/ch,dungdchtruyntnhmchAugmentin1,2gnuchasdng ngay sau khi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi. kin khc (ghi r):.................................... BtphatimUNASYN1,5g(ampicilin1g+sulbactamnatri500 mg) A. Theo anh/ch, Unasyn 1,5g c th dng theo ng tim bp khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn B 1. Theo anh/ch, dung mi thch hp dng pha dung dch tim bp Unasyn 1,5g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 2.Theo anh/ch, gim au khitim bp, c th trn Unasyn 1,5gvilidocain c nng l: Lidocain 0,5% Lidocain 1% Lidocain 2% Khng c trn kin khc (ghi r):.................................... 3. Theo anh/ch, th tch dung mi thch hp dng pha dung dch tim bp Unasyn 1,5g l: 1-2ml 2-3ml 3-4ml 4-5mlkinkhc(ghi r):.................................... 4. Theo anh/ch, dung dch tim bp Unasyn 1,5g nu cha s dng ngay sau khi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... B. Theo anh/ch, Unasyn 1,5g c th dng theo ng tim tnh mch khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn C 5. Theo anh/ch, dung mi thch hp dng pha dung dch tim tnh mchUnasyn 1,5g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 6. Theo anh/ch, th tch dung mi thch hp dng pha dung dch tim tnh mch Unasyn 1,5g l: 5 ml 10 ml 20 ml 40 mlkinkhc(ghi r):.................................... 7. Theo anh/ch, thi gian thch hp tim tnh mch Unasyn 1,5g l: Di 1 pht1-2 pht2-3 pht 3-5 pht5-10 pht kin khc (ghi r):.................................... 8. Theo anh/ch, dung dch tim tnh mch Unasyn 1,5g nu cha s dng ngay sau khi pha th: B i C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... C. Theo anh/chUnasyn 1,5g c th dng theo ng truyn tnh mch khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin b qua phn C 9.Theoanh/ch,dungmithchhpdngphadungdchtruyntnhmch Unasyn 1,5g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 10.Theoanh/ch,thtchdungmithchhpdngphadungdchtruyntnh mch Unasyn 1,5g l: 50 ml 100 ml 200 ml 500 mlkinkhc(ghi r):.................................... 11. Theo anh/ch, thi gian thch hp truyn tnh mch Unasyn 1,5g l: 15-30 pht 30-60 pht60-120 pht kin khc (ghi r):.................................... 12.Theoanh/ch,dungdchtruyntnhmchUnasyn1,5gnuchasdngngay sau khi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi. kin khc (ghi r):.................................... Bt pha tim ZINACEF 750 mg (cefuroxim 750mg) A. Theo anh/ch, Zinacef 750mg c th dng theo ng tim bp khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn B 1. Theo anh/ch, dung mi thch hp dng pha dung dch tim bp Zinacef 750mg l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 2.Theo anh/ch, gim au khi tim bp, c th trn Zinacef 750mgvi lidocain c nng l: Lidocain 0,5% Lidocain 1% Lidocain 2% Khng c trn kin khc (ghi r):.................................... 3. Theo anh/ch, th tch dung mi thch hp dng pha dung dch tim bp Zinacef 750mg l: 1-2ml 2-3ml 3-4ml 4-5mlkinkhc(ghi r):.................................... 4. Theo anh/ch, dung dch tim bp Zinacef 750mgnu cha s dng ngay sau khi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... B. Theo anh/ch, Zinacef 750mg c th dng theo ng tim tnh mch khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn C 5. Theo anh/ch, dung mi thch hp dng pha dung dch tim tnh mch Zinacef 750mg l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 6. Theo anh/ch, th tch dung mi thch hp dng pha dung dch tim tnh mch Zinacef 750mg l: 5 ml 10 ml 20 ml 40 mlkinkhc(ghi r):.................................... 7. Theo anh/ch, thi gian thch hp tim tnh mch Zinacef 750mg l: Di 1 pht1-2 pht2-3 pht 3-5 pht5-10 pht kin khc (ghi r):.................................... 8.Theoanh/ch,dungdchtimtnhmchZinacef750mgnuchasdngngay sau khi pha th: B i C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... C.Theoanh/chZinacef750mgcthdngtheongtruyntnhmch khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin b qua phn C 9.Theoanh/ch,dungmithchhpdngphadungdchtruyntnhmch Zinacef 750mg l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 10.Theoanh/ch,thtchdungmithchhpdngphadungdchtruyntnh mch Zinacef 750mg l: 50 ml 100 ml 200 ml 500 mlkinkhc(ghi r):.................................... 11. Theo anh/ch, thi gian thch hp truyn tnh mch Zinacef 750mg l: 15-30 pht 30-60 pht60-120 pht kin khc (ghi r):.................................... 12. Theo anh/ch, dung dch truyn tnh mch Zinacef 750mg nu cha s dng ngay sau khi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi. kin khc (ghi r):.................................... Bt pha tim BIOTAKSYM 1g (cefotaxim 1g) A. Theo anh/ch, Biotaksym 1g c th dng theo ng tim bp khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn B 1. Theo anh/ch, dung mi thch hp dng pha dung dch tim bp Biotaksym 1g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 2.Theo anh/ch, gim au khi tim bp, c th trn Biotaksym 1gvi lidocain c nng l: Lidocain 0,5% Lidocain 1% Lidocain 2% Khng c trn kin khc (ghi r):.................................... 3.Theoanh/ch,thtchdungmithchhpdngphadungdchtimbp Biotaksym 1g l: 1-2ml 2-3ml 3-4ml 4-5mlkinkhc(ghi r):.................................... 4.Theoanh/ch,dungdchtimbpBiotaksym1gnuchasdngngaysaukhi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... B. Theo anh/ch, Biotaksym 1g c th dng theo ng tim tnh mch khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn C 5.Theoanh/ch,dungmithchhpdngphadungdchtimtnhmch Biotaksym 1g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 6. Theo anh/ch, th tch dung mi thch hp dng pha dung dch tim tnh mch Biotaksym 1g l: 5 ml 10 ml 20 ml 40 mlkinkhc(ghi r):.................................... 7. Theo anh/ch, thi gian thch hp tim tnh mch Biotaksym 1g l: Di 1 pht1-2 pht2-3 pht 3-5 pht5-10 pht kin khc (ghi r):................................... 8. Theo anh/ch, dung dch tim tnh mch Biotaksym 1g nu cha s dng ngay sau khi pha th: B i C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... C.Theoanh/chBiotaksym1gcthdngtheongtruyntnhmch khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin b qua phn C 9.Theoanh/ch,dungmithchhpdngphadungdchtruyntnhmch Biotaksym 1g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 10.Theoanh/ch,thtchdungmithchhpdngphadungdchtruyntnh mch Biotaksym 1g l: 50 ml 100 ml 200 ml 500 mlkinkhc(ghi r):.................................... 11. Theo anh/ch, thi gian thch hp truyn tnh mch Biotaksym 1g l: 15-30 pht 30-60 pht60-120 pht kin khc (ghi r):.................................... 12. Theo anh/ch, dung dch truyn tnh mch Biotaksym 1g nu cha s dng ngay sau khi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi. kin khc (ghi r):.................................... Bt pha tim SULPERAZON 1g (cefoperazon 500 mg + sulbactam natri 500 mg) A. Theo anh/ch, Sulperazon 1g c th dng theo ng tim bp khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn B 1. Theo anh/ch, dung mi thchhp dng pha dung dch tim bp Sulperazon 1g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 2.Theo anh/ch, gim au khi tim bp, c th trn Sulperazon 1gvi lidocain c nng l: Lidocain 0,5% Lidocain 1% Lidocain 2% Khng c trn kin khc (ghi r):.................................... 3.Theoanh/ch,thtchdungmithchhpdngphadungdchtimbp Sulperazon 1g l: 1-2ml 2-3ml 3-4ml 4-5mlkinkhc(ghi r):.................................... 4.Theoanh/ch,dungdchtimbp Sulperazon1gnuchasdngngaysaukhi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... B. Theo anh/ch, Sulperazon 1g c th dng theo ng tim tnh mch khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn C 5.Theoanh/ch,dungmithchhpdngphadungdchtimtnhmch Sulperazon 1g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 6. Theo anh/ch, th tch dung mi thch hp dng pha dung dch tim tnh mch Sulperazon 1g l: 5 ml 10 ml 20 ml 40 mlkinkhc(ghi r):.................................... 7. Theo anh/ch, thi gian thch hp tim tnh mch Sulperazon 1g l: Di 1 pht 1-2 pht 2-3 pht 3-5 pht 5-10 pht kin khc (ghi r):.................................... 8. Theo anh/ch, dung dch tim tnh mch Sulperazon 1g nu cha s dng ngay sau khi pha th: B i C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... C.Theoanh/chSulperazon1gcthdngtheongtruyntnhmch khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin b qua phn C 9.Theoanh/ch,dungmithchhpdngphadungdchtruyntnhmch Sulperazon 1g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 10.Theoanh/ch,thtchdungmithchhpdngphadungdchtruyntnh mch Sulperazon 1g l: 50 ml 100 ml 200 ml 500 mlkinkhc(ghi r):.................................... 11. Theo anh/ch, thi gian thch hp truyn tnh mch Sulperazon 1g l: 15-30 pht 30-60 pht60-120 pht kin khc (ghi r):.................................... 12. Theo anh/ch, dung dch truyn tnh mch Sulperazon 1g nu cha s dng ngay sau khi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi. kin khc (ghi r):.................................... Bt pha tim RIGOFIN 1g (ceftriaxon 1g) A. Theo anh/ch, Rigofin 1g c th dng theo ng tim bp khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn B 1. Theo anh/ch, dung mi thch hp dng pha dung dch tim bp Rigofin 1g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 2.Theoanh/ch,gimaukhitimbp,cthtrnRigofin1gvilidocainc nng l: Lidocain 0,5% Lidocain 1% Lidocain 2% Khng c trn kin khc (ghi r):.................................... 3. Theo anh/ch, th tch dung mi thch hp dng pha dung dch tim bp Rigofin 1g l: 1-2ml 2-3ml 3-4ml 4-5mlkinkhc(ghi r):.................................... 4. Theo anh/ch, dung dch tim bp Rigofin 1g nu cha s dng ngay sau khi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... B. Theo anh/ch, Rigofin 1g c th dng theo ng tim tnh mch khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn C 5. Theo anh/ch, dung mi thch hp dng pha dung dch tim tnh mch Rigofin 1g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 6. Theo anh/ch, th tch dung mi thch hp dng pha dung dch tim tnh mch Rigofin 1g l: 5 ml 10 ml 20 ml 40 mlkinkhc(ghi r):.................................... 7. Theo anh/ch, thi gian thch hp tim tnh mch Rigofin 1g l: Di 1 pht 1-2 pht2-3 pht 3-5 pht 5-10 pht kin khc (ghi r):.................................... 8. Theo anh/ch, dung dch tim tnh mch Rigofin 1g nu cha s dng ngay sau khi pha th: B i C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... C. Theo anh/chRigofin 1g c th dng theo ng truyn tnh mch khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin b qua phn C 9.Theoanh/ch,dungmithchhpdngphadungdchtruyntnhmch Rigofin 1g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 10.Theoanh/ch,thtchdungmithchhpdngphadungdchtruyntnh mch Rigofin 1g l: 50 ml 100 ml 200 ml 500 mlkinkhc(ghi r):.................................... 11. Theo anh/ch, thi gian thch hp truyn tnh mch Rigofin 1g l: 15-30 pht 30-60 pht60-120 pht kin khc (ghi r):.................................... 12. Theo anh/ch, dung dch truyn tnh mch Rigofin 1g nu cha s dng ngay sau khi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi. kin khc (ghi r):.................................... Bt pha tim PREPENEM 1g (imipenem 500 mg + cilastatin 500 mg) A. Theo anh/ch, Prepenem 1g c th dng theo ng tim bp khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn B 1. Theo anh/ch, dung mi thch hp dng pha dung dch tim bp Prepenem 1g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 2.Theo anh/ch, gim au khi tim bp, c th trn Prepenem 1gvi lidocain c nng l: Lidocain 0,5% Lidocain 1% Lidocain 2% Khng c trn kin khc (ghi r):.................................... 3.Theoanh/ch,thtchdungmithchhpdngphadungdchtimbp Prepenem 1g l: 1-2ml 2-3ml 3-4ml 4-5mlkinkhc(ghi r):.................................... 4. Theo anh/ch, dung dch tim bp Prepenem 1g nu cha s dng ngay sau khi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... B. Theo anh/ch, Prepenem 1g c th dng theo ng tim tnh mch khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn C 5.Theoanh/ch,dungmithchhpdngphadungdchtimtnhmch Prepenem 1g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 6. Theo anh/ch, th tch dung mi thch hp dng pha dung dch tim tnh mch Prepenem 1g l: 5 ml 10 ml 20 ml 40 mlkinkhc(ghi r):.................................... 7. Theo anh/ch, thi gian thch hp tim tnh mch Prepenem 1g l: Di 1 pht1-2 pht2-3 pht 3-5 pht5-10 pht kin khc (ghi r):.................................... 8. Theo anh/ch, dung dch tim tnh mch Prepenem 1g nu cha s dng ngay sau khi pha th: B i C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... C. Theo anh/chPrepenem 1g c th dng theo ng truyn tnh mch khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin b qua phn C 9.Theoanh/ch,dungmithchhpdngphadungdchtruyntnhmch Prepenem 1g l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 10.Theoanh/ch,thtchdungmithchhpdngphadungdchtruyntnh mch Prepenem 1g l: 50 ml 100 ml 200 ml 500 mlkinkhc(ghi r):.................................... 11. Theo anh/ch, thi gian thch hp truyn tnh mch Prepenem 1g l: 15-30 pht 30-60 pht60-120 pht kin khc (ghi r):.................................... 12. Theo anh/ch, dung dch truyn tnh mch Prepenem 1g nu chas dngngay sau khi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi. kin khc (ghi r):.................................... Dung dch tim CLINDAMYCIN 600mg/4 ml (clindamycin 600mg) A. Theo anh/ch, Clindamycin 600mg c th dng theo ng tim bp khng?

C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn B 1.Theoanh/ch,dungmithchhp dng phadungdchtimbpClindamycin 600mg l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 2.Theoanh/ch,gimaukhitimbp,cthtrnClindamycin600mgvi lidocain c nng l: Lidocain 0,5% Lidocain 1% Lidocain 2% Khng c trn kin khc (ghi r):.................................... 3.Theoanh/ch,thtchdungmithchhpdngphadungdchtimbp Clindamycin 600mg l: 1-2ml 2-3ml 3-4ml 4-5mlkinkhc(ghi r):.................................... 4. Theo anh/ch, dung dch tim bp Clindamycin 600mg nu cha s dng ngay sau khi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... B.Theoanh/ch,Clindamycin600mgcthdngtheongtimtnhmch khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn C 5.Theoanh/ch,dungmithchhpdngphadungdchtimtnhmch Clindamycin 600mg l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 6. Theo anh/ch, th tch dung mi thch hp dng pha dung dch tim tnh mch Clindamycin 600mg l: 5 ml 10 ml 20 ml 40 mlkinkhc(ghi r):.................................... 7. Theo anh/ch, thi gian thch hp tim tnh mch Clindamycin 600mg l: Di 1 pht 1-2 pht2-3 pht 3-5 pht 5-10 pht kin khc (ghi r):.................................... 8.Theoanh/ch,dungdchtimtnhmchClindamycin600mgnuchasdng ngay sau khi pha th: B i C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... C. Theo anh/chClindamycin 600mg c th dng theo ng truyn tnh mch khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin b qua phn C 9.Theoanh/ch,dungmithchhpdngphadungdchtruyntnhmch Clindamycin 600mg l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 10.Theoanh/ch,thtchdungmithchhpdngphadungdchtruyntnh mch Clindamycin 600mg l: 50 ml 100 ml 200 ml 500 mlkinkhc(ghi r):.................................... 11. Theo anh/ch, thi gian thch hp truyn tnh mch Clindamycin 600mg l: 15-30 pht 30-60 pht60-120 pht kin khc (ghi r):.................................... 12. Theo anh/ch, dung dch truyn tnh mch Clindamycin 600mg nu cha s dng ngay sau khi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi. kin khc (ghi r):.................................... Dung dch tim PEFLACINE 400mg/5 ml (pefloxacin 400mg) A. Theo anh/ch, Peflacine 400mg c th dng theo ng tim bp khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn B 1.Theoanh/ch,dungmithchhpdngphadungdchtimbpPeflacine 400mg l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 2.Theo anh/ch, gim au khi tim bp, c th trn Peflacine 400mgvi lidocain c nng l: Lidocain 0,5% Lidocain 1% Lidocain 2% Khng c trn kin khc (ghi r):.................................... 3.Theoanh/ch,thtchdungmithchhpdngphadungdchtimbp Peflacine 400mg l: 1-2ml 2-3ml 3-4ml 4-5mlkinkhc(ghi r):.................................... 4. Theo anh/ch, dung dch tim bp Peflacine 400mg nu cha s dng ngay sau khi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... B.Theoanh/ch,Peflacine400mgcthdngtheongtimtnhmch khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin chuyn sang phn C 5. Theo anh/ch, dung mi thch hp dng pha dung dch tim tnh mch Peflacine 400mg l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 6. Theo anh/ch, th tch dung mi thch hp dng pha dung dch tim tnh mch Peflacine 400mg l: 5 ml 10 ml 20 ml 40 mlkinkhc(ghi r):.................................... 7. Theo anh/ch, thi gian thch hp tim tnh mch Peflacine 400mg l: Di 1 pht1-2 pht2-3 pht 3-5 pht5-10 pht kin khc (ghi r):.................................... 8. Theo anh/ch, dung dch tim tnh mch Peflacine 400mg nu cha s dng ngay sau khi pha th: B i C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi kin khc (ghi r):.................................... C. Theo anh/chPeflacine 400mg c th dng theo ng truyn tnh mch khng? C Nu la chn C,xin tr li nhng cu hi sau Khng Nu la chn Khng, xin b qua phn C 9.Theoanh/ch,dungmithchhpdngphadungdchtruyntnhmch Peflacine 400mg l: Nc ct NaCl 0,9%Glucose 5% Ringer lactat kin khc (ghi r):.................................... 10.Theoanh/ch,thtchdungmithchhpdngphadungdchtruyntnh mch Peflacine 400mg l: 50 ml 100 ml 200 ml 500 mlkinkhc(ghi r):.................................... 11. Theo anh/ch, thi gian thch hp truyn tnh mch Peflacine 400mg l: 15-30 pht 30-60 pht60-120 pht kin khc (ghi r):.................................... 12.Theoanh/ch,dungdchtruyntnhmchPeflacine400mgnuchasdng ngay sau khi pha th: B i. C th bo qun trong t lnh 2-80C trong vng 24 gi. C th bo qun nhit thng trong vng 8 gi. C th bo qun nhit thng trong vng 24 gi. kin khc (ghi r):.................................... Bng I. Khuyn co cch dng ca cc khng sinh trong nghin cu [1, 15, 20, 30] Khng sinh Hm lng ng dng Dung miV (ml)* t (pht) * Tim bp NCPT; lidocain 0,5%, 2% 3,2 Tim TMNCPT3310 15 ampicilin + sulbactam 1,5 g Truyn TMNaCl 0,9%50 10015 30 Tim TMNCPT, NaCl 0,9%203 - 4 amoxicillin + clavulanic acid 1,2 g Truyn TMNaCl 0,9%10030 40 Tim bpNCPT3 Tim TMNCPT6 - 103 - 5cefuroxim0,75 g Truyn TMNaCl 0,9%, glucose 5%50 30 Tim bpLidocain 1%3,5 Tim TMNCPT102 4ceftriaxon1 g Truyn TMNaCl 0,9%, glucose 5%50 - 100 30 Tim bpNCPT2 Tim TMNCPT103 5cefotaxim0,5 g Truyn TMNaCl 0,9%, glucose 5%5020 - 60 Tim TMNCPT, NaCl 0,9%203 - 5 piperacilin + tazobactam 4,5 g Truyn TMNaCl 0,9%, glucose 5% 50 30 Ph lc 3: Hng dn thc hnh s dng ca mt s khng sinh Tim bpNCPT3,4 Tim TMNCPT3,4 3 cefoperazon + sulbactam 1 g Truyn TMNaCl 0,9%2015 - 60 pefloxacin0,4 gTruyn TMglucose 5%12560 Tim bp--- imipenem + cilastatin 0,5 g Truyn TMNaCl 0,9%10020 - 30 Tim bp--- clindamycin 0,6 g/ 4ml Truyn TMNaCl 0,9%50 20 metronidazole 0,5 g/ 100 ml Truyn TM-- 20 v (ml) *: th tch dung mi c khuyn co (n v ml) t (pht) *: thi gian tim truyn c khuyn co (n v pht) Bng 2: Mt s tng k cn trnh Khng sinhHm lngDung mi tng k ampicilin, sulbactam1, 5 gglucose 5%; NaHCO3 amoxicillin, clavulanic acid 1,2 gglucose 5%; NaHCO3 cefuroxim0,75 gNaHCO3 ceftriaxone1 g Dung mi c cha ion Calci. VD: ringer lactat, Hartmanns. Khng dng cng dung mi ny qua Y site. cefotaxim1 gNaHCO3 piperacillin, tazobactam4,5 g ringer lactat, NaHCO3, Hartmanns cefoperazon + sulbactam1 gringer lactat imipenem, cilastatin0,5 g NaHCO3, dung mi cha ion lactate. VD: ringer lactat (tuy nhin vn c th cng dng qua Y site). metronidazole 0,5 g/ 100 ml glucose 5%, Hartmanns. Ph lc 4: Cch tnh th tch dung mi v tc truyn cho 1 n v phn liu Vidytruyncbumgit20git/1ml,thtchdungmivtc truyn cho 1 n v phn liu c th tnh theo cng thc sau: Trong :v:l th tch dung mi pha long 1 n v phn liu, n v: ml/1 l. t:l thi gian truyn ca 1 n v phn liu, n v: pht/ 1 l. V0: th dung dung mi pha long liu dng 1 ln. Hm lng v liu 1 ln : n v mg v= V0 m lng u 1 ln t=v20 S git trong 1 pht DANH SCH BNH NHN TRONG NGHIN CU Vi mc tiu: Kho st cch s dng khng sinh dng ng tim bnh vin Ph sn Trung ng. Thi gian thc hin: t 01/ 2013 n 06 /2013 Ngi thc hin: Nguyn Th Vn An STTH v tn bnh nhnM bnh n 1Nguyn Th N.17238.MD 2Phm Thanh H.1000.12.UBT 3Nguyn Th O.1001.12.UXTC 4Hong Thi T.1002.12.UXTC 5Hong Th H.1011.12.UXTC 6Nguyn Th S.1012.12.UXTC 7 Th M.1013.12.UXTC 8Nguyn Th Thanh T.1014.12.UXTC 9Lng Th C.1015.12.UXTC 10Nguyn Th Q.1016.12.UXTC 11 Thuy H.1020.12.UXTC 12Nguyn Th T.1022.12.UXTC 13Nguyn Th Thanh H.1025.12.UXTC 14Nguyn Th X.1026.12.UXTC 15ng Th T.1027.12.UXTC 16Nguyn Th H.1028.12.UXTC 17Mau Th K.1030.12.UXTC 18 Th V.1031.12.UXTC 19Mai Th T.1034.12.UXTC 20Trn Th L.1035.12.UXTC 21o Th T1038.12.UXTC 22Trn Th T1039.12.UXTC 23Bi Thi H.1043.12.UXTC 24Chu Th A.1047.12.UXTC 25L Th Thu T.1052.12.TB 26Nguyn Th H.1106.12.UXTC 27L Th Y.1107.12.UXTC 28Nguyn Hoa P.1118.12.UXTC 29Nguyn Th L.1119.12.UXTC 30Nguyn Th Bch N.1124.12.UXTC 31V Th T.1125.12.UXTC 32Nguyn Hng N.1127.12.UXTC 33Trn Th H.1128.12.UXTC 34Trn Th D.1129.12.UXTC 35Trn Th Tuyt H.1130.12.UXTC 36Nguyn Th L.1132.12.UXTC 37L Th H.1138.12.UXTC 38m Thu M.1153.12.TB 39Phm Th T.1156.12.TB 40Phm Th Bch H.1158.12.TB 41Dng Th M.1164.12.TB 42L Th P.1166.12.TB 43T Th Minh C.1169.12.TB 44ng Thi Bich T.1172.12.TB 45L Th P.1177.12.TB 46Phm Th T.1179.12.TB 47 Hng L.1183.12.TB 48V Th T.1184.12.TB 49inh Th L.1189.12.TB 50inh Thi H.1192.12.TB 51Nguyn Th N.1195.12.TB 52ng Tuyt M.1196.12.TB 53Ng Th V.1200.12.TB 54Hong Th N.1219.12.TB 55Phm Th T.1257.12.TB 56Nguyn Th H.1258.12.TB 57L Th Thu H.1260.12.TB 58L Th T.1265.12.TB 59m Th D.1269.12.TB 60o Th Thy T.1272.12.TB 61Hong Th L.1274.12.TB 62La Th N.1300.12.TB 63Hong Th D.1301.12.TB 64Nguyn Th L.1312.12..TB 65L Th S.1319.12.TB 66Nguyn Th Ngc H.1320.12.TB 67Nguyn Th Thanh N.1321.12.TB 68Nguyn Th L.1328.12.TB 69V Th H.1329.12.TB 70Nguyn Minh Y.1346.12.TB 71Nguyn Th Vn T.1350.12.TB 72T Th N.1356.12.TB 73Phng Th H.1357.12.TB 74Mai Th H.1358.12.TB 75V Th Ngc H.1359.12.TB 76 Th Y.1376.12.TB 77L Th D.1380.12.TB 78Hong Th H.1382.12.TB 79Dng Mai H.1409.12.TB 80La Vit H.1425.12.TB 81L Th H.1429.12.TB 82Phan Th Thanh H1439.12.TB 83Phm Kim X.1443.12.TB 84Nguyn Thu H.1446.12.TB 85Nguyn Hong A.1451.12.GEU 86V Th H.1452.12.GEU 87Trng Th T.1452.12.TB 88Nguyn Thanh T.1453.12.GEU 89Nguyn Th Thanh T.1454.12.GEU 90Nguyn Th S.1455.12.GEU 91Nguyn Thu Thanh H. 1455.12.TB 92Trn Th H.1456.12.GEU 93Nguyn Th Kim T.1457.12.GEU 94Dng Cm B.1458.12.GEU 95Nguyn Th H.145