BỘ Y TẾ Số: 1904 /QĐ-BYT Độc lập - Tự do - Hạnh phúc Hà Nội

B Y T

S: 1904 /Q-BYT

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

H Ni, ngy 30 thng 5 nm 2014

QUYT NH

V vic ban hnh ti liu Hng dn quy trnh k thut

chuyn ngnh Hi sc- Cp cu v Chng c

B TRNG B Y T

Cn c Lut khm bnh, cha bnh nm 2009;

Cn c Ngh nh s 63/2012/N-CP ngy 31/8/2012 ca Chnh Ph quy

nh chc nng, nhim v, quyn hn v c cu t chc ca B Y t;

Xt Bin bn hp ca Hi ng nghim thu Hng dn Quy trnh k thut

khm bnh, cha bnh chuyn ngnh Hi sc, cp cu v chng c ca B Y

t;

Theo ngh ca Cc trng Cc Qun l Khm, cha bnh,

QUYT NH:

iu 1. Ban hnh km theo Quyt nh ny ti liu Hng dn quy trnh

k thut chuyn ngnh Hi sc, cp cu v chng c, gm 232 quy trnh k

thut.

iu 2. Ti liu Hng dn quy trnh k thut chuyn ngnh Hi sc, cp

cu v chng c ban hnh km theo Quyt nh ny c p dng ti cc c

s khm bnh, cha bnh.

Cn c vo ti liu hng dn ny v iu kin c th ca n v, Gim

c c s khm bnh, cha bnh xy dng v ban hnh ti liu Hng dn quy

trnh k thut chuyn ngnh Hi sc, cp cu v chng c ph hp thc

hin ti n v.

iu 3. Quyt nh ny c hiu lc k t ngy k ban hnh.

iu 4. Cc ng, b: Chnh Vn phng B, Cc trng Cc Qun l

Khm, cha bnh, Chnh Thanh tra B, Cc trng v V trng cc Cc, V

thuc B Y t, Gim c cc bnh vin, vin c ging bnh trc thuc B Y t,

Gim c S Y t cc tnh, thnh ph trc thuc trung ng, Th trng Y t

cc B, Ngnh v Th trng cc n v c lin quan chu trch nhim thi hnh

Quyt nh ny./.

Ni nhn: - Nh iu 4;

- B trng B Y t ( b/c);

- Cc Th trng BYT;

- Bo him X hi Vit Nam ( phi hp);

- Cng thng tin in t BYT;

- Website Cc KCB;

- Lu VT, KCB.

KT. B TRNG

TH TRNG

k

Nguyn Th Xuyn

DANH MC T VIT TT

ALT Alanine transaminase

ALTMTT p lc tnh mch trung tm (Central venous pressure- CVP)

ALTT p lc thm thu

ARDS Hi chng suy h hp cp tin trin (Acute respiratory distress

syndrome-ARDS)

AST Aspartate transaminase

NGI BNHP Yu t thi natri no-niu (Brain natriuretic peptide-

NGI BNHP)

BPTNMT Bnh phi tc nghn mn tnh

(Chronic Pulmonary Ostructive Disease-COPD)

CPAP p lc ng th dng lin tc (Continuous positive airway pressure)

CT scan Chp ct lp vi tnh (Computed Tomography scanner)

CVVH Lc mu tnh mc-tnh mch lin tc (Continuous Veno-Venous

Hemofiltration)

DIC ng mu ri rc trong lng mch (Disseminated Intravascular

Coagulation- DIC)

EPAP p lc dng th th ra (Exspiratory positive airway pressure)

FiO2 Nng xy kh th vo (Fraction of inspired oxygen)

GGT Gamma-glutamyl Transferase

HA Huyt p

HATB Huyt p trung bnh

HATT Huyt p tm thu

HATTr Huyt p tm trng

HPQ Hen ph qun

IPAP p lc dng th th vo (Inspiratory positive airway pressure)

LDH Lactic acid dehydrogenase

MRI Chp cng hng t ht nhn (Magnetic Resonance Imaging)

PaCO2 p lc ring phn CO2 trong mu ng mch

(Partial pressure of carbon dioxide in arterial blood)

PaO2 p lc ring phn oxy trong mu ng mch (Partial pressure of

arterial oxygen)

PEEP p lc dng cui th th ra (Positive end exspiratory pressure)

Pro NGI BNHP N-terminal pro B-type natriuretic peptide

SaO2 bo ho xy mu ng mch (Saturation of arterial oxygen)

SpO2 bo ho xy mu ngoi vi (Saturation of Peripheral Oxygen)

VTC Vim tu cp

MC LC

CHNG 1: QUY TRNH K THUT TRONG CP CU HI SC

BNH L H HP ............................................................................. 1

Quy trnh k thut chc ht dch mng phi cp cu ............................................. 2

Quy trnh k thut dn lu kh mng phi cp cu ................................................ 4

Quy trnh k thut dn lu mng phi .................................................................... 6

Quy trnh k thut t ng ni kh qun ng ming bng n trachlight ........... 9

Quy trnh k thutchc ht kh mng phi cp cu .............................................. 14

Quy trnh k thut t ni kh qun ...................................................................... 17

Quy trnh k thut khai thng ng th .............................................................. 22

Quy trnh k thut ly mu xt nghim kh mu qua catheter ng mch ........... 26

Quy trnh k thut ni soi kh ph qun cp cu .................................................. 28

Quy trnh k thut thi ngt .................................................................................. 33

Quy trnh k thut m kh qun cp cu ............................................................... 35

Quy trnh k thut m mng phi cp cu ........................................................... 39

Quy trnh k thut t ni kh qun kh trong cp cu ........................................ 42

Quy trnh k thut iu tr tiu si huyt alteplase trong tc ng mch phi cp ..... 45

Quy trnh k thut ni soi ph qun ly nt m .................................................. 49

Quy trnh k thut thay ng ni kh qun ............................................................. 52

Quy trnh k thut th oxy lu lng cao qua mt n venturi .............................. 56

Quy trnh k thut th oxy qua gng knh ............................................................ 58

Quy trnh k thut th oxy qua mt n c ti ....................................................... 60

Quy trnh k thut th oxy qua t-tube ni kh qun .............................................. 62

Quy trnh k thut rt canuyn m kh qun .......................................................... 65

Quy trnh k thut rt ni kh qun ....................................................................... 67

Quy trnh k thut chm sc ng ni kh qun ..................................................... 70

Quy trnh k thut chm sc canuyn m kh qun ............................................... 72

Quy trnh k thut t canuyn mayo ..................................................................... 75

Quy trnh k thut ht m ng h hp di bng h thng ht kn .............. 77

Quy trnh k thut v rung lng ngc Ngi bnh hi sc cp cu v chng c . 80

Quy trnh k thut thng kh khng xm nhp vi hai mc p lc dng

(BIPAP) ................................................................................................................ 83

Quy trnh k thut thng kh khng xm nhp vi p lc dng lin tc (CPAP) .... 86

Quy trnh k thut thng kh nhn to xm nhp phng thc iu khin th tch (VCV) .. 89

Quy trnh k thut thng kh nhn to xm nhp phng thc iu khin p lc (PCV) . 92

Quy trnh k thut thng kh nhn to xm nhp phng thc h tr p lc (PSV) .... 95

Quy trnh k thut thng kh nhn to xm nhp p lc dng lin tc (CPAP) ........ 98

Quy trnh k thut thng kh nhn to xm nhp phng thc x p (APRV) ...... 102

Quy trnh k thut t ng thng o in th c honh trong phng thc th my

xm nhp h tr iu khin bng tn hiu thn kinh .......................................... 105

Quy trnh k thut thng kh nhn to xm nhp phng thc thng kh h tr iu

khin bngtn hiu thn kinh (neurally adjusted ventilatory assist-nava) .............. 110

Quy trnh k thut thng kh nhn to xm nhp phng thc th tn s cao (HFO) . 115

Quy trnh k thut huy ng ph nang bng phng thc CPAP 40 cmH2O trong

40 giy ................................................................................................................ 119

Quy trnh k thut huy ng ph nang bng phng thc cpap 60 cmH2O trong

40 giy ................................................................................................................ 122

Quy trnh k thut huy ng ph nang bng thng kh kim sot p lc (PCV) ..... 125

Quy trnh k thut thng kh nhn to xm nhp phng thc h tr/iu khin

th tch ................................................................................................................ 129

Quy trnh k thut thng kh nhn to trong hi chng suy h hp cp tin trin (ARDS) 133

Quy trnh k thut cai th my ........................................................................... 136

Quy trnh k thut cai th my bng th ng ch t ngt qung ......................... 140

Quy trnh k thut cai th my bng phng thc th kim sot ngt qung ng

th (SIMV) .......................................................................................................... 144

Quy trnh k thut cai th my bng phng thc h tr p lc (PSV) ........... 148

Quy trnh k thut th nghim t th CPAP ...................................................... 152

Quy trnh k thut t th bng ng ch t ........................................................... 156

Quy trnh k thut ni soi ph qun cp cu Ngi bnh th my ............... 159

Quy trnh k thut ni soi ra ph qun cp cu ly bnh phm xt nghim

Ngi bnh th my ........................................................................................... 162

Quy trnh k thut ni soi ph qun cp cu iu tr xp phi Ngi bnh th my

............................................................................................................................. 165

Quy trnh k thut ni soi ph qun cm mu cp cu ....................................... 168

Quy trnh k thut ni soi ph qun cp cu, sinh thit xuyn thnh Ngi bnh

th my ................................................................................................................ 171

Quy trnh k thut m kh qun c chun b cho Ngi bnh nng trong hi sc

tch cc ................................................................................................................ 174

Quy trnh k thut m kh qun mt th theo phng php ciaglia cho Ngi

bnh nng trong hi sc cp cu ........................................................................ 179

Quy trnh k thut thay canul m kh qun c nng trong cho Ngi bnh nng

trong hi sc cp cu chng c ..................................................................... 186

Quy trnh k thut thay canul m kh qun c ca s cho Ngi bnh nng trong

hi sc cp cu chng c ............................................................................... 190

Quy trnh k thut bm ra mng phi ti cc khoa hi sc cp cu ................ 194

Quy trnh k thut chm sc Ngi bnh th my ............................................. 197

Quy trnh k thut o p lc ca bng chn Ngi bnh t ng ni kh qun

hoc m kh qun ................................................................................................ 203

Quy trnh k thut kh dung cho Ngi bnh th my ....................................... 205

Quy trnh k thut ly bnh phm dch ph qun xt nghim ca Ngi bnh cm

khoa hi sc cp cu ........................................................................................ 207

Quy trnh k thut ly mu xt nghim Ngi bnh cm khoa hi sc - cp

cu v chng c................................................................................................. 210

Quy trnh k thut v sinh v kh khun my th .............................................. 213

Quy trnh k thut rt ng ni kh qun .............................................................. 216

Quy trnh k thut ly bnh phm dch ph qun qua ng ni kh qun, m kh

qun bng ng ht thng xt nghim Ngi bnh th my ..................... 219

Quy trnh k thut ly bnh phm dch ph qun qua ng ht m c u bo v

xt nghim Ngi bnh th my ................................................................ 222

Quy trnh k thut m kh qun cp cu ............................................................. 225

Quy trnh k thut thng kh nhn to nm sp trong hi chng suy h hp cp

tin trin (ARDS) ................................................................................................ 230

Quy trnh k thut lc mu lin tc cvvh trong hi chng suy h hp tin trin

(ARDS) ............................................................................................................... 233

Quy trnh k thut ht m cho Ngi bnh c t ni kh qun, m kh qun .. 237

Quy trnh k thut ht m cho Ngi bnh c t ng ni kh qun v m kh

qun bng ng ht m kn ............................................................................... 241

CHNG 2: QUY TRNH K THUT TRONG CP CU HI SC BNH

L TUN HON ............................................................................ 245

Quy trnh k thut t catheter tnh mch trung tm mt nng di hng dn

ca siu m ......................................................................................................... 246

Quy trnh k thut t catheter tnh mch trung tm bng catheter hai nng di

siu m ................................................................................................................ 251

Quy trnh k thut t catheter tnh mch trung tm bng catheter ba nng di

siu m ................................................................................................................ 257

Quy trnh k thut rt catheter tnh mch trung tm .......................................... 262

Quy trnh k thut o p lc tnh mch trung tm bng ct nc (thc o p lc) .. 264

Quy trnh k thut p tim ngoi lng ngc ......................................................... 257

Quy trnh k thut o cung lng tim PICCO ................................................... 271

Quy trnh k thut t catheter ngoi vi ............................................................. 274

Quy trnh k thut s dng thuc tiu si huyt trong iu tr nhi mu c tim cp .. 276

Quy trnh k thut chm sc catheter tnh mch trung tm ................................ 280

Quy trnh k thut kch thch tim tm thi vi in cc ngoi lng ngc ......... 282

Quy trnh k thut chc dch mu mng tim trong hi sc cp cu ............. 286

Quy trnh k thut siu m tim cp cu ti ging ngi bnh hi sc ......... 290

Quy trnh k thut siu doppler mch Ngi bnh hi sc cp cu ............... 301

Quy trnh k thut siu m nh gi tin gnh ti ging Ngi bnh sc trong

hi sc cp cu ................................................................................................... 306

Quy trnh k thut o huyt ng bng my uscom (ultrasound cardiac output monitor) 313

Quy trnh k thut t catheter ng mch phi ................................................ 317

Quy trnh k thut o p lc bung tim, p lc ng mch phi bng catheter

swan- ganz .......................................................................................................... 323

Quy trnh k thut o cung lng tim bng catheter ng mch phi ............... 328

Quy trnh k thut trao i oxy qua mng trong h tr h hp ti ging (phi

nhn to) .............................................................................................................. 332

Quy trnh k thut tim phi nhn to trong h tr tim ti ging ...................... 336

Quy trnh k thut t catheter tnh mch trung tm di hng dn siu m ......... 340

Quy trnh k thut chm sc catheter ng mch Ngi bnh hi sc cp cu ..... 344

Quy trnh k thut chm sc catheter swan ganz Ngi bnh hi sc cp cu 347

Quy trnh k thut o v theo di lin tc p lc tnh mch trung tm qua cng o

p lc trn my theo di ...................................................................................... 350

Quy trnh k thut chc ht dch mng tim di hng dn ca siu m .......... 354

Quy trnh k thut t catheter ng mch ......................................................... 358

Quy trnh k thut iu tr thuc tiu si huyt ng tnh mch trong nhi mu

no cp................................................................................................................. 362

Quy trnh k thut ghi in tim ti ging ......................................................... 366

Quy trnh k thut hi sinh tim phi nng cao .................................................... 369

Quy trnh k thut cp cu ngng tun hon c bn .......................................... 371

Quy trnh k thut sc in ngoi lng ngc ...................................................... 374

Quy trnh k thut to nhp tm thi ngoi da .................................................... 377

CHNG 3: QUY TRNH K THUT TRONG CP CU HI SC BNH

L THN TIT NIU V LC MU ......................................... 380

Quy trnh k thut thay huyt tng bng huyt tng ng lnh ..................... 381

Quy trnh k thut thay huyt tng bng albumin ............................................ 388

Quy trnh k thut thay huyt tng bng gelatin hoc dung dch cao phn t ...... 394

Quy trnh k thut t catheter tnh mch i lc mu cp cu .................... 401

Quy trnh k thut thay huyt tng trong iu tr t cp lupus ban h thng

vi dch thay th albumin 5% ............................................................................. 403


vi dch thay th albumin 5% kt hp vi hydroxyetyl starch (hes) .................. 408


vi dch thay th huyt tng ti ng lnh ..................................................... 413

Quy trnh k thut k thut lc mu lin tc qua ng tnh mch - tnh mch

(CVVH) ............................................................................................................... 418

Quy trnh k thut lc mu kt hp thm tch lin tc ........................................... 422

Quy trnh k thut siu lc mu chm lin tc ................................................... 426

Quy trnh k thut lc mu lin tc trong hi chng tiu c vn cp ................ 430

Quy trnh k thut lc mu thm tch lin tc trong hi chng tiu c vn cp ..... 435

Quy trnh k thut chm sc catheter tnh mch i Ngi bnh iu tr tch

cc v chng c ................................................................................................ 439

Quy trnh k thut t catheter trn khp v ti khoa hi sc cp cu .............. 441

Quy trnh k thut t ng thng bng quang dn lu nc tiu ...................... 444

Quy trnh k thut ly nc tiu lm xt nghim Ngi bnh c ng thng tiu ... 449

Quy trnh k thut chm sc catheter thn nhn to Ngi bnh hi sc cp cu 451

Quy trnh k thut ra bng quang Ngi bnh hi sc cp cu v chng c .. 455

Quy trnh k thut lc mu cp cu Ngi bnh c m thng ng tnh mch (FAV)

............................................................................................................................ 458


BNH L THN KINH ................................................................. 461

Quy trnh k thut lc huyt tng vi hai qu lc ............................................ 462

Quy trnh k thut thay huyt tng trong iu tr hi chng guillain-barre..... 468

Quy trnh k thut thay huyt tng trong iu tr hi chng guillain-barre vi

dch thay th albumin5% .................................................................................... 473


dch thay th albumin 5% kt hp vi dung dch cao phn t .......................... 478


dch thay th huyt tng ti ng lnh ........................................................... 483

Quy trnh k thut thay huyt tng trong iu tr cn nhc c ...................... 488

Quy trnh k thut thay huyt tng trong iu tr cn nhc c vi dch thay th

albumin 5% ......................................................................................................... 493


albumin 5% kt hp vi dung dch cao phn t ................................................. 498


huyt tng ti ng lnh ................................................................................ 503

Quy trnh k thut tiu si huyt no tht trong iu tr xut huyt no chy mu

no tht ................................................................................................................ 508

Quy trnh k thut chm sc mt Ngi bnh hn m (mt ln) .................... 513

Quy trnh k thut iu tr an thn gin c < 8 gi trong hi sc cp cu v chng

c ....................................................................................................................... 515

Quy trnh k thut dn lu no tht ra ngoi ...................................................... 519

Quy trnh k thut iu tr thuc tiu si huyt ng tnh mch trong nhi mu

no cp................................................................................................................. 521


BNH L HUYT HC ................................................................. 525

Quy trnh k thut thay huyt tng trong iu tr ban xut huyt gim tiu cu

huyt khi (TTP) vi dch thay th huyt tng ti ng lnh ........................ 526


BNH L TIU HA ..................................................................... 532

Quy trnh k thut t ng thng d dy ............................................................. 533

Quy trnh k thut thay huyt tng bng plasma ti ng lnh trong iu tr

suy gan cp .......................................................................................................... 537

Quy trnh k thut gan nhn to trong iu tr suy gan cp ............................... 544

Quy trnh k thut lc mu lin tc trong iu tr suy a tng ........................... 550

Quy trnh k thut lc mu thm tch lin tc (CVVHDF) trong vim ty cp ....... 554

Quy trnh ni soi thc qun d dy t trng cm mu cp cu ti n v hi

sc cp cu v chng c ................................................................................... 558

Quy trnh k thut ni soi d dy t trng iu tr chy mu do lot bng tim

x ti n v hi sc tch cc .............................................................................. 562

Quy trnh k thut ni soi tiu ha cm mu cp cu bng vng cao su ti n v

hi sc tch cc ................................................................................................... 566

Quy trnh k thut ni soi thc qun d dy - t trng cm mu bng kp clip

n v hi sc cp cu v chng c .................................................................. 570

Quy trnh k thut ni soi thc qun d dy t trng gy m ti n v hi sc

tch cc ................................................................................................................ 574

Quy trnh k thut siu m bng cp cu ........................................................ 578

Quy trnh k thut chc ht dn lu dch bng di hng dn ca siu m

trong iu tr vim ty cp .................................................................................. 583

Quy trnh k thut chc dch tho bng di hng dn siu m trong khoa hi

sc cp cu .......................................................................................................... 587

Quy trnh k thut o p lc bng gin tip qua bng quang ........................ 591

Quy trnh k thut cho n qua ng thng d dy (c kim tra th tch dch tn d) ... 593

Quy trnh k thut nui dng lin tc qua ng thng hng trng ................... 596

Quy trnh k thut t ng thng d dy Ngi bnh hi sc cp cu ........... 599

Quy trnh k thut t ng thng hu mn Ngi bnh hi sc cp cu v chng c 602

Quy trnh k thut tht tho cho Ngi bnh khoa hi sc cp cu v chng c 603

Quy trnh k thut thay huyt tng trong iu tr vim ty cp do tng triglyceride 607

Quy trnh k thut t ng thng blakemore ...................................................... 611

Quy trnh k thut o v theo di lin tc p lc bng gin tip qua bng quang 605


BNH L TRUYN NHIM ........................................................ 618

Quy trnh k thut lc mu hp ph bilirubin trong iu tr suy gan cp .......... 619

Quy trnh k thut lc mu hp ph bilirubin trong iu tr suy gan cp .......... 623

Quy trnh k thut lc mu hp ph cytokine vi qu lc pmx (polymicin b) ...... 627

Quy trnh lc mu lin tc trong vim ty cp nng .......................................... 631

CHNG 8: QUY TRNH K THUT TRONG CHN ON V IU

TR NG C ................................................................................ 635

Quy trnh k thut lc mu thm tch lin tc (cvvhdf) trong suy a tng ...... ..636

Quy trnh k thut soi ph qun iu tr sc phi Ngi bnh ng c cp ... 640

Quy trnh k thut cp cu ngng tun hon cho Ngi bnh ng c............. 643

Quy trnh k thut kim ha nc tiu tng thi tr cht c (mi 8 gi)......... 647

Quy trnh k thut lc hp ph mu qua ct resin trong iu tr ng c cp (mt

cuc lc) .............................................................................................................. 651

Quy trnh k thut lc hp ph mu qua ct than hot trong ng c cp (mt

cuc lc) .............................................................................................................. 658

Quy trnh k thut iu tr co git trong ng c ............................................... 666

Quy trnh k thut gy nn cho Ngi bnh ng c qua ng tiu ha ........ 670

Quy trnh k thut ra d dy loi b cht c qua h thng kn ...................... 672

Quy trnh k thut ra rut ton b loi b cht c qua ng tiu ha (WBI) ..... 676

Quy trnh k thut iu tr gim nng canxi mu .......................................... 679

Quy trnh k thut iu tr tng kali mu ........................................................... 682

Quy trnh k thut iu tr gim kali mu .......................................................... 685

Quy trnh k thut iu tr gim kali mu ........................................................... 688

Quy trnh k thut iu tr tng natri mu ........................................................... 691

Quy trnh k thut iu tr gim natri mu ......................................................... 695

Quy trnh k thut s dng than hot a liu trong cp cu ng c qua ng

tiu ha ................................................................................................................ 699

Quy trnh k thut iu tr thi c bng phng php tng cng bi niu ..... 703

(bi niu tch cc) ................................................................................................ 703

Quy trnh k thut gii c ng c ru ethanol .............................................. 707

Quy trnh k thut iu tr thi c ch ............................................................... 711

Quy trnh k thut iu tr ng c cp ma ty nhm opi ................................. 716

Quy trnh k thut t vn cho Ngi bnh ng c ........................................... 719

Quy trnh k thut ra mt ty c ..................................................................... 722

Quy trnh k thut v sinh rng ming c bit Ngi bnh ng c, hn m

th my (mt ln) ................................................................................................ 725

Quy trnh k thut x trmu xt nghim c cht ............................................. 727

Quy trnh k thut nh tnh mt ch tiu c cht bng sc k lp mng ......... 730

Quy trnh k thut xt nghim nh tnh mt ch tiu ma ty trong nc tiu ....... 733

Quy trnh k thut xt nghim sng lc v nh tnh 5 loi ma ty .................... 736

Quy trnh k thut nh tnh pbg trong nc tiu ............................................... 739

Quy trnh k thut xt nghim nh tnh porphyrin trong nc tiu .................. 741

Quy trnh k thut nh lng cp nh3 trong mu .............................................. 743

Quy trnh k thut o p lc thm thu dch sinh hc (mt ch tiu) ................. 745

Quy trnh k thut nh tnh mt ch tiu c cht bng my sc k lng khi ph ... 748

Quy trnh k thut nh lng mt ch tiu thuc trong mu bng my sc k

lng khi ph ....................................................................................................... 752

Quy trnh k thut nh lng mt ch tiu kim loi nng trong mu bng my quang

ph hp ph nguyn t ......................................................................................... 756

Quy trnh k thut xc nh thnh phn ho cht bo v thc vt trong dch sinh hc

bng sc k kh khi ph ...................................................................................... 760

Quy trnh k thut nh tnh c cht bng sc k kh khi ph ........................ 764

Quy trnh k thut nh lng mt ch tiu bng sc k kh khi ph ............... 768

Quy trnh k thut nh lng methanol bng my sc k kh khi ph ............ 772

Quy trnh k thut nh lng ethanol bng my sc k kh khi ph .............. 776

Quy trnh k thut xt nghim nh lng mt ch tiu thuc bng my sinh ho

min dch ............................................................................................................ 780

Quy trnh k thut s dng thuc gii c trong ng c cp (cha k tin thuc) 783

Quy trnh k thut s dng huyt thanh khng nc rn ..................................... 787

Quy trnh k thut gii c ng c ru methanol v ethylene glycol ............ 792

Quy trnh k thut bng p bt ng s cu rn c cn ................................... 798

Quy trnh k thut iu tr gim nng natri mu Ngi bnh b rn cp nia cn.

............................................................................................................................ 801

CHNG 9: QUY TRNH K THUT CP CU CHN THNG ....... 805

Quy trnh k thut cm mu vt thng chy mu ............................................ 806

CHNG 10: QUY TRNH K THUT CHM SC NGI BNH ...... 814

Quy trnh k thut vn chuyn Ngi bnh cp cu .......................................... 815

Quy trnh k thut gi u ty c cho Ngi bnh nng ng c cp ti ging .. 823

Quy trnh k thut tm ty c cho Ngi bnh nng nhim c ha cht ngoi

da ti ging ....................................................................................................... 826

Quy trnh k thut xoa bp phng chng lot (mt ngy) ................................. 829

Quy trnh k thut thay bng rn cn hoi t rng, bng rng .......................... 832

Quy trnh k thut bc dn lu nc tiu ........................................................... 834

Quy trnh k thut thay bng rn cn hoi t ..................................................... 836

Quy trnh cn Ngi bnh nng ti ging ........................................................ 838

Quy trnh k thut chm sc mt cho Ngi bnh nhc c ............................. 840

Quy trnh k thut tm ti ging cho Ngi bnh hi sc cp cu v chng c ..... 842

Quy trnh k thut chm sc rng ming c bit .............................................. 846

Quy trnh k thut chm sc ng dn lu Ngi bnh hi sc cp cu v chng c

............................................................................................................................ 849

Quy trnh k thut gi u Ngi bnh hi sc cp cu v chng c .......... 852

Quy trnh k thut th ng mu mao mch .................................................... 855

Quy trnh k thut d phng lot Ngi bnh hi sc cp cu v chng c ..... 857

Quy trnh k thut chm sc vt lot Ngi bnh hi sc cp cu v chng c . 860

Quy trnh k thut thay bng vt m Ngi bnh hi sc cp cu v chng c . 865

Quy trnh k thut truyn thuc bng bm tim in ........................................ 868

Quy trnh k thut truyn dch bng my truyn dch ....................................... 872

Quy trnh vn chuyn Ngi bnh i lm cc th thut can thip v chp chiu

Ngi bnh hi sc ............................................................................................. 875

1

CHNG 1: QUY TRNH K THUT

TRONG CP CU HI SC

BNH L H HP

2

QUY TRNH K THUT CHC HT DCH MNG PHI CP CU

I. I CNG

Chc ht dch mng phi nhm mc ch ht dch, mu, m, kh c nhiu trong

khoang mng phi gy suy h hp cp nhm hn ch nguyn nhn gy t vong.

II. CC CH NH CHNH

1. TKMP trn mt tn thng phi: gin ph nang, x phi, lao phi, t cu phi,...

2. Trn mu mng phi.

3. Trn m mng phi.

4. Trn dch hoc trn mu mng phi ti pht nhanh (nhm gy dnh).

III. CHUN B TRC DN LU

1. Ngi bnh

- XQ phi mi( cng ngy chc ).

- MC - M.

- Gii thch cho ngi bnh v ng vin ngi bnh hp tc vi ngi thc

hin.

- Tim atropin 0,5mg.

- Tim an thn nu ngi bnh lo lng hoc c nguy c dy da nhiu.

- T th ngi bnh: c t th nm v ngi.

+ Nm: ngi bnh nm nga, thng ngi, u cao, thn ngi nghing v

pha phi lnh, tay pha bn t dn lu gi cao ln pha u.

+ Ngi: ngi bnh ngi trn gh ta, mt quay v pha vai gh, 2 tay khoanh

trc mt t ln vai gh, ngc t vo vai gh (c m mt gi mm).

2. Dng c

Kim kch thc ln 25G hoc kim c km theo catheter dn lu

3. Ngi thc hin

Chun b nh lm phu thut:

- i m, eo khu trang.

- Ra tay x phng.

- St trung tay bng cn.

- Mc o m.

- i gng v trng .

4. H s bnh n

Gii thch v k thut cho ngi bnh, gia nh ngi bnh v k cam kt

ng k thut, phiu ghi chp theo di th thut.

3

IV. CC BC TIN HNH

1. Chn im chc

Phi khm thc th xc nh vng trn dch mng phi, xem phim Xq

ngc thng nghing, v c bit nu c siu m nn s dng xc nh v

tr chnh xc nht.

2. Tin hnh th thut:

- Gii thch cho Ngi bnh, k giy lm th thut

- St khun vng da nh lm th thut.

- Gy t bng Xylocain ln lt tng lp thnh ngc, dng kim gy t chc

thm d mng phi.

V tr chc kim c u tin la chn l im ni gia ct sng ti

ng nch sau. G t trn xung cho ti khi pht hin vng g c v dch

xung thm mt khoang lin sn na. Khng nn chc vo vng cnh ct

sng hoc su qu lin sn 9. S dng kim 25G trong c cha lidocain to

mt nt phng nh trn da. Sau chc qua nt phng gy t ti ch tng lp

tng lp su hn. PhI gi kim vung gc vi mt da trong sut qu trnh lm

th thut.To chn khng trong bm tim cho ti khi ht ra dch, tip tc y

su vo 2-3 mao mch sau rt nng ra y kim su vo khoang mng phi.

C nh catheter chc chn.

Ly dch lm xt nghim t bo, sinh ha, cy, nhum v cc phn ng

PCR tm lao.

Nu mc tiu chc ht dch iu tr nn ni kim vi h thng ti gom.

Nn rt khng qu 1500 ml dch trnh gy ph phi do tI n phi nhanh.

Mt bin php khc l ht lin tc duy tr p lc m 20 cmH2O.

Nn chp phim ngc sau chc ht.

V. THEO DI

Theo di M, HA, SpO2 15 pht/ln trong 3 gi sau lm th thut

VI. TAI BIN

- Chc khng ra dch

- Trn kh mng phi

- Phn x ph v

- Chy mu mng phi

TI LIU THAM KHO

1. Temes RT. Thoracentesis. N Engl J Med. 2007 Feb 8;356(6):641

2. Alexsander C.Chen, Thoracentesis, The Washington Manual of Critical Care,

A Lippincott Manual 2012, trang 605 609.

4

QUY TRNH K THUT DN LU KH MNG PHI CP CU

I. I CNG

- Chc ht, dn lu kh mng phi l 1 k thut cp cu.

- Thng thc hin cc khoa cp cu iu tr cc Ngi bnh b trn

kh mng phi.

- L k thut quan trng nhng khng phi kh thc hin, l yu cu bt

buc phi nm r i vi cc bc s cp cu.

II. CH NH

1. Trn kh mng phi t nhin tin pht.

2. Trn kh mng phi p lc.

III. CHNG CH NH

1. Khng c chng ch nh tuyt i.

2. Chng ch nh tng i:

- Trn kh mng phi t pht th pht (thng m dn lu mng phi).

- Trn kh mng phi do chn thng khng p lc.

3. Ch khi c:

- Ri lon ng mu: nhng bt thng nh gim tiu cu, ri lon ng

mu nn c iu chnh sm nu cn thit.

- Nhim trng da ti v tr d nh chc ht kh, (nn chn v tr da khng b

nhim trng).

VI. CHUN B

1. Ngi bnh

1. Gii thch cho Ngi bnh yn tm, v khi ht kh ra, Ngi bnh s

kh th.

2. o cc chc nng sng (mch, nhit , huyt p, nhp th, SpO2).

3. Kim tra phim XQ phi, xc nh chnh xc bn b trn kh.

2. Dng c

1. Dung dch st trng da: cn, iod.

2. Dng c gy t ti ch: Lidocain 2%, kim 25G, xylanh 5ml.

3. Gng, m, o, khu trang v trng.

4. Toan v trng.

5. Dng c theo di SpO2.

6. Kim chc ht kh mng phi, thng dng loi 16-18G hoc ln hn

nu cn, khng nn dng cc loi kim c mi vt qu nhn d gy

thng v v cc bng kh nhu m phi (tt nht dng catheter chc

mng phi chuyn bit).

5

7. Dy dn gn vi kha chc 3.

8. Bm tim ht kh loi 50-100ml hoc my ht cc bnh dn lu.

9. B m mng phi, nu khi cn s m dn lu mng phi.

3. H s bnh n

Gii thch v k thut cho Ngi bnh, gia nh Ngi bnh v k cam kt

ng k thut, phiu ghi chp theo di th thut

V. CC BC TIN HNH

- Ngi bnh ngi ta lng vo gh ta hoc nm t th Fowler.

- Khm v xc nh v tr trn kh mng phi, i chiu vi phim XQ.

- St trng v tr chc.

- Gy t ti v tr chc ch giao nhau gia khoang lin sn II (hay III) v

ng gia xng n, hoc khoang lien sn IV (hay V) ng nch gia.

- Lp kim vo xyranh 5ml, m kim thng gc vi mt da ngay b trn

xng sn di ( trnh b mch thn kinh lin sn).

- Va m kim va ht chn khng n khi vo n khoang mng phi (lc

ht trn xyranh gim t ngt, Ngi bnh ho do b kch thch mng phi), rt

nng trong, tip tc lun v ngoi vo.

- Lp chui catheter vo dy dn c gn kha chc 3 hoc ng cao su c

kp km Kocher thay cho van.

- Ht kh bng bm tim cho n khi ht khng ra g (ngng ht khi gp

khng lc, Ngi bnh ho). ng chc 3 v c nh catheter.

- Theo di 6-8 gi, chp lai phim XQ phi, nu ht kh, Ngi bnh ht

kh th c th cho v nh theo di.

- Nu ht khng ht kh, lp vo my ht lin tc.

VI. TAI BIN BIN CHNG

- Chy mu v au do chc vo b mch thn kinh lin sn.

- Nhim trng: do th thut thiu v trng.

- Trn kh di da.

TI LIU THAM KHO

1. Shahriar Zehtabchi (2007). Management of Emergency department

patiens with primary spontaneous pneumothrax. Annals of Emergency

Medicine.

2. Shoaib Faruqi, (2004). Role of simple needle aspiration in the

management of pneumothorax.

6

QUY TRNH K THUT DN LU MNG PHI

I. I CNG

Dn lu khoang mng phi l mt can thip ngoi khoa ti thiu, t mt

ng dn lu vo khoang mng phi nhm:

- Dn lu sch mu, dch v kh trong khoang mng phi

- Gip phi n tt

- Ti to p lc m trong khoang mng phi

II. CH NH

- Cc trng hp trn kh mng phi :

+ C van (xupap)

+ Ngi bnh ang dng my th

+ C p lc sau khi chc kim ban u gim p

+ Dai dng hoc ti pht sau khi chc ht n thun

+ Th pht Ngi bnh trn 50 tui

+ Trn mt tn thng phi: gin ph nang, x phi, t cu phi, lao phi

- Trn mu mng phi

- Trn m mng phi

- Trn mu hoc trn dch mng phi ti pht nhanh (nhm gy dnh)

III. CHNG CH NH

- Phi ng c dnh vo thnh ngc khp mt na phi

- Trn dch mng phi do suy tim, suy thn, nu kh th ch chc ht,

khng dn lu.

- Ri lon ng mu nng

IV. CHUN B

1. Ngi bnh

- Chp Xquang phi mi (cng ngy dn lu)

- Gii thch cho Ngi bnh hiu v hp tc vi ngi thc hin

- Tim 0,5mg atropin di da

- Tim an thn nu Ngi bnh lo lng hoc c nguy c kch thch nhiu

- T th Ngi bnh: C th nm hoc ngi tu trng hp c th

+ Ngi: Ngi bnh ngi trn gh ta, mt quay v pha vai gh, hai tay khoanh

trc mt t ln vai gh, ngc t vo vai gh.

+ Nm: Ngi bnh nm nga, thng ngi, thn ngi nghing v bn phi

lnh, tay pha dn lu nng cao ln pha u.

2. Dng c

- Dn lu:

7

+ Dn lu Monod: ng dn lu bng cao su v trocar, dn lu to v cng nn

thng dng cho trng hp trn mu, m mng phi.

+ Dn lu Joly: ng dn lu c mandrin bn trong, t dng v nng st bn

trong c th gy bin chng nh: chn thng phi, mch mu, tim.

+ Dn lu Monaldi

- My ht v h thng ng ni

- B m mng phi

- Bm tim, kim tim

- Sng v khun, bng gc, cn 700 , cn iod, gng v khun

- Xylocain 2 %

3. Ngi thc hin

Nh chun b lm phu thut:

- i m, eo khu trang

- Ra tay x phng

- St trng tay bng cn

- Mc o m

- i gng v trng

4. H s bnh n

Gii thch v k thut cho Ngi bnh, gia nh Ngi bnh v k cam

kt ng k thut, phiu ghi chp theo di th thut.

V. CC BC TIN HNH

1. Chn im chc

- Trn kh mng phi: khoang lin sn 2, 3 ng gia n bn c trn kh

- Trn dch mng phi, trn mu mng phi: khoang lin sn 7, 8 ng

nch gia (nch trc) bn c tn thng

- Trn dch, trn kh mng phi: Dng c 2 ng hoc khoang lin sn

4,5 ng nch gia

- Dch m nhiu: Dng c 2 ng, 1 dn lu, 1 bm ra

2. t ng dn lu

- St khun vng da nh lm th thut

- Gy t bng xylocain tng lp thnh ngc ng thi chc thm d mng phi

- Rch da t 0,5 - 1cm dc theo b trn xng sn di

- Dng panh kocher khng mu tch dn cc th c thnh ngc

- t dn lu vo khoang mng phi:

+ Dn lu Monod: Chc trocar vung gc vi thnh ngc vo khoang mng

phi, rt lng trocar. Kp u ngoi ng dn lu, lun ng dn lu vo trocar ri

y vo khoang mng phi n v tr nh (lun su 6-10 cm) rt trocar ra.

8

+ Dn lu Joly: Chc dn lu vung gc vi thnh ngc rt nng dn lu ra 1 cm

ri y dn lu vo khoang mng phi n v tr nh, rt nng dn lu ra.

- Ni dn lu vi my ht hoc bnh dn lu

- C nh dn lu vo da bng ch khu. t mt ng khu ti hoc khu

ch U quanh ng dn lu tht li khi rt ng.

- Kim tra li dn lu

3. Dn lu

- Dn lu 1 bnh: p dng cho Ngi bnh trn kh mng phi n thun

- Dn lu 2 bnh: p dng trong dn lu dch v kh

VI. THEO DI

- Tnh trng Ngi bnh: SpO2, nhp th, ran phi, tnh trng trn kh bng

phim chp phi hng ngy.

- Tnh trng nhim trng chn ng dn lu, theo di v iu chnh p lc

ht (khng qu 40 cmH2O).

VII. X TR BIN CHNG

- Chy mu: hay gp vi dn lu Joly hoc chc phi mch mu, cm mu

bng khu hoc tht ng mch lin sn.

- Ph phi: thng do ht qu nhanh v qu nhiu, cn gim p lc ht v

iu tr ph phi cp.

- Trn kh di da: thng do tc dn lu, cn kim tra v thng ng dn lu

- Nhim khun: nhim trng ti ch t dn lu, vim m mng phi, nhim

trng huyt. S dng khng sinh kinh nghim v theo khng sinh .

- Tc ng dn lu: do cc mu ng,m c, do gp dn lu, do t dn lu

khng ng v tr. Cn thay ng dn lu mi.

TI LIU THAM KHO

1 D Laws, E Neville, J Dufy. Thorax 2003- BTS guidelines for the insertion

of a chest drain.

2 M- Henry, T Arnold, J Harvey. Thorax 2003- BTS guidelines for the

management of spontanous pneumothorax.

9

QUY TRNH K THUT T NG NI KH QUN NG MING

BNG N TRACHLIGHT

I. CH NH

Ging ch nh ca t ni kh qun thng quy:

1. Nhng Ngi bnh c ch nh h hp h tr bng th my xm nhp: Vim

phi, suy h hp, gy m phu thut

2. bo v ng th

- Ngi bnh c nguy c sc, tc nghn ng h hp trn nh bng, vim

thanh mn, chn thng thanh mn

- Ri lon thc

- Mt phn x thanh mn

Ch nh u tin: Ngi bnh c chn thng ct sng c, t np c

II. CHNG CH NH

1. Khng c chng ch nh hon ton trong t ni kh qun

2. Lu t ni kh qun kh thc hin trong trng hp:

NGI BNH b chn thng vng ming, xng hm di

III. CHUN B

1. Bng ambu

2. B ht m ri

3. H thng cung cp oxy

4. Nng dn v h thng n ca ni kh qun Trachlight: thn n c hai pin

AAA, nng dn cng c lun trong nng dn mm, nng dn mm c

bng n u v dy dn t ngun ti bng .

Hnh 1: Nng dn cng v h thng n sng km nng dn mm

5. ng NKQ : Chun b nhiu loi ng

+ Lun nng dn vo trong lng ni kh qun bng n cch mt vt ca ni

kh qun khong 2cm trnh gy tn thng hu hng, thanh mn do nng dn

cng.

+ Kha c nh ni kh qun vo h thng n.

10

+ Un cong ni kh qun ti im hng dn trn nng dn thnh gc 90

(ging nh hnh gy nh gn)

6. Monitor theo di nhp tim, SpO2

7. ng nghe, my o huyt p

8. Cc phng tin bo h: knh mt, khu trang, gng, o th thut, m.

9. Thuc t, thuc an thn, gim au

- Cc thuc khi m (Thiopentone, Fentanyl, Midazolam).

- Thuc gin c Suxamethonium hoc Rocuronium

- Atropine

- Adrenalin 10ml dung dch 1/10.000

Ngoi ra cn chun b thm: cng ging nh t ni kh qun thng quy

10. Dng c m mng nhn gip.

+ Dao m

+ Canun m kh qun c bng chn

11. My soi ph qun

12. B m kh qun

IV. QUY TRNH T NI KH QUN

Bc1. Ngi bnh

- Gii thch cho Ngi bnh v/hoc gia nh

- Bnh nm nga u ngang vi thn, khng k gi

- Mc my theo di, ht m, dch d dy

- t 1 ng truyn tnh mch ngoi bin

Bc 2. Khi m: Khi m nhanh

- Cung cp oxy 100% trc trong 3-4 pht.

- Xt xylocain 2% vo li, hng, thanh mn

- Thuc khi m: phi hp hoc dng ring r

+ Fentanyl: 1 1,5 g/kg tim tnh mch

+ Midazolam: 0,3 mg/kg tim tnh mch

+ Kt hp vi Suxamethonium 1mg/kg hoc s dng Propofol

+ Bp bng oxy mask oxy 100%

Bc 3: Lun ng ni kh qun c n Trachlight

- Gim cng nh sng trong phng th thut

- Tay tri m ming Ngi bnh, ng thi nng hm di v ko li

Ngi bnh khai thng ng th.

- Tay phi cm n ni kh qun a v gia ming ca Ngi bnh y

li v np thanh mn ln trn. Ch quan st vng trn sn gip.

11

- V tr ng u n soi nm im chnh gia trn sn gip. Hi nga

tay phi a n soi v pha u Ngi bnh ( Hnh 4) Khi n soi

s chiu nh sng vng trn sn gip Ngi bnh qua 2 dy thanh

thnh hnh trn (nu n soi v tr lch hoc khng ng th nh sng

n vng trn sn gip s m hoc khng nhn thy)

- Rt nng dn cng, y n di chuyn xung pha di nu n ng

v tr trong ni kh qun th nh n ti v tr trn xng c s c hnh

nn.

- Rt nng dn mm, y ni kh qun vo su n su thch hp

Hnh 2: K thut m ming v a n ni kh qun Trachlight

Hnh 3: Thit ct dc v tr ng ca u n soi khi s dng n ni kh

qun Trachlight

12

Hnh 4: Thit ct dc k thut di chuyn tay v n ni kh qun

Trachlight quan st c nh n pha trn xng mng

Bc 4: Kim tra ng

- u NKQ nm 1/3 gia ca kh qun TB n: 20- 21 cm v nam: 22- 23cm

- C nhiu cch xc nh v tr NKQ:

+ Nghe phi, nghe vng thng v

+ Xem hi th c pht ngc ra khng?

+ o ET CO2 kh th ra

+ chp Xquang

Bc 5: C nh ng

+ C nh bng dnh hoc bng dy bng c ngng ming

+ Bm bng chn v kim tra p lc bng chn duy tr p lc bng chn

18- 22 mmHg.

Bc 6: Ghi chp h s v theo di Ngi bnh sau khi t NKQ

V. THEO DI V X TR TAI BIN

1. Theo di

Kim tra v tr ca ng ni kh qun bng chp XQ phi. u ng phi

cch Carina 3-5cm hoc ngang D2-4.

Nhp tim, SpO2 trn my monitor.

Kh mu ng mch.

o huyt p Ngi bnh.

2. X tr

Ngng tim: cp cu ngng tun hon.

Nhp chm: Ngng th thut, tim Atropin 0,5-1 mg TM

Tt huyt p sau t NKQ: Thng do gin mch, tc dng ca thuc an

thn, gim tin gnh ca tim do thng kh p lc dng. X tr: Truyn

dch nhanh 500- 1000ml dch ng trng, t ng truyn TMTT theo

di CVP, vn mch nu huyt p khng p ng vi truyn dch.

13

Chy mu do chn thng hng, np thanh mn: bm ra, ht sch.

Ph n np thanh mn v dy thanh m, kim tra cc bin chng ny trc

khi rt ni kh qun.

Nhim khun phi v ph qun: khng sinh.

TI LIU THAM KHO

1. V Vn nh, t ng ni kh qun cp cu, Hi sc cp cu ton tp,

nh xut bn y hc, trang 517 520.

2. Micheal Lippmann, Endotracheal intubation, The Washington Manual of

Critical Care, A Lippincott Manual (2012), trang 582 588.

14

QUY TRNH K THUTCHC HT KH MNG PHI CP CU

I. I CNG

- Chc ht kh mng phi l 1 k thut cp cu, thng thc hin cc

khoa cp cu x tr ban u cc Ngi bnh b trn kh mng phi

- L k thut quan trng nhng khng phi kh thc hin, l yu cu bt

buc phi nm r i vi cc bc s cp cu

Mc gii phu: v tr cc khoang lin sn

II. CH NH

- Trn kh mng phi t nhin tin pht

- Trn kh mng phi p lc

15

Trn kh mng phi phi Trn kh mng phi p lc

III. CHNG CH NH

- Khng c chng ch nh tuyt i

- Chng ch nh tng i:

+Trn kh mng phi th pht (thng m dn lu mng phi)

+ Trn kh mng phi do chn thng khng tng p lc

+ Ch khi c: nhng bt thng nh gim tiu cu, ri lon ng mu (cn

nhc li ch v nguy c). Nhim trng da ti v tr d nh chc ht kh, (nn

chn v tr da khng b nhim trng)

IV. CHUN B

1. Ngi lm th thut

- Bc s: 01 ngi, c o to v nm vng k thut ch ht kh mng phi

- iu dng: 02, c o to v ph gip bc s chc ht kh mng phi

2. Dng c

- Dung dch st trng da: cn, iod

- Dng c gy t ti ch: Lidocain 2%, kim 25G, xylanh 5ml

- Gng, m, o, khu trang v trng

- Toan v trng

- Dng c theo di SpO2

- Kim chc ht kh mng phi, thng dng loi 16-18G hoc ln hn nu

cn, khng nn dng cc loi kim c mi vt qu nhn d gy thng v v

cc bng kh nhu m phi (tt nht dng catheter chc mng phi

chuyn bit)

- Dy dn gn vi kha chc 3

- Bm tim ht kh loi 50-100ml hoc my ht cc bnh dn lu

- B m mng phi, nu khi cn s m dn lu mng phi

3. Ngi bnh

- Gii thch cho v k thut NGI BNH yn tm, hp tc

- o cc chc nng sng (mch, nhit , huyt p, nhp th, SpO2)

- Kim tra phim XQ phi, xc nh chnh xc bn b trn kh

4. H s bnh n

16

Kim tra li h s bnh n, giy k cam kt ng thc hin th thut

ca Ngi bnh, gia nh Ngi bnh, phiu ghi chp theo di th thut.

V. CC BC TIN HNH

1. Kim tra h s bnh n

Kim tra li h s bnh n, giy cam kt ng thc hin th thut ca

Ngi bnh, gia nh Ngi bnh, phiu ghi chp theo di th thut.

2. Kim tra Ngi bnh

nh gi li cc chc nng sng ca Ngi bnh c an ton cho thc hin

th thut.

3. Thc hin k thut

- Ngi bnh ngi ta lng vo gh ta hoc nm t th Fowler

- Khm v xc nh v tr trn kh mng phi, i chiu vi phim XQ

- St trng v tr chc

- Gy t ti v tr chc ch giao nhau gia khoang lin sn II (hay III) v

ng gia xng n, hoc khoang lin sn IV (hay V) ng nch gia.

- Lp kim vo xyranh 5ml, m kim thng gc vi mt da ngay b trn

xng sn di ( trnh b mch thn kinh lin sn)

- Va m kim va ht chn khng n khi vo n khoang mng phi (lc

ht trn xyranh gim t ngt, Ngi bnh ho do b kch thch mng

phi), rt nng trong, tip tc lun v ngoi vo

- Lp chui catheter vo dy dn c gn kha chc 3 hoc ng cao su c

kp km Kocher thay cho van

- Ht kh bng bm tim cho n khi ht khng ra g (ngng ht khi gp

khng lc, Ngi bnh ho). ng chc 3 v c nh catheter

- Theo di Ngi bnh 6-8 gi, chp lai phim XQ phi, nu ht kh, Ngi

bnh ht kh th c th cho v nh theo di.

- Nu ht khng ht kh, lp vo my ht lin tc

VI. TAI BIN V BIN CHNG

- Chy mu v au do chc vo b mch thn kinh lin sn

- Nhim trng: do th thut thiu v trng

- Trn kh di da

TI LIU THAM KHO

1. V Vn nh. Chuyn mn k thut hi sc cp cu

2. Shahriar Zehtabchi, (2007). Management of Emergency department patiens

with primary spontaneous pneumothrax. Annals of Emergency Medicine.

3. Shoaib Faruqi, (2004). Role of simple needle aspiration in the

management of pneumothorax.

17

QUY TRNH K THUT T NI KH QUN

I. I CNG

t ni kh qun l vic lun ng ni kh qun qua ng mi hoc ng

ming vo trong kh qun. Cho ti nay y vn cn l mt phng php kim

sot ng th tt nht v hiu qu nht. Yu cu i vi ngi bc s trong

thc hnh phi thun thc k thut t ni kh qun. C nhiu phng php t

ni kh qun trong t ni kh qun bng n soi thanh qun c coi l

phng php thng quy.

II. CH NH

- Tc ng th cp tnh: chn thng, ht phi, nhim khun...

- Ht cht tit

- Bo v ng th

- Suy h hp: ARDS, hen PQ, COPD

III. CHNG CH NH

1. Chng ch nh t NKQ ng ming

- Chn thng thanh kh qun

- Chn thng bin dng hm mt

- Phu thut hm hng

- Cng, sai khp hm

2. Chng ch nh t NKQ ng mi

- Ngng th

- Chn thng, bin dng mi hm mt

- Tc nghn c hc ng h hp do: chn thng, u, d vt

- Chn thng thanh kh ph qun

- Ri lon ng mu, gim tiu cu, ang iu tr chng ng

- Chy dch no tu qua xng sng

- Vim xoang, ph i cun mi, polyp mi

IV. CHUN B

1. Ngi thc hin

- Bc s: 01 ngi, c o to v nm vng k thut t ni kh qun

- iu dng: 02, c o to v ph gip bc s t ni kh qun

2. Dng c

- Dng c, thuc gy t ti ch: Lidocain 2%, bm tim 5ml

- Gng, m, khu trang

- My theo di SpO2

- n soi thanh qun li thng v cong

18

- Kp Magill

- Thuc tin m: midazolam, propofol

- ng ni kh qun cc c, cch chn ni kh qun:

+ Tng ng ngn nhn ca Ngi bnh.

+ N 7,5 - 8, nam 8 - 9; tr em = 4 + tui (nm)/ 4.

+ ng NKQ t ng mi < ng ming 1mm.

+ Bng c NKQ vi tui:

Tui ng knh trong ca ng (mm)

Ngi ln, tr > 14 t 8 9

Tr 10 6,5

Tr 6 t 5,5

tr 4t 5

tr 1 t 4

tr 3 thng 3,5

tr s sinh 3

3. Ngi bnh

- Gii thch cho v k thut gia nh NGI BNH yn tm, hp tc

- o cc chc nng sng (mch, nhit , huyt p, nhp th, SpO2)

- t Ngi bnh t th thch hp, nm nga, cho th oxi hoc bp bng

qua mt n ty tnh trng Ngi bnh. Nu c chn thng ct sng c

phi chn phng php t NKQ cho Ngi bnh chn thng c.

- Mc my theo di, ht m, dch d dy

4. H s bnh n

Kim tra li h s bnh n, giy k cam kt ng thc hin th thut

ca Ngi bnh hoc gia nh Ngi bnh, phiu ghi chp theo di th thut.

V. CC BC TIN HNH

1. t NKQ ng ming

1.1. Kim tra h s: Kim tra li ch nh, chng ch nh v cam kt ng

thc hin th thut.

1.2. Kim tra li Ngi bnh: Kim tra li cc chc nng sng ca Ngi bnh

trc khi tin hnh th thut

1.3. Thc hin k thut

1.3.1. Cho Ngi bnh th oxy hoc bp bng qua mt n

1.3.2. Dng an thn, tin m

+ Midazolam 0.1-0.4 mg/kg

+ Hoc Fentanyl 5-7g/kg

19

+ Hoc Ketamine 1.5mg/kg

+ Hoc Thiopental 3-5 mg/kg

+ Hoc Propofol 1-2 mg/kg

- Thuc gy bloc thn kinh c (thuc dn c): C th ch nh trong mt s

trng hp cn thit

+ Succinylcholine 1.5 mg/kg khng dng khi Ngi bnh tng kali mu

+ Hoc thay th bng Rocuronium 0.6-1mg/kg

1.3.3. Lm nghim php Sellick, bo v trnh tro ngc

1.3.4. Bc l thanh mn

Tay tri:

- Cm n soi thanh qun, lun li n vo ming gt t P qua T

- Nng n bc l thanh mn v np thanh mn

- a u li n st gc np thanh mn n li cong (H2)

- Hoc ln np thanh mn i vi n li thng (H1)

- Nng n bc l r thanh mn khng ly cung rng hm trn lm im ta

1.3.5. Lun ng NKQ

- Tay tri vn gi n t th bc l thanh mn

Hinh 1 Hinh 2

Thanh mn Hai dy thanh

Sn np TM

20

- Tay phi cm u ngoi ng NKQ:

+ Lun ng vo u trong ca ng st vo thanh mn

+ Nu kh khn: th thut Sellick, panh Magill, dy dn...

+ Qua thanh mn y ng vo su thm 3- 5 cm

1.3.6. Kim tra ng

- u NKQ nm 1/3 gia ca kh qun TB n: 20- 21 cm v nam: 22-

23cm

- C nhiu cch xc nh v tr NKQ:

+ Nghe phi , nghe vng thng v

+ Xem hi th c pht ngc ra khng?

+ S v tr bng chn

+ o ET CO2 kh th ra

+ Xquang ngc ...

1.3.7. C nh ng

+ Bm bng (cuff) ca NKQ khong 20 mmHg

+ C nh bng dnh hoc bng dy bng c ngng ming

2. K thut t NKQ ng mi

2.1. Kim tra h s: Kim tra li ch nh, chng ch nh v cam kt ng

thc hin th thut.

2.2. Kim tra li Ngi bnh: Kim tra li cc chc nng sng ca Ngi bnh


2.3. Thc hin k thut

2.3.1. Cho Ngi bnh th oxi hoc bp bng qua mt n

2.3.2. Dng an thn, tin m

- C th p dng phng php gy t (GT) ti ch:

- GT ng mi: kh dung, phun m...

- GT phn trn hai dy thanh m, gc li

- GT phn di hai dy thanh m

- Khng dng thuc gy bloc thn kinh c

2.3.3. Lun ng qua mi

- a u ng vo l mi trc, mt vt quay v pha cun mi.

- y ng vung gc vi mt NGI BNH, va y va xoay nh.

- Khi u ng NKQ i qua l mi sau c cm gic nh hng tay

21

2.3.4. Lun ng vo kh qun

Dng n:

- Tay tri t n vo ming NGI BNH v bc l thanh mn

- Tay phi lun ng qua thanh mn vo kh qun tng t nh khi t -

ng ming.

t NKQ khng dng n (t m):

- Tay tri: lng bn tay t vo chm phi hp vi tay phi iu chnh u

trong ca ng NKQ

- Tay phi: cm u ngoi ng NKQ:

+ D tm v tr c lung hi th ra mnh nht.

+ i n u th ht vo, y ng vo su thm khong 5 cm.

+ ng i vo qua thanh mn c cm gic nh tay, c hi chng xm nhp

Ngi bnh ho sc sa v c hi th pht qua ming ng

+ ng vo d dy ngi bnh khng ho sc, khng hi th pht ra ming ng

+ ng vo cc xoang hai bn thanh mn c cm gic y nng, vng ng v

khng i su c na lc ny nn rt ra vi cm chnh lai hng ng

2.3.5. Kim tra v tr ng:

- Tng t t ng ming

- t ng vo su hn ng ming 3 - 4 cm

2.3.6. C nh ng:

Tng t t ng ming

V. TAI BIN V BIN CHNG TRONG KHI T NKQ

- Tn thng ct sng, tng p lc ni s.

- Ht phi: dch d dy, rng, cht tit hu.

- Tn thng rng, hu, thanh qun, kh qun.

- t nhm vo thc qun.

- t NKQ vo ph qun gc phi.

- Chy mu.

- Thiu xy.

- Ri lon v tim mch thng gp hn nhng ngi thiu mu c tim

TI LIU THAM KHO

1. Michael Dunham C; Robert D. Barraco et al Guidelines for

emergency tracheal intubation immediately following trauma injury.

2. Christopher Kabrhel, Todd W. Thomsen, Gary S. Setnik, Ron M.

Walls (2007) - Orotracheal Intubation - N Engl J Med 356;17.

22

QUY TRNH K THUT KHAI THNG NG TH

I. I CNG

Khai thng ng th l mt k thut cp cu rt quan trong i vi cc

ngi thc hin cp cu nhm m bo xy v thng kh y cho Ngi

bnh.

II. CH NH

- Tc nghn ng th do tt li

- Tc nghn ng th do dch tit

- Tc nghn ng th do di vt

III. CHNG CH NH

Khng c chng ch nh

Lu : nu nghi c chn thng ct sng c th phi c nh ct sng c

trc khi tin hnh bt k k thut no lm thay i t th c Ngi bnh.

IV. CHUN B

1. Ngi thc hin: bc s, iu dng, k thut vin thnh tho k thut.

2. Phng tin: Forcep ly d vt, canuyn hu ming, canuyn hu mi, sonde

ht m v my ht m

3. Ngi bnh: nu Ngi bnh tnh cn gii thch r th thut

4. H s bnh n:

Gii thch v k thut cho Ngi bnh, gia nh Ngi bnh trong trng hp

cn thit yu cu gia nh Ngi bnh k cam kt ng thc hin k thut,

phiu ghi chp theo di th thut.

V. CC BC TIN HNH

1. Kim tra h s: Kim tra li ch nh, chng ch nh v cam kt ng thc

hin th thut.

2. Kim tra ngi bnh: Kim tra li cc chc nng sng ca Ngi bnh


3. Thc hin k thut

3.1. K thut nga u/nng cm: Ngi bnh nm nga.

Bc 1: Ngi thc hin ng mt bn ca Ngi bnh

Bc 2: Mt tay t di cm v nng cm ln trn, tay cn li t trn

trn, p xung di v v pha thn

Bc 3: Kim tra ng th v ly b d vt nu c

23

3.2. K thut n gi hm

Bc 1: Ngi thc hin ng pha u Ngi bnh

Bc 2: Ngn tay tr v ngn gia ca hai tay mc vo gc hm, ngn ci t vo

cm. Dng lc ca cng tay ko cm Ngi bnh ln trn v v pha u


3.3. K thut Heimlich: khi Ngi bnh tnh v hp tc

Bc 1: Ngi thc hin ng pha sau Ngi bnh

Bc 2: Mt bn tay nm li, tay cn li cm c tay ca tay nm. Dng lc ko

ca cnh tay git mnh v dt khot ng th vi th th ra ca Ngi bnh

Bc 3: Kim tra ng th v d vt bt ra ngoi cha

3.4. K thut Heimlich: khi Ngi bnh bt tnh

Bc 1: Ngi thc hin ngi ln i Ngi bnh

Bc 2: Mt bn tay nm li, tay cn li an cho vi bn tay nm. Ci tay t

trn vng thng v ca Ngi bnh. Dng trng lc ca na thn mnh, y

thng cnh tay vi cng tay vi ng tc mnh v dt khot ng th vi th th

ra ca Ngi bnh


24

3.5. K thut ly b d vt bng tay

Bc 1: Ngi thc hin ng 1 bn ca Ngi bnh

Bc 2: M ming Ngi bnh. Ngn tay ci ca mt tay mc vo hm

di v y xung di. Ngn tay tr ca tay cn li mc vo khoang

ming ly d vt

Bc 3: Kim tra ng th

3.6. K thut v lng/p ngc cho tr nh

T th nm sp:

Bc 1: Ngi thc hin t tr p ln mt trong ca mt cng tay, bn tay

gi cho c thng

Bc 2: u tr thp v hng mt tr xung di. Ngi thc hin dng tay

cn li v nh nhng dng khot vo vng lng tr

Bc 3: Lt nga tr kim tra ng th v ly b d vt

T th nm nga:

Bc 1: Ngi thc hin t tr nm nga ln mt trong ca mt cng tay, bn

tay gi cho c thng

Bc 2: u tr thp. Ngi thc hin dng ngn tr v ngn gia ca tay

cn li p nh nhng dng khot vo vng thng v ca tr

25

Bc 3: Kim tra ng th v ly b d vt

3.7. K thut t canuyn hu ming

Bc 1: t Ngi bnh nm nga. Ngi thc hin ng bn phi ca Ngi

bnh

Bc 2: M ming Ngi bnh. a u trong canuyn vo gia hai hm rng,

phn cong ca canuyn hng ln trn. Tip tc y vo trong cho n khi c

cm gic vng th t t xoay ngc li u trong i theo chiu cong gii

phu ca mn hu. y vo n khi u ngoi vo st cung rng

Bc 3: Kim tra ng th

3.8. K thut t canuyn hu mi

Bc 1: t Ngi bnh nm nga u nga ti a. C th k mt gi mm

di c. Ngi thc hin ng bn phi ca Ngi bnh

Bc 2: Bi trn pha ngoi ca canuyn bng du parafin. Lun canuyn vo mt

bn mi v y t t n khi u ngoi vo st cnh mi

Bc 3: Kim tra ng th

VI. THEO DI

- Theo di cc du hiu chc nng sng ca Ngi bnh

- Theo di tnh trng ng th. Mt k thut hiu qu khi Ngi bnh d

chu hn. Ht cc triu chng ca tc nghn.

VII. TAI BIN: t tai bin nu tin hnh ng k thut

26

QUY TRNH K THUT LY MU XT NGHIM KH MU QUA

CATHETER NG MCH

I. I CNG

o pH v kh mu l xt nghim rt quan trng theo di v iu chnh cc

thng s cho Ngi bnh nng, Ngi bnh suy h hp, Ngi bnh th my.

Xt nghim kh mu cho php nh gi tnh trng oxi ha mu, tnh trng thng

kh v thng bng kim toan. Kh mu l mt xt nghim thng quy rt quan

trng, c thc hin ti ging cho cc Ngi bnh hi sc cp cu.

II. CH NH

Ly kh mu nhiu ln cc Ngi bnh suy h hp, sc, Ngi bnh th

my do tn thng phi theo di thng xuyn kh mu.

III. CHNG CH NH

Ri lon ng mu, bnh a chy mu (hemophilia), tn thng mch mu, da

m mm vng nh t catheter.

IV. Chun b

1. Ngi lm th thut: Bc s c o to k thut t catheter ng mch

2. Ngi bnh: Ngi bnh phi c gii thch y trc khi tin hnh

ly mu lm xt nghim. Nu catheter ng mch c t chi trn, nn

tay t th trung gian sao cho tay ngang mc vi tim. Ly y

thng tin cn thit: mch, huyt p, nhit , SpO2, cc thng s my th

(nu th my), thng s nng xy v dng c th xy (nu Ngi

bnh th xy).

3. Dng c

- Mt catheter ng mch c t sn m bo thng tt. u catheter nn

c ni vi mt chc ba

- B dng c ly mu ng mch: xy lanh trng sn Heparin, lp bt u xy

lanh, bng st trng bng cn, gc v khun

- Xy lanh 5 mL hoc 10 mL dng ui khong cht

- Gng tay v khun

- Form ch nh vi cc thng tin cn thit khi xt nghim kh mu ng mch.

4. H s bnh n: Kim tra li h s bnh n, giy k cam kt ng thc hin

th thut ca Ngi bnh, gia nh Ngi bnh, phiu ghi chp theo di th

thut.

V. CC BC TIN HNH

1. Kim tra li h s bnh n



27

2. Kim tra li Ngi bnh

nh gi li cc chc nng sng ca Ngi bnh c an ton cho thc hin

th thut.

3. Thc hin th thut

Bc l u catheter ng mch, v chc ba

St trng phn chc ba cn ly mu

Dng xy lanh 5 hoc 10 ly ton b lng dch v mu trong catheter. Th

tch cn ly c khuyn co l 3 n 5 ln th tch khong cht ca catheter

(ty theo nh sn sut quy nh)

Kha chc ba v tho xy lanh ui khong cht

Kt ni vi xy lanh ly mu, m chc ba v ly 0,5-1 mL mu

Kha chc ba v tho xy lanh mu xt nghim. ng li chc ba.

ui phn khng kh u xy lanh vo gc v khun.

V nh xy lanh trn u vi Heparin

Gi n phng xt nghim v lm xt nghim ngay. Thi gian t khi ly mu

n khi lm xt nghim khng c qu 15 pht.

Kt ni li h thng theo di huyt p lin tc.

VI. CC TAI BIN V BIN CHNG

- Tc mch

- Tc catheter

- Chy mu

- Nhim trng qua catheter

Hnh 1: Ly ton b lng mu khong cht ca catheter

TI LIU THAM KHO

1. Gerald T.Golden, Roger W.Litwiller, et al; The interpretation of arterial

blood gases: A Concise Guide for Clinicians, Southern medical journal ,

September, 2009, Vol 66, No 9.

2. Wagner P D - Interpretation of blood gases, Chest 1980;77;131-132.

3. Orlando Regional Healthcare, Education&Development; Interpretation of

the blood gases, Self-Learning Packet 2004.

28

QUY TRNH K THUT NI SOI KH PH QUN CP CU

I. I CNG

- Ni soi kh ph qun l bin php thm khm trong lng ph qun bng

ng ni soi

- Ni soi ph qun c th thc hin bng ng ni soi cng hoc ng ni soi mm

- So vi ng ni soi ph qun cng, ng ni soi ph qun mm d thc hin

hn v an ton hn cho Ngi bnh, c th quan st thy c ton b cy ph

qun v khng cn gy m ton thn hoc thc hin trong phng m

II. CH NH

1. Ch nh chn on

1.1. Ho ra mu

- Xc nh v tr chy mu v chn on nguyn nhn

- Vi chy mu ang tip din, v tr v cn nguyn c pht hin vo

khong 90%. T l ny gim xung 50% sau khi cm mu

1.2. Xp phi

Ngoi tc nghn ph qun do khi u c tnh hoc d vt th bt tc do dch

nhy l ph bin nht. Bt tc do dch nhy thng m rng ra ngoi vi vt

khi tm quan st ca ng ni soi ph qun

1.3. Bnh nhu m lan ta

- Sinh thit phi qua ph qun (transbronchial lung biopsy) v ra ph qun

ph nang (BAL - bronchoalveolar lavage) c th cung cp thng tin v cc khi

u nhu m

- BAL l bin php gip chn on cc nhim trng c hi Ngi bnh

c suy gim min dch

- Sinh thit phi bng ng ni soi hunh quang (fluoroscopy) c th ci

thin c vic xc nh v tr v hn ch trn kh mng phi

1.4. Tn thng do ht cp tnh

- Xc nh v tr gii phu v mc nng ca tn thng sau khi ht phi khi

- Tc nghn ng h hp trn c th xut hin trong vng 24 gi ca tn

thng do ht

- Suy h hp cp tnh kh nng l do thay i nim mc ti cc ph qun

thy hoc ng h hp di

1.5. Chn thng ngc do vt t

- Ngoi t ng dn kh sau chn thng vt t th ho ra mu, xp thy

phi, trn kh trung tht hoc trn kh mng phi cng c th gp

29

1.6. nh gi tn thng sau t ng ni kh qun

- nh gi tn thng thanh qun hoc kh qun sau t ng ni kh qun

1.7. Nui cy vi khun

- xc nh vi sinh vt nh c ti ng h hp khi Ngi bnh khng

th khc m

- Nui cy nh lng bnh phm c ly bng bn chi c bo v ci

thin c mc chnh xc ca mu cy ly qua ni soi ph qun thng quy

- Ngi bnh khng t ng ni kh qun, mu bnh phm c ly qua

ni soi ph qun khng chnh xc hn mu bnh phm c Ngi bnh khc

nh. C hai mu ny u c dng tnh gi v m tnh gi cao

1.8. Chn on vim phi lin quan ti my th (VAP)

- Cung cp mu nui cy vi khun

- Bi tit m t cc ph qun ngoi vi trong th th ra c th d on c

vim phi lin quan ti my th

- Cc s liu gn y cho thy nui cy nh lng dch ra ph qun ph

nang c th khng chnh xc hn nui cy khng nh lng mu bnh phm ly

qua ni kh qun

2. Ch nh iu tr

2.1. Tng tit m qu mc/xp phi

- Xp thy phi khng p ng vi vt l tr liu lng ngc v ho

- Nh git thuc N-acetylcysteine (NAC), surfactant v DNase ti tng hp

c s dng gip ha lng cht nhy c c. Khng c th nghim lm

sng no ng h cho mc ch s dng ny

2.2. D vt

- Ni soi ph qun ng cng l th thut c la chn ly b cc d vt

ht phi

- Cc dng c i km c sn gip ly b d vt bng ng soi mm

2.3. t ng ni kh qun

- ng soi ph qun, c s dng nh dng c trm bt (obturator) c

lun qua bi ng ni kh qun, c th gip t ng ni kh qun qua ng mi

hoc ng ming Ngi bnh c ng dn kh kh

2.4. Ho ra mu

- p lng ph qun c th lm Ngi bnh n nh tip tc tin hnh cc

bin php iu tr trit hn

+ p lng ph qun c th thc hin c bi ng thng c bng u

chn vo cc l ph qun thy

- Ho ra mu t c th c kim sot bng ra nc mui sinh l

30

2.5. Tn thng tc nghn ng h hp trung tm

- Xem xt ct bng la-de (laser photoresection) hoc t gi (stent) qua

tn thng gy tc nghn thanh qun, kh qun v ph qun ln

2.6. ng l r kh qun mng phi

- quan st u gn hoc nh khu u xa hn ca l r

- Vt liu c tim qua ng ni soi ph qun c th ng c l r

2.7. M kh qun qua da ti ging

- Khi s dng thng quy, vic quan st qua ng ni soi ph qun trong khi

lm th thut lm gim ng k bin chng ca th thut

III. CHNG CH NH

- Bc s cha c o to v k thut, khng c kinh nghim

- Ngi bnh khng hp tc

- Khng th duy tr bo ha oxy y

- Ri lon ng mu Ngi bnh cn ni soi ph qun sinh thit (dng

bn chi hoc kp fooc-xp)

- Ngi bnh c tnh trng huyt ng khng n nh

- Ngi bnh hen ph qun c triu chng m cha c iu tr (ni soi

ph qun ng mm t khi c s dng lm gim tc nghn do nt nhy cho

Ngi bnh t ng ni kh qun c trng thi hen ph qun)

- Bnh phi tc nghn mn tnh nng c kt hp tng CO2 mu (tin m, an

thn, v h tr oxy phi c s dng mt cch thn trng)

- Tng p lc ni s (s dng phi hp cc thuc gy m bo v no, thuc

gin c trnh ho, v theo di st m bo p lc ti mu no y )

IV. CHUN B

1. Ngi lm th thut: L bc s, c o to v k thut ni soi ph qun,

thnh tho k thut, lun lun dnh thi gian kim tra Ngi bnh trc khi

tin hnh k thut ni soi ph qun

2. Ngi bnh

- Thm khm pht hin cc bnh l nn nh hen, bnh tim mch, suy thn,

ri lon ng mu

- Khai thc tin s d ng, thuc ang dng c nh hng ti chc nng

ng mu

- Kim tra xem Ngi bnh chp XQ phi v lm in tm cha?

bo ha oxy ca Ngi bnh nh th no?

- Ngi bnh phi nhn n trc khi lm th thut

- Ngi bnh v/hoc ngi thn phi ghi bn cam kt lm th thut

- t ng truyn tnh mch

31

3. Dng c

- My ni soi ph qun, my theo di Ngi bnh, SpO2, thuc tin m,

ng xt nghim.

- Dch truyn, bm tim, dy truyn,..

4. H s bnh n



V. CC BC TIN HNH

1. Kim tra h s: Kim tra li ch nh, chng ch nh v cam kt ng thc

hin th thut.

2. Kim tra Ngi bnh: Kim tra li cc chc nng sng ca Ngi bnh

trc khi tin hnh th thut.

3. Thc hin k thut

- Gy t cc b bng lidocaine kh dung v thch lidocaine ti ch.

+ Sau khi s dng gy t ti ch, lidocaine hp thu qua nim mc v t

c nng trong mu rt nhanh, thm ch c th gy c.

+ Nng trong phm vi iu tr thp t c nu tng liu s dng < 200 mg

+ t ngt thay i tnh trng thc, xut hin o gic, co git, tng nhu

cu thuc an thn hoc tt huyt p th phi ngh ti ng c lidocaine.

+ Methemoglobin mu cng c m t khi s dng cc thuc gy t

dng ester ti ch.

- Ngi bnh khng c ni kh qun: ni soi ph qun qua mi hoc ming

- Ngi bnh c ng ni kh qun:

+ ng ni kh qun c a qua mt chc ni xoay (swivel adapter) c

mng cao su trnh mt th tch kh lu thng (Vt). S dng khun bm (bite

block) trnh h hi ng ni soi ph qun.

+ Cn nhc cc iu sau trc khi v trong khi ni soi ph qun.

ng ni kh qun c ng knh trong 8 mm cho php m bo c

th tch kh lu thng (Vt) v di chuyn an ton ng ni soi ph qun kch c

ngi ln.

Ni soi ph qun c th to ra mt p lc dng cui th th ra (PEEP)

vo khong 20 cmH2O do c nguy c gy ra chn thng do p lc

PEEP ci t sn cn c b

Nng oxy th vo (FiO2) phi c tng ln 100%

Th tch kh th ra (Vte) phi c theo di lin tc; th tch kh lu

thng (Vt) thng phi c tng thm ti 40% - 50%

Ht m/dch tit s lm gim kh lu thng (Vt) do cn phi c hn ch

+ Trong qu trnh ni soi ph qun, liu php oxy lin tc, theo di nng

oxy mu, in tm v huyt p l rt cn thit

32

VI. THEO DI SAU NI SOI PH QUN

- Chp XQ phi loi tr trn kh mng phi

+ Sau khi sinh thit qua ph qun (transbronchial biopsy) Ngi bnh

khng c ng ni kh qun

+ Sau khi ni soi ph qun thng quy Ngi bnh c ng ni kh qun,

thng kh nhn to

Tr li cho Ngi bnh thng kh nhn to cc thng s ci t my th

nh trc khi tin ni soi ph qun

Ngi bnh khng c ng ni kh qun, th oxy lin tc trong 4 gi

Theo di cc du hiu sng cho ti khi Ngi bnh n nh trong t nht 2 gi

Ngi bnh khng c n v/hoc ung cho ti khi thuc gy t cc b

ht tc dng (khong 1 2 gi)

St sau ni soi ph qun thng gp l do gii phng cc cytokin; st c

km rt run v xut hin mun > 24 gi th c kh l do nng vim phi sau ni

soi ph qun

VII. BIN CHNG V TAI BIN

- Khi c thc hin bi bc s c o to th ni soi ph qun bng ng

mm thng quy rt an ton

- T l t vong khng vt qu 0,1%

- T vong do tin m qu mc hoc gy t ti ch, ngng th do chy mu,

co tht thanh qun, co tht ph qun v ngng tim do nhi mu c tim

- T l bin chng chung < 8%

- Bin chng khng gy t vong: st, vim phi, cc phn ng ca thn

kinh giao cm, co tht thanh qun v co tht ph qun, tt huyt p, ri lon nhp

tim, trn kh mng phi, cc vn lin quan ti gy t, v mt ting

TI LIU THAM KHO

1. Oren P. Schaefer, Richard S. Irwin. Bronchoscopy. In: Richard S. Irwin, James M.

Rippe, Manual of Intensive Care Medicine 4th

Edition 2010.

2. Bollinger CT, Sutedja TG, Strausz J, et al. Therapeutic bronchoscopy

with immediate effect: laser, electrocautery, argon plasma coagulation and

stents. Eur Respir J 2006;27:12581271.

3. Canadian Critical Care Trials Group. A randomized trial of diagnostic

techniques for ventilator associated pneumonia. N Engl J Med

2006;355:26192630.

This multicenter trial found no differences in two different diagnostic

strategies for VAPBAL with quantitative culture vs. endotracheal

aspirate with nonquantitative culture.

33

QUY TRNH K THUT THI NGT

I. I CNG

- Thi ngt l phng php cp cu nn nhn ngng th t ngt do nhiu

nguyn nhn khc nhau gy nn (sp hm, ui nc, in git, ng c...)

nhng cha c ngng tun hon hoc c ngng tun hon.

- Thi ngt c tin hnh bng cch ngi cp cu thi trc tip hi ca

mnh qua mm nn nhn.

II. CH NH

- Ngng tun hon

- Ngng th t ngt nhng cha c ngng tun hon

III. CHNG CH NH

- Khng c chng ch nh.

- Tuy nhin khng thi ngt trc tip vi nhng nn nhn nghi c nhiu

kh nng mc bnh truyn nhim: HIV...

VII. CHUN B

1. Ngi thc hin

- Bc s, iu dng hoc ngi c o to v nm c k thut

2. Dng c: hp dng c cp cu ngng th ngng tim, c chun b sn

- Bng, mt n, ng NKQ, my theo di Ngi bnh c in tim, bm tim

5ml, gng, m, khu trang,..

- My sc in, oxi,

- Thuc Adrenalin, dch truyn, catheter ngoi bin,.

3. Ngi bnh

t Ngi bnh t th nm nga

IV. CC BC TIN HNH

- Nn nhn nm nga, m ng dn kh bng cch nga u v nng cm

+ t mt bn tay (thng l tay khng thun) ln trn nn nhn v y

nga u nn nhn ra sau mt cch nh nhng trong khi vn th cc ngn tay ci

v tr t do bp bt mi nn nhn nu cn thi ngt

+ t cc u ngn tay ca bn tay cn li (thng l tay thun) di cm

nn nhn, nng cm ln m ng dn kh.

34

Hnh 1 v 2: T th nga u v nng cm

(Khng c y mnh hm nn nhn v ng tc ny c th lm ct sng

c b tn thng nng hn nu c km chn thng. V vy, nn m ng dn

kh (nga u v nng cm) mt cch thn trng cho c nn nhn c hoc khng

c tn thng ct sng c).

- Gi m ng dn kh, kim tra h hp (quan st, nghe ngng v cm

nhn nhp th).

V. THEO DI

Nu thi ngt c kt qu:

Ch t th Ngi bnh, sc mt, ng t, nhp th, mch, huyt p...

Vn chuyn Ngi bnh n c s y t gn nht nu Ngi bnh ti lp c t

th.

35

QUY TRNH K THUT M KH QUN CP CU

I. I CNG

- M kh qun cp cu l to mt ng th nhn to qua mng nhn gip

- L mt k thut khai thng ng th nhanh chng, c bit trong cp

cu ngt th cp.

- Mng nhn gip c mc gii phu tng i r v d i vo ng th nht

- C 2 loi k thut: chc mng nhn gip v m mng nhn gip

Mc gii phu:

Mng nhn gip nm gia sn gip v sn nhn, c c nhn gip che ph

1. Sn np thanh mn 5. C phu sau

2. L nhnh trong TK thanh qun 6. Sn gip

3. Mng gip mng 7. Phn ng c nhn gip

4. Cc c phu cho v ngang 8. Phn chch c nhn gip

9. Kh qun

II. CH NH cc trng hp khai thng ng th cp cu:

- Suy h hp cp, ngt th cp t ni kh qun tht bi hoc c chng

ch nh

- Ngi bnh b chn thng hm mt, chn thng ct sng c, hoc

a chn thng

III. CHNG CH NH: khng c chng ch nh tuyt i

- Ngi bnh c cc bnh l thanh qun nh ung th, vim sn np

thanh qun

- Thn trng Ngi bnh c bnh v mu

- Tr em di 10 tui do thanh qun nh c hnh phu m phn nh nht

l sn nhn

36

IV. CHUN B

1. Ngi thc hin

- Bc s : 02 ngi, c o to, thnh tho k thut.

- iu dng: 02 iu dng ph gip bc s, c o to v ph gip bc

s m kh qun.

2. Ngi bnh

- Ngi bnh nm nga

- K mt gi di c hoc vai, nu c chn thng ct sng c khng k

gi v phi bt ng u v c Ngi bnh

- St trng ti ch

- Gy t ti ch bng xylocain 2%

3. Dng c

2.1. Chc mng nhn gip bng kim chc trc tip:

- Bm tim, trong bm tim ht sn 2-3ml Natriclorua 0.9%

- Kim to:

o kim s 14 (14-gauge) vi ngi ln

o Kim s 18 (18-gauge) vi tr em

- Cc dng c khc: gng, st trng, gy t

2.2. M mng nhn c rch da vi b dng c MINITRACH :

- Dao m

- Canuyn c ng knh trong 4mm

- Nng dn

- Khp ni ni kh qun

2.3.M mng nhn gip c rch da vi b dng c MELKER:

- Bm tim ht sn 2-3ml Natriclorua 0.9%

- Kim s 18 hoc catheter

- Dao m

- Dy dn (guidewire)

- Que nong da (Curved dilator)

- Canuyn

4. H s bnh n



V. CC BC TIN HNH




37


- nh gi li cc chc nng sng ca Ngi bnh c an ton cho thc hin

th thut.

3. Thc hin k thut

3.1. Chc mng nhn gip bng kim chc trc tip

- St trng

- Xc nh v tr mng nhn gip, gy t qua mng nhn gip

- Chc kim vo mng nhn gip theo ng gia, chch mt gc 45 so vi

thn ngi v hng mi kim xung pha di

- Va chc va dng bm tim ht thm d n khi ht ra kh

- Tho bm tim khi c kim

- Ngi bnh c th th t nhin qua kim

- Hoc bp bng bng cch lp khp ni ca ni kh qun s 3-3.5 vo c kim

3.2. M mng nhn c rch da vi b dng c MINITRACH

- St trng

- Xc nh v tr mng nhn gip, gy t da v gy t kh qun qua mng nhn gip

- Dng dao m rch da

- Chc nng dn (mang theo canuyn) qua ng rch da. Khi vo n lng kh

qun th lun nng dn thm vi cm sau y canuyn trt theo nng dn

vo trong kh qun ri rt nng dn ra.

- C nh canuyn

3.3. M mng nhn gip c rch da vi b dng c MELKER

- Xc nh v tr mng nhn gip, gy t da v gy t kh qun qua mng nhn gip

- Rch da thnh mt ng thng theo ng gia di 1-1.5 cm

- Chc kim c lp bm tim qua mng nhn gip qua vt rch da theo mt gc

45 so vi thn ngi (hng kim v pha chn Ngi bnh) ti ng

gia, va chc va ht n khi ra kh

- Tho bm tim, li kim, lun dy dn qua catheter vo ng th

- Rt kim, li dy dn

- Lun canuyn

- Rt que nong v dy dn

- C nh

VI. TAI BIN V BIN CHNG

1. Tai bin v bin chng sm

- Ngt th hoc tc nghn ng th

- Chy mu ti im chc, rch da

- Tn thng thanh kh qun, mch mu

38

- Thng kh qun, thc qun hoc chc vo trung tht

- Trn kh di da, trn kh mng phi, trung tht

- Lun cauyn, kim khng vo ng kh qun

- Chn thng dy thanh m

2. Tai bin v bin chng mun

- Hp di sn gip v hp kh qun

- Tc canuyn

- Mt chc nng nut

- Thay i ging ni

- Nhim trng

- Chy mu mun

- D kh qun thc qun

- Lu lin ch m

TI LIU THAM KHO

1. V Vn nh. K thut m kh qun. Chuyn mn k thut hi sc cp cu.

2. Trnh Xun n . Gii phu thanh qun. Bi ging Gii phu hc

3. Aaron E Bair- Emergent surgical cricothyrotomy. Uptodate, 2012

4. Peter A. Walts - Techniques of surgical tracheostomy. Clin Chest Med

24 (2003) 413 422

39

QUY TRNH K THUT M MNG PHI CP CU

I. I CNG

M mng phi cp cu l mt th thut t mt ng v khun vo khoang

mng phi ,kt ni vi mt h thng kn nhm ht kh hoc dch xut hin trong

khoang mng phi. Mc ch:

- Khi phc li p lc m trong khoang mng phi, gin n phi

- Ngn chn cc nguy c ri lon v huyt ng do nu trn kh ,trn mu

mng phi kiu p lc

- Mc ch iu tr v theo di trong trn m trn mu mng phi

II. CH NH

Trn kh mng phi m c mt trong cc tnh trng sau: Trn cc Ngi

bnh ang th my. Trn kh mng phi s lng ln. Cc Ngi bnh ang

trong tnh trng nng. Trn kh mng phi p lc m sau khi chc kim gii p

trc . Trn kh mng phi th pht sau chn thng ngc kn. Trn kh

mng phi sau th thut chc dn lu kh hoc dch ti thiu, trn kh ny c s

lng ln v c cc biu hi lm sng nng. Trn kh- trn mu mng phi do

chn thng. Thng thc qun c dch d dy d vo khoang mng phi

III. CHNG CH NH

- Khng c chng ch nh tuyt i cho m mng phi, ngoi tr trng

hp Ngi bnh c bnh l lm phi dnh hon ton vo thnh ngc

- Chng ch inh tng i trong cc trng hp Ngi bnh c nguy c

chy mu do ri lon ng mu v dng thuc chng ng, Cc trng hp ny

c th tin hnh th thut khi truyn cc yu t ng mu v tiu cu

m bo mc nguy c chy mu thp tr ln (Tiu cu > 60G/L v APTT

bnh/chng < 1.5)

IV. CHUN B

1. Ngi thc hin th thut: 01 bc s c o to thnh tho k thut, 01

iu dng thnh tho ph gip bc s m mng phi.

2. Ngi bnh

Gii thch th thut cho Ngi bnh hoc ngi nh Ngi bnh. Trong

trng hp khn cp c th khng kp gii thch. t Ngi bnh t th nm

nga u cao, tay bn tin hnh th thut t di u Ngi bnh, sao cho bc

l r vng tam gic an ton

V tr m dn lu l tam gic an ton: b trc l c ngc ln, b sau l c

lng rng, b di l khang lin sn 5

40

3. Phng tin, dng c

Mt b m mng phi c cc dng c cn thit c ng trong mt

hp v khun, bao gm cc dng c sau: 01 dao m v cn dao c 11, mt s

dng c phu thut: Pinch, kp phu tch, c bit phi c 1 Pinch cong u t

bc tch cc lp c khoang mng phi. 01 khn v khun c l ng knh

10cm. 01 xylanh 10ml v 01 xylanh 20ml. Thuc gy t, ng dn lu cht liu

Silicon chng dnh do cc mu ng hnh thnh c kch thc theo ch nh dn

lu. H thng ht dn lu kn p lc m lin tc

4. H s bnh n

Kim tra li h s bnh n, giy k cam kt ng thc hin th thut ca


VIII. CC BC TIN HNH





nh gi li cc chc nng sng ca Ngi bnh c an ton cho thc hin th thut.

3. Thc hin k thut

- Ra tay, mc o i gng

- St khun v tr dn lu bng Betadin, cn

- Tri khn v khun

- Gy t tng lp: da, c mng phi, khoang mng phi, nguyn tc gy t l

bt u t ngang xng sn ngay di khoang lin sn nh dn lu tin

dn ln v i su vo khoang lin sn

- Dng dao m rch da v tr ngang xng sn 5 nch gia, chiu di rch

1.5 n 2cm, rch qua lp da vo n lp c

- Dng Pinch cong c u t (Kelly) bc tch tng lp c theo hng t

ngang xng sn ln khoang lin sn v i su vo khoang mng phi

- Khi n khoang mng phi s c cm gicHng tay v c kh hoc dch

tro ra ngoi

- Dng ngn 1 bn tay a vo khoang mng phi thm d v kim tra

ng dn lu vo khoang mng phi ng thi c th bc tch mt phn

khoang mng phi nu c dnh ti ch dn lu

- Sau khi chc chn vo khoang mng phi, tin hnh lun ng Sonde dn

lu: dng Pinke cong kp u ng dn lu a theo ng m trn, khi vo

41

khoang mng phi s c dch hoc kh qua ng dn lu. Nu dn lu kh, cho

u ng hng ln trn. Nu dn lu dch cho u ng hng xung di

- Khu c nh ng dn lu

Ni ng dn lu vi h thng ht lin tc

Kim tra v tr ng dn lu

Chp XQ phi kim tra ng dn lu

V. CC TAI BIN V BIN CHNG

Chy mu kh cm ti v tr dn lu: lin quan n ri lon ng mu,hoc

trong qu trnh m dn lu c ct xuyn qua mch mu

Th thut th bo lm tn thng cc tng bn trong lng ngc : tim phi,mch mu thm ch gy tn thng gan lch trong trng hp xc nh

v tr khng tt

Lm tn thng cc mch mu ln: ng mch ch, ng mch lin sn, trn kh di da,

Do hin tng ti tun hon tr v khi tho dch mng phi qu nhanh gy ph phi cp

Nhim trng ti v tr dn lu, vim m mng phi

Tc ng dn lu do cc mu ng hoc v tr u ng dn lu khng ng

VI. RT DN LU

1) La chn thi im rt dn lu

Nu dn lu kh: sau kp dn lu 12-24h chp li XQ phi khng c trn kh.

Nu dn lu dch mng phi: khi dch mng phi cn ra

42

QUY TRNH K THUT T

NI KH QUN KH TRONG CP CU

I. I CNG

t ng ni kh qun (NKQ) l mt th thut rt thng gp trong x tr

cp cu ngn chn hin tng gim thng kh, gim xy v bo v ng

th nhng Ngi bnh suy h hp, tun hon, thn kinh.

t ng NKQ kh c nh ngha: thi gian t NKQ nhiu hn 10 pht

v /hoc nhiu hn hai ln dng n soi thanh qun c hoc khng dng cc th

thut khc (Sellick, BURP...) v c thc hin bi nhng ngi c kinh

nghim. (trng hp gi kh khi ngi lm th thut t kinh nghim)

II. NH GI NHANH NKQ KH

1. c im gii phu

- Khong cch cm - gip: l khong cch t b trn sn gip n phn

gia cm. Nu khong cch ny < 6 cm (3 khot ngn tay) l t ng

NkQ kh.

- Khong cch gia 2 cung rng o v tr h ming ti a nu < 3 cm l

t ng NKQ kh.

2. Tiu chun lm sng theo Mallampati

Ngi bnh t th ngi, c nga thng, h ming th li, pht m "A":

I: Thy khu ci cng, khu ci mm, li g, thnh sau hng, tr trc v

tr sau Amydan.

II: Thy khu ci cng, khu ci mm, mt phn li g v thnh sau hng

III: Thy khu ci cng, khu ci mm v nn ca li g

IV: Ch thy khu ci cng

Nu l mc III, IV l t NKQ kh.

Hnh 1: Tiu chun lm sng theo Mallampati

3. Hi gy m ca M a cc yu t tin lng sau:

- Cc khi u vng ming hng, u mu, mu t

43

- Nhim khun: vim vng hm di, p xe quanh hng, vim np thanh qun

- Bt thng cu trc bm sinh

- D vt

- Chn thng vng mt: thanh qun, v hm trn, di, chn thng ct sng c

- Bng h hp

- Bo ph

- Hn ch nga c: vim ct sng dnh khp, vim ct sng c do thp

- Thay i v gii phu rng ca nh, c ngn, li to, hm nh...

III. CHUN B

1. Ngi thc hin: Bc s c hun luyn t NKQ, 2 iu dng.

2. Dng c

- n soi thanh qun li thng v cong vi nhiu c li khc nhau

- Kp Magill, nng dn

- Thuc tin m: midazolam, propofol, fentanyl

- ng ni kh qun cc c: 7.0 , 7.5, 8.0

- Oxy, bng mask, cannuyn ming - ming

- Cc dng c khc: my ht ng ht, gng tay, gc, bng dnh, ng nghe,

my theo di

- Cc dng c h tr t NKQ kh (ty trang b ca c s) c th:

+ B t ng NKQ ngc dng

+ B t NKQ bng ng soi mm

+ Mask thanh qun

+ ng NKQ combitube

+ n Trachlight

+ B m kh qun cp cu

IV. CC BC TIN HNH

Bc 1: Ngi bnh

- Bnh nm nga k gi di chm nu khng c CTCS c, nu c CTCS

c khng k gi hoc chn phng php t NKQ khc

- Mc my theo di, ht m, ht dch d dy

- Th xy 100% trc 2 - 5 pht, bp bng mask oxy 100% khi SpO2 <

90% hoc Ngi bnh ngng th.

Bc 2: Dng an thn, gin c (nu cn)

Bc 3: Lm nghip php bo v Sellick

Bc 4: Bc l thanh mn

Bc 5: Lun ng NKQ

Bc 6: Kim tra ng

Bc 7: C nh ng

44

V. CC K THUT H TR NKQ KH

- Tr gip bng tay:

+ Chnh lai t th Ngi bnh, u t th Jackson k gi dy 6

cm di u cho php trc thanh qun v hu ming thng hng

+ Nghim php BURP n thanh qun sang phi, ra trc v ln trn

- t NKQ m ng ming khi m ming hn ch, li to, nga c hn

ch

- t NKQ m qua ng mi dng nng dn sng

- t NKQ ngc dng

- t ng NKQ bng ng soi mm

- t ng NKQ combitube

- Mask thanh qun

- t NKQ dng n Trachlight

- M kh qun qua da

- M mng nhn gip

Ch : Ngi bnh s khng cht v t NKQ tht bi m cht v thng kh tht bi.

VI. TAI BIN V BIN CHNG TRONG T KHI NKQ

- Cc chn thng chy mu: Mi, li, rngrch cun mi

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