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BO CO THC TP DC LM SNGPHN TCH CA LM SNG
NHIM TRNG BN CHN TRN BNH NHN I THO NG
T 3 Nhm 1Ging vin hng dn:TS.DS. V Th H
Cu 1: Nu nhng du hiu v triu chng ca nhim trng bn chn bnh nhn o
tho ngYu t nguy c (*):
Tn thng a dy thn kinh lan ta (40% BNT), lm gim kh nng cm nhn au,
nng hay lnhNguy c cao x cng mch mu (20% BN T), lm gim lng mu n cc c
quan trong c thD b nhim trng (ng mu cao v tun hon mu km + suy gim
chc nng bch cu trung tnh lm phn ng bo v chng nhim trng din ra chm
hn v km hiu qu hn)Ngoi ra cn do bo ph, gim th lc, b bnh T lu, kim
sot ng mu km, bnh thn, ri lon m mu,
(*) suckhoedoisong.vn Link:
http://suckhoedoisong.vn/bien-chung-ban-chan-o-benh-nhan-dai-thao-duong-n10354.html
Tn thng a dy thn kinh lan ta: gp khong 40% bnh nhnT, lm gim kh
nng cm nhn au, nng hay lnhNguy c cao v chng x cng mch mu, lm gim
lng mu n cc c quan trong c th, c khong 20% BN T c hp hoc tc cc ng
mch chn, gy kh khn cho qu trnh lm lnh mt vt thng
6
St, n lnh, m sng, tot m hi, chn n, mt n nh huyt ng (v d: nhp tim
nhanh, h huyt p)
Clinical Signs of Infection in Diabetic Foot Ulcers With High
Microbial Load - Sue E. Gardner, PhD, RN, Stephen L. Hillis, PhD,
and Rita A. Frantz, PhD, RNTon thn:
Lon chuyn ha (v d: nhim toan, ri lon ng huyt, bt thng in gii,
tng ure huyt)
Ban , ph n, nng v au - du hiu ca vim Vim m cng vi dch tit - du
hiu "c in " ca nhim trngC dch tit huyt thanh, chm lnh.M ht b, m ht
b i muC mi hiHnh thnh cc bng nc
Ti ch:
Cu 2: Trng hp no cn ch nh khng sinhVt thng khng b nhim trng,
khng nn iu tr bng khng sinh Nn k khng sinh vi tt c cc vt thng b
nhim trng (hin din ca dch tit m (m) hoc t nht l 2 trong nhng
biu hin ch yu ca tnh trng vim (b , nng, sng hoc s chai cng, au),
lu cn kt hp vi chm sc vt thng thch hp (ra vt thng, bng b cn
thn,..).
Bc s c th chn phc iu tr khng sinh theo kinh nghim da trn c s mc
nghim trng ca nhim trng v tc nhn gy bnhNhim trng nh n va phi (gn y
khng dng khng sinh), th ch cn nhm mc tiu cu khun Gr(+) l Nhim trng
nghim trng, nn bt u iu tr khng sinh ph rng theo kinh nghim, nu cha
c kt qu cy vi khun v khng sinh iu tr dt khot c da trn kt qu cy VK v
khng sinh Tip tc iu tr khng sinh cho n khi khng cn du hiu ca nhim
trng, nhng ch khng phi cha lnh hon ton cc vt thng, thi gian dng KS:
nhim trng m mm nh n va trong khong 1-2 tun, v 2-3 tun vi nhim khun
nng.Cu 2: Trng hp no cn ch nh khng sinh
Cu 3: Phn loi mc nhim trng bn chn bnh nhn i tho ng Cp Mc nhim
trngBiu hin lm sng1Khng nhim trngVt thng khng chy m hoc khng c bt k
du hiu no ca vim2Nhim trng nhC t nht 2 du hiu ca vim nh mng m hoc
sng, , au, nng. Vim m t bo hoc ban rng di 2cm xung quanh vt lot;
nhim trng khu tr b mt da v di da nng3Nhim trng trung bnhDa trn 2cm,
xut hin di vim bch mch, nhim trng lan rng xung di b mt nim mc hoc p
xe m su, lan rng vo c, gn, khp, xng hoc hoi t4Nhim trng nngNhim c h
thng km theo triu chng ton thn nh st, rt run, tim p nhanh,tng bch
cu, huyt p thp, l ln, tng glucose huyt hoc ure huyt
Theo Hip hi cc bnh nhim trng Hoa K- IDSA
Cu 4: Nhng tc nhn gy nhim trng bn chn trn bnh nhn i tho ng c th
gp l g?Cu khun Gr(+): chim u th trong S. aureus v -hemolytic
streptococci (nhm A, C, G, c bit l nhm B) l tc nhn thng gp nht c
nui cy t cc mu xng, tip theo l Staphylococcus epidermidis.Trc khun
Gr(-): Escherichia coli, Klebsiella pneumoniae, Proteus l nhng tc
nhn gy bnh ph bin nht, tip theo l P. aeruginosa. Tn s ca c lp ca vi
khun k kh (ch yu l Peptostreptococcus, Peptococcus, v Finegoldia
magna) l thp. C s gia tng ca t l ca vi khun a khng (nh MRSA hoc
khng vancomycin enterococci [VRE])Nhim trng cp tnh bnh nhn cha dng
khng sinh thng n nhim (mt mt loi Gr(+) hiu kh), nhim trng mn tnh
thng a khun (3-5 loi, bao gm hiu kh Gr(+) v Gr(-) v vi khun ym
kh)Ch : nn nui cy cc mu t m su, thu c bng cch sinh thit hoc no, sau
khi vt thng c lm sch. Trnh dng mu tm bng, c bit l t cc vt thng h,
do n cho kt qu km chnh xc hn
Cu 5: Nhng vn chnh cn cn nhc khi la chn liu php iu tr nhim trng
theo kinh nghim trong ca ny?a) La chn mt phc khng sinh thch hp: vn
quan trng trong iu tr nhim trng bn chn i tho ng.
Khng khuyn khch vic s dng khng sinh iu tr vt thng khng b nhim
trng, k c tng cng cha bnh hoc s dng d phng.Ton b vt thng nhim trng
cn iu tr khng sinh. Kh khn quyt nh vt thng c nhim trng khng (v d,
khi chn thiu mu cc b v c bin chng thn kinh), th c th tm kim du hiu
th cp ca nhim trng, chng hn nh mu sc bt thng, mi hi thi, m ht b, mp
vt thng l lot, au
Cc phc iu tr khng sinh ban u thng c la chn theo kinh nghim, v c
th l sa i sau ny trn c kt qu cy VK v khng sinh .Cu 5: Nhng vn chnh
cn cn nhc khi la chn liu php iu tr nhim trng theo kinh nghim trong
ca ny?iu tr theo kinh nghim nn c da trn mc nghim trng ca nhim trng
v bt k d liu vi sinh vt c sn, nh kt qu cy gn y v s ph bin ti a phng
ca cc mm bnh, chng c bit l khng khng sinh.
Cu 5: Nhng vn chnh cn cn nhc khi la chn liu php iu tr nhim trng
theo kinh nghim trong ca ny?- a s nhim trng nh, va phi, c th iu tr
bng KS c ph tng i hp, thng ch cu khun hiu kh. cc nc c kh hu m p,
gram m c phn lp (c bit l P. aeruginosa) ph bin. iu tr KS trc y, hay
nhim trng nng mn tnh: phn lp nhiu cc sinh vt k kh, tuy nhin, chng
khng phi l tc nhn gy bnh ch yu mc nh nht n trung bnh iu tr bng khng
sinh ung (tt hn vi loi sinh kh dng cao) thng thch hp cho nhim trng
nh n va phi- i vi nhim trng nng, mn tnh bt u iu tr vi phc ph rng.
Cc KS c ph chng cu khun Gr(+), cng nh vi khun gram m v sinh vt k kh
bt buc- i vi cc bnh nhim trng nghim trng hn, bt u vi iu tr bng ng
tim, thng c th c chuyn sang KS ung trong vng mt vi ngy khi bnh nhn
c biu hin tt v c kt qu cy
Cu 5: Nhng vn chnh cn cn nhc khi la chn liu php iu tr nhim trng
theo kinh nghim trong ca ny?
Cu 5: Nhng vn chnh cn cn nhc khi la chn liu php iu tr nhim trng
theo kinh nghim trong ca ny?Benjamin A. Lipsky et al. Clin Infect
Dis. 2004;39:885-910
Cu 5: Nhng vn chnh cn cn nhc khi la chn liu php iu tr nhim trng
theo kinh nghim trong ca ny?
Cu 5: Nhng vn chnh cn cn nhc khi la chn liu php iu tr nhim trng
theo kinh nghim trong ca ny?Nu nhim trng khng p ng vi phc thc
nghim, chn cc KS c ph chng li tt c cc chng.Thi gian iu tr khng sinh
nn da vo mc nghim trng ca nhim trng, s hin din hay vng mt ca nhim
trng xng, v p ng lm sng iu tr. Cc bnh nhn ch nhim trng da v m mm nn
iu tr trong 1-2 tun v 2-3 tun vi nhim khun nng. Thuc khng sinh thng
c th c ngng khi nhng du hiu lm sng v triu chng ca nhim trng c gii
quyt. Khng c bng chng ng h vic tip tc iu tr khng sinh cho n khi vt
thng c cha lnh nhanh chng lin vt thng hoc ngn chn cc nhim trng tip
theo.
Cu 5: Nhng vn chnh cn cn nhc khi la chn liu php iu tr nhim trng
theo kinh nghim trong ca ny?b) Nguy c khng khng sinhNn xc nh nhim
trng ny l nhim ti cng ng hay mc phi bnh vin la chn phc ph hp:+ Nhim
ti cng ng: VK cn nhy cm vi nhiu loi KS.+ Mc phi ti bnh vin: ch yu l
cc chng a khng thuc.Khi ht du hiu v triu chng nhim trng, nn ngng
khng sinh, trnh dng ko di lm tng nguy c khng thuc.Theo di bnh nhn s
dng khng sinh, m bo liu liu trnh lm gim tnh trng khng thuc
Cu 5: Nhng vn chnh cn cn nhc khi la chn liu php iu tr nhim trng
theo kinh nghim trong ca ny?b) Chng ch nh, thn trngBnh nhn d ng vi
penicillin -> khng nn la chn cc khng sinh cng cu trc vi nhm
penicillinBnh nhn b suy thn nh (CLcr ~ 44 ml/p), nn hiu chnh liu
khng sinh ph hp v ch thn trng vi cc khng sinh gy c thn
Cu 6: Hy nhn xt v liu php la chn khng sinh trong trng hp ny v bn
lun v liu php thay thTnh trng bnh nhnLiu php la chnTin s d ng vi
penicillinBch cu trung tnh tngSuy thn nhChc nng gan bnh thngBn chn
lot, c nguy c ct b chn; nhim vi khun Gr(+), Gr(-), k kh (tuy khng
ng tin cy do mu ly b mt vt lot)Nhp tim tngHA hang dng Gabapentin
(gim au TK)Piperacillin l khng sinh thuc nhm penicillin, c tc dng
dit khunTazobactam l mt cht c ch b-lactamase , ngn nga kh nng khng
thuc ca vi khunL mt khng sinh dit khun, ph rng
Cu 6: Hy nhn xt v liu php la chn khng sinh trong trng hp ny v bn
lun v liu php thay thNhn xt:Thuc c th b CC do bnh nhn c tin s d ng
vi penicillinBnh nhn l ngi gi, b suy thn nh, nn khi s dng phi cn
thn do c nguy c qu liu. Nn p dng ch hiu chnh liu cho bnh nhn suy
thn.Do bnh nhn b nhim trng nng, nhim a khun + suy gim min dch nn
phi la chn khng sinh dit khun ph rng bao ph c cc vi khun m bnh nhn
c th mc phi ( Gr(-), Gr (+), k kh )Dng ng tnh mch nn lm tng nng
thuc cc vng c ti mu km, y cng l n khuyn khch s dng khi u trong nhim
trng nng
Cu 6: Hy nhn xt v liu php la chn khng sinh trong trng hp ny v bn
lun v liu php thay thC th s dng c KS nhm fluoquinolon do c ph rng,
ch hiu chnh liu ph hp, do c th gy c gan thnVt thng c mi hi do c VK
k kh, nn dng Metronidazol hay ClindamycinC nhim khun mu nn dng cc
KS ph rng, dit c c MRSA: Vancomycin, Teicoplanin, Linezolid,
Daptomycin (ch hiu chnh liu Vancomycin)Cn thn trng trong chn KS dit
VK Gr(-), nn chn Ciprofloxacin thay v Gentamicin khi phi hp vi
Vancomycin
Cu 6: Hy nhn xt v liu php la chn khng sinh trong trng hp ny v bn
lun v liu php thay th
Cu 6: Hy nhn xt v liu php la chn khng sinh trong trng hp ny v bn
lun v liu php thay thC th phi hp KS:
Clindamycin +
Gentamicin/Ciprofloxacin/Ceftazidim/AztreonamCeftriaxone +
Metronidazone (+Ciprofloxacin)Vancomycin/Daptomycin/Linecozid +
Metronidazol + Gentamicin/Ciproxacin/Ceftazidim/Aztreonam
Cu 8: Cc kt qu cn lm sng sau 12h nhp vin trn bnh nhn ny c ngha
g?Glucose huyt 34 mmol/l (3-7.8 mmol/l) -> Hi chng tng p lc hn m
thm thu khng nhim ceton -> lm suy gim min dchCreatinin huyt 120
mcmol/l (62-115 mcmol/l) -> suy thn nh -> cn hiu chnh liu ph
hp khi s dng thuc. (Do BN mc Hi chng tng p lc hn m thm thu nn c th
l suy thn do mt dch -> nn b thm dch)Bch cu 11.2 x 109/L (4-11 x
109/L) + Bch cu trung tnh 7.6 x 109/L (2-7.5 x 109/L) + CRP 110
mg/L (< 10 mg/L) -> nhim trng (vim)Cy mu: cu khun Gr (+)
trong c 2 chai -> nhim khun huyt -> p ng iu tr km, cn iu tr
bng KS ph rng, c tc dng trn MRSAMRI: khng c vim ty xng -> c th
iu tr Khng sinh ngn ngy
Cu 10: Hy nh gi nhng bin php gim st iu tr trong trng hp ny.Gim
st hiu qu bao gm(*):a) Ti ch: M lot v ct b m cht, dn lu dch v chm
sc vt thng thch hp rt quan trng. Loi b cc p lc t cc vt thng bn chn
l rt quan trng cho vic cha lnh vt thngCn: dn lu ht m, rch rng vt
thng, ct b m hoi t.C th dng my ht chn khng ht ht dch v kch thch lin
vt thngTi to tun hon, bc cu ng mch tng ti mu. vt thng kh thong, s
dng loi bng ph hp; cn chn giy ph hp cho bnh nhn (half-shoes,
sandals,), tt nht l ngh ngi ti ging, nu cn di chuyn nnngi xe lnVt
thng c xem l ht nhim trng khi c cc du hiu: hnh thnh m ht, s vng mt
ca cc m hoi t, v ng ca ca vt thng,
http://www.aafp.org/ Link:
http://www.aafp.org/afp/2008/0701/p71.html
Cu 10: Hy nh gi nhng bin php gim st iu tr trong trng hp ny.b)
Ton thn: iu tr khng sinh thch hp (vic la chn KS trnh by cc cu trc)
v iu chnh ri lon chuyn ha (kim sot ng huyt: dng insulin - kim sot
ng huyt tt c th gip tiu dit cc nhim trng v thc y vt thng chng lnh)
v iu chnh ri lon in gii (truyn dch)
Cu 10: Hy nh gi nhng bin php gim st iu tr trong trng hp ny.Phng
ngaPhng chng lot bn chn i tho ng bt u vi vic xc nh bnh nhn c nguy
c. Tt c cc bnh nhn i tho ng nn c mt cuc kim tra chn hng nm bao gm
nh gi cho d dng gii phu, ph v da, ri lon mng tay, mt cm gic bo v,
cung ng mch gim, v giy dp khng ph hp. Bnh nhn c nguy c cao ca lot
bn chn nn phi thng xuyn kim traGio dc bnh nhn v ngi chm sc v chm sc
chn ph hp v t kim tra chn nh kCan thip lm sng hiu qu khc bao gm ti
u ha kim sot ng huyt, ngng ht thuc, m ca nhng cc chai, v mt s loi
phu thut chn d phng
Ti liu tham kho
2012 Infectious Diseases Society of America Clinical Practice
Guideline for the Diagnosis and Treatment of Diabetic Foot
Infectionsa
Clinical Signs of Infection in Diabetic Foot Ulcers With High
Microbial Load
Ti liu tham khohttp://www.aafp.org/ Link:
http://www.aafp.org/afp/2008/0701/p71.htmlClinical Infection
Diabetic. 2004 - Benjamin A. Lipsky et al. suckhoedoisong.vn Link:
http://suckhoedoisong.vn/bien-chung-ban-chan-o-benh-nhan-dai-thao-duong-n10354.html
DANH SCH T:Ypp banL Th GiangTn N Linh GiangH Th HTrn Ngc HiNg ng
Trng Hi
