B Y T TRNG I HC DC H NI V T THNG KHO ST NHN THC VHIU BIT CA NHN VIN Y T, NGI NH BNH NHN V AU V CC BIN PHP GIM AU SAU PHU THUT KHA LUN TT NGHIP DC S H NI - 2013 B Y T TRNG I HC DC H NI V T THNG KHO ST NHN THC VHIU BIT CA NHN VIN Y T, NGI NH BNH NHN V AU V CC BIN PHP GIM AU SAU PHU THUT KHA LUN TT NGHIP DC S Ngi hng dn: 1.ThS. Ng Thanh Hoa 2.ThS. BS. Nguyn Th Thu H Ni thc hin: Bnh vin Nhi Trung ng H NI 2013 LI CM N utin,tixinchnthnhcmnThS. BS. NguynThThuH KhoaPhuthutGymhiscBnhvinNhiTrungng,Th.S Ng Thanh Hoa Ging vin B mn Dc lc - trng i hc Dc H Ni trc tip hng dn v ch bo tn tnh cho ti trong sut qu trnhthc hin kha lun tt nghip. Ti xin gi li cm n su sc n TS. Dng Th Ly Hng - Ging vin khoa Y Dc, i hc Quc gia H Ni, ngi tin tng, nh hng v gip ti hon thnh kha lun. Ti cng xin gi li cm n n: CcbcsviudngvinkhoaPhuthutGymhi sc v cc khoa thuc khi ngoi Bnh vin Nhi Trung ng Nginhcaccbnhnhicphuthutticckhoathuc khi ngoi Bnh vin Nhi Trung ng PhngotovphngkhochtnghpBnhvinNhi Trung ng Cc cn b, gio vin, k thut vinBmn Dc lc trng i hc Dc H Ni to iu kin thun li gip ti hon thnh kha lun ny. Ticngxinbytlngknhyuvbitntigianh,bnb lun ng vin, gip ti trong qu trnh hc tp v hon thnh kha lun. H Ni, thng 5 nm 2013 Sinh vin V T Thng MC LC DANH MC CC K HIU, CH VIT TT DANH MC CC BNG DANH MC CC HNH V T VN .................................................................................................... 1 Chng 1 TNG QUAN ................................................................................ 3 1.1.AU ...................................................................................................... 3 1.1.1.Tnh hnh dch t ............................................................................ 3 1.1.2.Khi nim au, phn loi cm gic au, vai tr ca au ............... 4 1.2.AU TR EM .................................................................................. 6 1.2.1.Vn iu tr au tr em .......................................................... 6 1.2.2.c im au tr em ................................................................... 7 1.2.3.nh gi au tr s sinh v tr em ............................................. 8 1.2.4.Cc cng c nh gi au .............................................................. 9 1.3.QUN L AU CP TNH SAU PHU THUT .......................... 10 1.3.1.Mc tiu ca gim au cp tnh sau phu thut ........................... 10 1.3.2.Nhim v ca nhn vin y t trong qun l au sau phu thut .. 11 1.3.3.Nhim v ca ngi nh bnh nhn trong qun l au sau phu thut.. ..................................................................................................... 13 1.3.4.Cc bin php gim au khng dng thuc ................................. 15 1.4.THUC GIM AU ......................................................................... 15 1.4.1.Mc tiu v nguyn tc dng thuc gim au tr em ............... 15 1.4.2.K thut a phng thc ............................................................. 17 1.4.3.Thuc gim au non-opioid ......................................................... 17 1.4.4.Opioid .......................................................................................... 20 1.4.5.Thuc gy t ti ch, gy t vng ................................................ 21 1.4.6.Cc thuc ph tr gim au ......................................................... 22 1.4.7.Bnh nhn kim sot thuc gim au .......................................... 23 Chng 2 -I TNG V PHNG PHP NGHIN CU ................. 24 2.1.i tng nghin cu ......................................................................... 24 2.2.a im, thi gian nghin cu .......................................................... 24 2.3.Phng php nghin cu .................................................................... 24 2.4.Ni dung nghin cu .......................................................................... 24 2.4.1.Kho st mi quan tm, nhn thc v hiu bit ca ngi nh bnh nhn v au v cc bin php gim au cho bnh nhn sau phu thut.. .................................................................................................... .24 2.4.2.Kho st mi quan tm, nhn thc v hiu bit ca nhn vin y t v au v cc bin php gim au cho bnh nhn sau phu thut. ........... 25 2.5.C mu ................................................................................................ 25 2.6.X l thng k .................................................................................... 25 Chng 3 KT QU V BN LUN ........................................................ 26 3.1.KT QU ........................................................................................... 26 3.1.1.c im i tng nghin cu................................................... 26 3.1.2.Mi quan tm, nhn thc v hiu bit ca ngi nh bnh nhn v au v cc bin php gim au cho bnh nhi sau phu thut. ................... 28 3.1.3.Mi quan tm, nhn thc v hiu bit ca nhn vin y t v au v cc bin php gim au cho bnh nhi sau phu thut. ......................... 35 Chng 4 - BN LUN .................................................................................. 38 4.1.V c im mu nghin cu ...................................................... 38 4.2.V mi quan tm, nhn thc v hiu bit ca ngi nh bnh nhn v au v cc bin php gim au cho bnh nhi sau phu thut ...... 39 4.3.V mi quan tm, nhn thc v hiu bit ca nhn vin y t v au v cc bin php gim au cho bnh nhi sau phu thut .................... 42 Chng 5 - KT LUN V KIN NGH ...................................................... 46 5.1.KT LUN ........................................................................................ 46 5.2.KIN NGH ........................................................................................ 46 TI LIU THAM KHO PH LC DANH MC CC K HIU, CH VIT TT Ch gii FPS-RFaces Pain Scale-Revised (thang gng mt au sa i) VASVisual analogue scale (thang c lng bng mt) NRSNumerical rating scales (thang s) PCAPatient controlled analgesia - Bnh nhn kim sot thuc gim auNSAIDsNon-steroidanti-inflammatorydrugs-Thucchngvimkhng steroid DANH MC CC BNG BngTn bngTrang 1.1Cng c nh gi au sau phu thut hay s dng cho tr10 3.1T l nhn vin y t tham gia nghin cu27 3.2 Trnh v thm nin cng tc ca nhn vin y t tham gia tr li phiu kho st 28 3.3 Miquantmcanginhbnhnhnvgimausau phu thut 29 3.4 Nhn thcca nginh bnh nhn v gim ausau phu thut 29 3.5Phng php nh gi au ca ngi nh bnh nhn30 3.6 Ccbinphpgimaukhngdngthuccanginh bnh nhn 31 3.7Kh nng nh tn thuc gim au ca ngi nh bnh nhn33 3.8 Kt qa trao i thng tin gia nhn vin y t v ngi nh bnh nhn 34 3.9 Miquantm,nhnthccanhnvinytvtmquan trng ca vic kim sot au sau phu thut 35 DANH MC CC HNH V HnhTn hnhTrang 1.1S dn truyn auPh lc 3 1.2Thang COMFORT Ph lc 4 1.3Thang FLACC Ph lc 4 1.4Wong and Baker FACES Pain ScalePh lc 4 1.5Faces Pain Scale-Revised (FPS-R)Ph lc 4 1.6Visual analogue (VAS) v Numerical rating scale (NRS)Ph lc 4 1.7Bc thang thuc gim au ca WHOPh lc 5 1.8C ch gy c vi gan ca paracetamolPh lc 5 3.1Phn b bnh nhn theo gii, tui26 3.2Phn b bnh nhn nhm tui di 327 3.3c im ngh nghip ngi nh bnh nhn27 3.4Mc dng thuc gim au cho tr ca ngi nh bnh nhn 32 3.5Thi im dng thuc gim au cho tr32 3.6Kh nng nh liu lng thuc v s ln dng thuc gim au m bc s k cho tr 33 1 T VN Hin nay au c xem l mt trong nm du hiu sng (5th Vital Sign) cn ctheodiviutr.Phuthutlmttrongnhngnguynnhnquantrng gy au sau m, v mc d l iu t hi nht m tr phi tri qua trong qu trnh nm vin, nhng n b nh gi thp v thc s c cha tr km, tt hu hn so vi ngi ln trong nhiu nm qua. Vic iu tr khng tha ng cc cn au sauphuthuttremlnutincnhnmnhhn20nmtrcy[49]. Mt cuc kho st ti thi im pht hin ra rng 40% tr em sau phu thut tri qua cm gic au mc trung bnh hoc nng v 75% khng c gim au thch hp[49].Trongnm2006,hainghinculnvqunlautrssinh AustraliavNewZealandtitlhuhtcccsytkhngthngxuynthc hinnhgiauvkhngcphcrrngchoiutraugyrabiphu thut.Chc1/3csthngsdngccphngphpgimauchotrs sinhtriquaphuthut.Mtnghincuchothyhuhttremtriquaausau m khng ng c, vi 15% tri qua cn au nghim trng [12]. au tr em gy ra cng thng khng ch cho chng m cn cho cha m v nhn vin y t. au tr s sinh, tr em c tc ng tiu cc tng t nh ngi ln. Nu khng iu tr kp thi, cn au cp c th gy ra tng huyt p, tng nhp tim, tr tun hon, c nguy c thay i hnh vi tr em trong mt thi gian di (ln n 1 nm) sau khi phu thut. Tr s c nguy c hnh thnh b nh au v au mn tnh, do li mt s hu qu v th cht v tm l cho ti khi ln [1], [12], [13], [18].Vn chnh trong iu trau tr em,c bit l trmi sinh,l nhng khkhntrongnhgiau.Khichngtakhngthnhgimcauhoc hiu qu gim au, chng ta khng th chc chn c bin php gim au no l cn thit v khi no th cn n. Mt yu t quan trng na hu ht cc nc ang phttrin(chim80%dnsthgii)lcciudngchacotohoc thiu thuc v trang thit b cho cc phu thut thm ch cn n gin [38]. 2 Do , gimau sau phu thut chiu qu, cn lp k hoch gimau trc, trong v sau phu thut [3], [18], [37], [49], [51]. Mt s yu t na gp phn qun l au sau phu thut c hiu qu l nhn thc ca i ng nhn vin y t cng nhcabnhnhnvnginhbnhnhnvtmquantrngcagimausau phuthut.Bncnh,ccyutnhcutrccaingqunl,cngtc tuyntruyn-giodcbnhnhn,otonhnvinytthngxuyn,sdng hp l thuc gim au, nh gi authng xuyn bng cng c nh gi v iu chnhccphcpngnhucucabnhnhncnggpphnvoqunl au mt cch hiu qu [3], [18].Bnh vin Nhi Trung ng l n v hng u trong iu tr v chm sc sc khe cho cc bnh nhi nh tui. Nhn thc c tm quan trng ca vic kim sot au i vi sc khe ca tr nh, n v chng au c thnh lp v i vo hot ng. nh gi mi quan tm, nhn thc v hiu bit ca nhn vin y t v nginhbnhnhnivivngimausauphuthut,tiKhost nhn thc v hiu bit ca nhn vin y t,ngi nh bnh nhn v auvcc bin php gim au sau phu thut c tin hnh nhm cc mc tiu sau: 1.Kho st mi quan tm, nhn thc v hiu bit ca ngi nh bnh nhn v au v cc bin php gim au cho bnh nhi sau phu thut. 2.Kho st mi quan tm, nhn thc v hiu bit ca nhn vin y t v au v cc bin php gim au cho bnh nhi sau phu thut. 3 Chng 1 TNG QUAN 1.1.AU 1.1.1.Tnh hnh dch t aulmttrongnhngldophbinnhtkhinbnhnhntmns chm sc y t. au cng thng xuyn b phn nn bi bnh nhn, v l mt trong nhng khiu ni y t ph bin [3], [11], [46]. Theo mt bo co gim au ca vin bocoYhcHoaK(InstituteofMedicineReport)nm2010,hn100triu ngi M chu aumn tnh, 60%ngi t 65 tui tr ln chobith tri qua au ko di mt nm hoc nhiu hn. Hng triu ngi M tng tri nghim au b nh hngsu scn cht lng cuc sng. au gy ra haoph thi gian lm vic nhng ngi lao ng. Ngoi ra, trong nhng nm gn y, s ch ca cc quc gia tp trung vo s lm dng thuc k n, c bit l opioid. T vong do quliuthuctiMvtqu36.000caminm,tronghn55%cctrng hp lin quan n s dng thuc k n. Opioid chim gn 75% ca 20.000 ca v qu liu thuc k n gy t vong c bo co trong nm 2008 [3].Phu thut l mt trong nhng nguyn nhn quan trng gy au cp tnh v cn phi c kim sot y . Gim au khng sau phu thut gy kh chu, lm tng bin chng, ko di thi gian hi phc. N cn li hu qu xu v mt sinh l v tm l chobnh nhn vtn kmv mt ti chnh. Gim au khng sauphuthutlmtvnlntrntonthgii.Rtnhiucuciutratrong mt thi gian di cho thy nhiu bnh nhn vn b au t trung bnh n nng sau m mc d cng c nhiu tin b trong qun l au [48].Nhn thc c s ph bin rng ri v t l mc v chatr kmhiu qu caau,nm1996,tinsJamesCampbell,chtchHiauM(AmericanPain Society) pht biu "Nu cn au c nh gi vi cng mt nhit tm nh cc du hiu sng, n s c c hi tt hn c iu tr ng cch". V cm t "Pain 5th Vital Sign" (au du hiu sng th 5) c to ra thc y s nh gi 4 authngxuyncngviccduhiusinhtnquantrngcabnhnhnnh: mch, huyt p, nhit c th, nhp th [20]. 1.1.2.Khi nim au, phn loi cm gic au, vai tr ca au 1.1.2.1. Khi nimau TheoHiphinghincuauquct(IASP),aucnhnghal [18], [37]. Nhvy,aulmttrigiccthvchquan,baogmcctnhiucm gic, cm nhn xc cm v phn x ng x. au l mt tn hiu cho bit m ang b eda,hocbtnthng.Tuynhin,cngctrnghpaukhngcnguyn nhn thc th r rt.1.1.2.2.Vai tr ca au C th thy au l mt cm nhn kh chu v cm gic v cm xc, thng mangtnhchquanvcth,songcnglmttnhiuchobitmbeda, v/hoc tn thng. Nh vy, au ng vai tr tch cc, mang ngha cnh bo v gip ngi bnh phi bt ng, va trnh au, va trnh cho cc m c th b tn thng tip [18]. Tuy nhin, nu au qu mc cng em li nhng tc ng xu ti tng c th ngi bnh, ty vo cn au cp tnh, hay au mn tnh. Tc ng tiu cc ngn hn ca cn au cp tnh bao gm: Gy kh chu v cm xc v th cht cho bnh nhn Ri lon gic ng (vi tc ng tiu cc n tm trng v hot ng) Tc dng ph trn tim mch (nh cao huyt p, nhp tim nhanh), gy ra tr trong lu ng mu v thc y huyt khi Tngtiuthoxy(vitcngtiucctrongtrnghpcabnhng mch vnh), nh hng n chc nng h hp. 5 Rilonnhungrut(opioidgyratobnhocbunnn,hockhng c iu tr au cng l mt nguyn nhn gy gim nhu ng rut hoc nn, bun nn sau phu thut) [18]. Tc ng tiu cc lu di ca cn au cp tnh bao gm [18]: au cp tnh nng l mt yu t nguy c i vi s pht trin thnh au mn tnh [18]. au mn tnh lm nh hng nhiu n th cht, tm lca ngi bnh, n gy mt sc, gim vn ng, ri lon gic ng, suy gim min dch, d mc bnh nhim khun, gy chn chng, ph thuc vo thuc, ph thuc vo cc thnh vin trong gia nh v nhng ngi chm sc khc. au mn tnh cng li mt gnh nng kinh t tng i ln. Nhng ngi b au mn tnh c kh nng gp kh khn trong cng vic gp hai ln [12]. au cp tnh nng c nguy c lm thay i hnh vi tr em trong mt thi gian di (ln n 1 nm) sau khi phu thut. Tr s c nguy c hnh thnh b nh au,dolimtshuquvthchtvtmlchotikhiln[1],[12], [13], [18]. 1.1.2.3. Phn loi auC ch bnh sinh ca au lin quan n hot ng phc tp ca mng li h thn kinh trong no, hot ng bng cch kch thch sn xut ra nhng cm gic m chng ta bit l au (hnh 1.1- Ph lc 3). Trong cn au cp tnh, s iu tit nylngn,nhngtrongmtstrnghp,nhngthayicthtnti,v phttrinthnhaumntnh.Tyvothigianxuthinvtnticnaum ngitachiaaulm2loi:aucptnhvaumntnh[11],[23],[34],[37], [47], [50]. 1.1.2.3.1. au cp tnh L trng thi au xut hin khi chn thng hay phu thut, thng hn nh, gim dnkhi vt thng lnh.au cp tnhsau phuthut thngko di 7 ngy [18]. Triu chng bao gm: nhp th nhanh, nhp tim nhanh, tng hot ng ca h thn kinh giao cm, nh xanh xao, chy m hi, gin ng t. Hn na au cp tnh 6 cn gy ra stress v lm tn hi n h min dch do gii phng ra cc corticosteroid ni sinh. au cp kiu thn th pht sinh t tn thng xng, da, c, khp v m, n thng c hn nh ti vng chn thng. au cp kiu ni tng lin quan n tn thng dy thn kinh trn c quan ni tng (v d, c quan tiu ha hoc gan) v c th l au lan ta, kh xc nh. au cp thng l au kiu th cm, cng c khilkiuauthnkinh.aucptnhcnciutrtchcc,thmchtrc khichnoncxclp,ngoitrtrongiukinauuhocchnthng bng ni au c th c xc nh trong chn on phn bit. 1.1.2.3.2. au mn tnh aumn tnh kodi, thng vt ra ngoithi gianbnh thngd kin, thng trn3 thng. aumn tnh c th lau do th th,vim, thn kinh, hoc chc nng. au mn tnh c th tng t hoc lin tc, hoc c hai. Phn ng sinh l quan st thy trong cn au cp tnh thng xuyn vng mt trong au mn tnh, tuynhin,cctriuchngkhccthchimuth.Cctcngchnhcacn aumntnhl:1)nhhngnchcnngvtl,2)thayitml,3)gyra nhng hu qu x hi. 1.2.AU TR EM 1.2.1.Vn iu tr au tr em auhindinnhlmttriuchngngsnhtcabnh,vmcdl iu t hi nht m tr phi tri qua trong qu trnh nm vin, nhngn b nh gi thp v thc s c cha tr km trong nhiu nm [8]. V vy m Hip hi Nhi khoaM(AmericanAcademyofPediatrics)vHiauM(AmericanPain Society)banhnhmttuynbchungvithgiirngauphiccng nhnviutrtchcchntrem.Cchngdnccungcpbicct chcnhHiauM,cquannghincuvnhgichtlngchmscsc khe(AHRQ)araccktlunvthnghimgimautremcung cp bng chng cho cc hng dn iu tr sau ny. H ch ra mt s quan nim sai lm c th dn n cha tr au km hiu qu tr em nh sau [3]: 7 Quan nim sai lm cho rng trssinh v tr emkhng cm thyau n, hoc cm thy au t hn ngi ln. Thiu nh gi au thng xuyn tr em. Thiukinthclinquannphngthcmivphcthchhpcho vic s dng thuc gim au tr em. Nhng lo ngi v suy h hp hoc tc dng ph ca cc thuc gim au khc. Quan nim rng ngn nga cn au tr em tn nhiu thi gian v n lc.Hinnay,bcmnbmtvconngdntruynaunotrc vn ln. Cng vi l s pht trin v xc nhn cc cng c nh gi au cho tr emm iu tr au tr em ctin b ln trong thp kqua. Qun l au sau phuthutkhngchgimthiuauncabnhnhnmcngimtlmc bnh,nhanhchngphchi,nhanhchngcxutvinvdochiphcha bnhcnggimi.Nm1786,ThomasJeffersonvit:Ngh thut ca cuc sng l trnh au n. C l khng nhm tui ang b bnh no cn c trang b trnh au hn l tr s sinh v tr em [14].1.2.2.c im au tr emVonm1987,mtnghincutrntrssinhvtrnbothaichng minh rng mt ca th th au tr l tng t nh ngi ln. Kt ni ca cc th th ny vi trung ng thn kinh tn ti tun th 30 ca thai k v cc kch thchaucngctruynquaccsimyelinvkhngmyelin.Nhvynhn thc au c lc mi sinh. Cc nh thn kinh hc v chuyn gia au cho rng, do phn ng vim mnh hn v thiu nh hng ca s c ch trung ng, tr s sinh v tr nh c th thc s tri qua phn ng thn kinh ln hn, tc l cm gic au nhiu hn v lo lng lin quan n au nhiu hn sau mt kch thch c hi hn so vi ngi ln. Tc ng ca tri nghim au ln h thn kinh non tr nh hng cc kludi,baogmckhnngchungauhxungnhiuthngsaumts kin gy au [8], [14]. 8 Tr c th ni rng chng cm thy khng tt hoc l khng thoi mi hoc mun cha m, nhng khng c kh nng cnh bo hoc ch ra ang au n [8]. Hn na, nhng trcha nic, ang pht trin vlini cthmu thun, au khng c m t chnh xc. Kt qu l cn au tr khng c cng nhn, b hiu lm v cha tr khng tt [44]. Song iu cng khng th bin minh cho vic cha tr km cn au trong mt thi gian di.1.2.3.nh gi au tr s sinh v tr em V tr em c mt phm vi gii hn v tri nghim, kh c th dng nhng t ng y th hin s kh chu ca chng, nn xc nh mt a tr ang tri qua au n th no c th kh khn. Yu t nhn thc, hnh vi, tnh cm v tm l x hi (gia nh, hc tp, vn ha), v cc yu t khc (gii tnh) ng vai tr quan trngtrongvictringhimaucamtatr.Vitremvthanhthiunin, p ng vi cc yu t c hi khc nhau cc giai on pht trin khc nhau [3].olngauliucnthitqunliutrautt.Mcnghim trng v au sau phu thut nn c o thng xuyn nh gi nhu cu thuc gim au v p ng iu tr. Mt s cng c nh gi au ra i. Phng php o lng au tr em c th c chia thnh 3 loi [14]: T bo co: bao gm cc thang im hi, thang s v thang hnh. Ccbinphpolngaudavohnhvi:baogmpngvn ng, nt mt, khc v phn ng hnh vi phc tp. Cc thang cho php cc quan st vinnhgiaudatrnshindinhayvngmtcanhnghnhngc cho l lin quan n au. Tuy nhin mi tr em u c nhng chin lc c nhn i ph vi au, hnh vi c th khng c hiu cho d on mc au [38]. Ccbinphpolngdavothngssinhlcaau:baogm nhng thay i ca nhp tim v huyt pDo , c th nh gi au da trn cc thng s khc nhau, m cc thng s ny c th c o trc tip bn ging bnh hoc trong phng th nghim. 9 T bo co: Khi t bo co l bin php trc tip ch ra cn au, n thng c coi l tiu chun vng v nh gi mc au [43]. Cc nghin cu ch ra rng tr em t 18 thng tui c th dng t ni v au, nh tr 3 tui c th by t v xc nh au kh chnh xc vi s gip ca cc thang nh gi au, v tr c th t ch n khu vc c th, ni chng ang b au [38]. Tht khng may, iu ny ch c th nh gi tr kh nng nhn thc v giao tip. tr di 1 tui hoc nhng tr d tt v nhn thc, vic t nh gi l kh, do cn da vo nh gi quan st hnh vi, thng s sinh hc [22]. Mt bin php quan st hnh vi nn s dng kt hp vi t bo co vi tr 3-5 tui [9]. au c o cng chnh xc cng tt, nn da vo cc nguyn tc lm c s cho nh gi cc la tui khc nhau [7]. Ngi hi nn kin nhn v dng ngn t thch hp vi tr. Tt hn ht l ni chuyn vi cha m trc khi hi tr v nn s dng ngn t hay c dng mtaugianh.Trembtklatuinoucthphnhnaunu ngihirtngshocnginlchngsnhnvinmcoblousetrng, hoc chng e rng s phi tim nu ni rng au [22]. 1.2.4.Cc cng c nh gi auCng c t bo co Cc cng c t bo co l kh thi nht, da trn tui, trnh phttrin v loi au, c khuyn co s dng trong th nghim lm sng (ph lc 4):Wong and Baker FACES Pain Scale (thang gng mt au)Faces Pain Scale-Revised (FPS-R) (thang gng mt au sa i) Trn y l hai thang im nh gi au thch hp s dng rng ri, dnh cho tr t 3 tui tui tr ln. Thang khun mt c th khng ihi kh nng sp theo hng hoc c tnh s lng v chn ra mt trong cc khun mt c coi l d dng hn so vi c tnh nh tnh nh hai thang s sau y [7]: Visual analogue scale (VAS) (thang c lng bng mt) Numerical rating scale (NRS) (thang s) 10 Cng c quan st hnh vi Thang COMFORTThang FLACCCc thng s sinh l Cc thngs sinh l nh thay i nhp tim, thayi trongnng cortisol trongncbtcthgintipchrashindincaau.Tuynhin,huytp, nhp tim v nhp th c chng minh l ch s khng ng tin cy tr s sinh v tr em sau phu thut ln t 0 - 3 tui. Cc thng s sinh l ny nn s dng kt hp vi cc cng c khc xc nh s hin din v cng au [7]. Theo khuyn co caHip hi bc s gym nhi khoa vng quc Anh v Ireland,mtscngcnhgiausauphuthuthaycsdngchotrc nhn thc/pht trin bnh thng nh sau: Bng 1.1. Cng c nh gi au sau phu thut hay s dng cho tr [7] TuiCng c Mi sinh 3 tuiCOMFORT hoc FLACC 4 tuiFPS-R + COMFORT hoc FLACC 5 7 tuiFPS-R 7 tui tr lnVAS hoc NRS hoc FPS-R 1.3.QUN L AU CP TNH SAU PHU THUT 1.3.1.Mc tiu ca gim au cp tnh sau phu thutCi thin cht lng sng ca bnh nhn. To iu kin thun li phc hi nhanh chng, phc hi chc nng. Gim t l mc bnh. Gim thi gian nm vin [13], [18]. 11 1.3.2.Nhim v ca nhn vin y t trong qun l au sau phu thut 1.3.2.1.Nhn thc v au Nhnvinytcnckinthcphhpvaucngnhhiubitcc nguyntcchungvnhgivqunlcnautrem,gmkinthcvk thut nh gi au v s dng thuc gim au ty theo la tui [7]. Nh vy nhn viny t cn c o to thng xuyns dng cc cngc nh gi au v thnh tho trong vic s dng chng. Cc nghin cu chng minh rng nhn vin y t nh gi au tr em l ty theo mi c nhn, nh hng x hi v theo hon cnh. Cc nhn vin y t cn phi linh hot, c thi tch cc hn v nim tin lin quannviciutrauchotrem[7],[18].Nhiunghincuviudng chm sc bnh nhn sau phu thut cho thy rng cc iu dng khng c kin thc, c bit l trong lnh vc thuc, c mt s quan im tiu cc v opioid [17], [53].Vvy,nhnvinytcnmrngkinthcvcnautremvcc nguyn tc, k thut v qun l au tr em [3-5]. Gimausauphuthutcnclpkhochvtchctrckhiphu thut,thamkhokinbnhnhnvgianh,ccthnhvincaichmsc quanh phu thut [7], [13]. Cng tc phng chng au sau m phi c thc hin trc khi phu thut, trong chuyn thm trc phu thut bng cch ni chuyn vi c tr em v cha m ca chng [8]. Ccnhnvinytnncungcpthngtinvlikhuynrrnglinquan nvnausauphuthut,phngphpnhgiauvsdngthucgim au cho bnh nhn vgia nh[26], [32]. Hn na, nhn vinytnn cham bnh nhn cng tham gia nh gi au v quyt nh dng thuc gim au bi cha m l ngi nh gi mc au ca con kh chnh xc v h bit r a tr nht [1].Chambnhnhncnchtrtinhthnhthyrvaitrcamnh trong cn au ca tr. Cha m, ngi chm sc tr nhn thc khng ng v iu tr au, c th s nhm ln v s au n ca tr. Do nhn vin y t cn phi hng dn h mt cch cn thn [7]. 12 1.3.2.2.nh gi au Nhn vin y t cn bit: qun l au sau m hiu qu th mc au phi cnhgimtcchthchhp.Ccmctiucanhgiaulxcnh mc au, gip la chn thuc gim au cho ph hp vi mc au c th v nh gi tnh hiu qu ca iu tr au. Nhn vin y t nn khuyn khch bnh nhn ch ng tham gia nh gi au v s dng cng c thch hp [53]. La chn cng c nh gi: Khng c binphp o lng no cth c s dngrng ri nh gi au trntt c tr emhocmi hon cnh. V vy mi nhn vin y t cn c nhng la chn cng c s dng. C nhiu hnh thc la chn, ph thuc vo tui, s pht trin thn kinh v nhn thc ca tr [16], [49]. Ttnhtlkthp:tcuhivauvitremvchamchng,sdngmt thang nh gi au, nh gi thay i hnh vi v sinh l [7], [38], [22].Mt nghin cu cho thy vic nh gi ca iu dng trong qun l au sau mlkhngy.Mtsbocochrarngimautrongtiliucacc nhn vin y t l thp hn ng k so vi im s bo co ca cc bnh nhn [28], [53]. V vy, nhng vn m nhn vin y t cn ch khi nh gi au sau phu thut cng gm nhng iu sau y [18], [26], [42], [53]: nhgiauclcnghvlcvnngnhgitnhtrngchcnng ca bnh nhn. Ch ghi li kt qu nh gi au gm: cng , tn s, v tr, thi gian v khongthigiangiacccnau,yutlmnngthmhocduicnau, phng php iu tr trc y v hiu qu ca n. nhgiautrcvsaumilniutrcanthipxcnhhiuqu iu tr. cc n v gymhi sc sau phu thut,cnnh gi cng au v nh gi li thng xuyn (mi 15 pht u, sau mi 1-2 gi khi cng au gim). khoa iu tr, nhn vin y t cn nh gi v nh gi li thng xuyn (mi 4-8 gi) c au v p ng iu tr ca bnh nhn. 13 Xc nh im au ti a khi dng thuc gim au (ngng can thip).Khi c au d di bt ng, c bit nu c du hiu sng thay i (h huyt p, nhp tim nhanh, st), ngay lp tc nh gi. cc thnh vin trong gia nh tham gia qun l au trc tip. 1.3.2.3.iu tr au Ccphngphpgimausauphuthutphiphhpvitui,loi phu thut v c th nghim lm sng m bo an ton, gim au mnh v linh hot vi mt t l thp cc tc dng ph [7]. Nhn viny t nn sdngmt phng php tip cn a phng thc, kt hp thuc gim au nu khng c chng ch nh c th, nh thuc gy t, opioid, NSAIDs v paracetamol, khng qu liu khuyn co [7]. Dng cc thuc gim au theo khuyn co ca WHO vi 4 nguyn tc sau: Dngthuctheobcthangthucgimau,theongh,theongdngthch hp nht, theo tng c th [16], [35], [52]. Do s dng thuc gim au opioid trong thi gian ngn nn khng cn quan tm n vn nghin opioid. Nhn vin y t cn c kh nng d on cc kiu au c th can thip v gimstphhp,chnoncctrnghpaumntnhsaunycphc thch hp [38]. Kimsotktquiutrau,gimstthngxuynchophpphthin bin chng mt cch nhanh nht. Ghi li kt qu s hu ch cho vic iu tr, thng tin lin lc gia cc nhn vin, kim sot cht lng [53]. S dng cc phng php khng dng thuc lm gim au [26], [53]. 1.3.3.Nhimvcanginhbnhnhntrongqunlausau phu thut Nhngnghincutrcychothysauphuthut,nhiuchamkhng cung cp cho con h thuc gim au c k n, a s cc bc cha m dng thuc cho tr di mc iu tr c v liu lng v tn s ln dng thuc. Hn na, 14 nhiunghincuxcnhrocnthicachamlmtyutlinquan n qun l au ca tr em. l, khi cha m c nhiu quan nim sai lm, khng chc chn v s dng thuc gim au tr em, cng nh ni lo s tc dng ph v nguycnghinthucgimaunnhcungcpchotremtliuthucgim au.Dohchorngthucgimauchcsdngnhmtphngsch cui cng, v paracetamol ch dng cho cn au nghim trng [24], [39]. V vy, nhn thc ng n ca cha m v au s gip h i ph tt hn vi tnhhnhbnhcatr[38].Shiubitvhtrtchamlrthuchtrong qun l au cho tr v hn ai ht, cha m l ngi hiu r con mnh nht. Khi tr em cthkhngyucugimaunhngilncthlm,champhithchin minlcdoncnau,cbitltrssinhvtremkhngthth hin bn thn bng li ni [38]. Mt cu hi t ra l tr em c lun ni vi bn khi n au khng? Ngay c khi chng c k nng giao tip y , c mt s l do tr em c th khng bo co au.Tremcthshikhi(1)nichuynvibcs,(2)phthinramnhb bnh, (3) tht vng hoc kh chu vi cha m vnhng ngi khc, (4) tim hoc dng thuc, (5) quay tr li bnh vin hoc tr hon vic c ra vin, (6) phi phu thut hoc t dng c xm ln, hoc (7) b tc dng ph ca thuc.V cui cng l, tr ch c th khng ngh rng l cn thit khi phi ni vi cc nhn vin y t v cn au ca chng. Do , cha m phi lun quan st tnh hnh ca tr [38].Cham, ngi chm sc cng cn tmhiu thng tin v thuc gim au v sdngccngcnhgiaunumunchiuqutrongvicqunlau ca tr [7]. Mt nghin cu ch ra rng ngi nh bnh nhn c ti liu v au v iu tr au c thi tch cc hn trong vic dng thuc gim au [15]. Do vy, cha m v tr nn c cc ti liu v iu tr au trc khi phu thut. N c th xua tan ni s hi v quan nim sai lm v au v cc loi thuc c s dng iu tr au.Hn na, gia nh bnh nhn nn: 15 Thc hin y y lnh, dng thuc theo n ca bc s Thng bo cho nhn vin y t khi cn au u tin bt u Thng bo cho nhn vin y t nu cn au khng thuyn gimKhibocomcaucnbocongthct,trnhcngiuhoc cam chu, iu ny s dn n vic nh gi v dng thuc khng ng [18] Thng bo cho nhn vin y t v bt k tc dng ph ng nghi ng ca cc thuc gim au a ra bt k cu hi c th c lin quan n iu tr auCh n ccyu t tinh thn, tnh cm c th thay i ngng au. Lo u trm cm, mt mi, gin d v s hi c bit lm gim ngng ny, trong khi tm trng thoi mi, ngh ngi, s cm thng, chia s v s hiu bit nng cao ngng chu au. Do nn kt hp cc bin php khc cng vi thuc gim au.1.3.4.Cc bin php gim au khng dng thucHtrcmxc(ani,btckhinocth,chamnncngconem mnh). Phng php vt l (ng chm: vut ve, masage; b dong, chm lnh hoc m, th gin bng cch th su). Cc phng php nhn thc (ru, gi hnh nh, k chuyn cho tr; lm mt tp trung,hngschcatrvovickhcnhchotrngheht,xemhothnh, c sch, chi chi, hot ng nh). Cu nguyn (ty thc t ca tng gia nh) [16], [38], [52]. 1.4.THUC GIM AU 1.4.1.Mc tiu v nguyn tc dng thuc gim au tr em S dng thuc gim au sau phu thut t c 3 mc tiu sau y [13]: Kim sot cn au. Ngn nga v iu tr sm triu chng lin quan n tc dng ph. Nhanh chng tr li vi hot ng bnh thng hng ngy. 16 C 4 nguyn tc cho vic s dng thuc gim au tr, gm [16], [52]: Dng thuc theo bc thang thuc gim au Dng thuc theo ng h Dng thuc theo ng dng thch hp nht Dng thuc theo tng c thDng thuc theo bc thang thuc gim au TheoWHO,c3mcaugm:aunh,auvavaunng.Thuc gim au c la chn ty theo mc au (Hnh 1.7 - Ph lc 5):-Bc1(aunh):dngthucgimaunon-opioidnhparacetamol, NSAIDs. -Bc2(auva):phihpthucloiopioidyu(codein,oxycodon)vi paracetamol, NSAIDs hoc thuc ph tr gim au. -Bc3(aunng):dngthucgimauloiopioidmnh:morphin, methadon... Kt hp paracetamol, NSAIDs hoc thuc ph tr gim au. Dng thuc theo ng h Ccthucnndngtheolchtrnhsnttrchnltheonhucuvtr khngthniranhucugimauchnhxc,vlctrs,cnaucachngs khkimsotvcthtngln.Thmna,liuopioidphngautiphts thphnliuchonhngcnaukhngthngxuyn.Do,trnncdng thucgimauvonhngkhongthigiannhsn,datrnmcauv thi gian tc dng ca thuc [16], [52]. Dng thuc theo ng dng thch hp nht ngdngthucchotrnnnginvhiuqunht,tgyraauti ch a thuc nht. Thuc thng c dng ng ung, bo ch dng vin. Tim tnh mch, tim di da l nhng ng thch hp. Thng thng, tim bp t c 17 khuyn co v n gy au cho tr. ng trc trng khng d chu nhng dng tt trong trng hp tr nn ma, khng nut c [16], [52]. Dng thuc theo tng c th Liudngmithucphidatrnhoncnhcatngatr(tui,cn nng,bnhmckm).Cnthitphikimsotautrthngxuyniu chnhliuchophhp.Liucaopioidchiuqugimauthayirtnhiu gia nhng a tr v trn mt a tr nhng thi im khc nhau. V vy, vic da trn mc au ca mi tr l rt cn thit [16], [52].1.4.2.K thut a phng thc iu tr au a phng thc tr thnh xu hng trong vi nm qua. au do nhiu c ch nn ti u nht l iu tr bng k thut gim au a phng thc. Cckhinimvgimauaphngthccgiithiuhnmtthpk trc y nh l mt k thut nng cao tc dng gim au v gim t l lin quan n tc dng ph ca opioid [41]. Gim au a phng thc c khuyn co cho gim au sau phu thut l c hiu qu. N c thc hin bng cch kt hp cc thuc gim au khc nhau m tc dng theo nhng c ch khc nhau, ti cc im khc nhau trong h thng thn kinh (Opioid, NSAIDs v thuc gy t ti ch), kt qu l tng thm tc dng gim au, tng liu thp hn khi dng ring tng thuc, v t tc dng ph hn. Hiu qucamt thuc gim au n thun kimsot cn au thng b nh gi thp. Do mt cch tip cn a phng thc phng v iu tr au thng c s dng [19], [27], [45].1.4.3.Thuc gim au non-opioidParacetamol,ibuprofen,naproxen,diclofenac,ketorolaclccnon-opioid hay c dng iu tr au. Khi s dng mt mnh, n iu tr au nh v cnphickthpviccthuckhciutrautrungbnhnnng. Nhng loi thuc nyc s dng tt nht khi kt hp vi thuc opioid gim liu v tc dng ph ca opioid [13], [30], [33], [38], [45]. 18 1.4.3.1.Paracetamol Paracetamolthnghaycdngnhtgimauchotremdottc dng ph ng k. C ch gim au l c ch s to thnh prostagladin, lm gim chtPgyrastngau,viuchnhvicsnxutnitricoxidegytngau trongtysng.Ncdngchoaunhnva,vthngkthpvithuc gim au opioid cho bnh nhn au nng hn [45].Paracetamol c th dng theo cc ng khc nhau nh ung, t trc trng, tnh mch. Liu dng c chia ra nh sau: ng ung: 10 - 15 mg/kg/liu mi 4 - 6h, khng qu 5 liu/24h. Liu tiamtngykhngqu75mg/kgivitrem,60mg/kgivitrssinh di 10 ngy tui, 45 mg/kg cho tr s sinh thiu thng > 34 tun mang thai.ng trc trng: thch hp cho nhng tr khng nut c. Thuc qua ng trc trng hp thu chm nhng tng i hiu qu. Liu dng 1 ln t 35 40 mg/kg hoc duy tr 20 mg/kg/liu mi 6h. Liu ti a l 120 mg/kg/ngy. Khng nn dng ng trc trng di ngy. ngtnhmch:Trssinh7.5mg/kgmi46h,tia30 mg/kg/ngy. Tr em > 10 kg: 10 15 mg/kg mi 4 6h, ti a 60 mg/kg/ngy. Liu ti a mt ngy khng nn a ko di hn 48h i vi tr di 3 thng, 72h i vi tr trn 3 thng tui.Tcdngphcaparacetamolphbinlbandahocmncmvi thuc. Tc dng ph ng ngi nht l vim gan cp. C ch gy c nh sau (Hnh 1.8 - Ph lc 5): liu iu tr, 90% paracetamol c chuyn ha thnh dng lin hpviglucuronidevsulfate,sauothiquathn.Phncnlica paracetamol,50%cbititkhngiquanctiu,vphncnlic chuyn ha quah thng cytochrome P450,to ra chtchuyn hac vigan l N-acetyl-p-benzoquinoneimine(NAPQI).GlutathioneganlinhpviNAPQI to ra cht chuyn ha khng c hi c o thi qua thn. Vi liu paracetamol 19 gy c, con ng glucuronide v sulfat ha tr nn qu ti, glutathione gim, dn n hoi t t bo gan do NAPQI [3], [33], [36]. Cc nghin cu cho thy liu trn 150 mg/kg/ngy c th dn ti suy gan cp [10], [25], [40]. Cc ca nhim c gan sau khi dng cc liu lp li l him, v n c cho rng do s tch ly paracetamol [40]. Mt s nghin cu ch ra tr em c th b nhim c gan nu dng > 150mg/kg/ngy ko di t 2 8 ngy [6]. Cc t chcnhFDA,trungtmphntchkimsotchtc,ccnghinculmsng chraliuiutr75mg/kg/ngylanton.Ngcganliuiutr75 mg/kg/ngy tr em rt him khi xut hin [31]. iviccbnhnhncbnhganttrc,nghincuhincnhng bnh nhn b bnh gan mn tnh, ch ra rng mc d thi gian bn hy ca thuc paracetamol c th ko di, cytochrome P-450 hot ng khng tng v glutathione khngttxungnmctihntrongnhngngidngliukhuynco[21]. Hnna,paracetamolcnghincutrongnhiuloibnhganmkhngc bngchngvnguycnhimcganliukhuynco.Vvy,paracetamolc th c s dng mt cch an ton nhng bnh nhn b bnh gan [54], [29], [2].1.4.3.2.Thuc chng vim khng steroid - NSAI Ds Ngoi tr trong giai on s sinh, khi thi gian bn thi di hn ng k, th dclchcvdcnghccathuckhngvimkhngsteroid(NSAIDs) tr em khng c nhiu khc bit so vi ngi ln. Mc d kh nng tiu ha, thn v c tnh khc tn ti, t l mc nhng vn ny tr em c th t hn so vi nhngvngpphitrongqutrnhiutrcangiln.CcNSAIDcch enzyme cyclo-oxygenase, c chs hnh thnh prostagladin ti vng b thng v chngvim.Cgngtrnhtimbphoctimdida.Tcdngkhngmong mun chung ca c nhm l nguy c lot d dy, suy thn, chy mu, mn cm vi thuc [13], [30], [33], [38], [45]. Diclofenac: L thuc gim au hiu qu sau phu thut nh tr em. Liu cho tr em ca diclofenac l 1 mg/kg mi 8 gi, dng ng ung, trc trng, 20 hoc tim tnh mch. Diclofenac dng ng trc trng c sinh kh dng tng i ln hn v t nng cao sm hn sau khi ung.Ibuprofen:ylmtthucgimautthnparacetamol,c khuyn co dng cho tr trn 3 thng. Liu ung 4-10 mg/kg/liu mi 6-8 gi l kh hiu qu. Liu ti a l 60 mg/kg/ngy.Ketorolac:Ketorolaclmtthucgimaurthuch.Tcdng ko di t 4-6 gi. Gn y, ng tim tnh mch cng c xc nh l an ton tr em. 1.4.4.Opioid Cc thuc nhm ny c tc dng gim au do c ch trung tm au no v ngn cn ng dn truyn cm gic au t ty sng ln no. Opioid l thuc chnh trong vic iu tr au sau phu thut v lm tng kh nng chu au. tr s sinh, thanh thi gim bt v thi gian bn thi b ko di so vi tr ln hn. Tr t 3 - 6 thng tr nn t nhy cm hn vi suy h hp. Nhng vn cn quan st cht ch tr s sinh. Vic s dng opioid tr di hai thng phi c gim st thch hp. thanh thi v thi gian bn thi tr em trn hai thng tui cng tng t nh ngi ln. tr em 1 - 6 tui, opioid c th c s dng mt cch an ton. ng tnh mchlttnhtchogimauhuphuvngimaungaylptc.Tcdng khng mong mun ca opioid khng ph thuc vo liu l to bn, bun nn, nn. Dosdngtrongthigianngn,khngcnquantmnvnnghinopioid trong giai on hu phu [13], [30], [33], [38], [45]. Opioid c chia lm 2 nhm: -Nhm gim au mnh: morphin, fentanyl, methadon, meperidin -Nhm gim au trung bnh: codein, tramadon 1.4.4.1.Morphin Morphine vn l opioid tiu chun gim au tr s sinh v tr em mi la tui. N c coi l an ton nht mt liu 0.1 mg/kg tim bp khi tr th mt cch t nhin. Tuy nhin, tim bp khng c khuyn khch v kt qu l nng 21 daongvchtimau.trtsuthngnmtnm,timtnhmch morphine0.1mg/kghoc0.05mg/kgcthcsdng.Theodihhpcn thn v cc c s cho hi sc phi c sn v c th c vn v suy h hp. 1.4.4.2.Tramadol Tramadol t an thn v t tc dng trn h hp hn so vi opioid khc, y l mt li th hn cc thuc gim au opioid c s dng gim au sau phu thut tr em.1.4.5.Thuc gy t ti ch, gy t vng Lm gim au hiu qu nht. Gimphnngcngthngkhiphuthuthiuquhnhnbtk thuc gim au no khc, bng cch ngn chn c hai con ng au hng tm v au ly tm. Gim nhu cu opioid v do gim tc dng ph ca opioid. C th lm gim tn sut cn au mn tnh. Gy t ti ch hoc gy t vng c thc hin tt nht trc khi phu thut, v b sung ti ch c xm ln trong phu thut [13], [30], [33], [38], [45]. 1.4.5.1.Bupivacain Bupivacaine c c tnh cao nht trong s cc amide gy t ti ch, song n vn ph bingy t vng chotr s sinhv tr em.Hu ht cc bo cov co git lin quan n truyn bupivacaine xy ra trong qu trnh truyn vt qu gii hn cho php. Tc dng ph trn tim c th l chm nhp tim, lon nhp tim. 1.4.5.2.RopivacainChottnhgyttngngbupivacainenhngctnhthn,tc tnh trn tim hn nn khi truyn lin tc l an ton, c bit tr s sinh. 1.4.5.3.Lidocain Lidocain lmt amide, n c s dng gy t ti ch v khidy thn kinh.Nkhiphtnhanhchngvtcdnggytthuctrongmtvipht, 22 thi gian gy t trung bnh. B sung mt cht co mch lm gim hp thu ton thn v tng c tc khi pht v thi gian tc dng ca lidocain. Lidocain l mt cht gy m ti ch hu ch nhng n c th c hp thu nhanh chng v rng ri sau khi bi ln mng nhy, v tc dng ton thn c th xy ra. 1.4.6.Cc thuc ph tr gim au 1.4.6.1.Thuc ch vn alpha 2 Clonidin Clonidin hot ng trong no v dy ct sng bng cch kch thch alpha-2 lm c chcctrungtmvnmch,gyragimdntruynticcm.Vicbsung clonidinvothucgyttichcchngminhtngcngthigianv hiu qu c ch cc khi dy thn kinh trung ng v ngoi vi. u im chnh ca clonidin (so vi cc opioid) l rt t c ch h hp [13], [30], [33], [38], [45].Dexmedetomidin Lmtchtcngungcimidazole,ctnhchvn,chnlccaoalpha-2. Dexmedetomidincnlthucanthn,gimau.Nlmgimscnthitphi dngccthucgimaukhc,cchgiaocm,gimgiiphngcatecholamin. Dexmedetomidincrtttcdngphvgichobnhnhnbnhtnhtrongmt thi gian di [13], [30], [33], [38], [45]. 1.4.6.2.Ketamin Ketamine c s dng thng xuyn gn 3 thp k. Vai tr ca receptor N-methyl-D-aspartate (NMDA) trong vic x l u vo nhn cm au dn ti mt s quan tm i mi thuc i khng th th NMDA nh ketamine. N c th c dng mt mnh hoc kt hp vi cc tc nhn khc thng qua cc ng ung, trc trng, tim bp, tim di da, tim tnh mch [13], [30], [33], [38], [45]. 23 1.4.6.3.Midazolam Midazolam thng c dng trc phu thut an thn, gim lo lng tr [13], [30], [33], [38], [45].1.4.7.Bnh nhn kim sot thuc gim au Bnhnhnkimsotthucgimau(Patientcontrolledanalgesia-PCA) c s dng rng ri gim au sau phu thut c tr em v ngi ln. PCA l mtcmyclptrnhcungcpngliuthucgimaubngcchtim tnh mch hoc tim di da. PCA cho php bnh nhn nm quyn kim sot thuc gimaumkhngcnscanthipcaiudngbngcchtnnt.Trc phu thut, vic hng dn v khuyn khch tr c th c lp s dng my bm PCAchothythiuqu.CthkthpPCAviNSAIDv/hoc paracetamol bng nguyn tc theo ng h. Cc nghin cu cho thy PCA cho im s au thp hn, v s hi lng tt hn khi s dng morphin tim bp, mc d, tng s morphine c s dng, t l mc bun nn, nn hoc b tiu l ging nhau [13], [30], [33], [38], [45]. . 24 Chng 2 -I TNG V PHNG PHP NGHIN CU 2.1.i tng nghin cu Tiu chun la chn: Nhn vin y t (bc s, iu dng vin) cc khoa thuc khi ngoi Bnh vin Nhi Trung ng Nginhcabnhnhncphuthutcckhoathuckhingoi Bnh vin Nhi Trung ng Tiu chun loi tr: Nhn vin y t, ngi nh bnh nhn t chi tham gia cuc kho st.2.2.a im, thi gian nghin cu Thi gian thc hin: 4/3/2013 5/4/2013 a im: cc khoa thuc khi ngoi Bnh vin nhi Trung ng 2.3.Phng php nghin cu Nghin cu thng k m t tin cu. S dng bng cu hi kho st cc i tng nghin cu. Trc tip n cc khoa ngoi phng vn ngi nh bnh nhn c con c phu thut. Pht cho nhn vin y t phiu kho st nhn vin y t t in. 2.4.Ni dung nghin cu 2.4.1. Khostmiquantm,nhnthcvhiubitcanginh bnh nhn v au v cc bin php gim au cho bnh nhn sau phu thut. Mi quan tm, nhn thc vtm quan trng ca vic ki ssau phu thut: Mc lo lng ca ngi nh bnh nhn v cuc phu thut Li ch (mc tiu) ca gim au sau phu thut. 25 Trao i vi nhn vin y t v tnh trng au sau phu thut: mc au ca tr, tr s c p dng nhng bin php gim au g sau m v vic s dng thuc gim au. Hiu bit vv cc bin php gimsau phu thut: Cc phng php nh gi au cho tr em Cc thuc gim au thng dng m tr c dng (tn thuc, hm lng, liu dng), liu trnh dng thuc (thi im v mc dng thuc gim au cho tr) Cc bin php gim au khng dng thuc. 2.4.2. Kho st mi quan tm, nhn thc v hiu bit ca nhn vin y t v au v cc bin php gim au cho bnh nhn sau phu thut. Mi quan tm, nhn thc v tm quan trng ca vic ki ss pu thut: Mc tiu ca gim au sau phu thut Gii thch v au v k hoch iu tr au trc v sau phu thut cho bnh nhn v ngi nh bnh nhn. Hiu bit vn php gis pu thut: Phng php nh gi au v ghi li c im cn au ca bnh nhn. Ccthucthngcchnhchogimausauphuthuttrem(tn thuc, liu dng, tc dng khng mong mun) v cc thuc b tr gim au sau phu thut. 2.5.C mu Ttcnhnvinyt,nginhbnhnhncconemcphuthutti cc khoa thuc khi ngoi Bnh vin Nhi Trung ng ng tham gia cuc kho st trong thi gian t 4/3 5/4/2013. 2.6.X l thng k Cc s liu thu c trong qu trnh iu tra c nhp vo phn mm SPSS, s dng php thng k m t v phn tch khi bnh phng phn tch s liu. 26 Chng 3 KT QU V BN LUN 3.1.KT QU 3.1.1.c im i tng nghin cu 3.1.1.1.Ngi nh bnh nhn v bnh nhn c im i tng bnh nhn Hnh 3.1: Phn b bnh nhn theo gii, tui Nhn xt: trong nghin cu ny, t l bnh nhn nam gp nhiu hn n vi tltngngl67%v33%.Tuitrungbnhthnggpl3,960,36.Tl nhm tr s sinh n 3 tui chim 58%. Trong nhm tui ny, t l tr s sinh n 1 tui l kh cao (hnh 3.2). 67% 33% Gii tnh bnh nhn NamN 58% 23% 19% Nhm tui Tr s sinh - 3 tui Trn 3 7 tui Trn 7 tui 27 Hnh 3.2: Phn b bnh nhn nhm tui di 3 c im i tng ngi nh bnh nhn Hnh 3.3: c im ngh nghip ngi nh bnh nhn Nhn xt:Trongs100nginhbnhnhnthc40%ngilmngh nng. Trong khi ch c 20% ngi tri thc (bao gm cc ngh: gio vin, k s, k ton, nhn vin...).3.1.1.2. Nhn vin y t Bng 3.1: T l nhn vin y t tham gia nghin cu S lngT l % Tng s bc s, iu dng vin cc khoa ngoi 150 Tng s bc s, iu dng vin ng tham gia kho st70100% Tng s bc s, iu dng vin c tr li phiu kho st4462,9% 40 11 7 0 10 20 30 40 50S sinh - 1 tui 2 tui 3 tui Nhm tr s sinh - 3 tui 20% 13% 40% 27% Ngh nghip ngi nh bnh nhn Tri thcCng nhnLm rung T do 28 Nhn xt:Mcdslngnhnvinytcckhoangoil150ngi, song ch c 70 nhn vin y t ng tham gia kho st. Trong s , ch c 44 nhn viny t c tr li vo phiu kho st (chim 62,9%). Chnh v vy, chng ti ch phn tch kt qu da trn s liu ca 44 phiu kho st ny. Bng 3.2: Trnh v thm nin cng tc ca nhn vin y t tham gia tr li phiu kho st Trnh Thm nin cng tc > 2 nm S lngT l %S lngT l % Bc s818,2818,2 iu dng3681,82761,4 Tng s441003579,6 Nhn xt: Trong s cc nhn vin y t tham gia tr li phiu kho st, c ti 81,8% l iu dng, cn li 18,2% l bc s. Phn ln s bc s v iu dng ny u c thm nin cng tc trn 2 nm (chim 79.6%). 3.1.2.Miquantm,nhnthcvhiubitcanginhbnhnhnv au v cc bin php gim au cho bnh nhi sau phu thut. Mi quan tm, nhn thc ca ngi nh bnh nhn v v au v tm quan trng ca vic kim sot au sau phu thut kho st mi quan tm v nhn thc ca ngi nh bnh nhn v iu tr au sau phu thut, chng ti da vo bng cu hi v ngh ngi nh bnh nhn cho im da trn cc mc ng hay khng ng vi cu hi, c th l: 1 - Rt khng ng , 2- Khng ng , 3 - Khng c kin, 4 - ng , 5 - Rt ng . Kt qu thu c c th hin bng 3.3 Bng 3.3: Mi quan tm ca ngi nh bnh nhnv gim au sau phu thut 29 Cu hi T l % im trung bnh12345 Anh/ch c lo lng v cuc phu thut sp din ra 00110894,88 Theo anh/ch, phu thut s gy au01211864,82 Theo anh/ch, con em mnh s c khng ch tt cm gic au sau cuc phu thut. 0029534,01 Nhn xt: Mc d 99% ngi nh bnh nhn c lo lng v cuc phu thut, song phn ln ngi nh (98%) u tin tng v vic iu tr au cho tr sau phu thut s c khng ch tt.Bng 3.4: Nhn thc ca ngi nh bnh nhn v gim au sau phu thut Cu hi T l %im trung bnh 12345 Theo anh/ch, gim au sau phu thut tt th s ci thin cht lng cuc sng ca tr 00150494,48 Theo anh/ch, gim au sau phu thut tt th s chng lnh bnh. 00153464,45 Theo anh/ch, gim au sau phu thut tt th s chng ra vin. 00261374,35 Theo anh/ch, gim au sau phu thut tt th s tit kim c chi ph iu tr. 042259153,85 Sau phu thut, anh/ch thng xuyn hi nhn vin y t v vic iu tr au cho con/em mnh 10114844,8 Anh/ch c thng bo vi nhn vin y t v cm gic au ca con/em mnh 0016237 4,36 Nuthycon/emmnhvnausaukhidng thuc, anh/ch c hi nhn vin y t xin thm thuc 5985721 3,8 Theoanh/ch,nuniqulnvnauca 991000 1,01 30 con/emmnhnhncliulngthuc cao hn th s c hiu qu gim au tt hn Theoanh/ch,nunigimivnauca con/emmnhthtphidngthuchn,stt hn 991000 1,01 Nhn xt:asnginhbnhnhnnhnthcrngvicgimausau phuthutttscithinchtlngcucsng(99%),chnglnhbnh(99%), chngravin(98%),titkimchiphiutr(74%).Nginhbnhnhntham gia vo vic qun l au ca con em mnh bng cch: thng xuyn hi nhn vin y t v vic iu tr au (98%), thng xuyn thng bo vi nhn vin y t v cn au (99%). 78% ngi nh khi thy tr vn au sau khi dng thuc th c hi nhn vin y t xin thm thuc. 100% ngi nh bnh nhn khng ni qu ln hoc gim i v cn au ca tr. Hiu bit cangi nh bnh nhn v auvccbin php gim au sau phu thutTng t nh trn, nh gi hiu bit ca ngi nh bnh nhn v au v ccbinphpgimausauphuthut,chngtitinhnhhinginhbnh nhn nhng cu hi c sn, sau phn tch kt qu da vo cu tr li ca ngi nh bnh nhn. Bng 3.5: Phng php nh gi au ca ngi nh bnh nhn Nhm tui Phng php nh gi au p Hi tr Quan st thi ca tr Hi tr v quan st thi ca tr Tr s sinh - 3 tui8,6%86,2%5,2% < 0,05Trn 3 7 tui78,3%0%21,7% Trn 7 tui89,5%0%10,5% Nhn xt: kt qu nghin cu bng 3.5cho thy nhm tui ssinh 3 tui, phn ln (86,2%) cha m nh gi au bng cch quan st thi ca tr. Trn 31 3 tui, cha m thng hi tr hoc kt hp hi tr vi quan st thi ca tr. C s khc bit c ngha thng k gia phng php nh gi au vi la tui ca tr. Kt qu kho st cng cho thy khng c ngi nh bnh nhn no c nhn vin y t hng dn cch s dng thang au nh gi au. Bng 3.6: Cc bin php gim au khng dng thuc ca ngi nh bnh nhn Nhm tui Bin php lm gim au khng dng thuc p An i An i + b dong An i +gi hnh nh, k chuyn +lm sao nhng An i + b dong +gi hnh nh, k chuyn +massage An i + gi hnh nh, k chuyn +lm sao nhng +masage Tr s sinh - 3 tui 1,7%74,1%1,7%8,6%13,8% < 0,05Trn 3 7 tui 0%0%39,1%0%60,9% Trn 7 tui 0%0%26,3%0%73,7% Nhn xt: 100% cc gia nh u chn bin php an i lm gim au cho con emmnh.i vitr s sinh- 3 tui, tr cn c b dong kt hp vi ani (chim74,1%).Vicctrlnhn(trn3-7tuivtrn7tui),trcnc nghekchuyn(39,1%v26,3%tngng)hockthpnghekchuynvi massage (60,9 % v 73,7% tng ng). C s khc bit c ngha thng k v la chn bin php gim au khng dng thuc vi la tui ca tr (p3lntrong2pht quan st) 5.Huyt p cao 15% tr ln Nhp tim1.Nhp tim di mc trung bnh 2.Nhp tim lun mc trung bnh 3.Nhptimkhngthngxuyntrn 15% so vi trung bnh (1-3 ln trong 2 pht quan st) 4.Nhp tim thng xuyn trn 15% so vitrungbnh(>3lntrong2pht quan st) 5.Nhp tim cao 15% tr ln Tng im Hnh 1.2: Thang COMFORTim s: 0 - 17: khng au au nh 18 27: au va > 27: au va au nng Ngy/gi Face Khun mt 0. Khng biu cm c bit hoc ci 1. Tnh thong nhn nh hoc c v kh chu, th 2. Thngxuyncmrun,nghincht hm Legs Chn 0. Trng thi bnh thng hoc th gin 1. Khng thoi mi, bn chn, cng2. chn hoc co rm li Activity Hot ng 0. Nmyn,trngthibnhthng, chuyn ng d dng 1. Qun qui, y ln pha trc, cng 2. Cong, cng ngc hoc git Cry Khc 0. Khng khc (tnh hoc thc) 1. Rn r hoc tht tht, i khi ku ca 2. Khclu,thtln,hocthnthc, thng ku ca Consolability C th an i 0. Bng lng, du i 1. An i bng cch cho vut ve, m, ni chuyn, lm sao nhng 2. Kh an i hoc lm thi mi Tng im Hnh 1.3: Thang FLACCim s: 0 : khng au; 1 3 : au nh; 4 7 : au va; 8 10 : au nng Hnh 1.4: Wong and Baker FACES Pain Scale Hnh 1.5: Faces Pain Scale-Revised (FPS-R) Hnh 1.6: Visual analogue (VAS) v Numerical rating scale (NRS) 02468100 Khng au Hi au mt cht au hn mt cht au nhiu hn au rt nhiuau rt ti t PH LC 5 Hnh 1.7: Bc thang thuc gim au ca WHO Hnh 1.8: C ch gy c vi gan ca paracetamol [36] PH LC 6 DANH SCH NHN VIN Y T V NGI NH BNH NHN THAM GIA KHO ST ti:Khostnhnthcvhiubitcanhnvinyt,nginhbnh nhn v au v cc bin php gim au sau phu thut. Ngi thc hin: V T Thng Thi gian thc hin: 4/3 5/4/2013 A.Danh sch nhn vin y t S lng: 44Nithchin:PhngphuthutGymhisc,cckhoathuckhingoi Bnh vin Nhi Trung ng. B.Danh sch bnh nhn S lng: 100 Nithchin:PhngphuthutGymhisc,cckhoathuckhingoi Bnh vin Nhi Trung ng. TT M s bnh n H tn bnh nhnTui Ngy phu thut Khoa iu tr sau phu thut 111328688Nguyn Vn H.6 tui4/3/2013A6 213011380Nguyn Ngc A.2 thng5/3/2013A6 312275428Nguyn Vn B.2 tui1/3/2013A5 413001338Trn Minh .15 thng6/3/2013A3 51313112Nguyn Thu T.47 ngy6/3/2013A6 613046930Nguyn c T.6 thng6/3/2013A3 712421408Dng V Ngc L.5 tui7/3/2013A6 812969461Nguyn Phng T.11 thng7/3/2013A5 913056814Hong c C.7 thng7/3/2013A3 107197323L Nh A.6 tui7/3/2013A5 1112756001 m Minh T.3 tui8/3/2013A5 12 12213592Nguyn Hu K.13 tui12/3/2013A6 139191643Bi Quang M.4 tui6/3/2013A3 1413036743Bi Tun H.8 tui6/3/2013A3 1513029500Nguyn Minh K.4,5 thng8/3/2013A6 169876484Don Th T.12 tui8/3/2013A6 177420166Nguyn Minh .6 tui8/3/2013A3 1813016212Hong Th T.10 thng9/3/2013A6 1912347854V Vn T.5 thng13/3/2013A5 2012372642V Q.4 thng12/3/2013A5 2113044401Nguyn Hong Minh Q.6 tui14/3/2013A3 2212403862 Th Tho N.12 thng11/3/2013A5 2313007303Nguyn Thnh V.8 tui12/3/2013A6 2412213592Nguyn Hu K.13 tui12/3/2013A6 2513406765Trn Th B.10 tui12/3/2013A6 261363386Nguyn Th Qunh A.7 tui13/3/2013A6 279075507La Vn D.4 tui13/3/2013A6 2812255639Thiu Minh C.7 thng12/3/2013A5 2912376447Nguyn Thy D.4 thng12/3/2013A5 3012394923Trn Phng T.4 thng11/3/2013A5 311355665Linh Quc .9 thng14/3/2013A5 3213006856Nguyn Th Kim C.4 thng12/3/2013A5 3313047927on Th nh N.8 tui12/3/2013A6 349144686 H T.4 tui7/3/2013A6 357063612on Hi N.8 tui7/3/2013A3 3611228188o Xun B.2 tui8/3/2013A6 3713018804Bi Mai L.16 thng8/3/2013A6 383036552Trn Tun H.7 tui8/3/2013A6 3913023559Nguyn Bo T.6,5 thng8/3/2013A5 4013055485Li Phng N.10 tui10/3/2013A6 4112386872Nguyn nh .9 tui11/3/2013A3 4212068190Bi Minh .2 tui11/3/2013A3 4313054423Nguyn Vn T.18 thng12/3/2013A3 4410300607Nguyn Phng A.6 tui12/3/2013A3 4512330454V Nguyn Hong L.3,5 thng12/3/2013A5 4613911664V Minh C.5 thng12/3/2013A5 4712422508on Tin L.2 thng13/3/2013A3 4812896653H Cng H.12 thng13/3/2013A3 4913566046o Minh C.23 ngy14/3/2013A5 5013010535Hong Phc T.2,5 thng14/3/2013A6 518079833Cao c H.9 tui15/3/2013A5 5213059420Dng Anh T.5 tui15/3/2013A5 5312395366Nguyn Vn T.4 thng15/3/2013A5 5412183084Nguyn c Q.4 tui15/3/2013A5 5513056722V Minh C.5 thng13/3/2013A6 5611025569H Quang H.18 thng13/3/2013A5 5712338816Nguyn Vn T.6 thng15/3/2013A5 5812428909Trng Th Cm V.5,5 thng18/3/2013A5 5912421333Lng Hong P.5 tui18/3/2013A5 6013049458 Vn T.5 tui9/3/2013A6 611353910Phm Th H.12 thng18/3/2013A6 6202656239inh Gia B.8 thng19/3/2013A5 6311067172V Hong B.26 thng19/3/2013A5 6412867657Nguyn Hu Tun K.9 thng18/3/2013A5 6513056879V Th H.4 thng19/3/2013A5 6613058191Lu Phng L.10 tui19/3/2013A6 6706030210Chu M.8 tui20/3/2013A5 6813078273Nguyn Ch T.5 thng20/3/2013A5 6913065699Bi Trung K.6 thng19/3/2013A5 7008058648inh Cnh T.5 tui20/3/2013A5 7113009982Trng Tun A.2 tui21/3/2013A5 7211342621Nguyn Bo A.1 tui21/3/2013A5 7312428602Nguyn Khnh Nam P.2 thng20/3/2013A3 7410684143Nguyn Thnh T.5 tui20/3/2013A3 7512425662Phm Minh A.15 thng18/3/2013A3 7613046573L Phan Anh T.7 thng21/3/2013A3 7713698767Trng Tun H.3 thng21/3/2013A3 7812353597Nguyn Hu Hng Q.5 tui21/3/2013A3 7913010686Nguyn c T.3 thng21/3/2013A3 8013056497Nguyn Nht Linh A.18 thng19/3/2013A3 8109186298Lc Tin .3 tui19/3/2013A5 8212546233Gip Qunh N.1 tui19/3/2013A5 8304087164Trnh nh V.8 tui14/3/2013A3 8408001850Nguyn Trn Vit L.6 tui15/3/2013A3 8511127306Ha H N.20 thng4/3/2013A3 8606054293Nguyn Nh Anh D.14 tui16/3/2013A3 8712353617Tn c T.3 thng18/3/2013A3 8812426212Trng L Bo N.3 tui11/3/2013A3 8906132670V Minh T.14 tui18/3/2013A3 9012327422ng Nht H.3 tui19/3/2013A3 9112119524Nguyn Ngc Tng L.3 tui15/3/2013A3 9210864533o Tin T.4 tui18/3/2013A3 9306195425Nguyn ng Phng A.8 tui19/3/2013A6 9413021509Nguyn Trng T.3 thng15/3/2013A6 9513051696L Th C.5 tui18/3/2013A6 9613693170Bi Hng P.6 thng26/3/2013A6 9713063281Phm B M.5 tui27/3/2013A5 9813081681Trn Nh Q.5 tui16/3/2013A5 9913054133Trn Vn H.7 tui25/3/2013A3 10013684031Nguyn L H.3 tui18/3/2013A3 Xc nhn ca CN B HNG DN PHNG KHTH BV NHI TW