B Y T TRNG I HC DC H NI V TH ANH V KHO ST CCH S DNGTHUC DNG NG TNH MCH TI KHOA THN - TIT NIUBNH VIN E KHA LUN TT NGHIP DC S H NI- 2014 B Y T TRNG I HC DC H NI V TH ANH V KHO ST CCH S DNGTHUC DNG NG TNH MCH TI KHOA THN - TIT NIU BNH VIN E KHA LUN TT NGHIP DC S Ngi hng dn: 1.ThS. Trnh Trung Hiu 2.TS. V Th Thu Hng Ni thc hin: 1.B mn Dc lm sng-Trng i hc Dc H Ni 2.Bnh vin E H NI 2014 LI CM N LicmnutintixincginThS.TrnhTrungHiu,ging vinbmnDclmsng,TrngihcDcHNivTS.VThThu Hng, ph trng khoa Dc, bnh vin E, l nhng ngi thy trc tip hng dn v chbocho ti ht sc tn tnhtrong sut qutrnh tithc hin ti tt nghip ca mnh. TixinchnthnhcmnThS.CaoThBchTho,gingvinTrng i hc Dc H Ni v DS. Nguyn Th H, dc s bnh vin E v nhng kin nggphtscqubuvsgipnhittnhticthhonthnhti ny. Ti xin cm n cc thy c gio trong bmn Dc lm sng, Trng i hcDcHNilunhtlnggiipnhngkhcmctrongqutrnhthc hin ti. TixingilicmnntpthkhoaDc,khoaThn-Titniuv phng lu tr h s bnh n thuc bnh vin E nhit tnh gip v gp phn rt ln cng ti thc hin ti. Nhn dp ny, xin c gi li cm n trn trng v chn thnh n cc thy c gio Trng i hc Dc H Ni, nhng kin thc v k nng m thy c dy c vn dng khng ch trong qu trnh thc hin ti ny m trn c chng ng ti s i tip trong tng lai. V cui cng, mt cch su sc nht, xin cm n gia nh, bn b lun bn vi nhng li ng vin kp thigip ti vt qua nhng thiim kh khntrong cuc sng. H Ni, thng 05/2014 Sinh vin V Th Anh V MC LC T VN ................................................................................................................. 1 PHN 1. TNG QUAN ................................................................................................. 2 1.1.i cng v dng thuc ng tim v truyn tnh mch ................................. 2 1.1.1.i cng v dng thuc ng tnh mch ................................................ 2 1.1.2.Tim tnh mch ............................................................................................ 3 1.1.3.Truyn tnh mch ........................................................................................ 4 1.2.Sai st trong ch nh v thc hin cc thuc dng ng tnh mch ................. 6 1.2.1.Sai st lin quan n thuc ......................................................................... 6 1.2.2.Sai st trong k n .................................................................................... 7 1.2.3.Sai st trong thc hin thuc ca iu dng ............................................ 9 1.2.4.Nghin cu v sai st thuc ti Vit Nam ................................................. 11 PHN 2. I TNG V PHNG PHP NGHIN CU .................................. 13 2.1.Kho st ch nh ca bc s trong s dng cc thuc dng ng tnh mch .. 13 2.1.1.Mc tiu nghin cu ................................................................................. 13 2.1.2.i tng nghin cu ............................................................................... 13 2.1.3.Phng php nghin cu .......................................................................... 13 2.2.Kho st cc sai lch trong thc hin thuc dng ng tnhmchca iu dng ............................................................................................................................. 14 2.2.1.Mc tiu nghin cu ................................................................................. 14 2.2.2.i tng nghin cu ............................................................................... 14 2.2.3.Phng php nghin cu .......................................................................... 14 2.3.Phng php x l s liu .................................................................................. 16 PHN 3. KT QU V BN LUN ......................................................................... 17 3.1.Kho st ch nh ca bc s trong s dng thuc dng ng tnh mch ........ 17 3.1.1.c im bnh nhn ................................................................................. 17 3.1.2.c im ch nh thuc dng ng tnh mch ca bc s .................... 17 3.2.Cc sai lch gp phi trong qu trnh thc hin thuc dng ng tnh mch ca iu dng .............................................................................................................. 25 3.2.1.c im bnh nhn ................................................................................. 25 3.2.2.c im ca ngi thc hin thuc ........................................................ 26 3.2.3.c im thc hin thuc dng ng tnh mch ca iu dng .......... 26 3.3.Bn lun .............................................................................................................. 31 3.3.1.V vic ch nh v thc hin ng dng cc thuc tim truyn tnh mch31 3.3.2.V vic la chn dung mi v th tch dung mi ...................................... 31 3.3.3.V tc tim truyn cc thuc ................................................................ 33 3.3.4.V cc trng hp c nguy c xy ra tng k......................................... 36 3.3.5.u im v hn ch ca nghin cu ......................................................... 37 KT LUN V XUT .......................................................................................... 38 1.Kt lun .............................................................................................................. 38 1.1.V ch nh thuc dng ng tnh mch trong cc bnh n ................... 38 1.2.V cch thc hin thuc dng ng tnh mch ca iu dng ............ 38 2. xut ............................................................................................................... 39 DANH MC CC CH VIT TT KCTKhong tin cy GluGlucose NCPTNc ct pha tim DANH MC CC BNG BngTrang Bng 3.1. S lng thuc dng ng tnh mch trong bnh n17 Bng 3.2. Tnh hp l ca vic la chn ng dng cc thuc 18 Bng3.3.cimlachndungmihatanvthtchdungmi ha tan trong ch nh ca bc s 20 Bng 3.4. c im la chn dung mi pha long v th tch dung mi pha long trong ch nh ca bc s 21 Bng 3.5. c im ch nh tc truyn22 Bng 3.6. Thng tin v tc truyn ca drotaverin, acid tranexamic, piracetam, diazepam 23 Bng 3.7. Cc cp ch nh c nguy c gy tng k24 Bng 3.8. c im nhn khu hc ca bnh nhn25 Bng 3.9. c im ca ngi thc hin thuc26 Bng 3.10. c im ch nh ca bc s v thc hin th tch dung mi pha long ca iu dng 28 Bng 3.11. c im thc hin tc truyn ca iu dng29 Bng 3.12. Cc trng hp thc hin thuc c nguy c xy ra tng k30 1 T VN Ti cc bnh vin hin nay, vi m hnh bnh tt ngy cng phc tp v cc loi thuc a dng c v hot cht, dng bo ch, ng dng th vic xy ra sai st trong s dng thuc l kh trnh khi. Trong , hai bc quan trng thuc n vibnhnhnlkncabcsvthchinthuccaiudngtimn khng t nguy c sai st nh hng n hiu qu iu tr ca thuc v an ton ca bnh nhn.Timtruyntnhmchlnhngngdngphbinnhttrongccbnh vin, c bit trn nhng bnh nhn c thi gian nm vin ko di. Vic k n v thc hin cc thuc dng ng tnh mch cng phc tp hn do phi m bo tnh chnh xc ca nhiu yu t nh dung mi, tc tim truyn, cch thc pha ch mt s loi thuc c bit ko theo nhiu nguy c sai st hn. Ti bnh vin E thi im thc hin ti, cha c mt hng dn c th v ch nh v thc hin cc thuc dng ng tnh mch. V th, chng ti thc hin tiKhostcchsdngthucdngngtnhmchtikhoaThn-Tit niu bnh vin E vi cc mc tiu sau: 1.Kho st s ph hp gia ch nh ca bc s so vi cc ti liu tra cu trong s dng cc thuc dng ng tnh mch. 2.Kho st s ph hp trong thc hin cc thuc dng ng tnh mch ca iu dng so vi ch nh ca bc s. 2 PHN 1. TNG QUAN 1.1.i cng v dng thuc ng tim v truyn tnh mch 1.1.1.i cng v dng thuc ng tnh mch Tim truyn tnh mch l ng dng ph bin hin nay trong cc bnh vin docnhiuuimsoviccngdngkhc.Thucsdngngtim truyntnhmchchohiuqunhanh,cthtnhtonliuchnhxcvdon chiuqucathuc.Mtkhc,thuctgyauhnsovingtimbp hoc tim di da v c th pha long nhiu ln gim kch ng. y c coi l ngdngthchhpkhibnhnhnkhngthungthuchockhngdungnp thuc qua ng ung.Tuy nhin, vic s dng thuc ng tnh mch cng c mt s nhc im cn lu . Trc ht l nguy c nhim khun hoc tai bin khi dng thuc rt nguy him,thmchcthdntitvong.Ccthucngtnhmchchcthc hin bi nhn viny t c chuyn mn v yu cu c y dng c tim truyn. Hn na, gi thnh ca cc dng bo ch thuc dng ng tnhmch thng t hn ng ung [16],[35]. Chnhvvy,trongchnhvthchinthuctimtruyntnhmchcn lunmtsvnnhnguyctngk,thtchgiatngcathucvk thut kim tra trc quan trc khi tim truyn. Tngklccphnnghahchocvtlxyragiathucvidung mi hoc gia cc thuc vi nhau. Tng k c th xy ra khi cc thuc c trn ln trong mt kim tim hoc dch truyn hoc cc thuc c dng chung qua dy truyn, qua ng thng, qua kim lun. Nguy c xy ra tng k tng ln cng vi s lngthuccsdngngthi.Cnhiuyutnhhngnkhnng tng k gia cc cht vi nhau. Trc ht l nng thuc. Nng thuccng caothnguyctngkcngln,vd:chnngcaothaminophylinmi tng k vi mt s thuc. Tng tc gia cc thuc c th xy ra sau vi giy- vi ngy.Thuccngtipxcluvinhaucngdxyratngk,vvythucch 3 nncphangaytrckhisdngvphicbisau24-48gi.Nhit cng lmtyu t nh hng bi phn lncc thuc c n nh tt hn trong iu kin nhit thp. Mtyu tna cn c xem xt l pHv cc dungdch thuc c pH khc nhau khi s dng ng thi c th gy kt ta. Ngoi ra, pH ca dung mi cng c th nh hng n n nh ca thuc [35].trnhbtkvntngknocthxyra,cnmboluntrng dytruyngia2lnathuckhcnhauquacngdytruynbngdungmi tng hp vi c 2 thuc. Dung mi thng dng trong cc trng hp ny l NaCl 0,9% hoc glucose 5%. trng ng thng cn 5- 10 ml dung mi, trng dy truyn cn 20 ml dung mi [16]. Vn tip theo cn lu l th tch gia tng.i vi cc thuc tim dng bt ng kh cnc hon nguyn trc khi dng, th tch sau khi hon nguyn c th ln hn th tch dung mi dng pha ban u. Th tch chnh lch ny gi lthtchgiatng.Thtchgiatngcthkhngnhhngnhiuquvan ton ca thuc trong trng hp ton b thuc ca mt liu c ch nh pha s dngmtln.Tuynhin,phichngitrnytnhliutrongtrnghp ch s dng mt phn thuc pha [16]. Mt vn na l k thut kim tra trc quan trc khi tim truyn. K thut nyphicxemnhlmtphntrongqutrnhchunbthuc,dosnphm thuc trc khi s dng trn bnh nhn c th b ln cc ht vt cht bung ra t v cao suca l thuc. Mt quytrnh kim tra chun c khuyn co nh sau: cm ng tim hoc vt cha dung dch truyn n trc ngunsng, nhn thng v o ngcsnphm.Ccbtkhthngdichuynxoyvhnglntrn,cnquan st thm mt vi giy pht hin bt c vt g di chuyn xung di hoc bt c s thay i mu sc no [16]. 1.1.2.Tim tnh mch Tim tnh mch l cch a thuc vo tnh mch vi mt th tch dung dch nhtrongthigianngn(thngthngngnhn5pht).Timtnhmchcth 4 thc hin qua ng tim trn ng dy truyn, ng kim lun trong tnh mch hoc ng tim thng vo tnh mch. Tim tnh mch thng c thc hin trong cc trng hp: bnh nhn cp cu, cn mt nng thuc ln trong thi gian ngn, bnh nhn cn hn ch truyn cht lng hoc vi cc thuc c cc nh sn xut khuyn co tim tnh mch pht huy hiu qu cao nht [16]. Thtchdungdchtimthngl5ml(10ml)hocthn,trmts trng hp thuc kh tan phi dng th tch dung mi ha tan ln, tuy nhin khng qu 25 ml [35]. Tc tim l vn rt quan trng cn lu trong qu trnh thc hin tim tnh mch mt thuc. Tc tim qu nhanh c th dn n sc do nng thuc trong mu tng cao t ngt [16]. Theo cc khuyn co, tim tnh mch thng thc hindi5pht,tuynhinkhngttrnghpcnphitimchmhn,vd: ampicillin + sulbactam cn c tim trong khong t 10-15 pht [33]. 1.1.3.Truyn tnh mch Truyn tnh mch l cch thc a thuc trc tip vo tnh mch vi th tch dung dch ln v thi gian di hn ng tim tnh mch. Dch truyn c th c a vo c th bng cch cm kim truyn trc tip vo tnh mch hoc qua nhnh ch Y. Thuctruyntnhmchcthdngdchtruynphasn,dungdchtim cn pha long hoc thuc bt cn hon nguyn v pha long trc khi truyn. Cc dung mi pha long thng c s dng lNaCl 0,9% hoc glucose 5%, vi cc th tch khc nhau. y l cc dung mi ng trng vi mu v khng gy ra tnh trng tan huyt trong khi truyn. Thuc c s dng c th tng hp vi c 2 loi dung mi trn, mc d tnh tan v thi gian bo qun sau khi pha thuc vi mi loi dung mi l khc nhau [16]. Trong thc hnh lm sng, c hai cch truyn tnhmchph binl truyn tnh mch lin tc v ngt qung.5 Truyntnhmchngtqunglkthuttruynthucvotnhmchtrong thi gian t 20 pht n vi gi vi liu duy nht hoc liu lp li [16]. K thut ny thch hp trong cc trng hp i hi tc a thuc vo c th chm m kh c ththchinbngngtimtnhmch.Thuccavocthbngcch truyn tnh mch ngt qung c th t c nng nh v y cn thit pht huy ti a hiu qu [35]. Th tch ca dch truyn dng pha long thuc l t 50 500ml.Trongthchnhlmsng,thtch100mlthngclachn truyn dch trong vng t 20-30 pht [16]. Truyn tnh mch lin tc l k thut cho php cung cp v duy tr mt nng thucnnhtrongmtthigiandi.Trongmtstrnghp,mtliuln c a vo c th t c nng nh trc khi thuc c truyn lin tc. K thut truyn tnh mch lin tc lm tng hiu qu ca mt s thuc nh lidocain hoc heparin [35]. Nhngvncnlukhithchinthuctruyntnhmchltc truyn thuc, hin tng qu ti dch v nguy c tng k.Trong qu trnh truyn thuc cn phi kim sot tc trnh trng hp thuccavocthqunhanh.Mtsthuckhitruyntnhmchcnc thit b o th tch thuc c truyn vo, v d: lidocain hoc morphin [16]. Khitruyntnhmchngtqungnhiulnhoctruynlintcvikhi lng dch qu ln cn lu n hin tng qu ti dch, do s lng dch qu ln v tc truyn nhanh gy tng t ngt th tch tun hon. Khi c hin tng qu ti dch, bnh nhn c th gp cc du hiu suy tim, tng huyt p, phi c rale, tnh mch c ni v kh th [35]. Ngoira,cncntrngvittcccthucdngcngngtnhmch trong sut thi gian truyn trnh tng k v ch n hin tng thot mch ti v tr truyn [35]. 6 1.2.Sai st trong ch nh v thc hin cc thuc dng ng tnh mch1.2.1.Sai st lin quan n thuc Saistthuccnhnghalbtcskinnocthngnchnc dnndngthucmtcchkhngthchhphocgyhichobnhnhnkhi thuc ang c s dng bi chuyn gia chm sc sc khe, bnh nhn hoc ngi tiu dng [27]. Ti M, ngi ta c tnh rng c 44000 - 98000 ca t vong mi nm lin quan n sai st thuc [9].C nhiu phng php c dng pht hin v kim tra cc sai st thuc. u tin l thng qua ngun d liu hnh chnh, tuy nhin cc thng tin lm sng ngun d liu ny khng nhiu. Th hai l cc bo co s c, ngun thng tin ny ctincycaonhngnhiukhicnmangtnhiphhoctrchnhim.Cui cng, phng php sn c nht l quan st trc tip nhng c th thc hin c phng php ny phi c s ng tnh ca t chc m nghin cu hng n [22].Trong mt chu trnh thc hin thuc c 5 giai on l k n, sao chp n, pha ch, cp pht v thc hin thuc trn bnh nhn th sai st thuc xy ra ph bin nht giai on k n v thc hin thuc. Trong cc sai stthng gp l sai v liu, ng dng, sai thuc c k, sai thi im dng thuc. Nguyn nhn ca sai st thuc ni chung l thiu thng tin, thng tin v thuc c k n khng r rng, thiu thng tin v bnh nhn, hay c tnh vi phm cc quy nh [26]. Timtruyntnhmchniringcnhiunghincunhgilng dng xy ra sai st nhiu nht so vi cc ng dng khc. Mt tng quan h thng vi d liu l cc nghin cu c cng b bng ting Anh t nm 1985 n thng 5/2012 nhm xem xt t l v bn cht ca cc sai st thuc cho thy sai st thuc dngngtnhmchxyramc53,3%sovi20,1%saistthucxyravi cc ng dng khc [19]. Nghin cu ti 1 bnh vin Nhi ca Anh trn c s hi cu cc bo cosai st thuc t 04/1994 n 08/1999 cng cho thysai st thuc xyraphbinnhtiviccthucdngngtnhmch(56%)[27].Mt nghin cu nh gi 73769 sai st c lin quan n s dng thuc ng tnh mch t cc d liu bo co sai st thuc quc gia ca M t nm 2000 n 2005 ch 7 rarng2,92%-5,03%ccsaistlinquannthucdngngtnhmchlc hivtlnyluncaohntlsaistthucchittcccngdng. Nghin cunycngnhn nh chng trnh bo co li t nguyn lmt c hi ci thin chm sc bnh nhn v cn tip tc tm hiu v bn cht cc sai st lin quan n thuc ng tnh mch [18].Cohen lit k cc vn mang tnh h thng lin quan n sai st thuc, l thng tin v thuc v bnh nhn, cch tip nhn v trao i thng tin v vic s dng thuc, quy trnh bo qun, phn phi, dn nhn v ng gi thuc, cc thit bsdngthuc,ccyutthucvmitrnglmvic,giodcchonhn vin y t v bnh nhn, quy trnh m bo cht lng v qun l cc yu t nguy c. y l cc yu t cn c xem xt khi mt sai st lin quan n thuc xy ra nhm tm nguyn nhn ca sai st v ci thin chng [8]. 1.2.2.Sai st trong k nSai st trong k n c nh ngha l s la chn thuc khng ph hp vi cc hng dn, thuc chng ch nh, cc tin s d ng bit, cc thuc hin ang sdngvccyutkhc[21].Mtnhnghakhccasaisttrongknl nhng sai st dn n gim ng k hiu qu v tnh kp thi ca vic iu tr, hoc lm tng nguy c gy hi ca thuc so vi cc hng dn chung [15]. xemxt t l v bn cht ca ccsai sttrong kniu tr ni tr t cc nghin cu cng b, Lewis v cng s tin hnh mt tng quan h thng vo nm 2009. Kt qu cho thy t l sai st trung bnh l 7% (dao ng t 2% n 14%) cc n thuc, c 100 bnh nhn nhp vin th c 52 (dao ng t 8 n 227) liknxyra.Saistxyraphbinnhtvithuckhngsinh.Dngthuc trn bnh nhn l ngi ln xy ra sai st nhiu hn trn tr em v liu lng thuc khng chnh xc l sai st ph bin nht trong nghin cu ny [21]. NghincutimtbnhvinAnhtrongthigian4tunvi36200n thuc c k xc nh c sai st trong k n xy ra mc 1,5% (KTC 95%: 1,4-1,6), trong t l li nghim trng l 0,4% (KTC 95%: 0,3-0,5). Khong mt 8 na sai st thuc (54%)c lin quan n liu. T l sai st c khcbit ng k nhng giai onkhcnhau ca bnh nhn, theo nthuc trong thi gianiu tr ni tr c sai st nhiu hn n thuc nhp hoc xut vin [11].Nhiu sai st lin quan n k n khng c pht hin v bo co nhng cthgynnhuqungktrnlmsng.Nghincutincutinhnh trong 3 thng h nm 2009 ti 3 bnh vin Anh pht hin c 1025 sai st trong 974 trn tng s 6605 n thuc. Khi nh gi mc nh hng trn lm sng ca 183 sai st th kt qucho thy 34 sai st trong s l nghim trng. Cc sai st thucnghimtrngthngllithiuthuc,dngthuckhngngchnh, dng sai liu. ng ch hn, trung bnh 2 liu thuc c thc hin trn mi bnh nhn trc khi cc sai st c sa cha [15]. i vi cc thuc ng tim truyn, vic k n v thc hin thuc phi c s lin kt cht ch vi nhau. n k phi bao gm y cc thng tin cn thit: tn thuc, liu dng, s ln dng, ng dng, loi dung mi dng ha tan, pha longvthtch,nngsaucngcadungdch,tctimtruynngthi phictrnhbyrrngccytcththchinchnhxcylnh.Bcs cngcnhnchvicsdngccthuctimtruyn,chkhikhngcphng phpnokhcchiuqulmsnghnvcnchcchnrngcnhngthitb tim truyn ph hp v tng thch vi loi thuc s k trn bnh nhn [16]. Nghin cu tin hnh nm 1998 v cc sai st trong k n v thc hin thuc dng ng tnhmchniring,ktquchothy14,0%nkkhngphhpviccquy nh chung, 0,6% n k kh c, 4,5% s dng tn thng mi v 11,2% n k c nh gi l khng thch hp v mt lm sng [17]. Cnhiunguynnhngyrasaisttrongknthuc,nhsmttp trung trong lc k n, hoc khng p dng cc quy nh c lin quan. Nhiu yu t nguycnhmitrnglmvic,khilngcngvic,vnthchtvtinh thn,kinthccabcs.Nhiunguynnhnmangtnhhthngnhoto khngy,khngcaotmquantrngcabckn,vkhngtnhn thc c sai st xy ra [12]. c bit i vi cc bc s mi (sau ra trng 1 hoc 9 2 nm), khi lng cng vic v p lc thi gian cng nh thiu kin thc v kinh nghim, thiu ti liu y v cc thuc l nhng yu t nguy c cao i vi sai st trong k n thuc [28]. Ccbinphpnhmlmgimsaisttrongknthucccp trong nhiu nghin cu, trong ng ch l chin lc pht trin gio dc, cp nht thng tin cho cc bc s k n v s dng k n in t trong bnh vin [15]. Ngoi ra, cn trin khai cho cc dc s thc hin duyt n thuc trc khi a ra sdng[11].Trongccbinphpny,dcsviudngngvaitrquan trng trong vic pht hin ra cc sai st trong n thuc. Mt nghin cu thun tp tin cu trong 6 thng trn tt c cc bnh nhn nhp vin ti hai bnh vin i hc Mchothygnmtnaccsaisttrongkncphthin,trong iu dng pht hin c 55 n v dc s pht hin c 8 n c sai st [20]. 1.2.3.Sai st trong thc hin thuc ca iu dng Saisttrongqutrnhthchinthuccaiudnglssailchtrong vic chun b cc thuc so vi n thuc ca bc s, hng dn ca bnh vin hoc nhsnxut[4],[25].Thchinccthuctimtruyntnhmchphithngqua nhiu bc kh phc tp v tim n nhiu nguy c sai st. Rt nhiu nghin cu v quy trnh thc hin thuc tim truyn xem xt cc sai st vng dng, dung mi, tc tim truyn, nguy c tng k trong qu trnh thc hin thuc cng nh nguyn nhn ca vn ny. Nghin cu tin cu ti khoa Chnh hnh, khoa Phu thut v khoa Tiu ha ca mt bnh vin ging dy Tehran (Iran) trn tng s 357 lt chun b v thc hin thuc cho bnh nhn ch ra rng vi mi thuc trong tng s 28 thuc c k n nhiu nht th c t nht 1 sai st xy ra. Cc sai st thng gp l sai tc truyn v tim tnh mch nhanh (20,6%).Trong tt c cc loi thuc c nh gi, metronidazolelthucbdngsaiphbinnht(24,3%),tiptheolranitidin (21,8%), ceftriaxon (18,9%). Nghin cu rt ra mt s nguyn nhn dn n sai st trongthchinthucnhkhilngcngviccacciudng,bunngv 10 mt mi lm mt tp trung, ng thi ra cc gii php tng s lng iu dng ti khoa gim p lc cng vic, c s tham gia ca dc s lm sng trong chun b,thchinthuc,thnhlphthngbocosaistcngnhtiuhavic chun b thuc [4]. Mt nghin cu tin cu quan st cc lt thc hin thuc dng ng tnh mchtrnccbnhnhntimtbnhvinihcMalaysiatrongthigiant 12/2006n03/2007choktqul341trongtngs349ltchunbvthc hin thuc dng ng tnh mch c t nht 1 sai st, trong tim tnh mch nhanh hn tc khuyn co l mt trong nhng sai st ch yu [25]. xc nh t l mc v mc nghim trng v mt lm sng ca cc sai st trong chun b v thc hin thuc ng tnh mch ca iu dng, mt nghin cu tin cu c tin hnh ti 10 bnh vin Anh trong 6-10 ngy ti mi khoa phngphthin249lidngthuc.212trntngs430ltthchinthuc ngtnhmchcxyratnht1saist(49%),trong3saist(1%)c nh gi l nghim trng, 126 sai st (29%) mc va phi v 83 (19%) sai st nh. Hu ht cc sai st xy ra trong tim tnh mch v vi cc thuc cn chun b nhiu bc [32].Nhm xc nh nguyn nhn v cc yu t nh hng n sai st trong thc hinthuccaiudng,mtnghincunhtnhtinhnhtiiLoanda vo bng cu hi gm 3 phn: m t sai st, kin thc ca iu dng v cc yu t gpphnvosaistthucctinhnhtrncciudng.Cciudng tham gia nghin cu s nhc li mt trong nhng sai st thuc quan trng nht m h tng mc phi v xc nh cc yu t nh hng ti sai st thuc t bng cu hi trn. Trong 72 iu dng tham gia, 55 ngi (76,4%) tin rng c hn 1 yu t gp phnvoccsaisttrongthchinthuc.Trong,3yutchnhl:xaolng trch nhim c nhn (86,1%), khi lng cng vic nng nhc (37,5%), nhn vin mi (37,5%) v 3 iu kin hng u dn n sai st trong thc hin thuc l: cn phi gii quyt cng vic khc trong lc thc hin thuc, chun b thuc m khng kimtrali,iudngmittnghip.Ccsaistphbinnhtlsailiu 11 (36,1%)vsaithuc(26,4%),khngsinhlloithucbdngsainhiunht (38,9%) [30]. gim thiu cc sai st xy ra trong qu trnh chun b v thc hin thuc dngngtim,iudngckhuyncothchinmtsnhimvsau. Trcht,phikimtratnhtrngdngcabnhnhnvmboy thngtincthsdngthucanton.Ngoira,cnxemxtsphhpca thit b tim truyn vi bnh nhn loi thuc ang s dng. Mt bc ht sc quan trngtrongqutrnhthchinldnnhnthucchnhxcchotngbnhnhn. Cui cng, iu dng cn theo di bnh nhn v nhn thc c cc phn ng ph c th xy ra trong sut qu trnh thc hin thuc [16]. 1.2.4.Nghin cu v sai st thuc ti Vit Nam TiVitNam,nghincuvsaistthucllnhvccnkhmimv cha ph bin. Cc nghin cu ch yu tin hnh ti mt s bnh vin ring l, s lng cc nghin cu c cng b trn cc tp ch cn t. Chng ti xin c gii thiu 2 nghin cu sau. Nghincutincunhmxcnhtl,loivmcnghimtrngca cc sai st trong chun b v thc hin thuc ti 2 bnh vin Vit Nam. 4 sinh vin dc quan st cc bc chun b v thc hin thuc ca iu dng ti 6 khoa trong 7ngylintip.Ktquchothytlsaistthucl37,7%trongtngs5635 lt quan st. Sai st ch yu gp phi k thut chun b v thc hin, thiu thuc v liu. Cc sai st ny c phn loi theo mc nghim trng: cao (8,8%), trung bnh(87,8%)vnh(3,4%).Cngtheonghincuny,khongbaphntlt dng thuc ng tnh mch c xy ra sai st [24]. Nghincutinhnhtikhoahisctchcc(ICU)vkhoahuphu (PSU) mt bnh vin Vit Nam theo di vic thc hin cc thuc dng ng tnhmchcayttrcvsaukhicscanthipcadcslmsng.Scan thip bao gm: cc bi ging, cc bui hng dn da trn thc t ti khoa, cc ti liu, cng c thc hin bi mt dc s lm sng v mt y t. Kt qu quan 12 st trn 1204 lt thc hin thuc ng tnh mch, bao gm 516 lt trc khi c hng dn v 688 sau khi c hng dn. T l sai st trn lm sng gim ng k tikhoaICU(t64%xung48,9%,p=30 pht [3] 3 CiprofloxacinDch truyn pha sn 200mg/100ml Truyn tnh mch [3] **** >=60 pht [5] Dung mi: NaCl 0.9%, Glu 5%, NaCl- Glu, Ringer lactateQua nhnh ch Y: digoxin, metronidazol [3] ampicillin, amoxicillin, ceftazidim,furosemid,methyprednisolon [3] 4 Ciprofloxacin Dung dch 200mg/20ml Truyn tnh mch ** NaCl 0.9%,Glu 5% n nng = 60 pht [5] Dung mi: NaCl 0.9%, Glu 5%, NaCl- Glu, Ringer lactateQua nhnh ch Y: digoxin, metronidazol [3] ampicillin, amoxicillin, ceftazidim,furosemid,methyprednisolon [3] 5 Diazepam Dung dch 10mg/2ml Tim tnh mch [3] **** 3 pht (tr em) [2] Dung mi:NaCl 0.9%,Glu 5% [3] KCl, furosemid [3] Truyn tnh mch lin tc [3] ** NaCl 0.9%,Glu 5% [3] >= 200 ml [3] Truyn qua thit b c o th tch [3] 6 Pethidin HCl Dung dch 100mg/2ml Tim tnh mch [3] ** NCPT, NaCl 0.9%,Glu 5% [3] nnng 10mg/ml [3] 2-3 pht [3] Dung mi: NaCl 0.9%, Glu 5%, NaCl- Glu, Ringer lactate.Qua nhnh ch Y: ampicillin, cefotaxim, ceftrazidim, ceftriaxon, digoxin, gentamicin, methylprednisolon, metronidazol, vancomycin [3] natri bicarbonat, furosemid, heparin, imipenem v cilastatin [3] 7 EsomeprazolBt pha tim 40mg Tim tnh mch [3] NaCl 0.9%[3] 5 ml [3] **>=3 pht [3] Dung mi: NaCl 0.9%, Glucose 5%[3] _ Truyn tnh mch [3] NaCl 0.9% [3] 5 ml [3] NaCl 0.9%[3] Ngt qung:50-100 ml Lin tc: 80-100ml [3] Ngt qung: 10-30 pht (liu 80mg phi truyn n 30 pht) Lin tc: 10 gi (khong 8mg/gi) [3] 8 Cefoperazon vSulbactam Bt pha tim cefoperazon 500mg, Sulbactam 500mg Tim tnh mch [5] NCPT [5] Va ha tan Glu 5%,NaCl 0.9%, NCPT [5] 20 ml [5] >= 3 pht [5] Dung mi: Glu 5%, NaCl 0,9% aminoglycosid [5] Truyn tnh mch[5] NCPT [5] Va ha tan Glu 5%,NaCl 0.9%, NCPT [5] 20 ml [5] 15-60 pht [5] 9 Furosemid Dung dch 20mg/2ml Tim tnh mch(liu 50mg) [3] ** NaCl 0.9%, Ringer lactate [5] 250 ml cho liu 240mg [5] = 60 pht,(>=90 pht vi liu 750mg) [2] Dung mi:NaCl 0.9%,Glu 5%, NaCl- Glu.Qua nhnh ch Y: vancomycin [3] furosemid, insulin, heparin [3] 11 ParacetamolDch truyn pha sn 1g/100ml Truyn tnh mch [3] **** >=15 pht [3] Dung mi:NaCl 0.9%,Glu 5% [3] _ 12 L- ornithin L- aspartat Tim tnh mch [5] ****Chm [5] __ Truyn tnh mch [5] ** Dung mithng thng [5] = 250mg) [3] Dung mi km theo NaCl 0.9%, Glu 5%, NaCl- Glu [3] Thng dng 100-250 mlNaCl 0.9% [3] >=30 pht [3] 19 CeftazidimBt pha tim 1g Tim tnh mch [3] NCPT [3] 10ml [3] **3-5 pht [3] Dung mi: NaCl 0.9%, Glu 5%, NaCl- Glu, Ringer lactate Qua nhnh ch Y: furosemid, metronidazol [3] gentamycin,vancomycin, natri bicarbonat [3] Truyn tnh mch [2] NaCl 0.9%Glu 5% [2] 10ml [2] NaCl 0.9%, Glu 5% [2] n10mg/ml [2] 15-30 pht [2] 20 Ofloxacindch truyn pha sn200mg/100ml Truyn tnh mch [3] **** >= 30 pht [3] Dung mi: NaCl 0.9%, Glu 5%, NaCl- Glu. [3] heparin [3] 21 Albumin dung dch 20%Truyn tnh mch ** NaCl 0.9%, Glu 5%, Ringer lactate [2] * 15- 30 pht [5] Dung mi: NaCl 0.9%, Glu 5% _ 22 PiracetamDung dch 1g/5ml Tim tnh mch *****__ 23 Acid tranexamic Dung dch 250mg/5ml Tim tnh mch [5] **** 1ml/ pht [5] NaCl 0.9%, Glu 5%penicillin 24 Cc acid aminhng gan Truyn tnh mch [5] ****