2.1 huong dan phong ngua viem phoi benh vien

B Y T

HNG DN

PHNG NGA VIM PHI BNH VIN

TRONG CC C S KHM BNH, CHA BNH (Ban hnh km theo Quyt nh s: 3671/Q-BYT ngy 27 thng 9 nm 2012 ca B Y t)

H NI, THNG 9/2012

1

DANH MC T VIT TT

Tn vit tt Tn y

HSTC Hi sc tch cc

NKBV Nhim khun bnh vin

NVYT

VPBV

Nhn vin y t

Vim phi bnh vin

2

I. t vn

Vim phi bnh vin (VPBV) l loi nhim khun lin quan n chm sc y t

thng gp ti khoa Hi sc tch cc (HSTC) v l nguyn nhn gy t vong hng

u (30% 70%) trong s cc loi nhim khun bnh vin (NKBV). Vim phi bnh

vin l nh ng vim phi xut hin ngi bnh sau khi nhp vin 48 gi, khng

trong giai on bnh hoc mc bnh vo thi im nhp vin.

Vim phi bnh vin l mt vn rt kh khn m cc khoa c bit khoa

HSTC ang phi ng u v kh chn on, iu tr v phng nga. Cc du hiu

gip chn on VPBV nh thm nhim phi mi hoc thm nhim tin trin km st,

bch cu tng, m m thng khng c hiu. (Xem ph lc 1 v tiu chun chn

on VP V chi tit). Cy dch kh qun c th m c vi khun do s pht trin ca vi

khun thng tr phn trn ca ng th lm kh phn bit gi a vi khun thng

tr v tc nhn gy bnh tht s, dn n vic iu tr da trn kt qu dng tnh gi.

Cy vi khun nh lng sau khi ly m bng phng php chi ph qun c bo v

hoc phng php ra ph nang c nhy v c hiu cao nhng hin cha c

ng dng rng ri do ngun lc cn hn ch.

Theo cc nghin cu cc nc pht trin, VP V chim 15 trong tng s

cc loi NKBV, chim ti 7 trong cc NK V khoa HSTC (CDC 2003). Trong

s cc VP V, loi VP V lin quan n th my (vim phi bnh vin xut hin sau

khi th my 48 gi) chim t l 9 . VP V lm k o di thi gian nm vin khong

6,1 ngy lm tn thm chi ph khong 1 . US n 4 . US cho mt trng hp.

Ti Vit Nam, kt qu iu tra ton quc nm 5 trn 19 bnh vin cho thy

VP V chim t l cao nht trong s cc NK V khc: 55.4 trong tng s cc NK V

(BYT, 2005). Theo cc nghin cu cc bnh vin trong ton quc, t l VP V t

21%-75 trong tng s cc NK V. T l vim phi lin quan n th my c bit

cao trong nhm ngi bnh nm ti khoa HSTC (43-63.5/1000 ngy th my). VPBV

l nguyn nhn hng u gy t vong trong s cc loi NK V (3 -7 ), k o di thi

gian nm vin thm 6-13 ngy, v tng vin ph t 15 n 3 triu ng cho mt

trng hp.

3

Cc nghin cu chng minh vic thc hin cc bin php phng nga

VPBV tng hp mang li nhiu thnh cng nh ci tin cc bin php phng nga

VP V ti khoa HSTC hng ngy, tuyn truyn bng tranh, bi vit phn hi cho nhn

vin y t (NVYT), nhc nh m i ngi cng thc hin hng ngy. Mt s bnh vin

gim c t l VP V xung cn 1 1 ngy th my qua cc bin php can

thip. Ti nc ta cha c nhiu nghin cu nh gi v tc ng ca phng php

phng nga VP V. Thc hin cc bin php d phng VP V nh lm gim ht sc

ca ngi bnh, ngn nga nhim khun ch o t tay NVYT, kh khun v tit khun

ng cch cc dng c h hp, cng tc gio dc cho NVYT v ngi bnh cha

c thc s y ti cc bnh vin trong nc. Mt nghin cu ci tin v ht

m ti bnh vin Ch Ry cho thy t l VP V nhm dng ng ht mt ln gim

48% so vi nhm dng ng ht s dng li.

II. Sinh bnh hc

1. Tc nhn gy bnh

Tc nhn gy VPBV c th khc nhau gi a cc bnh vin, a l do ngun

bnh v phng php chn on khc nhau. Tc nhn gy VPBV do nhiu loi vi

khun ( ng 1), thng l vi khun Gram m hiu kh (83 theo s liu ca Estes RJ

1995) nh Pseudomonas aeruginosa, Acinetobacter spp, Klebsiella spp, Enterobacter

spp, E coli, Providencia spp, vi khun Gram dng nh Staphylococcus aureus v

Streptococcus pneumonia cng chim t l kh cao ( 7 , 14 theo th t). Nh ng vi

khun ny thng a khng thuc nn gy kh khn cho iu tr. Cc nghin cu ti

Vit Nam cng cho thy vi khun gy bnh thng gp tng t. ( ng 1)

Tc nhn gy vim phi lin quan th my xut hin sm (di 4 ngy)

thng do vi sinh vt t khng khng sinh nhng nu xut hin mun hn thng

do vi sinh vt a khng thuc. Cc nghin cu cho thy vi khun gy vim phi lin

quan th my sm thng do cc Enterobacteriaceae spp, methicillin-susceptible

Staphylococcus aureus (MRSA) v Haemophilus influenza. Vim phi mun thng

do Acinetobacter baumannii v MRSA. Tc nhn gy bnh cng khc nhau cc

khoa khc nhau. ( ng 1)

4

B ng 1: Tc nh n g y vi m ph i i n quan th my ti mt s n v HSTC

Tc nhn * Ester 1995 N=

%

BV Ch Ry 2008 N=108

%

BV Hu 2010 N=98

%

Pseudomonas sp.

Acinetobacter sp.

E. coli

Klebsiella sp.

Proteus sp.

Burkholderia cepacia

Tc nhn Gram m khc

Streptococcus spp

Staphylococcus aureus

Hemophilus influenza

Vi khun ym kh Nm

30

19

8

6

11

4

14

27

9

2

4

32.9

15.8

7.9

14.4

7.9

2.0

9.2

6.1

32.7

3.1

12.2

1.0

2.0

10.2

14.3

* o trng hp cy dng tnh vi nhiu loi vi sinh vt trn cng mt mu nn s t l

tng ln hn 1

2. Cc ng v o c vi sinh v t gy bnh

Vi sinh vt xm nhp vo phi t:

1- Cc cht tit t vng hu h ng

2- ch d dy b tro ngc

3- Cc dng c h tr h hp hoc bn tay NVYT b nhim.

4- ng mu, bch mch

Cc dng c h tr h hp nh bnh lm m oxy, my kh dung, my ni soi

ph qun, ph dung k, dng c gy m l cc cha vi khun, c th t dng c n

ngi bnh, t ngi bnh ny n ngi bnh khc, t mt v tr ca c th n

ng h hp di ca cng mt ngi bnh qua bn tay hoc qua dng c.

ng gip th (ambu) l ngun a vi khun vo phi ngi bnh qua mi ln

bp bng v bng rt kh ra sch v lm kh gi a cc ln dng, ngoi ra bng cn

b nhim khun thng qua bn tay ca NVYT. Cn lm gim nguy c ly nhim t

cc dng c y t s dng li bng cch ra sch, kh khun v tit khun ng cch.

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Cc my kh dung thng dng phun cc loi thuc gin ph qun,

corticoid cng l ngun gy VP V v my b nhim khun qua bn tay ca NVYT,

b phn cha thuc b nhim khun do khng c kh khun thch hp gi a cc ln dng.

y th dng vi b phn lm m l ngun cha vi khun gy vim phi

ngi bnh th my, nc lng ng ng ng v t li b phn by nc

(water trap) lm cho dy th nhanh chng b nhim khun, thng l do vi khun

xut pht t vng ming v hu. V th cn dn lu tt nc trong ng ng trnh

gy vim phi do nc b nhim khun trong ng ng chy vo phi ngi bnh.

3. Yu t nguy c

Yu t nguy c VP V thng c phn thnh nh ng nhm sau:

- Cc yu t thuc v ngi bnh:

Tr s sinh, ngi gi trn 65 tui, ngi b o ph, ngi bnh phu thut

bng, ngc, u v c, ngi bnh c bnh l nng km theo nh c ri lon chc

nng phi nh bnh phi tc nghn mn tnh, bt thng lng ngc, chc nng phi

bt thng, suy gim min dch, mt phn x ho nut.

Ngi bnh hn m, kh nut do bnh l h thn kinh hoc thc qun lm

tng nguy c vim phi ht

+ Cc yu t lm gia tng s xm nhp v nh c ca vi khun (colonization).

ngi kho mnh, t bo biu m nim mc ming c ph mt lp fibronectin

ngn chn s bm dnh ca vi khun gram m, lp bo v ny b mt i trong nh ng

trng hp bnh nng lm cho vi khun gram m bm dnh vo biu m vng hu

h ng nhiu hn. o vi khun thng tr vng hu h ng ngi ln kh e mnh

l vi khun ym kh v lin cu tan mu (Streptococci -hemolytic), ngc li vng

hu h ng ca cc ngi bnh nhp vin thng b cc vi khun Gram m hiu kh

ng rut c tr, iu ny gii thch t l vi khun gram m thng nhiu hn vi

khun gram dng trong cc trng hp VP V.

- Cc yu t do c n thip y t

t ni kh qun hoc m kh qun.

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t ng thng mi d dy: ng thng lm gia tng vi sinh vt k sinh vng

mi, hu, gy tro ngc dch d dy, vi khun t d dy theo ng ng n ng

h hp trn.

+ Cc iu kin to thun li cho qu trnh tro ngc hoc vim phi do ht

sc: nh t ni kh qun, t ng thng d dy, t th nm nga. Nghin cu cho

thy lng ng ni kh qun nhanh chng b ph mt lp mng sinh h c c th cha

n hng triu vi khun cm2. S pht trin ca vi sinh vt k sinh ng ni kh qun

v kh qun do vi khun t cht tit ng pha trn bng chn ca ng ni kh qun i

vo v pht trin kh ph qun.

+ Cc bnh l cn th my k o di: lm tng nguy c tip xc vi cc dng c

b nhim khun, bn tay ca NVYT b nhim bn. Ngi bnh th my b mt cc c

ch bo v bnh thng do ng ni kh qun ngn cn c ch bo v bnh thng ca

c th v l ni vi khun n c tr v pht trin, ngoi ra vi khun pht trin t cht

tit ng pha trn bng ca ng ni kh qun i vo kh qun. Lng ng ni kh

qun b ph lp mng sinh h c cng l yu t lm gia tng nhim khun. Ngi bnh

th my c nguy c vim phi gp t 6 1 ln so vi ngi bnh khng th my.

Nghin cu ca Fagon cho thy nguy c vim phi gia tng 1 cho mi ngy th

my v trung bnh khong 5 ngi bnh HSTC th my b VP V.

+ Cc yu t cn tr qu trnh khc m: nh cc phu thut vng u, c,

ngc, bng, bt ng do chn thng hoc bnh, dng thuc an thn hay hn m.

+ Ngi bnh c dng thuc khng acid d dy d phng xut huyt tiu

ha do stress c nguy c VP V cao hn ngi bnh c d phng bng sucralfate.

pH acid d dy c tc dng dit vi khun c nut vo cng vi thc n v nc

b t, duy tr mi trng v khun ng tiu ha trn. Khi acid ca dch d dy

b gim do dng thuc khng acid, c ch H2, c ch bm ion H hoc nui n qua

ng thng, vi khun nut vo pht trin trong d dy v l ngun d tr vi khun gy

vim phi khi c tnh trng tro ngc.

Nui n qua ng tiu ha c th gy ly ch o vi khun thng qua qu

trnh chun b dung dch nui n v lm cho pH d dy tng ln, ngoi ra s tro

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ngc v vim phi ht d xy ra khi d dy gia tng v th tch v p lc.

- Cc yu t mi trng, dng c

+ Ly truyn cc vi khun gy VP V nh trc khun Gram m v t cu qua

bn tay ca NVYT b nhim bn thng qua cc thao tc nh ht m, cm vo dy

my th, vo ng ni kh qun. V th NVYT phi tuyt i ch n vn ra tay,

mang gng khi chm sc ngi bnh, c bit ti cc khoa/n v HSTC.

Ly truyn cc vi sinh vt gy VP V qua dng c khng c kh tt

khun ng quy cch

Ly truyn cc vi sinh vt gy VP V qua mi trng khng kh, qua b mt

b nhim.

III. Cc bin php phng ng vim phi bnh vin

1. Hun uyn, o t o

1.1 NVYT c h c sinh, sinh vin thc tp phi c o to, cp nht v cc

bin php phng nga, kim sot VP V. Ngi bnh, khch thm cn c hng

dn v cc bin php phng nga VPBV.

2. Gim st

2.1 Gim st nh k hoc khi c dch VPBV trn nh ng ngi bnh c nguy

c cao b VPBV ti cc n v sn sc c bit, HSTC xc nh cc yu t nh vi

khun gy bnh v s nhy cm i vi khng sinh, cng b cc s liu v t l

nhim khun ngi bnh HSTC hoc ngi bnh ang th my. T l VP V nn

tnh theo s ngi bnh b VP V/100 ngy HSTC hoc 1 ngy th my. Phn hi

kt qu cho lnh o bnh vin, hi ng KSNK v khoa ni thc hin gim st.

2.2 Gim st mc tun th ca NVYT i vi hng dn phng nga

VP V da theo bng kim xy dng sn (Ph lc 2).

2.3 Ch thc hin gim st thng quy nui cy cc bnh phm, cc dng c,

thit b dng cho iu tr h hp, nh gi chc nng phi, gy m khi c dch.

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3. Kh khun, tit khun dng c h tr h hp

Dng c in qu n n th my v h tr h hp khc

3.1 Tit khun hoc kh khun mc cao tt c cc dng c, thit b tip

xc trc tip hoc gin tip vi nim mc ng h hp di theo ng hng dn v

kh khun, tit khun dng c c ban hnh.

3.2 Thay ton b dy th oxy, mt n, dy dn oxy khi dng cho ngi bnh khc.

3.3 Kh khun thng quy bn ngoi my th bng dung dch kh khun mc

trung bnh. o d ng, kh khun nh k my th theo hng dn ca nh sn xut.

3.4 Tit khun hoc kh khun mc cao bnh lm m oxy

3.5 Kh khun mc cao bng gip th (ambu) sau khi s dng.

Dng c in qu n n th kh dung

3.6 Gi a cc ln phun kh dung trn cng mt ngi bnh, cc dng c phi

kh khun mc cao Khi dng cho ngi bnh khc phi thay my phun kh dung

c v khun hoc kh khun mc cao. Ch dng dch v khun phun

kh dung. Khi rt dch vo my phun cng theo nguyn tc v khun. Nu l thuc

dng nhiu ln th khi thao tc, rt dch, lu tr phi theo hng dn ca nh sn xut.

3.7 Tit khun hoc kh khun mc cao b phn ngm vo ming, ng dy,

ng ni theo hng dn ca nh sn xut khi dng cho ngi bnh khc. o d ng

nh k cc b phn bn trong ca my o chc nng h hp, my o nng bo

ha xy ngoi vi (pulse oximetry)

Dng c in qu n n my gy m

3.8 o d ng, lm sch, tit khun hoc kh khun cc thnh phn ca my

gy m theo hng dn ca nh sn xut.

3.9 Kh khun h thng th ca my gy m bao gm dy th, bung v cht

hp thu CO2, bng th (bellow) v ng ng, b phn lm m, van hn ch p lc

v cc b phn ph khc: mt n, bng d tr , b phn lm m sau khi dng cho

ngi bnh.

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4. Phng ng y nhim do nhn vin y t

4.1 V sinh tay

Tun th theo 5 thi im v sinh tay ca T chc Y t th gii: sau khi tip

xc vi nim mc, cht tit ng h hp hoc nh ng vt dng b dnh cht tit

ng h hp d c mang gng hoc khng, trc v sau khi tip xc vi ngi bnh

c t ni kh qun hoc m kh qun, trc v sau khi tip xc vi bt k dng c h

hp no c dng cho ngi bnh.

4.2 Mang gng

Mang gng khi tip xc bng tay vi cht tit ng h hp, hoc nh ng dng

c c dnh cht tit ng h hp. Mang gng v khun khi ht m qua ni kh qun

hoc ng m kh qun

Thay gng v v sinh tay gi a cc ln tip xc vi ngi bnh, sau khi tip xc

vi cht tit ng h hp hoc nh ng dng c c dnh cht tit ng h hp, sau

khi dn lu, nc trong dy my th, by nc.

4.3 Cc phng tin phng h khc

Mc o chong khi d on c th b dnh cht tit ng h hp ca ngi

bnh, thay o chong sau khi tip xc v trc khi chm sc ngi bnh khc. Mang

khu trang, mng che mt, mt knh bo v khi d on c kh nng b vng bn mu

hoc dch tit ln mt mi ming.

5. Ch m s c ngi bnh hn m, phng ng vim phi do ht phi

5.1 t ngi bnh t th nm nghing u cao (semirecumbent) 300 - 450

nu khng c chng ch nh.

5.2 V sinh rng ming bng dung dch st khun, tt nht dng Chlohexidine

0,12%. Nu s dng bn chi, chm sc rng ming ngy ln; nu ch dng gc,

chm sc rng ming mi 2 - 4 gi. (Ph lc 4)

5.3 ng ng ht m v khun cho mi ln ht hoc h thng ht m kn

nu c iu kin. Tt nht mi ng ht ch a vo ng th 1 ln ht. ng nc

10

v khun lm sch cht tit ca ng ht m trong qu trnh ht. Khng nn bm

nc vo trc khi ht. Thay dy ni t ng ht n my ht hng ngy hoc khi

dng cho ngi bnh khc. Thay bnh ht mi 4 gi v thay khi dng cho ngi

bnh khc tr khi dng trong thi gian ngn (v d ngi bnh hu phu).

5.4 Thng xuyn kim tra ng thng nui n xem c nm ng v tr khng,

nh gi nhu ng rut bng cch nghe, kim tra th tch ng ca d dy iu

ch nh th tch v tc nui n trnh hin tng tro ngc, ngng cho n khi d dy

cng hoc khng c nhu ng rut.

6. Ch m s c ngi bnh c t ni kh qun, m kh qun, thng kh h tr khc

a) Ngi bnh c t ni kh qun

6.1 Ht sch cht tit vng ming, hu h ng trc khi t v rt ng ni kh

qun. Vi ni kh qun c bng chn phi ht trc khi x bng chn.

6.2 Ngng cho n qua ng v rt ng ni kh qun, rt canuyn m kh qun, ng

thng d dy, ng thng hng trng khi nh ng ch nh ht.

6.3 Nu tin lng cn ni kh qun di ngy, nn dng ng ni kh qun c

thm dy ht trn bng chn ht cht tit vng di thanh qun.

6.4 Ch c nh tt ng ni kh qun sau khi t.

b) Ngi bnh m kh qun

6.5 M kh qun trong iu kin v khun.

6.6 Khi thay canuyn m kh qun: ng k thut v khun v thay bng canuyn

khc tit khun hoc kh khun mc cao nu dng li. Thay bng v c nh

canuyn m kh qun ng k thut.

6.7 Che canuyn m kh qun bng gc v khun hoc bng dng c che chuyn dng.

c) Ngi bnh c thng kh nhn t o

6.8 Nn s dng thng kh h tr khng xm nhp cho nh ng ngi bnh nu

khng c chng ch nh.

11

6.9 Dn lu v thng xuyn nc ng trong dy th, b phn cha nc

ng, by nc.

6.10 Khi ht m hoc dn lu nc ng trong dy th, tho dy th, ch

thao tc trnh lm chy nc ngc t dy th vo ng ni kh qun.

6.11 Dy th phi v tr thp hn phn trn ca ng ni kh qun.

6.12 S dng nc v khun cho vo b lm m ca my th. Khng c

nc trn mc vch quy nh.

6.13 C th s dng b trao i m nhit (mi nhn to) thay cho b lm m

nhit. Thay thng quy b trao i m nhit mi 48 gi. Thay khi thy bn hoc khi

b ri lon chc nng.

6.14 Nn s dng l c vi khun gi a dy th v my th l c vi khun giai

on ht vo v trnh a cht tit vo my th v l c vi khun nhnh th ra ca

dy th trnh ly nhim cho mi trng.

6.15 Thay dy th v b lm m khi thy bn hoc khi dy khng cn hot ng

tt. Thay ngay sau khi s dng cho ngi bnh v kh khun mc cao hoc tit

khun trc khi dng cho ngi bnh. Khng cn thay thng quy dy th cho mt

ngi bnh.

6.16 Nu c s dng bng phi gi th phi thay hng ngy.

7. Ch m s c ng h hp cho ngi bnh h u phu

7.1 Hng dn ngi bnh trc khi phu thut c bit nh ng ngi bnh c

nguy c vim phi cao cch tp ho, th su.

7.2 Khuyn khch ngi bnh hu phu ho thng xuyn, th su, thay i t

th tr khi c chng ch nh. Kt hp vt l tr liu cho ngi bnh c nguy c vim

phi cao.

7.3 Cn kim sot au hu phu tt v au lm ngi bnh khng dm th su, ho.

8. Cc bin php d phng khc

8.1 Nn chng nga vacxin ph cu cho nh ng ngi bnh c nguy c cao b

cc bin chng khi nhim ph cu. Ngi bnh c nguy c cao bao gm tui 65, c

bnh phi hoc bnh tim mch mn tnh, tiu ng, nghin ru, x gan, suy gim

min dch, ct lch hoc lch mt chc nng, nhim HIV...

12

8.2 Khng dng thng quy khng sinh ton thn vi mc ch d phng

VPBV.

8.3 Khi nghi ng hoc c dch VP V, cn iu tra v c bin php cch ly kp thi

8.4 Hn ch s dng thuc an thn khi khng cn thit

T m tt cc bin php chnh trong phng ng VPBV

1. V sinh tay trc v sau khi tip xc ngi bnh v bt k dng c h

hp ang s dng cho ngi bnh

2. V sinh rng ming bng bn chi ngy ln hoc bng gc mi -4

gi ln bng dung dch kh khun

3. Rt cc ng ni kh qun, ng m kh qun, ng nui n, cai my th

cng sm cng tt khi c ch nh

4. Nm u cao 3 o-45o nu khng c chng ch nh

5. Nn s dng dng c chm sc h hp dng mt ln hoc tit khun

kh khun mc cao cc dng c s dng li

6. nc tn lu trong ng dy my th, by nc thng xuyn

7. y th phi v tr thp hn phn trn ca ng ni kh qun.

8. Thng xuyn kim tra tnh trng ng ca d dy trc khi cho n

qua ng

9. Gim st v phn hi ca VP V

13

Ph c 1: Tiu chun chn on vim phi bnh vin trn ngi bnh

ngi n theo tiu chun c CDC 2003

Vim Phi lin quan n th my l vim phi mc phi trong bnh vin, xy ra trong vng

48 gi sau t ni kh qun hoc th my. Tiu chun chn on Vim phi mc phi trong

bnh vin trn ngi bnh ngi ln nh sau:

Tiu chun 1: Vim phi xc nh trn lm sng

Tiu chun : Vim phi do nh ng vi khun thng gp

Tiu chun 3: Vim phi trn nh ng ngi bnh suy gim min dch

Cc tiu chun chn on

Tiu chun 1: Vim phi xc nh trn m s ng

Xquang Triu chng m s ng

Chng II

Hai hay nhiu phim Xquang phi c t nht mt trong cc du hiu sau:

thm nhim mi hay tin trin v k o di ng c to hang trn dch mng phi

Ch : nu ngi bnh khng c suy gim min dch, ch cn c thay i trn XQuang l c th chn on

c t nht mt trong cc triu chng sau - St (>38 C) m khng c nguyn nhn no khc - BC gim (< 4000/mm3) hoc tng (>1 mm3) - Ngi ln > 70 tui c thay i tri gic m khng c

nguyn nhn no khc

V

t nht trong cc triu chng sau:

- Xut hin m m hay thay i tnh cht ca m hay tng bi tit hay gia tng nhu cu cn ht m

- Xut hin ho hoc ho tng ln, hoc kh th hoc th nhanh

- C rales

- Kh mu xu i ( v d PaO FiO < 4 ) tng nhu cu Oxygen hoc tng nhu cu my th

14

Tiu chun 2 : Vim phi do nhng vi khun thng gp

Xquang Triu chng/ Xt nghim Xt nghim

Hai hay nhiu phim Xquang phi c t nht mt trong cc du hiu sau : thm nhim mi hay tin trin v k o di

ng c to hang trn dch mng phi

Ch : nu ngi bnhkhng c bnh phi hoc bnh tim i km (COPD, suy tim), ch cn mt XQuang thay i l c th chn on

c t nht mt trong cc triu chng sau

- St (>380C ) m khng c nguyn nhn no khc

- BC gim (< 4000/mm3) hoc tng (>1 mm3)

- Ngi ln > 70 tui c thay i tri gic m khng c nguyn nhn no khc

V

t nht 1 trong cc triu chng sau:



- C rales

- Kh mu xu i ( v d PaO2/ FiO2 < 241) tng nhu cu Oxygen hoc tng nhu cu my th

c t nht mt trong cc kt qu sau : Cy mu dng tnh khng lin quan n cc ngun nhim khun khc Cy dch mng phi dng tnh

Cy nh lng dng tnh bng phng php ly m qua ra ph nang hay chi c bo v

Soi ti trc tip (nhum Gram) c > 5 t bo t ra ph nang c cha vi khun ni bo

M h c c t nht 1 trong cc triu chng vim phi - To abces, hang hay ng c c tch t bach cu a nhn trung tnh trong tiu ph qun - Cy nhu m phi nh lng dng tnh - ng chng xm ln nhu m phi do nm fungal hyphae hoc pseudohyphae

15

Tiu chun 2b: Vim phi do virus, Legione v nhng vi khun khc


Hai hay nhiu phim Xquang phi c t nht mt trong cc du hiu sau : thm nhim mi hay tin trin v ko di

ng c to hang trn dch mng phi

Ch : nu ngi bnh khng c bnh phi hoc bnh tim i km (COPD, suy tim), ch cn mt phim XQuang thay

i l c th chn on

c t nht mt trong cc triu chng sau

- St (>38 C ) m khng c nguyn nhn no khc

- BC gim (< 4000/mm3) hoc tng (>1 mm3)

- Ngi ln > 70 tui c thay i tri gic m khng c nguyn nhn no khc

V

t nht trong cc triu chng sau:



- C rales

- Kh mu xu i ( v d PaO2 / FiO2 < 241) tng nhu cu Oxygen hoc tng nhu cu my th

c t nht mt trong cc kt qu sau : Cy dng tnh vi virus hoc Chlamydia t dch tit h hp Pht hin dng tnh vi khng nguyn virus hay khng

th t dch tit h hp (v d EIA. FAMA, shell vial assay,

PCR)

16

Tiu chun 3: Vim phi trn nhng ngi bnh suy gim min dch


1 phim Xquang phi c t nht mt trong cc du hiu sau :

thm nhim mi hay tin trin v ko di

ng c

to hang

trn dch mng phi

t nht 1 trong cc triu chng sau trn ngi bnh suy gim min dch:

St (> 380C ) m khng c nguyn nhn no khc

Ngi ln > 70 tui c thay i tri gic m khng c nguyn

nhn no khc

Xut hin m m hay thay i tnh cht ca m hay tng bi tit hay gia tng nhu cu cn ht m

Xut hin ho hoc ho tng ln, hoc kh th hoc th nhanh

C rales

Kh mu xu i (v d PaO2 /FiO2

17

Ph c 2: Bng ki m thc h nh m s ng phng vim phi bnh vin

Ch m s c ng n C Khng Khng p dng

Ghi

ch

1 Thc n c d tr ng theo khuyn co nh sn xut

2 Ra tay trc khi chun b thc n hoc thao tc vi ng n

3 ng n c trng bng nc v khun

5 S dng ng bm sch mi ln rt dch

6 Thc n ch bin c cho n trong vng 4 gi

7 Thng xuyn kim tra v tr ng n

8 Rt dch tn lu trc khi cho n qua ng

9 Thng xuyn kim tra tnh trng dch ng trong d dy

Ch m s c ng ni kh qun

1 Ngi bnh c nm u cao nu khng c chng ch nh

2 Ra tay khi chm sc ng ni kh qun

3 m bng chn sau khi t ng

5 V sinh rng ming theo hng dn

6 S dng gng v khun, ra tay khi ht m

7 Kim tra thung xuyn quyt nh c th rt ng NKQ sm

8 Ht sch m vng hu h ng trc khi x bng chn rt NKQ

Oxy tng

1 Khng c nc khi khng s dng

2 Dng nc v khun cho vo bnh

2 Khng c bi bm trn bnh Oxy

4 nh lm m c thay mi 4 gi, v khi cho ngi bnh mi

Dy th

1 Ra tay khi chm sc dy th

2 b nc ng trong dy th, by nc

3 phn mi nhn to, l c khng b m nc

5 Thay dy khi dng cho ngi bnh khc

6 Kh khun mc cao ton b h thng dy th

7 y th phi v tr thp hn phn trn ca ng ni kh qun.

8 Cho nc v khun vo bnh lm m

9 Kim tra dy th c c tit khun, kh khun mc cao trc khi s dng

18

Ph c 3: Quy trnh kh khun dng c s u th my

Kt thc th my

Tho ng ni my th, bnh lm m ra kh i thn my

X sch, c ra dng c bng dung dch ty ra

Lau kh, ngm ha cht kh khun mc

cao

Gi kh khun mc cao hoc tit

khun ti n v Tit khun trung tm

ng c cn s dng ngay

ng c c c s thay

Lm kh, ng gi, bo qun

Trng nc v khun

Lu tr , phn pht

19

Ph c 4: Bng theo di v sinh r ng ming

Th hai

Ngy_____

Th ba

Ngy_____

Th t

Ngy_____

Th nm

Ngy____

Th su

Ngy____

Th by

Ngy____

Ch nht

Ngy____

nh rng mi

1 gi

K tn

0800_____

2000_____

K tn

0800_____

2000_____

K tn

0800_____

2000_____

K tn

0800_____

1200_____

K tn

0800_____

1200_____

K tn

0800_____

1200_____

K tn

0800_____

1200_____

Chm sc rng

ming mi 4

gi bng dung

dch st khun

Thi gian v

k tn

__________

__________

__________

__________

__________

__________

__________

__________

__________

__________

__________

__________

Thi gian

v k tn

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

Thi gian

v k tn

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

Thi gian

v k tn

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

Thi gian

v k tn

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

Thi gian

v k tn

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

Thi gian

v k tn

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

_________

Ghi ch

20

T i iu th m kho

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care units using the Institute for Healthcare Improvement bundle. Am J Infect Control.

2010 Sep;38(7):552-6. Epub 2010 Apr 18.

2. Craven DE, Kunches LM, Kilinsky V, Lichtenberg DA, Make BJ, McCabe WR (1986). Risk

factors for pneumonia and fatality in patients receiving continuous mechanical ventilation.

Am Rev Respir Dis. 133: 792-796.

3. Craven DE, Steger KA, Barat LM, Duncan RA. Nosocomial pneumonia: epidemiology and

infection control. Intensive Care Med. 1992; 18(suppl 1): S3-S9.

4. Fagon JY, Chastre J, Hance AJ, Montravers P, Novara A, Gibert C. Nosocomial pneumonia

in ventilated patients: a cohort study evaluating attributable mortality and hospital stay. Am J

Med, 1993; 94: 281288.

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Med, 1993; 94: 281288.

6. Fox, M. Toward a zero VAP rate. Critical Care Nursing Quarterly, 2006; 29(2), 108-114.

7. Guide to the Elimination of Ventilator-Associated Pneumonia, APIC 2009

8. Guidelines for Preventing Health Care Associated Pneumonia, CDC, HICPAC 2003

9. Guidelines for prevention of nosocomial pneumonia. Centers for Disease Control and

Prevention.MMWR Recomm Rep 1997; 46(RR-1): 1-79.

10. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated and

Health Care Associated Pneumonia, American Thoracic Society Documents 2005

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