B Y T TRNG I HC DC H NI NGUYN THY GIANG KHO ST CCH S DNGTHUC CHNG UNG THTI KHOA PH UNG THBNH VIN PH SN TRUNG NG KHA LUN TT NGHIP DC S H NI- 2014 B Y T TRNG I HC DC H NI NGUYN THY GIANG KHO ST CCH S DNGTHUC CHNG UNG THTI KHOA PH UNG THBNH VIN PH SN TRUNG NG KHA LUN TT NGHIP DC S Ngi hng dn: 1.ThS. Trnh Trung Hiu 2.ThS. Thn Th Hi H Ni thc hin: 1.B mn Dc lm sng-Trng i hc Dc H Ni 2.Bnh vin Ph sn Trung ng H NI 2014 Li cm n Liutin,tixinchnthnhbytlngbitnsusctinhngngithy: ThS.TrnhTrungHiuBmnDclmsng,TrngihcDcHNi, ThS.ThnThHiHKhoaDcBnhvinPhsnTrungngvThS.Cao Th Bch Tho B mn Dc lm sng, Trng i hc Dc H Ni trc tip ng vin, hng dn, ch bo ti trong sut qu trnh thc hin v hon thnh kho lun tt nghip ny. TicngxinchnthnhcmnccthycgiocabmnDclmsng Trng i hc Dc H Ni nhng ngi thy lun sn sng chia s nhng kh khn, vng mc ca ti trong qu trnh hc tp cng nh qu trnh lm kho lun. Ti xin trn trng gi li cm n n ton th cc bc s, dc s, iu dng, cn b cng nhn vin ang cng tc ti khoa Dc, khoa Ph ung th, phng K hoch tng hp gip , to iu kin thun li nht cho ti trong sut qu trnh nghin cu. Cui cng, kho lun tt nghip ca ti s khng th hon thnh nu thiu s ng vin,gipcagianhvbnb.Cmnnhngngibnlunstcnh,s chia vi ti trongmihon cnh v c bitcmn bm lun bn con trong sut cuc i.H Ni, ngy 14 thng 05 nm 2014 Sinh vin

Nguyn Thy Giang MC LC T VN ............................................................................................................ 1 PHN 1.TNG QUAN ........................................................................................... 2 1.1.Mt s khi nim lin quan n thuc chng ung th ............................. 2 1.1.1.Thuc gy c t bo (Cytotoxic drugs) ................................................. 2 1.1.2.Thuc c hi (Hazardous drugs) .......................................................... 2 1.2.Sai st lin quan n thuc chng ung th................................................ 3 1.2.1.Sai st lin quan n thuc ..................................................................... 3 1.2.2.Sai st trong giai on k n ................................................................ 4 1.2.3.Sai st trong pha ch v thc hin thuc ................................................ 6 1.3.Nguy c phi nhim vi thuc c hi ...................................................... 7 1.3.1.Phi nhim ngh nghip vi thuc c hi ............................................ 7 1.3.2.nh hng ca vic phi nhim vi cc thuc c hi .......................... 9 1.3.3.Bin php phng trnh phi nhim vi thuc c hi ......................... 10 1.4.Tiu chun thc hnh trong pha ch v thc hin thuc chng ung th 12 1.4.1.Tiu chun thc hnh trong pha ch thuc chng ung th .................. 12 1.4.2.Tiu chun thc hnh trong thc hin thuc chng ung th ................ 13 PHN 2.I TNG V PHNG PHP NGHIN CU ......................... 14 2.1.Kho st ch nh thuc chng ung th ca bc s ................................. 14 2.1.1.Mc tiu nghin cu ............................................................................. 14 2.1.2.i tng nghin cu ........................................................................... 14 2.1.3.Phng php nghin cu ...................................................................... 14 2.1.4.Ch tiu nghin cu ............................................................................... 14 2.2.Kho st quy trnh pha ch v thc hin thuc chng ung th ca iu dng .................................................................................................................... 15 2.2.1.Mc tiu nghin cu ............................................................................. 15 2.2.2.i tng nghin cu ........................................................................... 15 2.2.3.Phng php nghin cu ...................................................................... 15 2.2.4.Ch tiu nghin cu ............................................................................... 16 2.2.5.X tr khi pht hin nhng sai lch nghim trng ................................ 17 2.3.Phng php x l s liu ......................................................................... 17 PHN 3.KT QU................................................................................................ 18 3.1.Kho st ch nh thuc chng ung th ca bc s ................................. 18 3.1.1.c im mu nghin cu .................................................................... 18 3.1.2.c im chung v ch nh ng dng, dung mi, tc ................ 18 3.1.3.c im la chn thuc chng ung th trong bnh n ...................... 20 3.1.4.c im la chn ng dng thuc .................................................. 21 3.1.5.c im la chn dung mi ha tan v dung mi pha long ............. 21 3.1.6.c im ch nh tc tim truyn ................................................... 24 3.1.7.Nguy c gp tng k ca cc thuc trong n .................................... 24 3.2.Kho st quy trnh pha ch v thc hin thuc chng ung th ca iu dng .................................................................................................................... 26 3.2.1.c im mu nghin cu .................................................................... 26 3.2.2.Sai lch trong pha ch v thc hin thuc chng ung th ca iu dng26 3.2.3.Sai lch trong qu trnh pha ch thuc ................................................. 27 3.2.4.Sai lch trong thc hin thuc .............................................................. 29 3.2.5.Vic thc hin k thut v khun trong pha ch v thc hin thuc .... 29 3.2.6.Vn bo h c nhn trong thao tc vi thuc chng ung th .......... 30 PHN 4.BN LUN ............................................................................................. 32 4.1.Kho st ch nh s dng thuc chng ung th ca bc s .................. 32 4.2.Kho st quy trnh pha ch v thc hin thuc chng ung th ca iu dng .................................................................................................................... 34 KT LUN V XUT .................................................................................... 40 Danh mc cc k hiu, ch vit tt ASHP(American Society of Health-System Pharmacists) Hi Dc s M ASCO(American Society of Clinical Oncology) Hi Ung th lm sng M BCCA(British Columbia Cancer Agency) C quan Ung th British Columbia BSC(Biological safety cabinet) T an ton sinh hc CAPhO(Canadian Association of Pharmacy in Oncology) Hi Ung th Dc Canada COSA(Clinical Oncological Society of Australia) Hi Ung th lm sng c ISOPP(International Society of Oncology Pharmacy Practitioners Standards Committee) Hip hi Quc t ca y ban tiu chun Dc hc Ung th NIOSH(National Institute for Occupational Safety and Health) Vin an ton lao ng v sc khe quc gia M OSHA(Occupational Safety and Health Administration) Cc an ton lao ng v sc khe M SHPA(Society of Hospital Pharmacists of Australia) Hi Dc s bnh vin c Danh mc cc bng Bng 2.1. Phn loi sai lch trong s dng thuc Bng 3.1. c im v chn on ca bnh nhn trong nghin cu Bng 3.2. T l cc thuc chng ung th c ch nh trong bnh n Bng 3.3. c im ch nh ng dng cc thuc chng ung th c ch nh Bng3.4.cimlachndungmiphalongchoccthucchngungth truyn tnh mch Bng 3.5. c im la chn th tch dung mi so vi khuyn co Bng 3.6. c im la chn tc truyn so vi khuyn co Bng 3.7. Cc trng hp ch nh c nguy c gy tng k Bng 3.8. c im quan st pha ch v thc hin thuc ca iu dng Bng 3.9. Sai lch trong pha ch v thc hin thuc chng ung th ca iu dng Bng 3.10. T l sai lch trong giai on pha ch thuc chng ung th ca iu dng Bng 3.11. T l sai lch trong giai on thc hin thuc chng ung th ca iu dng Bng 3.12. K thut v khun trong pha ch v thc hin thuc ca iu dng Bng3.13.Tlthchinccbinphpbohcnhntrongthaotcvithuc chng ung th ca iu dng Danh mc hnh Hnh 3.1. c im chung v cc ch nh khng ph hp trong bnh n 1 T VN Sai st lin quan n thuc c quan tm t lu. Trong , sai st lin quan n thuc chng ung th l mt vn rt quan trng do vic s dng thuc chng ung th phc tp hn so vi nhiu thuc. Nguyn nhn l do cc thuc ny thng c ch s iu tr hp; c tnh cao d liu iu tr [46]. Trong mt nghin cu, sai sttrongsdngccthucchngungthlnguynnhnphbinngthhai trongccsaistvthucdnntvong(chim15.4%strnghptvong) [52].Bn cnh , qu trnh s dng thuc chng ung th cho bnh nhn cn c th gy cc nh hng bt li ln sc khe ca cc nhn vin y t tip xc vi nhm thuc nytrongbtcthiimnocaqutrnhphnphi,phach,thchinthuc. Trn th gii v trong khu vc, vic pha ch thuc cho ha tr liu c thc hin tp trung ti khoa Dc v cho kt qu rt tt trn c ba mt an ton, hiu qu v tit kim. Thc t ti hu ht cc bnh vin Vit Nam, trong c bnh vin Ph sn Trung ng, victin hnhchun b thuc cho ha tr liu c thc hin ti cc khoa lm sng v ngi thc hin l nhn vin iu dng. Ti thi im kho st, bnh vin cng cha c mt hng dn c th v k n, pha ch v thc hin thuc chng ung th.Xut pht t thc t trn, chng ti tin hnh nghin cu ti Kho st cch s dngthucchngungthtikhoaPhungthBnhvinphsnTrungng vi mc tiu -Kho st ch nh thuc chng ung th ca bc s trn bnh n -Kho st quy trnh pha ch v thc hin thuc chng ung th ca iu dng tin ti ra mt quytrnh chun pha ch v thc hinthuc chng ung th, tng cng hiu qu, an ton trong qu trnh s dng thuc. 2 PHN 1. TNG QUAN 1.1.Mt s khi nim lin quan 1.1.1.Thuc gy c t bo (Cytotoxic drugs) Thuc gy c t bo (thuc ha tr liu-chemotherapy drugs, thuc chng ung th-antineoplastic drugs) l cc ha cht tc ng n s ln ln v sinh si ca t bo, hu ht trong s hoc lin quan trc tip n vt liu di truyn trong nhn t bo, hoc nh hng n s tng hp protein ca t bo. Thng thng,thuc gy c t bo khng phn bit gia t bo bnh thng v t bo ung th [34]. Thuc gy c t bo thng c dng cho bnh nhn suy gim min dch, v dohuhtccloithucnyucchty,vicnycthtbnhnhnvo nguy c cao pht trin nhim khun nng. V l do ny, khi pha chthuc gy c tbotim,kthutvtrngphithchinttngnnganhimkhun. Ngoi ra, do hu ht cc hot cht u c ch s iu tr hp, chnh xc ca vic chun b thuc phi c m bo [34]. 1.1.2.Thuc c hi (Hazardous drugs) TheoAHSP,mtchtchitisckhecnhnghalmtchtc bngchngxcthcvmtthngk,datrntnhtmtnghincutinhnh trn cc nguyn tc khoa hc c nh trc, c kh nng gy ra cc tc ng cp hoc mn tnh ln sc khe ngi lao ng tip xc vi n, bao gm cc cht ha hc gy ung th, cc tc nhn c c tnh cao, cc c t i vi sinh sn, cc cht gy kch thch, cc cht n mn, cht gy nhy cm (sensitizer), v tc nhn gy ra tc ng ln c quan ch [7]. TheoISOPP,trongvnphinhimnghnghip,thucchicnh ngha l mt thuc gy ra nguy him cho nhn vin y t do c tnh vn c ca n. Nhngthucnycxcnhdatrnmthochnbncimsauy:l nhngchtgyungth;gyclngen;gyquithai;hocchiliuthp trn m hnh ng vt hoc trn nhng bnh nhn c iu tr [34]. 3 Thuc c hi bao gm cc thuc chng ung th, thuc gy c t bo v mt s tc nhn khc. Mi b phn nhng ni lm vic cung cp dch v pha ch v thc hin thuc cn phi c mt danh sch cc loi thuc c hi c yu cu thao tc c bit [7]. 1.2.Sai st lin quan n thuc chng ung th 1.2.1.Sai st lin quan n thuc Sai st thuc c nh ngha l bt c s kin no c th ngn chn c m c th dn n sdng thuc khng thchhphoc gyhi cho bnh nhn trong khi thuc c s dng bi ca chuyn gia chm sc sc khe, bnh nhn hoc ngi tiu dng [8].Mt bo co ca Vin Y hc M (Institue of Medicine) c tnh rng khong t 44000 n 98000 ca bnh nhn t vong mi nm M do sai st y khoa, nhiu hn do tai nn giao thng, do ung th v hay do bnh AIDS [41]. D mt s trng hp l khng th trnh c, nhiu trng hp th c th ngn chn c, trong sai st v thuc l mt nguyn nhn chnh dn n nhng s c nh th [14]. Sai st v thuclmttrongnhngloisaistnghimtrngnhtvgyranhngthithi ng k [68]. Sai st v thuc i vi cc thuc chng ung th c th tr nn c bit nghim trng do (1) rt nhiu thuc c ch s iu tr hp; (2) c tnh cao d liu iu tr; (3) phc ha tr liu rt l phc tp; v (4) bnh nhn ung th l nhm d b nh hng bt li do h c kh nng chu ng km [46]. Trong mt nghin cu, sai st lin quan n cc thuc chng ung th l nguyn nhn ph bin ng th hai trong ccsaistvthucdnntvong(chim15,4%strnghptvong)[52]. Gn y, ngi ta c tnh rng 500 trng hp t vong xy ra mi nm do sai st v thuc lin quan n ha tr liu ung th v ch c 3% cc sai st c bo co [20] Bncnhvnbnhttvtvong,chiphhngnmdnhchoiutrcc phn ng ph do sai st v thuc c th ngn chn c c c tnh khong 17-4 29 t la mi nm [41]. Sai st v thuc l tn km cho bnh nhn, gia nh ca h, cho bnh vin, nhn vin chm sc sc khe, cc cng ty bo him, d vn cn c rt t cc c tnh tin cy v cc chi ph ny [12]. Ring i vi sai st v thuc ln quan n ha tr liu, mt nghin cu c tnh rng nu cc li b ngn chn khng c pht hin ra, h s c kt qul thi gian nm vinko dithm 216 ngy v chi ph c tnh hng nm tiu tn tng cng 92907 euro, bao gm 69248 euro (74%) cho chi ph nm vin v 23658 euro (26%) cho cc loi thuc b sung [53]. Saistvthuccthxyrabtcgiaionnotrongqutrnhsdng thuc, t k n cho n pha ch, phn phi v thc hin thuc trn bnh nhn. Hn th na, quy trnh s dng thuc lin quan n ton b i ng nhn vin y t, bc s, dc s, y t [47]. Sai st trong ha tr liu xy ra do rt nhiu nguyn nhn, bao gmtruyntsaichnhthucbngli,thiuthngtinvtnhtrngsckhe bnh nhn, s dng sai thng tin bnh nhn hocsai kt qu xt nghim, ng gi vghinhnkhngtchundonhsnxut,nvittaykhngcc,tn thuc nhn, pht m tng t nhau, s dng tn thuc vit tt, li sao chp v tnh sai liu, li khi thc hin thuc [38]. Hin nay trn th gii, cng tc phng chng sai st lin quan nthuc chng ung th c coi l mt u tin trong cc bnh vin [9], vi nhiuti liukhuyn co, hng dn c xut bn gim thiu kh nng xy ra sai st [18], [20], [30], [35]. Cc hng dn ny bao gm cc khuyn ngh cho mt h thng phng php tip cn a ngnh bao gm gim st s dng thuc, hng dn k n, phng php pha ch v phn pht, v thc hin thuc. 1.2.2.Sai st trong giai on k n Ha tr liu c a k da trn phc v s dng trn nhiu chu k lp i lp li. Cc thuc c k thng c hot tnh mnh v c hi, v thng c dng dng dch truyn. Liu lng thng c k da trn din tch b mt c th bnh nhn v/hoc chc nng thn. Do s phc tp ca cc phc hin c, nhiu sai st 5 c th xy ra trong k n, v cc sai st ny c kh nng dn n nhng hu qu nghim trng. Sai st trong k n c bo co l mt trong nhng nguyn nhn ph bin nht trong ccsai st trong ha tr liu. Mt nghin cu v sai sttrong s dngthuc gyctbongtimtruynchothy42%ssaistvthucxyragiai on k n ca bc s [29]. Trong mt nghin cu Ty Ban Nha, sai st v thuc c pht hin trn 17,2% s bnh nhn ha tr liu, trong 75,7% l sai st trong giai on k n thuc [58]. Trong mt nghin cu khc, sai st trong k n thuc ha tr liu chim t l cao nht (45,14%), trong ph bin nht l thiu liu (32,32%), qu liu (16,16%) v o liu (dose reversal) (11,11%) [71]. Nghin cu ca Daz-Carrasco 2007 cho kt quccsaisttrongknthuchatrliul:sailiu(38.5%),thiuthuc (21.5%), sai thuc (11.1%), li v tn sut v thi gian ca t iu tr (9.6% mi loi), sai bnh nhn (7,4%), sai tc dng thuc (1,5%) v sai ng dng thuc (0,7%). Tt c li ny u c phn vo mc nghim trng B (c sai st xy ra nhngsaistnykhngticbnhnhn)dochngcphthinbikhoa Dctrckhiphnphithuc.tnht66/135licthgyraccphnng khng mong mun tim n [25]. Trongmtnghincuvsaisttrongknhatrliuvvaitrcacng ngh thng tin trong k n, sai st k n bao gm k n khng thch hp (khng c thng tin khuyn khch s dng ch iu tr c k; n c kh nng gy ra cctngtcthuc,dngthucchi),nkhngy(thiuliu,nv, ng dng, loi v th tch dung mi, thi gian truyn), k n sai (sai thuc, sai liu,sainv,ngdng,loivthtchdungmi,thigiantruyn).Ktqu canghincunychothynkhngy(thiungdng,thtchdung mi, s lng thuc vin) chim t l cao nht, sau l k n sai (ch yu l sai liu)vknkhngthchhp.Phnlnccsaistnyuccholngn chn c. 72% sai st c xt l t gy nguy hi, 3% c kh nng gy thng tn ln hoc nghim trng [4]. 6 TrongnghincucaSlama(2005)vsaisttrongknvsphhpca cc phng php phn loi sai st trong k n thuc gy c t bo, sai st trong k n c phn loi thnh cc sai st lin quan n phc (thuc khng hp l, thiu thuc, sai liu, sai thi gian t iu tr), sai st lin quan n tnh cht l ha (nng thuc ca dung dch cui cng, tng k), sai st lin quan n thc hin thuc (sai ng dng so vi phc , sai/thiu thi gian s dng)v sai st khc (nkhngthngtinhockhngcc).Ktquchothysaistchyu lin quan n tnh cht l ha ca ch phm (73,9%). Vic s dng h thng k n my tnh c th lm gim thiu cc sai st ny [60]. Cnhiunguynnhngyrasaisttrongknthuc,nhsmttptrung tronglckn,khngpdngccquynhclinquan,mitrnglmvic, khi lng cng vic p lc cao, vn th cht v tinh thn, thiu kin thc, cha nhn thc r vai tr ca k n [23]. Cc sai st trong k n nu khng c pht hin ra c th gy ra cc sai st trong thc hnh v nh hng n bnh nhn, tuy nhintheodliutrongcsdliuMEDMARXcaBcM,chc17,7%li tronggiaionknthcstcngctibnhnhndoccsaistnyc th c pht hin v ngn chn bi i ng dc s v iu dng trong qu trnh xc nhn, phn phi v s dng thuc sau [33]. 1.2.3.Sai st trong pha ch v thc hin thuc Giai on pha ch v thc hin thuc chng ung th gm nhiu bc phc tp v tim n nhiu nguy c sai st, ccsai st trong giai on ny c thtc ng trc tip ln ngi bnh. Trong cc nghin cu v sai st lin quan n pha ch v thc hin thuc, sai st lin quan n thuc trong giai on nyc nh ngha l cc sai khc trong qu trnh pha ch, thc hin thuc so vi ch nh ca bc s, hng dn ca bnh vin v nh sn xut [22], [51], [62]. Trong nghin cu ca Serrano-Fabia v vai tr ca h thng a ngnh trong pht hinccsaistlinquannthucchngungth,saisttrongphachvthc 7 hinthucchimtll21,0%v1,1%trongtngsccsaist.70%(41/58 trng hp) sai st trong giai on pha ch nh hng n bnh nhn (67,2% l sai st dung mi tng hp khng cn can thip, 3,4% sai st c tc ng thc s ln hiu qu iu tr do thiu liu) trong giai on thc hin thuc l 66,6% (2/3 trng hp). Trong cc sai st nh hng ln bnh nhn, t l ln nht (14,1%) thuc v sai sttrongphachthucdngngtnhmch,cthlphachthucvidung mi khc vi dung mi c quy nh trong phc [58]. Trong nghin cu v sai st lin quan n thuc trong ha tr liu tr em trong csdliuqucgiacaM,saisttronggiaionthchinthucchimtl caonht(48,1%),saulphnphi(30,3%)vkn(10,3%).Tllitrong giai on thc hin thuc cng l ln nht hai nghin cu khc cc n v iu tr ung th (43% v 41%) [24], [28]. Mt nghin cu khc v sai st lin quan n thuc gy c t bo ng ton thn cho thy 42% sai st xy ratrong giai on pha ch thuc khoa dc, 16% l do sai st xy ra trong qu trnh pha ch thuc ca iu dng v s dng thuc cho bnh nhn [29]. Nguyn nhn dn n cc sai st ny c th do thiu trang b, thiu nhn thc v nguy c, thiu kin thc, thng tin v thuc, cng thng, p lc cng vic [24], [55]. 1.3.Nguy c phi nhim vi thuc c hi i vi bnh nhn ung th, li ch ca vic iu tr vt xa so vi nguy c c tnh ca cc thuc chng ung th. Tuy nhin, i vi nhng ngi khe mnh, nguy c phi nhim vi nhng thuc ny gy nn nguy c tim tng i vi sc khe v sinh sn trong tng lai.1.3.1.Phi nhim ngh nghip vi thuc c hi Ngilaongcthbphinhimviccthucchibtkimno trong qu trnh sn xut, vn chuyn,phn phi, giao nhn, lu tr, pha ch v s dng, cng nh trong x l cht thi, bo tr v sa cha thit b [7]. Thuc c th vo c th do ht phi, tip xc vi da, hp thu qua da, tiu ha phi thc phm b 8 nhim hoc chm tay c dnh thuc ln ming, hoc do ngu nhin tim phi. Tip xc v hp thu qua da c th l con ng phi nhim chnh [7], [48]. Nhn vin thao tc vi cc thuc c hi c th ht phi nhng git nh, bi v hi ca thuc. Nhiu thao tc trong quy trnh pha ch v s dng thuc c th sinh ra cc ht kh dung nh rt tim ra khi l, s dng bm v kim tin hoc ng lc lun chuyn thuc, b ng tim [54], tim thuc vo dy truyn tnh mch, loi khkhibmtimhocngtruyn,vrrng,bmtim,hocimni vikhavn,khictkimtimvnghinngtimquasdng[34].Cctiu phnthuccthbayvokhngkhsaukhilmkhkhuvcbnhim.Mts thucchngungthcthbayhicghinhnlcyclophosphamid, carmustin, ifosfamide, thiotepa [34]. Phi nhim vi thuc qua da c th pht sinh do thuc gy c t bo c pha ngoi ca l thuc. Do , mi trng lm vic c th b nhim thuc ngay c trc khi bt u pha ch thuc. Cc nghin cu chng minh rng hu ht cc b mt lm vic vi thuc gy c t bo u b nhim cc loi thuc ny. B mt lm vic trong t an ton sinh hc (BSC), mt trn ca k, sn nh, cc thit b v cc b mt khc c ch ra c b nhim thuc trong nhng nghin cu t cc nc trn th gii. Nguy c ln nht l tip xc trc tip vi thuc qua da trong trng hp c s c trn hoc r r thuc xy ra [34]. Nhn vin y t c th phi nhim vi thuc c hi do v nut phi. Khi thc phmvungcchbin,lutrhoctiuthtrongkhuvclmvic, chng c th d dng b nhimcc tiu phnthuc gy c t bo c trong khng kh. Tng t nh vy, ht thuc l, dng m phm v nhai ko cao su cng c th dn n phi nhim thuc gy c t bo qua ng tiu ha.[34] Ccthaotcnghnghipcthdnnphinhimvithucgyctbo c lit k trong ph lc 1 [49]. 9 1.3.2.nh hng ca vic phi nhim vi cc thuc c hi Nghin cu c tin hnh bi Falcket v cng s trong nhng nm 1970 ch ra rng y t lm vic trong khu vc pha ch v s dng thuc c hi khng c bo hcnngccchtgytbintrongnctiucaohnsovinhngngi khng phi nhim [27]. Nghin cu ny cho rng nhn vin iu dng b phi nhim ngh nghip vi cc thuc gy c t bo, nhiu cht trong gy t bin. Githuytnycxcthcbngnhiunghincukhckimtratbin trong nc tiu, sai lch nhim sc th, trao i cc nhim sc th ch em v cc tiu ch khc trn dc s v y t thao tc vi cc thuc gy c t bo [10], [59], [61].Phi nhim vi cc thuc c hi ti ni lm vic dn n cc phn ng cp tnh v ngn hn, cng nh cc tc ng lu di. Tng quan ca Harrison v nguy c khi thao tc vi thuc gy c t bo nm 2001 cho thy nhng nhn vin y t tip xc viccthucchithnggpphicctriuchngcptnhnhkchngda, auhng,ho,chngmt,nhcu,phnngdng,tiuchy,bunnnvnn [32].Ngoiratnthngganvcctriuchngthnkinhcngcboco trn cc y t lm vic vi ha tr liu trong nhiu nm [11]. TngquancaHarrisonxemxt14nghincunhgicctcdngbtli trn sinh sn i vi nhn vinyt tipxcvi cc thuc c hi,9trong s cc nghincunychothyktqudngtnh.Ccnhhngchnhlnsinhsn c tm thy trong cc nghin cu ny l lm tng sy thai, d tt bm sinh, thiu cn, bnh bm sinh bt thng, v v sinh [32]. Mt nghin cu v nguy hi trn sc khe ca Elshamy v cng s trn cc y t tipxcvithuchatrliubocomtstcngnguyhinsckhe gia cc y t nhm th (y t khoa ung th) v nhm chng (y t khng thuc khoa ung th) nh sau: sy thai (31,4% so vi 10,3%), v sinh v kh c thai (14,3% so vi3,4%),sinhnon(14,3%sovi17,2%),tnthngmmmdosctrnv bn ha cht (14,3% so vi 0,0%), v bt thng trong s pht trin v hnh vi ca con ci ca cc y t (8,6% so vi 3,4%). Mu nc tiu ca y t trong nhm th cho thy c nhiu cht t bin hn so vi nhm chng (40 % so vi 10,3%) [26]. 10 Da trn s bi tit cyclophosphamide qua nc tiu dc sv y t, Bob v Sessink tnh ton s hp thu ton thn ca thuc. Vi mc phi nhim 3.6-18 mg/ngy, nhm tc gi xut s gia tng nguy c ung th t 1.4 n 10 ca ung th trn 1 triu nhn vin mi nm [13]. Theo mt nghin cu khc, phi nhim vi cyclophosphamid 16-80 mg/ngy c th dn n gia tng nguy c ung th c tnh khong thm 7-50 ca ung th trn 1 triu ngi [21].Tnhngnguyctrn,nhiutchc,cquanaracctiliukhuyn co, hng dn v thao tc an ton vi cc thuc c hi/thuc chng ung th cho mi nhn vin y t c lin quan n qu trnh phn phi, s dng cc thuc ny [7], [17], [34], [49], [54], [64], [69]. 1.3.3.Bin php phng trnh phi nhim vi thuc c hi Vic pha ch, thc hin, hy b thucc hi cn c tin hnhbi cc nhn vin c o to bi bn bo v chnh h, bo v thuc v bo v mi trng. Nhn vin y t cn thc hin ng cc hng dn bo h, s dng cc trang thit b bo h v mc trang phc bo h gim thiu vic gii phng cc phn t thuc c hi vomi trng pha ch, dnh vo sn phm pha ch v gim kh nng phi nhim ca bn thn vi nhm thuc ny. Nhn vin khng c n ung, nhai ko cao su, dng m phm hoc tr n gn khu vc pha ch. Nhn vin ang c thai, d nh c thai hoc ang cho con b nn c chuyn sang lm cc cng vic khckhngphitipxcviccthucchi.Ngiangmcccbnhnhim khun, iu tr bng thuc c ch min dchnn ngng vic pha ch thuc nu c th. Nhn vin nn c cc khong gii lao trong thi gian pha ch thuc duy tr kh nng tp trung [17], [34].Cc trang phc bo h c khuyn co s dng bao gm: Gng tay: nn eo hai lp gng trong bt c qu trnh no thao tc vi thuc c hi nh tip xc vi v hp v l thuc c hi, pha ch v thc hin thuc c hi, x l rc thi t thuc c hi v rc thi tbnh nhn iu tr vithuc ny, lau dnkhilmtrnthuc.Sdngloigngchtlngcao,khngcbt,lmt 11 latex, nitrile, polurethan, neoprene, hoc cc cht liu khc p ng tiu chun cho gng s dng cho ha tr liu. Do tt c cc loi gng u c th thm mt s cht nht nh v kh nng thm tng dn theo thi gian s dng nn cn phi thay gng thng xuyn (mi 30 pht hocmi gi) trong phach/s dng thuc hoc ngay khi gng b rch, thng, nhim ha cht [7], [17], [34], [49], [69]. o bo h: Nnmc o trm bo h trong pha ch, thc hin thuc, x l cht thi t bnh nhn iu tr vi thuc c hi, khi lau dn do trn thuc. o trm cn philmtchtliukhngcxvhybc,thmnckm/khngthm nc, kn hon ton ng trc v c, tay di c chunco gin hoc c tay m va kht. o trm ch mc trong ngy, khng c mc ra khi phng pha ch v phi thay ngay khi c h hi hoc nhim bn [7], [17], [34], [49], [69]. Khu trang: Khu trang nn c dng khi pha ch, thc hin thuc, lau dn ch thuc b trn, lau dn khu vc pha ch hoc bt c khi no c kh nng phi nhim vi thuc. Tuy nhin khu trang phu thut thng thng khng bo v c nhn vin y t khi vic ht phi cc ht kh dung [7], [34], [64], [69]. Thng thng vic pha ch thuc c hi c thc hin trong t BSC m bo an ton cho ngi pha ch, tuy nhin trong trng hp khng c t BSC, OSHA khuyn co s dng mt n c mng lc hiu sut cao gim bt phi nhim do ht phi [69].Knh bo h: Knh c khuyn co s dng khi bt k nguy c vng, bn thuc c hi no c th xy ra.Trong hu ht cc trng hp,mnchnbngknh ca BSCnncungcpysbovkhikhnngdungdchthucchibn, phun ra khi pha thuc. Nhn vin y t cn phi eo knh khi lau vt trn thuc [7], [17], [34], [49], [69]. Cc trang phc bo h khc:m trm tc v giy bo h nn c dngtrong qutrnhphachvkhuntrnhnhimkhunkhuvcphachhoctrong trng hp c th xy ra bt k s nhim thuc c hi no [7], [17], [34]. 12 1.4.Tiu chun thc hnh trong pha ch v thc hin thuc chng ung th 1.4.1.Tiu chun thc hnh trong pha ch thuc chng ung th Vic pha ch phi c tin hnh trong t an ton sinh hc gim thiu vic phi nhimvithucchonhnvin.TrongtrnghpkhngctantonOSHA khuyn cos dngmt n c mng lc hiu sut cao gim btphi nhim do ht phi [69]. Di y l cc hng dn thao tc an ton trong pha ch thuc chng ung th da trn tiu chun ca CAPhO [17]: oRa tay vi x phng v nc, eo gng theo hng dn oLau l thuc bng cn 70% loi b nhim bn thuc c hi oS dng kim tim c th tch ph hp, trnh ht y hn 75% chiu di ng timoMi kim khng dng chc qu 3 ln oKim tra dung dch sau hon nguyn m bo thuc c ha tan hon ton trc khi rt khi l/ng oiuchnhthtchdungdchv/hocloikhtrongkimtrckhirtkimra khi l oy np bm cha thuc khng dng c hai tay, pittong nn c ko xung loi thuc li kim tim v gn vi mt kim tim mi trc khi tim thuc vo ti truyn hoc trc khi a sang khu vc s dng. oCmbdytruynvotitruynchathucchihocxdytruynbng dung dch thuc c hi trong mi trng khng c kim sot cn phi trnh. Nn cm b dy truyn vo ti truyn trc khi thm thuc vo dung dch truyn oHon nguyn thuc trong l: St khun mc cao su vi gc tm cn tit trng, kh hon ton t nht 10 giy dit khun. B mt l phi kh trnh a cn vo trong l S dng k thut rt thuc p lc m hn ch vic thuc thot khi l do p lc trong l qu cao Nnsdnggctittrngtmcnbcquanhkimvnpltrongkhirt thuc khi l 13 oSau khi rt dung dch khi l, lau np l bng gc tm cn loiccgit nh thuc thot ra khi l oThao tc vi ng thuc G vo ng loi b dung dch thuc phn trn c ng thuc Lau c ng thuc bng gc tm cn Sdngthitbbnghocbcgcxungquanhcngbngthuc, khng s dng kp Koucher b ng oKim tra v ghi nhn cho sn phm ng quy nh oRa tay ngay sau khi tho b gng 1.4.2.Tiu chun thc hnh trong thc hin thuc chng ung th (Ngun: ASHP-Guidelines on Handling Hazadous Drugs [7]) oMc trang phc bo h: Ra tay, eo i gng th nht, mc o chong ri eo khu trang, sau eo i gng th hai. oLun lm vic di tm mt oKim tra trc quan thuc trc khi tim truyn otmtmingthmhtcmtsaulmbngplasticdivtrtimtruyn thm thuc r ra v ngn nga thuc tip xc vi da bnh nhn oNu vic x dy truyn c tin hnh khu vc thc hin thuc, x dy truyn bng dung dch tim truyn khng cha thuc c hi oKhi loi kh khi bm tim hoc ng truyn, nn chn u kim tim, bm tim, hoc ng truyn bng bng v trng tm cn thu hi bt c lng thuc chng ung th no c th tnh c thot ra oLun trng dy truyn hoc ng thng/dy truyn trc v sau mi ln thc hin thuc, gia hai thuc, bng dung mi tim truyn thch hp nh NaCl 0.9% hoc glucose 5% oLoibbmtim,chaitruyn(vngnvibdytruyn)sdngvo ti/hp cha rc thi c hi theo quy nh x l cht thi y t oTho v loi b gng cn thn, ra tay sau khi tho gng 14 PHN 2.I TNG V PHNG PHP NGHIN CU 2.1.Kho st ch nh thuc chng ung th ca bc s 2.1.1.Mc tiu nghin cu Kho st ch nh thuc chng ung th ca bc s trn v la chn ng dng, dung mi, th tch, tc tim truyn, kh nng tng k trong n. 2.1.2.i tng nghin cu i tng nghin cu l h s bnh n ca cc bnh nhn c ch nh iu tr bng thuc chng ung th ti khoa Ph ung th bnh vin ph sn Trung ng ra vin t 20/7/2013 n thng 20/2/2014.-Tiu chun la chn: bnh n c lu ti m bnh K v Chorio.-Tiu chun loi tr: cc bnh n t vong. 2.1.3.Phng php nghin cu -Thit k nghin cu: Nghin cu hi cu-Phngphplymu:Lymuthuntin,thngtintrnbnhncghi vo phiu thu thp thng tin bnh n (Ph lc 2). 2.1.4.Ch tiu nghin cu -T l ng dng khng ph hp vi hng dn -T l dung mi khng ph hp vi hng dn -T l la chn tc tim truyn khng ph hp vi hng dn -T l cc ch nh c th gy tng k Vicnhgichnhthucphhp/khngphhpcdatrnthngtin trong ti liu chnh l Australian Injectable drugs handbook 4th ed [16], i chiu v sosnhvithngtintrongcctiliu:AHFSDrugInformation[6],BCCA chemotherapy preparation and stability chart [15], Martindale [57], t hng dn s dng thuc. Cc thng tin ny c tng kt trong Ph lc 4. 15 2.2.Khostquytrnhphachvthchinthucchngungthcaiu dng 2.2.1.Mc tiu nghin cu-Kho st cc sai lch xy ra trong quy trnh pha ch v thc hin thuc chng ung th ca iu dng -Khostvicthchinkthutvkhuntrongphachvthchinthuc ca iu dng-Khostvicpdngccbinphpantontrongthaotcvithucchng ung th ca iu dng 2.2.2.i tng nghin cu i tng nghin cu l cc iu dng ti khoa Ph ung th bnh vin ph sn Trung ng lm nhim v pha ch v thc hin thuc chng ung th. 2.2.3.Phng php nghin cu -Thit k nghin cu: Nghin cu tin cu, quan st n thun, thi gian quan st t ngy 10/3/2014 n ngy 28/03/2014 -Phng php quan st: Quanstvinghinhnthngtinviudngtrc,ccchnhthucchng ung th ca bc s trong bnh n v trong s nht thuc ca iu dng bui chiu trc ngy quan st vo Bng kim pha ch v thc hin thuc ca iu dng, c thit k da trn cc ch tiu nghin cu (Ph lc 3) Quan st vin quan sttrc tip 2 iu dngtrclm nhim v pha chthuc trong ngy; sau theo di cc iu dng trong khi thc hin thuc chng ung th cho bnh nhn. Thng tin c ghi nhn v nh gi vo bng kim c chun b t bc trn. Tc tim truyn c xc nh bng cch bm thi gian t lc bt u n lc kt thc tim truyn thuc. Mtnghincuthnghimtrcctinhnhtngy3/3/2014n 7/3/2014.Trongnghincuthnghimny,quytrnhquanst,phngphpthu thp v x ls liu c kim tra th. Kinh nghim thu c t nghin cu ny c p dng hon thin quy trnh trong nghin cu chnh thc. 16 2.2.4.Ch tiu nghin cu oT l cc sai lch xy ra trong giai on pha ch v thc hin thuc chng ung th ca iu dng Trong nghin cu ny, chng ti khng nh gi cc sai st trong s dng thuc (medication errors) ti khoa. Nguyn nhn l v vic nh gi ny cn c mt cng c chun c ng thun ca c s thc hnh v c i ng chuyn gia nh gimcnghimtrngcaccsaist.Vngunlcchn,chngtichghi nhnccsailchtrongsdngthucsovichnhcabcs,hngdnca bnh vin v cc y vn, vi th t u tin l: ch nh ca bc s, ti liu thng tin thuc (u tin hng dn s dng thuc) v hng dn ca bnh vin. Cc sai lch quanstccphnloitheobng2.1(chyudatrncchphnloica Allan v Baker [5] v sai lch trong s dng thuc). Bng 2.1. Phn loi sai lch trong s dng thuc [5] Phn loi Gii thch Sai lch trong pha ch Sai thucS dng thuc khng c trong ch nh B thucThuc c ch nh nhng khng c pha ch Liu khng ng Lng thuc em ra pha ch khc vi liu thuc c ch nh Sai liu do li pha ch Thuc khng c phachnh xc vliu (v d: khngc ha tan hon ton) Thuc c nguy c b hng Thucquhndng,thuckhngcboqunng(vd: thuc nhy cm vi nh sng khng c trnh nh sng) K thut pha ch khng chnh xc Thuccphachkhngngcch(vd:saidungmihon nguyn, dung mi pha long, th tch dung mi, sai k thut lc) Sai lch trong thc hin thuc B thucLiu thuc khng c dng cho bnh nhn K thut thcSdngquytrnhkhngthchhp/kthutkhngngtrong 17 hin khng ng thchinthuc(vd:cbtkhtrongbmtim,dytruyn; khng tim truyn ht thuc; khng trng dy truyn trc v sau mi ln dng thuc) Tc thc hin sai Tc thc hin sai khc hn 10% so vi ch nh ca bc s [24]ng dng saing dng khc vi ch nh ca bc s oT l thc hin khng ng k thut v khun trong pha ch v s dng thuc: -Khng st khun np l/ng thuc trc pha ch -Chm tay vo cc b mt cn v khun (pt tng, u m bu, thn kim tim) trongqutrnhchunbthuctimthuc,kimchmvoccbmt nhim bn -S dng mt bm kim tim pha thuc duy nht pha cho nhiu l thuc -Ti s dng bm kim tim cho pha ch lt thuc mi -Khng st khun v tr tim -Khng st khun cng ni kim lun, chai truyn oT l p dng cc bin php bo h c nhn (gng, o chong, khu trang, knh, ra tay sau pha ch) trong thao tc vi thuc chng ung th ca iu dng 2.2.5.X tr khi pht hin nhng sai lch nghim trngNutrongqutrnhquanstphthincccsailchcthgynguyhin bnhnhn,ngiquanstsnhcnhiudngmtcchtnh,mbosai lch y khng xy ra cho bnh nhn. 2.3.Phng php x l s liu SliucnhpvlmschbngphnmmMicrosoftAccess2010.Sau c a vo phn mm thng k Stata 12 thc hin cc phng php thng k m t. 18 PHN 3. KT QU 3.1.Kho st ch nh thuc chng ung th ca bc s 3.1.1.c im mu nghin cu Trongnghincuny,chngtilachnc392bnhnthamntiu chunlachnsnglc.Trongs201bnhncchn,191bnhnb loi khi nghin cu do khng thuc khoa Ph ung th (40 bnh n) v thuc khoa Ph ung th nhng khng c thuc chng ung th c ch nh (151 bnh n). Trungvtuicabnhnhntrongmunghincul36tui(khongtphn v: 25-50 tui). 100% s bnh nhn trong nghin cu l n. Bnh nhn thuc nhm bnh nguyn bo nui chim t l cao nht, gn 60%, sau l bnh ung th bung trng (33,3%). c imv chn on cabnh nhnc trnhbyc thtrong bng 3.1. Bng 3.1. c im v chn on ca bnh nhn trong nghin cu 3.1.2.c im chung v ch nh ng dng, dung mi, tc Hnh3.1aramtcinhnkhiqutvtlccchnhthucchngungth khngphhpcabcs.Chnhtctruynkhngphhpchimtlcao nht(63,4%),saulchnhthtchdungmikhngphhp(31,5%),thp Chn onS lngT l (%) Chorio52,5 Cha trng xm ln10,5 Mole ln tui10,5 U nguyn bo nui11255,7 U bung trng ti pht10,5 U v10,5 Ung th bung trng6733,3 Ung th v136,5 Tng201100 19 nhtlchnhngdngthuckhngphhp(3,5%).Thngtinchititca tng vn ny c trnh by cc phn sau. Hnh 3.1. c im chung v cc ch nh khng ph hp trong bnh n 3.59.831.563.40204060ng dng Dung mi truyn Th tch truyn Tc truyn% (N=369)(N=235)(N=235)(N=235) 20 3.1.3.c im la chn thuc chng ung th trong bnh n Trong tng s 201 n c a vo nghin cu, mi n c t 1-4 thuc chng ung th c k, trung bnh l 1,8 thuc trn mi n. C tt c l 11 hot cht chng ung th trn tng s 369 ltthucchng ung thcchnhtrongbnhn.Trong,thucctlsdngcaonhtl methotrexat (38,5%), sau l etoposid (11,4%) v carboplatin (10,0%). T l tng hot cht c trnh by bng 3.2. Bng 3.2. T l cc thuc chng ung th c ch nh trong bnh n Hot chtS lngT l (%) Bleomycin174,6 Carboplatin3710,0 Cisplatin308,1 Cyclophosphamid277,3 Dactinomycin164,3 Docetaxel328,7 Doxorubicin133,5 Etoposid4211,4 Gemcitabin51,4 Methotrexat14238,5 Paclitaxel82,2 Tng369100 21 3.1.4.c im la chn ng dng thuc cimlachnngdngchomihotchtcthhinbng3.3. Trong tng s 369 lt thuc chng ung th c ch nh, t l ng truyn tnh mch l cao nht (63,7%). Hu ht cc thuc u ch dng theo ng truyn tnh mch(9/11hotcht).Doxorubicincchnh100%theongtruyntnh mch,tuynhinthngtintrongcctiliukhngkhuynkhchlachnng dng ny. Bng3.3.cimchnhngdngccthucchngungthcch nh Hot cht c im ng dng thuc Tng Ch nh khng ph hp Tim bpTim TMTruyn TM Bleomycin--17170 Carboplatin--37370 Cisplatin--30300 Cyclophosphamid--27270 Dactinomycin-169-160 Docetaxel--32320 Doxorubicin--131313 Etoposid--42420 Gemcitabin--550 Methotrexat9523241420 Paclitaxel--880 N (%)95 (25,7)39 (10,6)235 (63,7) 369 (100) 13 (3,5) 3.1.5.c im la chn dung mi ha tan v dung mi pha long 22 V dung mi ha tan: Trong tng s 11 thuc c ch nh, c 5 thuc dng bt cn phi ha tan l bleomycin, cyclophosphamid, doxorubicin, dactinomycin v gemcitabin.Tuynhinnghincucachngtithyrng100%cctrnghp ny dung mi ha tan khng c nu trong ch nh ca bc s.V la chn dung mi pha long: Cc thuc dng ng truyn tnh mch u cchnhdungmiphalong.Trongtngs235ltchnhtruyntnh mch,c23lt(9,5%)dungmicchnhkhngphhpvikhuynco. c im la chn dung mi cho tng thuc truyn tnh mch c trnh by trong bng 3.4 di y. Bng 3.4. c im la chn dung mi pha long cho cc thuc chng ung th truyn tnh mch Hot cht Dung mi pha long Tng Ch nh khng ph hp Glucose 5%NaCl 0,9%Khc Bleomycin16101716 Carboplatin3520370 Cisplatin2280302 Cyclophosphamid2421a 271 Docetaxel5270320 Doxorubicin741b+ 1c 132 Etoposid4101d 421 Gemcitabin14051 Methotrexat0240240 Paclitaxel08080 Tng132100323523(9,8%) a: Ch nh ringerlactat b: Khng ch nh dung mi; c: Vit sai dung mi (NaCl 5%); d: Vit sai dung mi (NaCl 0,5%) 23 Thngtinvdungmiphalongkhngccptrongmtchnh (doxorubicin).C2trnghpdungmibvitsailHTM5%vHTM 0,5%, iu ny c th do bc s vit vi trong khi k n. 18 trng hp (7,65%) bc s ch nh dung mi tng k vi thuc, trong bleomycin c ch nh vi dung mi tng k ti 16/17 lt ch nh. V th tch dung mipha long: Trong nghin cu ny, th tch dung mi pha long cho cc thuc truyn tnh mch c bc s ch nh thay i t 200-1000 ml, trongphnlnthuccchnhphalongtrong500mldungmi.Chc methotrexat c pha long vi 1000ml dung mi. Th tch dung mi c ch nh c so snh vi thng tin trong cc hng dn, kt qu c trnh by bng 3.5. a s cc trng hpth tch dungmi c ch nh l ph hpvi khuyn co (68,5%).Trongsccchnhthtchdungmikhngphhp,aphnlch nh th tch ln hn so vi cc hng dn (30,6%). Bng 3.5. c im la chn th tch dung mi pha long so vi khuyn co Thng tin trong ch nhS lngT l (%) Ph hp16168,5 Khng ph hp Ln hn Nh hn 7130,2 20,8 Thng tin khng r rng/ khng c thng tin 10,4 Tng235100 24 3.1.6.c im ch nh tc tim truyn Vi thuc tim: Trong 134 lt tim bp v tim tnh mch, 100% s lt bc s khng ch nh tc s dng thuc. Vi thuc truyn: Gn 2/3 s ch nh tc truyn l chm hn so vi khuyn co, s ch nh ph hp chim gn 40%, cn li l s ch nh tc truyn nhanh hnkhuynco.Bng3.6trnhbycimchnhtctruynccthuc chng ung th so vi khuyn co. Bng 3.6. c im la chn tc truyn so vi khuyn co Thng tin trong ch nhS lngT l (%) Ph hp8636,6 Chm hn13155,7 Nhanh hn187,7 Thng tin khng r rng/ khng c thng tin00 Tng235100 3.1.7.Nguy c gp tng k ca cc thuc trong n Cctrnghptrongchnhcnguycgytngkgiaccthuchoc gia cc thuc vi dung mi trong nghin cu ny c trnh by bng 3.7. C ti gn 50% s n k l c cp tng k (mi n xut hin mt cp). Nguyctngkcthgptrongnghincunychyulgia methylprednisolon vi mt s thuc chng ung th. Tng k c th xy ra nu cc thuc ny c trn chung trong cng xilanh hoc chai truyn, hoc c bm qua cng dy truyn nu khng trng dy gia cc ln a thuc. 2 trng hp c tng kxyragiathucvichnhdungmiphalongcchnhcanl bleomycin v cisplatin vi glucose. 25 Bng 3.7. Cc trng hp ch nh c nguy c gy tng k Tng kn% (N=201) Ampicillin-ondansetron10,5 Methylprednisolon-docetaxel3215,9 Methylprednisolon-etoposid189,0 Methylprednisolon-gemcitabin52,5 Methylprednisolon-ondansetron105,0 Methylprednisolon-paclitaxel73,5 Bleomycin-glucose168,0 Cisplatin-glucose21,0 Tng9145,3 26 3.2.Khostquytrnhphachvthchinthucchngungthcaiu dng 3.2.1.c im mu nghin cu C 7 iu dng ti khoa tin hnh pha ch v s dng thuc cho bnh nhn trong nghincu.Ttciudnguln,ctrnhchuynmnliudng trung cp. Cc iu dng c tui t 26 n 45 tui, tui trung bnh l 33,4. S nm lm vic ti khoa t 1-13 nm, trung bnh l 5 nm.S lng v t l cc lt dng thuc quan st c c trnh by trong bng 3.8. Bng 3.8. c im quan st pha ch v thc hin thuc ca iu dng S lngT l (%) Kiu pha ch149100 Dung dch tim truyn, khng cn pha long1711,1 Dung dch tim truyn, cn pha long8053,7 Hon nguyn n thun85,4 Hon nguyn + pha long3422,8 Thao tc c bit106,7 Thc hin141100 Tim bp00,0 Tim tnh mch chm1712,1 Truyn tnh mch12487,9 3.2.2.Sai lch trong pha ch v thc hin thuc chng ung th ca iu dng Trong nghin cu ny, chng ti quan st c 149 lt s dng thuc vi tng s sai lch xy ra l 473 sai lch, trung bnh c 3,2 sai lch trong mt lt s dng thuc. S lng v t l mi loi sai lch c lit k trong bng 3.9. Sai lch trong giai on thc hin thuc xy ra nhiu nht(67,7%), sai lch trong pha ch thn (32,3%). Thng tin chi tit ca tng sai lch c trnh by trong cc phn tip sau. 27 Bng 3.9. Sai lch trong pha ch v thc hin thuc chng ung th ca iu dng Phn loi n% Sai lch trong pha ch15332,3 Sai thuc00,0 B thuc81,7 Liu khng ng00,0 Sai liu do li pha ch296,1 K thut pha ch khng chnh xc9620,3 Thuc c nguy c b hng204,2 Sai lch trong thc hin32067,7 B st00,0 Sai ng dng00,0 Sai tc 14129,8 Sai k thut thc hin17937,8 Tng473100 3.2.3.Sai lch trong qu trnh pha ch thuc TikhoaPhungthBnhvinPhsnTrungng,qutrnhphachthuc chng ung th c thc hin trn xe tim trong phng tim.Ccsailchphthincqutrnhphachthucchngungthcaiu dngchim32,3%tngssailch,thngtinchititctrnhbytrongbng 3.10. Bng ny cho thy sai lch tp trung chyu k thut phach vi 96 lt (62,7%). Tip theo l cc li sai liu do pha ch vi 29 lt (18,9%), thuc c nguy c b hng vi 28 lt (13,1%) v b thuc (5,2%) 28 Bng 3.10. T l sai lch trong giai on pha ch thuc chng ung th ca iu dng Loi sai lch v m t c thS lt% (N=149) B thuc: Dactinomycin khng c thc hin do bnh nhn khng mua c thuc 85,4 Sai liu do li pha ch: Cisplatin khng c ly chnh xc theo th tch85,4 X dy truyn sau thm ha cht106,7Rt ha cht117,4 K thut pha ch khng chnh xc: Sai dung mi hon nguyn so vi hng dn2818,8 Sai th tch dung mi hon nguyn so vi hng dn2516,8 Sai dung mi pha long21,3 Sai th tch dung mi pha long3120,8 Vincristin c pha long vi nc ct pha tim, khng ng vi hng dn 32,0 Docetaxel khng c yn 5 pht sau khi lc74,7 Thuc c nguy c b hng: Cisplatin, carboplatin, doxorubicin, methotrexat khng c bao trnh nh sng sau khi pha ch xong 2013,4 C 8 trng hp b thuc, tuy nhin y khng phi do li ca iu dng m do thuc c k khng c trong danhmc thuc ca bnh vin v bnh nhn khng mua c thuc 29 3.2.4.Sai lch trong thc hin thuc Sai lch trong giai on thc hin thuc chim 67,7% tng s sai lch pht hin ctrongnghincucachngti.Ccsailchtronggiaionnyctrnh by chi tit trong bng 3.11. Chng ti thy rng sai lch v tc tim truyn, li khng trng dy truyntrc v saumi ln dng thuc l sailch ph bin nht, xy ra 100% s lt quan st. Bng 3.11. T l sai lch trong giai on thc hin thuc ca iu dng Loi sai lchM t c thS lt % (N=141) Sai tc Tctimtruynnhanhhntc ch nh/trong hng dn 141100 Sai k thut thc hin Khngtrngdytruyntrcvsau mi ln dng thuc 141 100 Thuc khng c truyn ht hon ton117,8 V chai truyn sau s dng khng c hy ngay 2719,1 Trong bng trn c 11 lt thuc khng c truyn ht hon ton do cn st li mt lng thuc nh trong chai truyn. Do khng c iu kin o lng, chng ti clngthtchthuckhngctruynhtvokhong3-15ml/milt truyn. 3.2.5.Vic thc hin k thut v khun trong pha ch v thc hin thuc K thut v khun l cc k thut khng lm pht sinh s lan truyn ca vi khun trongqutrnhsdngthuc,kthutnylcnthitchosantoncabnh nhn.Bng3.12trnhbytlkhngtunthmtsquynhvkthutv khun trong qu trnh pha ch v thc hin thuc ca iu dng. Trong bng ny, t l khng st khun np l/ng thuc trc pha ch v khng st khun cng ni, 30 chai truyn l cao nht, ln ti 100% s lt quan st. Sau l t l s dng kim c khi pha ch lt thuc mi (31,9%). Bng 3.12. K thut v khun trong pha ch v thc hin thuc ca iu dng n% Pha ch: S dng kim c khi pha ch lt mi4531,9 Khng kh trng np l/ng thuc141100 S dng mt bm kim tim pha thuc duy nht pha cho nhiu l thuc 3424,1 Chm vo cc b phn cn v khun53,5 Thc hin: Khng st khun b mt cc cng ni u kim lun, chai truyn 141100 Khng st khun v tr tim00 3.2.6.Vn bo h c nhn trong thao tc vi thuc chng ung th Vic p dng cc bin php bo h c nhn khi thao tc vi thuc chng ung th rt quan trng v n gip bo v ngi thc hin khi nhng tc ng ln sc khe ca nhm thuc c hi ny. Chng ti quan st vic p dng cc bin php bo h ca iu dng hai giai on pha ch v thc hin thuc chng ung th. Kt qu c trnh by bng 3.13. Theo bng ny, eo gng, khu trang v m c iu dngthchinvitlkhcaotronggiaionphach(78,6%-92,9%),tuy nhinccbinphpnyhunhkhngcpdngtronggiaionthchin thuc trn bnh nhn. Chngtighinhnthyttciudngucheo1lpgngytveo suttrongqutrnhphachthuc,khngthaygngthngxuyn.Khutrang csdngchlkhutrangthngthng,khngcmnglc,khngctc dng bo v iu dng khi vic ht phi thuc chng ung th. Knh v o bo h 31 khng c s dng trong c pha ch ln thc hin thuc do khng c cc trang b ny ti c s nghin cu. Ch c hn 70% iu dng ra tay sau khi tin hnh pha ch thuc chng ung th, v 0% iu dng ra tay sau thc hin thuc chng ung th trn bnh nhn. Bng3.13.Tlthchinccbinphpbohcnhntrongthaotcvi thuc chng ung th ca iu dngN% Pha ch14100 Gng1178,6 o bo h00,0 Khu trang1392,9 Knh00,0 M1285,7 Ra tay sau pha ch1071,4 Thc hin141100 Gng00,0 o bo h00,0 Khu trang64,3 Ra tay sau thc hin00,0 32 PHN 4. BN LUN 4.1.Kho st ch nh s dng thuc chng ung th ca bc s Trongnghincucachngti,ttcccchnhucthngtinvng dng, dung mi pha long, th tch, tc truyn. Hu ht cc thuc c s dng ngtruyntnhmchvphhpvicchngdn,trtrnghpca doxorubicin. Dung mi c ch nh cho thuc truyn tnh mch a s l ph hp vi khuyn co, t l ch nh dung mi khng ph hp l 9,8% s lt thuc truyn tnh mch, trong c ti 18 trng hp (7,7%) ch nh dung mi tng k. T l ch nh tc truyn tnh mch khng ph hp vi khuyn co kh cao, chim hn 60% s ch nh truyn tnh mch. V ng dng thuc: t l ch nh ng dng khng ph hp trong nghin cu ny chim 3,5%, cao hn so vi cc nghin cu v sai st trong k n ha tr liu khc(0,33-0,71%)[25],[31],[60],[70].Trongnghincucachngti, doxorubicin c bc s ch nh hon ton theo ng truyn tnh mch, tuy nhin khngkhuynkhchlachnngdngnydovictruyndoxorubicin hydrochlorid c th gy tn hi n cc m nu dch truyn xm nhp vo m[3]. Doxorubicinhydrocloridnncdngtimchmvodytruynnhgitdch NaCl 0.9% hoc glucose 5% t 3-5 pht gim nguy c huyt khi, thotmch, dn n vim t bo m v rp da, bong da [3], [6], [16], [57]. Vdungmivthtchdungmiphalong:Trongnghincunycachng ti, t l ch nh dung mi pha long khng ph hp l 9,8%, trong 7,7% l ch nh thuc vi dung mi tng k. Th tch dung mi c ch nh khng ph hp vikhuyncol31,5%.Cctlnycskhcbitsovitltrongmts nghin cu khc v sai st trong k n ha tr liu: t l dung mi pha long v th tch khng ph hp trong nghin cu ca Hamza nm 2013 l 4,89% v 2,0% [31], tlnthiuthtchdungmi/thtchkhngphhptrongnghincuca Aguirrezabalnm2003l31,66%[70].Tlchnhdungmitngkvsai 33 nngcadungdchsauphachtrongnghincucaSlamanm2005lnti 51%v22,9%[60].Vicsdngsaidungmicthgygimhatanbt thuc, c th dn n vic ln bt thuc khi tim truyn cho bnh nhn. S dng sai dung mi cng c th dn n gim n nh, hot tnh ca thuc, v gy ra kh nng thuc b ta, lng ng [22]. Vtctruyn:Tlchnhtctruynkhngphhpvikhuynco trongnghincunykhcao,chnhtcchmhnkhuyncochimti 55,7%,nhanhhnkhuyncol7,7%.Tltctruynkhngphhptrong nghin cu ny l kh cao so vi mt s nghin cu v sai st trong k n ha tr liukhc:ch1,5%trongnghincucaDiaz-Carrasconm2007[25],3,14% trong nghin cu caHamza nm 2013[31]. Tc truyn khngph hp c th gyramtsnhhngtrnbnhnhn.Tctruynquchmcthdnn vic khng t c nng iu tr ca thuc trong c th hoc p ng chm tr vithuc,tcngthngdodngchybtcnghn.Truynqunhanhkmvi lng dch truyn lnc th lmtngnng thuc trongmu t ngt, dn n sc; hoc gy qu ti dch, dn n thot mch, gy au, gy vim v mt s phn ng bt li khc. T l cc sai lch trong k n nghin cu ny nhn chung cao hn so vi cc nghin cu khc. iu ny c th l do ti c s nghin cu khng cmthng dn k n ha tr liu, ti liu thng tin thuc chng ung th no, n c vit tay v khng c mu n chun in sn cho thuc chng ung th, vic ny cng dn n tnh trng khng thng nht v thng tin trong cc n k, thiu thng tin, vit sai thng tin trong nghin cu. Nhiu nghin cu cho thy vic p dng h thng k n my tnh (computerised physicianorder entrysystem-CPOE system)hocmu n ha tr liu chun gip lm gim mt cch c hiu qu cc sai st trong k n ha tr liu [37], [56], [65], [67]. Nghin cu ca Voeffray nm 2006 cho thy t l sai st trong k n gim t 34 15% trc khi p dng h thng k n my tnh xung cn 5% sau khi p dng h thng k nmy tnh c a vo p dng, 92%s sai st saukhi h thng k n my tnh c p dng c ghi nhn trong cc n khng s dng my tnh. Ch c 0.6% s n k qua h thng k n my tnh c sai st v cc li ny u khng quan trng. Hng dn ca AHSP v cc hng dn khc u khuyn khch vic s dng mu n ha tr liu chun ha v h thng k n my tnh [8], [20], [39]. V nhng l do trn, chng ti thy rng cn thit c mt mu n chun v cc phccthngnhtgipvicknchnhxchn,gimthiusailch, m bo hiu qu, an ton cho ngi bnh. 4.2.Khostquytrnhphachvthchinthucchngungthcaiu dng Trong nghin cu ny, vic pha ch v thc hin thuc chng ung th c tin hnhtikhoaPhungthBnhvinPhsnTrungng,docciudngti khoatrctipthchin.Phachctinhnhtiphngphatimkhngch thngthngkh,khngctantondngchophachthucchi.Tronggiai onphach,sailchxyranhiukthutphach(62,7%sltquanst). Trong thc hin thuc, li v tc thc hin thuc v khng trng dy truyn gia mi ln dng thuc l li ph bin nht (100% s lt thc hin thuc). iu dng thchinkhngttkthutvkhuntrongphachvthchinthuc,100%s lt quan st iu dng khng st khun np l/ng thuc, st khun u cc cng ni. Vn p dng cc bin php bo h c nhn trong pha ch v thc hin thuc chng ung th cng l vn cn bn lun trong nghin cu ny. Vic so snh t l sai lch trong nghin cu ny vi cc nghin cu khc trn thuc chng ung th l khkhndoccnghincukhngsdngcchphnloivphngphptnh ton ging nhau. 35 V tc thc hin thuc:100% s lt thc hin thuc quan st c c tc thc hin cao hn tc c ch nh hay khuyn co. T l ny cao hn nhiu so vi t l trong mt nghin cu v sai st trong s dng thuc ha tr liu ng truyn tnh mch (6/205 lt quan st) [24]. Trong mt nghin cu a trung tm v sai st v thuc dng ng tnh mch Anh, c, Php, t l ny ln lt l 48%, 21% v 5% [22], v 85,1% trong nghin cu[51]. Cng nh cc nghin cu ny, trong nghincu ca chng ti sai lch v tc tim truyn l sai lch ph bin nht trong giai on thc hin thuc ca iu dng.Timtnhmchvitcqunhanhcthdnnshockdonngthuc trong mu tng cao t ngt n mc liu c [43]. Tc thc hin thuc nhanh c th dn n au, vim tnh mch [22]. Nguyn nhn dn n sai lch trong tc thc hin thuc ca iu dng trong nghin cuny c thdo thiu nhn thc vnguy c, p lc thi gian trong cng vic, thiu nhn lc, thiu thit b h tr. Trong s nht thuc ca iu dng cng khng ghi li thng tin v tc v ng dng thuc. Hn na, thng tin chi tit v tc tim tnh mch khng c trong ch nh ca bc s. iu dng ch c th tham kho thng tin trong t hng dn s dng ca sn phm. Vic cung cp cc thng tin sn c lin quan n tc dng trn bao b sn phm hoc cc bng tham kho nhanh cho nhn vin c th gip ci thin vn ny [22].V k thut v khun:Nghin cu ca chng ti cho thy trong tt c cc trng hp pha ch v thc hinthucquanstc,kthutvkhunukhngcthchintt,100% np l thuc v ng thuc, cng nh cc cng cm ng truyn, cng tim trn dy truyn u khng c st khun trc khi pha ch v tim truyn thuc.Trong mt nghin cu v sai st trong pha ch v thc hin thuc ti Malaysia, 98,7%npl/ngthuckhngcstkhun[51].Tlstkhunnpl/ng thuc trong mt nghin cu 3 quc gia ln lt l 96%, 46%, 1% ti Php, c, Anh [22]. St khun np l thuc trong pha ch t c thc hin trong mt nghin 36 cu v k thut v khun trong pha ch v thc hin thuc Anh v c (12% v 1%), Anh hn 1/3 s trng hp c st khun cng ni trc khi thc hin thuc, nhngkthutnykhngcpdngtiAnh[63].Skhcbitnycgii thch phn no l do cc bng chng v nhhng ca k thut v khun ln kh nngnhimtrngmulrtt,chngcdingiikhcnhautrongcchng dn ti mi quc gia, v do iu dng c th khng coi vic thc hin k thut v khun l quan trng. Cc nhn vin pha ch thng c gi nh chung rng cc thuc dng ng tnh mch thng c pha ch s dng ngay, thi gian s dng ngn c th khng vikhunphttrinnnkhnngnhimtrnglnh[22],[63].Tuynhin nghin cu ca chng ti v nghin cu v k thut v khun ti Anh v c trn cho thy thuc sau pha ch thng c lu tr nhit phng ti ging bnh nhiu gi trc khi s dng, mt s thuc c pha trong dung dch glucose, dung dch ny c bit n h tr s pht trin ca vi khun [63]. Mt nghin cu v s nhimkhunmtbnhvincchothy2trnghpbnhnhntvongdo vimmngnosaukhitimmtchtcnquangdnglaliubnhim Pseudomonasaeruginosa,dothaotcvboqunthuckhngtt[45].C3ca nhim khun huyt vi khun Gram m do nhim khun cho ti mt phng bnh tim cp, nguyn nhn c a ra l thuc c pha ch trong mi trng khng m bovdosthiunhnthcvquytrnhphachvsdngthucngtnh mch [40]. Victhchinkthutvkhuntrongquytrnhsdngthucccp trong cc hng dn v thc hnhthuc chng ung th, cng nh trong gio trnh iu dng c bn v Hng dn tim an ton ca B Y t [1], [2]. gim nguy cnhimtrnglinquanndngthucngtnhmch,cnphichnk thut v khun nh st khun tay, np l thuc, ng thuc, tim khng kh vo trong l khi rt thuc khi l, thi gian s dng v lu tr thuc, iu kin v tnh trng boquncalthuc.Tuynhin,phachtrongmitrngschlbinphptt nht gim t l nhim khun trong pha ch [36].37 V vn p dng cc bin php bo h an ton:T l iu dng s dng gng, khu trang trong pha ch thuc nghin cu ny lnltl78,6%v92,9%.Tuynhiniudngkhngeogngkhithchin thuctrnbnhnhn,chc4,3%ltthchinthuciudngceokhu trang. o trm v knh bo h khng c iu dng s dng trong c pha ch v thchinthuc.Trongqutrnhquanst,c2trnghpiudnglmrt thuc ra ngoi. Mt iu dng b bn thuc ln tay v o blouse khi pha ch, iu dngthaygngngaylptcnhngkhngthayo.Mtiudngkhivt chai cisplatin cn thuc vo hp cha rc lm ri l ra ngoi, khin thuc bn ln chn, tuy nhin iu dng ny ch dng khn lau thuc i m khng ra chn ngay lp tc. Trongccnghincucngcpnvnny,phnlnccytueo gngkhithaotcvithucchngungth(91%-97,4%)[19],[42],[44],[50], [66]. Nghin cu ca chng ti c lu rng iu dng ch eo 1 lp gng khi pha chvkhngthaygngtrongsutqutrnhphachthuc.Theocchngdn, mi nhn vin nn s dng 2 lp gng v thay gng mi 30 pht-1 ting trong khi thao tc vi thuc gy c t bo. T l s dng khu trang trong cc nghin cu trn thp hn so vi trong nghin cucachngti.Tuynhintrongmitrngphachkhngmboanton, vicchsdngkhutrangytkhngbovciudngkhinguycht phi hi thuc chng ung th. Tlsdngobohtrongccnghincutrnkhcnhau,55%,95%,21% trong nghin cu ca Martin 2003, Kyprrianou 2010, Nieweg 1997 [42], [44], [50]; trong nghin cu ca Elshamy 2010 v Chaudhary 2012 t l nyl rt thp 0.2% v 6% [19], [26]. Ti c s nghin cu ca chng ti, thc t khng c o chong bohdnhchophachthucchi,iudngchmcoblousethng thng, khng c kh nng chng thm. 38 Hu ht trong cc nghin cu trn v trong c nghin cu ca chng ti, khng c iu dng no s dng c 4 thit b bo h c nhn. Tnh trng p dng khng tt cc bin php bo h c nhn trong mi trng pha ch khng an ton lm tng nguy c phi nhim ca iu dng vi cc thuc c hi ny, c th dn n nhiu nhhngchilnsckhecaiudng.Theochngti,nguynnhndn n vn ny c th do iu dng c th cha nhn thc y v nguy c khi tip xc vi thuc chng ung th, khng c quy trnh thao tc chun, thiu trang b bo h ti c s nghin cu, cng c th do iu dng cm thy khng thoi mi, thuntinkhisdngcctrangbny.Thctrngxlkhilmrtthucln ngi v trang phc ca 2 iu dng trong nghin cu cho thy iu dng c th cha nhn thc y nguy c ca cc thuc chng ung th i vi sc khe. 4.3.u nhc im ca nghin cu Khitinhnhtiny,chngtinhnthynghincucnmtsimhn ch sau: Nghincucachngtisdngphngphplymuthuntin,vthkt qu cha thc s i din cho tnh trng s dng thuc chng ung th bnh vin.Trong vic nh gi quy trnh s dng thuc ca iu dng, vic quan st c th nh hng n thc trng thao tc ca iu dng, gy ra sai s. Ch c mt quan st vin nn khng quan st ht c cc trng hp s dng thuc v c th khng pht hin c y cc sai lch trong thao tc ca iu dng. Nghin cu khng nh gi cc vn trong sai lch lin quan n thuc nh cc sai lch v liu, tnh hp l ca phc trong k n ha tr liu, cc vn khc trongkthutvkhunnhvsinhkhuvcphach,rataytrckhiphach. Nghin cu mi ch dng li mc ghi nhn cc sai lch, cha nh gi c mc nh hng ca cc sai lch ny ln bnh nhn. Nhng vn ny c th l ch cho cc nghin cu tip theo. u im ca nghin cu ny l c s kt hp nghin cu hi cu v tin cu, thu c nhiu thng tin chi tit v chnh xc hn, trnh c sai s nh li. Hn na, nghincunhncsnghcabnhvin,khoadcvkhoaPhungth 39 nnctinhnhmtcchthunli,ylimquantrngnhtkhitinhnh nhng nghin cu lin quan n sai st trong s dng thuc. 40 KT LUN V XUT Da vo kt qu ca ti nghin cu, chng ti a ra mt s kt lun v xut sau: 1.Kt lun -Tronggiaionkn,gn100%schnhcabcsucthngtinv ng dng, dung mi pha long, th tch, tc truyn, tuy nhin khng c thng tin v thi im s dng thuc c th.-63,7%sthuccchnhsdngngtruyntnhmch,10/12hot cht.aschnhngdngthuclphhpvicchngdn,trtrng hp ca doxorubicin (chim 3,5%).-Ttcccthucdngngtimbpvtimtnhmchkhngcchnh dung mi i km. - Dung mi pha long c ch nh cho thuc truyn tnh mch a phn l ph hp (91,2%), 7,7% trng hp bc s ch nh thuc vi dungmitng k. ng lu l bleomycin c ch nh pha vi dung mi tng k ti 16/17 lt ch nh. - T l ch nh tc truyn tnh mch khng ph hp vi khuyn co kh cao, chim gn 60% s ch nh truyn tnh mch. - Sai lch lin quan n thuc chng ung th trong giai on t pha ch v thc hinthuctrongnghincunylkhcao(3,2sailch/ltsdngthuc),sai lch trong giai on thc hin chim phn ln (67,7%). Trong ph bin nht l cc sai lch v tc thc hin thuc, li khng trng dy truyn gia mi ln dng thuc. - iu dng cha thc hin tht tt k thut v khun v cc bin php bo h c nhn trong thao tc vi thuc chng ung th, c bit l gy nhiu tc hi ln sc khe. 2. xut Saukhithchinti,nhmnghincuchngtixinaramtsxut sau: 41 -Cncmttiliuhngdnvsdngthucchngungth,baogmcc thng tin v ng dng, dung mi, th tch dung mi, tc thc hin bc s v iu dng tham kho trong qu trnh k n v thc hin thuc- Xy dng mt mu n ha tr liu chun in sn hoc thit lp mt h thng k n my tnh gip vic k n chnh xc hn, gim thiu sai st, m bo hiu qu, an ton cho ngi bnh. - Ph bin v tp hun cho iu dng cc kin thc, quy trnh thao tc vi thuc chng ung th, bao gm tc hi, nguy c phi nhim vi thuc chng ung th, cc bin php thao tc an ton vi nhm thuc c hi ny. - Ph bin v tp hun cho iu dng cc kin thc lin quan n hu qu ca vic thc hin khng ng k thut v khun v tc tim truyn cc thuc chng ung th, tiu chun thc hin k thut v khun, quy trnh tim truyn. TI LIU THAM KHO Ting Vit 1.B Y T (2012), Hng dn tim an tontrong cc c s khm bnh, cha bnh, H Ni. 2.B Y T (2007), iu dng c bn II, Nh xut bn Y hc, H Ni. 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Cc thao tc ca nhn vin y t c th dn n phi nhim vi thuc c hi [49] -Honnguynthucdngbthocngkhvtiptcphalongthuc hon nguyn hoc cc dng dung dch m c thuc c hi. -Loi kh khi bm tim cha thuc c hi. -Thc hin thuc qua ng bp, di da, hoc tnh mch. -Ly liu thuc ung khng c bao v vin nn ra khi l a liu. -Tnh liu vin nn khng bao trong my m liu. -Nghin vin nn to dung dch ung -Phi hp cc dng thuc bt vo trong vin nang ty chnh liu -Tip xc vi thuc trn mt ngoi ca l thuc, b mt lm vic, sn nh, v sn phm thuc cui cng (chai, ti, bm tim) -Torakhdungtrongqutrnhthchinthuc,dotimhaytruyntnh mch -X dy truyn vi dung dch cha thuc gy c t bo bn ging bnh -Xldchcthhocquno,bng,khnvccvtliukhccnhim dch c th -Xlrcthitoratrongbtcbcnocagiaionphachvthc hin thuc -Tin hnhmt s th tc c bit (nh ha tr liu phc mc trong khi m) trong phng phu thut -X l thuc c hi khng c dng hoc rc b nhim thuc c hi -Kh trng v lm sch khu vc pha ch hoc lm sng -Vn chuyn bao b cha cht thi nguy hi, truyn nhim, ha cht -Loi b v x l cc thit b bo h c nhn sau khi thao tc vi thuc c hi hoc cht thi. Ph lc 2. Phiu thu thp thng tin bnh n H tn bnh nhn:...........................................Nm sinh: ............................................ M vo vin: M bnh nhn: .......M lu tr:.. Chn on:..................................................................................................................... Ngy nhp vin:.../..... /201.... Ra vin:.../.... /201.... Ngy dng thuc:.../..... /201... Thuc chng ung th c ch nh: STT Tn thuc/Bit dc Liung dngDung miTh tchTc 1 Truyn TM #: NaCl 0.9% Glucose 5% #:................ 2 Truyn TM #: NaCl 0.9% Glucose 5% #:................ 3 Truyn TM #: NaCl 0.9% Glucose 5% #:................ 4 Truyn TM #: NaCl 0.9% Glucose 5% #:................ Thuc khc c ch nh cng ng dng: STT Tn thuc ng dng STT Tn thuc ng dng 15 26 37 48 ID _______________ Phiu Pha ChTh ngy: / 03 /2014 iu dng PC: 1/..: Ra tayGngKhu trangKnhM 2/..: Ra tayGngKhu trangKnhM TT PC Bnh nhn GingM BN Bit dc SL DM hon nguyn DM pha long T/g PC Lu trong PC Ph lc 3. Phiu quan st pha ch v thc hin thuc LoiV (ml) BSPCLoiVBSPCBSPC SK Kim cChc 3ln ChmRt HCLc: SK Kim cChc 3ln ChmRt HCLc: SK Kim cChc 3ln ChmRt HCLc: SK Kim cChc 3ln ChmRt HCLc: SK Kim cChc 3ln ChmRt HCLc:. SK Kim cChc 3ln ChmRt HCLc:. SK Kim cChc 3ln ChmRt HCLc:. Phiu thc hinTh ngy: / 03 /2014 Bnh nhn Ging M BN Bit dc S lng DM pha longng dng Tc Lu TH Ph lc 3. Phiu quan st pha ch v thc hin thuc LoiVBS (g/p) YT (pht)BSSBSSBSSBSYT Ra tay trc Gng Khu trang Trng dy Truyn ht thucHy v ngay Ra tay sau Ra tay trc Gng Khu trang Trng dy Truyn ht thucHy v ngay Ra tay sau Ra tay trc Gng Khu trang Trng dy Truyn ht thucHy v ngay Ra tay sau Ra tay trc Gng Khu trang Trng dy Truyn ht thucHy v ngay Ra tay sau Ra tay trc Gng Khu trang Trng dy Truyn ht thucHy v ngay Ra tay sau Ra tay trc Gng Khu trang Trng dy Truyn ht thucHy v ngay Ra tay sau Ra tay trc Gng Khu trang Trng dy Truyn ht thucHy v ngay Ra tay sau Ph lc 4. Bng khuyn co s dng thuc chng ung th Hot cht/ Dng bo ch ng dng Hon nguyn vi Pha long viTc Tng k vi cc thuc thng c trong nBleomycin bt pha tim 15mg (15UI) Truyn TM 5 mlNaCl 0,9% [16] < 200mlNaCl 0.9% [16] 10-15 pht Glucose 5% [16] Dexamethason [16] Methotrexat [6] Carboplatin Dung dch tim truyn 150mg/15ml Truyn TM _ 500ml NaCl 0.9% hoc Glucose 5% [16] t 0.3-10mg/ml [15] 15-60 pht [16] Cisplatin Dung dch tim truyn 50mg/100ml Truyn TM _ 200-1000 ml NaCl 0.9% [16] >= 60 pht [16] Glucose 5% [16] Cyclophosphamid bt pha tim 200mg Truyn TM 10 ml NaCl 0.9% [16] 100-1000 ml NaCl 0.9% Glucose 5% [16] 1-2 gi [16] Dactinomycin Bt pha tim 0.5mg Tim TM 1.1 ml NCPT [16] __ Docetaxel** Dung dch khan 20mg/0,5ml; 80mg/2ml Truyn TM Dung mi km theo [16] 250 ml NaCl 0.9% Glucose 5% [16] > 1 gi [16] Methylprednisolon [6] Doxorubicine HCl bt pha tim 10mg Truyn TM* 5 mlNaCl 0.9% Glucose 5% [16] 100ml NaCl 0.9% [15] 2-15 pht Tim TM _ 3-5 pht[16] Etoposide Dung dch pha truyn 100mg/5ml Truyn TM _ 500ml -1000ml NaCl 0.9% hoc Glucose 5% [16] c dung dch 0.2-0.4 mg/ml [15] 30-60 pht [16] Gemcitabine HCl bt pha tim 200mg Truyn TM 5 mlNaCl 0.9% NaCl 0.9% c dung dch 0,1-10mg/ml 30-60 pht [6] Imimpenem/ Cilastatin Methylprednisolon Gemcitabin [6] Methotrexat Dung dch tim truyn 50mg/5ml Truyn TM __ > 20 pht [15] Gemcitabine Methylprednisolon [6] Tim TM/ bp __ PaclitaxelDung dch tim truynTruyn TM _ 0.3-1.2mg/ml [16]> 3 gi [16] Methylprednisolon [6] Vincristine 1mg Dung dch tim Tim TM __ >1pht [16] * Thng tin ny ch c trong 1 bit dc c lit k trong BCCA, khng phi bit dc c dng ti khoa ** Thuc c k thut lc c bit