KL - Tuong Tac Thuong Gap

B Y T
TRNG I HC DC H NI
HONG VN H
NGHIN CU XY DNG DANH SCH

TNG TC THUC CN CH TRONG
THC HNH LM SNG TI BNH VIN
THANH NHN
KHA LUN TT NGHIP DC S
H NI - 2012
B Y T
TRNG I HC DC H NI
HONG VN H
NGHIN CU XY DNG DANH SCH

TNG TC THUC CN CH TRONG
THC HNH LM SNG TI BNH VIN
THANH NHN
KHA LUN TT NGHIP DC S
Ngi hng dn:

1. TS. Nguyn Hong Anh
2. ThS. B i Vit
Ni thc hin:
1. Trung tm Quc gia v Thng tin
thuc v Theo di phn ng c hi ca
thuc Trng i hc Dc H Ni
2. Bnh vin Thanh Nhn
H NI - 2012
LI CM N
Khi ti c nhn ti ny, ti cm thy mnh l ngi may mn v ti
c c hi c lm mt th ti thch. V by gi, khi hon thnh kha lun, ti
vn cm thy ti l ngi may mn v ti c c hi hc c nhiu iu. l s
am m ht mnh vi iu mnh yu thch, l trch nhim hon thnh nhng cng
vic chn nn nht, l tnh cn thn trong tng vic lm, l cch lp k hoch
lm vic hp l, l cch lng nghe kin ngi khc, quan st ngi khc v c
bt chc ngi khc. Ti cn c lm vic vi nhiu ngi m ti v cng qu
mn.
i vi ti, ti cha tng suy tnh vic ti lm c quan trng hay khng.
Quan trng hay khng quan trng, ch cn ti hiu, ch cn ti thy vui v khi c
thc hin n. V vi ti iu mi thc s c ngha.
Li u tin, ti phi gi n ngi thy m ti v cng knh mn v ngng
m - thy Nguyn Hong Anh. Thy lm ti hiu c rng trong cuc sng hy c
lm iu mnh yu thch th cho d c bao nhiu kh khn mnh cng c th vt
qua. Thy khng ch l ngi hng dn cho ti thc hin ti, thy cn l hnh
mu ti tin rng trong cuc sng vn c nhng ngi v cng d mn v tt
bng, lun sn sng gip ngi khc khng v bt c l do no.
Th hai, ti mun gi li cm n n ch Nguyn Mai Hoa. Ch lun l
ngi v v, ng vin nhng lc ti chn nn. Ti lun cm thy mnh may mn
khi c ch h tr ti trong mi vn khi thc hin ti ny. Ti lun hi vng rng
sau ny ti s ging ch, ht lng v cng vic, ht lng v ngi khc v khng bao
gi tc gin, t nht l vi ti.
Tip theo, ti mun gi li cm n n c B i Vit to iu kin v ch
ng Lan Anh ht sc gip trong nhng giai on ti xung bnh vin Thanh
Nhn ly s liu. Ti cn mun gi li n nhng anh ch ang lm vic ti Trung
tm DI & ADR Quc gia. Cc anh ch lun vui v, thn thin v ci m khi ti
ln trung tm thc hin ti.
Cui cng, ti xin gi li cm n n b m. Nhng ngi c l khng hiu

ht nhng g ti lm nhng cha bao gi ht t ho v tin tng vo ti, cng l ch
da vng chc cho ti thc hin mi d nh trong cuc sng.
MC LC
DANH MC CC K HIU VIT TT
DANH MC CC BNG
T VN ................................................................................................. 1
Chng 1. TNG QUAN ................................................................................ 3
1.1. Tng tc thuc .................................................................................... 3
1.1.1. nh ngha tng tc thuc ........................................................... 3
1.1.2. Dch t hc v tng tc thuc ...................................................... 4
1.1.3. Hu qu ca tng tc thuc ........................................................ 5
1.1.4. Yu t nguy c gy tng tc thuc ............................................. 5
1.1.5. ngha lm sng ca tng tc thuc .......................................... 7
1.2. Kim sot tng tc thuc trong thc hnh lm sng ............................ 8
1.2.1. Cc c s d liu tra cu tng tc thuc ..................................... 8
1.2.2. Phn mm h tr k n cho bc s ............................................. 13
1.2.3. Bng cnh bo v nhng tng tc nghim trng ......................... 14
1.2.4. Mt s khuyn co chung kim sot tng tc thuc ............... 15
Chng 2. I TNG V PHNG PHP NGHIN CU ................. 17
2.1. i tng nghin cu ........................................................................... 17
2.1.1. Cc c s d liu tra cu tng tc thuc ..................................... 17
2.1.2. Danh mc thuc ........................................................................... 17
2.1.3. n thuc ngoi tr v bnh n ni tr ......................................... 17
2.1.4. Nhm chuyn mn ....................................................................... 18
2.2. Phng php nghin cu ...................................................................... 18
2.2.1. Xy dng danh sch tng tc thuc cn ch trong thc hnh lm
sng ti bnh vin Thanh Nhn ......................................................................... 18
2.2.2. Xy dng hng dn x tr cho cc tng tc thuc trong danh sch
cui cng .......................................................................................................... 21
2.2.3. Xc nh tn sut gp phi nhng tng tc trong danh sch c

xy dng trong n thuc iu tr ngoi tr v bnh n ni tr ti bnh vin ..... 22
2.4. X l s liu ......................................................................................... 22
Chng 3. KT QU NGHIN CU ........................................................... 23
3.1. Xy dng danh sch tng tc thuc cn ch trong thc hnh
lm sng ........................................................................................................... 23
3.2. Xy dng hng dn x tr cho cc tng tc thuc trong danh sch
cui cng .......................................................................................................... 27
3.3. Xc nh tn sut gp phi nhng tng tc trong danh sch c xy
dng trong n thuc iu tr ngoi tr v bnh n ni tr ti bnh vin .......... 27
Chng 4. BN LUN .................................................................................. 32
4.1. Xy dng danh sch tng tc thuc cn ch trong thc hnh
lm sng .......................................................................................................... 32
4.2. Xc nh tn sut xut hin 25 tng tc trong n iu tr ngoi tr
v bnh n ni tr ti bnh vin ....................................................................... 33
Chng 5. KT LUN V XUT ......................................................... 39
5.1. Kt lun ............................................................................................... 39
5.2. xut ................................................................................................ 39
TI LIU THAM KHO
PH LC
Ph lc 1: Danh sch hot cht s dng bnh vin Thanh Nhn ti thi im
thng 11/2012 theo phn loi ca Ph lc 1 trong BNF
Ph lc 2: 78 tng tc p ng tiu chun 1
Ph lc 3: Danh sch tng tc thuc cn ch v bin php x tr trong thc hnh
lm sng ti bnh vin Thanh Nhn
Ph lc 4: Mu phiu m t tng tc dnh cho nhm chuyn mn
Ph lc 5: Mu phiu chm im ca nhm chuyn mn
Ph lc 6: Phiu ly thng tin n thuc iu tr ngoi tr c tng tc
Ph lc 7: Phiu ly thng tin bnh n ni tr c tng tc
DANH MC CC K HIU VIT TT
BNF
British National Formulary 81
CSDL
C s d liu
DIF
Drug Interaction Facts 2010
MM
Micromedex 2.0 DRUG-REAX System
NSAID
Thuc chng vim khng c cu trc steroid
SDI
Stockleys Drug Intetactions Pocket Companion 2010
STT
S th t
TIM
Thsaurus des interactions mdicamenteuses
DANH MC CC BNG
TT
1
2
3
4
Tn bng
Trang
Bng 1.1. Mt s c s d liu tra cu v tng tc thuc
8-9
Bng 2.1. Quy c mc nh gi tng tc thuc c
19
ngha lm sng cc CSDL

Bng 2.2. Su tiu ch nh gi tng tc thuc ca nhm
20
chuyn mn
Bng 2.3. Thang im nh gi tiu ch 6
20 - 21
Bng 3.1. Danh sch 44 tng tc thuc c la chn trong
23 - 25
giai on 1 v kt qu nh gi ca nhm chuyn mn trong giai

on 2
Bng 3.2. Danh sch 25 tng tc thuc cn ch trong thc

hnh lm sng ti bnh vin Thanh Nhn
Bng 3.3. Tn sut k n v t l xut hin tng tc nm
26 - 27
27 - 29
trong danh sch 25 tng tc thuc cn ch c xy dng

trong n iu tr ngoi tr t ngy 07-18/03/2011
Bng 3.4. T l xut hin 25 tng tc trong danh sch tng
29 - 30
tc cn ch c xy dng trong n iu tr ni tr ti
bnh vin Thanh Nhn ngy 25/02/2012
Bng 3.5. Nhng tng tc c pht hin trong bnh n ni tr

ti bnh vin ngy 25/02/2012
30
T VN
Tng tc thuc l vn thng gp trong thc hnh lm sng v l mt
trong nhng nguyn nhn gy ra cc bin c bt li ca thuc, bao gm xut hin
c tnh hoc phn ng c hi trong qu trnh s dng, tht bi iu tr, thm ch c
th gy t vong cho bnh nhn [20]. kp thi pht hin, ngn nga v x tr
tng tc thuc, cc bc s v dc s thng phi tra cu thng tin trong cc c s
d liu (CSDL) khc nhau nh sch chuyn kho, phn mm, tra cu trc tuyn, tuy
nhin vic ny trong thc t cn gp nhiu kh khn. Th nht, cc CSDL v tng
tc thuc thng khng ng nht trong vic lit k tng tc v nhn nh mc
nghim trng ca cc tng tc [8], [38] khin cn b y t mt nhiu thi gian tra
cu cc CSDL khc nhau, khng ph hp vi thc t vn yu cu x l vn mt
cch nhanh chng. Th hai, trong nhiu trng hp cc CSDL cn a ra cnh bo
gi, ngha l cnh bo v nhng tng tc thuc khng c ngha trn lm sng.
Nu nhng cnh bo gi xut hin qu nhiu, cc bc s c xu hng b qua cnh
bo c a ra [14], [22] v iu ny tr nn nguy him nu h b qua c nhng
cnh bo v tng tc nghim trng. V vy, vic xy dng mt danh sch ngn
gn nhng tng tc thuc cn ch l rt cn thit vi ngi k n.
Bnh vin Thanh Nhn l bnh vin a khoa hng I c quy m ln ti H Ni
vi loi hnh bnh tt a dng v lun tip nhn s lng ln bnh nhn iu tr
khng thnh cng cc bnh vin tuyn di hoc c s iu tr khc chuyn n.
Do , tng tc thuc lun l vn c quan tm trong iu tr. Vi mc ch
trin khai cng c tra cu tng tc thuc ph hp vi thc t lm sng ti bnh
vin, nhm nghin cu thc hin ti Nghin cu xy dng danh sch tng
tc thuc cn ch trong thc hnh lm sng ti bnh vin Thanh Nhn vi hai
mc tiu sau:
- Mc tiu 1: Xy dng mt danh sch cc tng tc cn ch trong thc
hnh lm sng gia cc hot cht hin ang c s dng ti bnh vin da trn
bng chng ghi nhn trong y vn v s ng thun kin ca nhm chuyn mn
bao gm bc s v dc s; ng thi xy dng hng dn x tr nhng tng tc

ny trong thc hnh lm sng.
- Mc tiu 2: Xc nh tn sut gp phi nhng tng tc ny trong n
thuc iu tr ngoi tr v ni tr ti bnh vin.
Chng ti hi vng rng ti s gp phn tng cng cng tc kim sot v
gim thiu tng tc thuc bt li trong thc hnh lm sng; ng thi cng a ra
mt phng php lun xy dng hng dn thc hnh ti mt c s khm cha
bnh.
Chng 1. TNG QUAN

1.1. Tng tc thuc
1.1.1. nh ngha tng tc thuc
Tng tc thuc l s thay i tc dng dc l hoc c tnh ca thuc khi
dng ng thi hai hay nhiu thuc hoc c mt thuc khc c dng trc
[3]. V d, mt bnh nhn dng ng thi mt thuc chng nm nhm azol v mt
dn cht statin c nguy c b tiu c vn nghim trng. Bnh nhn dng thuc
chng trm cm nhm c ch monoamin oxidase (IMAO) c th tri qua cn tng
huyt p cp, nguy him n tnh mng nu bnh nhn ny n nhng thc n c
cha nhiu tyramin [32].
Thng thng, cm t tng tc thuc dng ch tng tc thuc
thuc, c ngha l tng tc gia hai hay nhiu thuc. Tuy nhin, tng tc thuc
cn c th c nhiu dng khc nhau. V d, tng tc thuc thc n, tng tc
thuc dc liu, tng tc thuc tnh trng bnh l, tng tc thuc xt
nghim, thuc thuc s dng qua ng tim [20]. Trong phm vi nghin cu ca
ti ny, cm t tng tc thuc ch cp n tng tc thuc thuc.
Tng tc thuc thng c phn ra lm hai loi l tng tc dc ng
hc (tng tc lm thay i qu trnh hp thu, phn b, chuyn ha, thi tr ca
thuc trong c th) [4] v tng tc dc lc hc (tng tc lm thay i p ng
ca bnh nhn i vi mt thuc m khng nh hng ln tnh cht dc ng hc
ca thuc ) [34].
Tng tc thuc thng gy ra nhng hu qu c hi n bnh nhn nhng
trong vi trng hp tng tc thuc c th em li li ch trong iu tr. V d, bc
s ch phi hp mt thuc h huyt p v mt thuc li tiu t hiu qu tt
hn trong iu tr, hay phi hp hai thuc iu tr i tho ng kim sot nng
ng mu bnh nhn i tho ng typ 2 hoc kt hp adrenalin v lidocain
ko di tc dng gy t [20], [32].
1.1.2. Dch t hc v tng tc thuc

T l tng tc thuc tng theo cp s nhn vi s lng thuc bnh nhn s
dng [4]. Trn thc t, vic bnh nhn phi dng phi hp nhiu thuc l ph bin,
c bit ngi cao tui hay bnh nhn ni tr. Ti Thy in nm 2002, mi
bnh nhn cao tui s dng trung bnh 4,4 thuc cng lc [16]. Mt nghin cu
thc hin ti bnh vin Hu Ngh nm 2004 ch ra rng mi n thuc ni tr c
trung bnh 6,1 thuc v tc gi cng a ra kt lun rng s thuc trong n cng
nhiu th s tng tc xut hin trong n cng ln [6]. Kt lun tng t cng
c a ra bi mt nghin cu thc hin ti bnh vin Bch Mai nm 2007 [5], tc
gi cn thng k s tng tc trung bnh trong mt n thuc ca bnh n ni tr c
9 thuc l 1,1 tng tc.
T l xut hin tng tc thuc a ra bi cc nghin cu khc nhau thng
khc nhau. iu ny ph thuc vo i tng nghin cu (bnh nhn ngoi tr hay
ni tr), loi tng tc thuc (mt tng tc thuc duy nht, tt c tng tc thuc
hay ch nhng tng tc nghim trng), thit k nghin cu (tin cu hay hi cu),
c im ca bnh nhn (bnh nhn cao tui hay tr tui) v phng php nhn
nh tng tc thuc (phn mm, sch tra cu hay kin nh gi ca chuyn gia).
Trong mt phn tch tin cu trn 18.820 bnh nhn, 1.225 bnh nhn nhp vin do
phn ng c hi ca thuc v 16% trong s gy ra bi tng tc thuc [30]. Mt
nghin cu ti Anh ch ra rng tng tc thuc l nguyn nhn dn n 51,9%
bin c c hi trong qu trnh iu tr ca bnh nhn [12]. Ti Vit Nam, theo mt
nghin cu tin hnh ti ba khoa Tim mch, Tiu ha, Tit niu bnh vin Hu
Ngh nm 2004, t l bnh n ni tr c xut hin tng tc l 50% [6]. Trong mt
nghin cu khc, khi r sot 1502 n thuc ngoi tr, t l n thuc c t nht mt
tng tc l 17,8%, trong , 2,9% n thuc c tng tc nghim trng khi kim
tra tng tc bng phn mm Micromedex 2.0 DRUG-REAX System [7]. Trong
khi , mt phn tch hi cu xc nh tng tc thuc nghim trng da vo phn
mm qun l s dng thuc v nh gi ca dc s lm sng, trn i tng bnh
nhn ngoi tr ti M ch ra rng t l ny l v cng thp (nh hn 1%) [28].
Mt nghin cu khc thc hin trn i tng l bnh nhn cao tui, ngoi tr th t
l xut hin tng tc thuc da trn danh sch 25 tng tc nghim trng l 2,15%
[25].
Khng mt nghin cu no c th a ra con s chnh xc v t l tng tc
thuc xut hin trong thc hnh lm sng. Cho d mt s nghin cu c a ra
nhng con s kh thp, s lng bnh nhn c nguy c chu hu qu (thm ch l
nghim trng) do tng tc thuc vn l khng nh, c bit trong bi cnh hin
nay khi thuc c k n v s dng ngy cng nhiu.
1.1.3. Hu qu ca tng tc thuc

Tng tc thuc c th gy nn thit hi v nhiu mt. Xt v hu qu trong
iu tr, tng tc thuc c th lm gim hiu qu iu tr, khng ci thin c
bnh cnh lm sng hoc lm xut hin nhng phn ng c hi, biu hin c tnh
trn bnh nhn. Nghim trng hn tng tc thuc c th gy ra cc tai bin nguy
him v thm ch l dn n t vong [1]. Bc s iu tr phi i mt vi trch
nhim y khoa nu hiu qu iu tr ca bnh nhn thp do nguyn nhn xut hin
trong n thuc mt tng tc c chng minh. Xt v hu qu kinh t, mt
bnh nhn gp tng tc thuc nghim trng phi nm vin di ngy hn v tn
nhiu chi ph iu tr hn. Nn cng nghip dc phm b thit hi v thi gian v
ngun ti chnh nu mt thuc b rt s ng k khi th trng, hay nh vng
phi nhng tranh chp kin tng. ng ch , nm trong mi thuc b thu hi khi
th trng M t 1998 n 2001 l do nhng thuc ny c nguy c gy ra nhng
tng tc thuc - thuc nghim trng [20].
1.1.4. Yu t nguy c gy tng tc thuc

S lng thuc bnh nhn s dng [4], [20]
S lng thuc bnh nhn s dng cng tng th bnh nhn cng c nguy c cao gp
phi tng tc thuc bt li.
S lng bc s k n cho bnh nhn [20], [34]
Nu bnh nhn c iu tr bi nhiu bc s cng lc, mi bc s c th khng

nm c y thng tin v nhng thuc bnh nhn c k n v ang s
dng. iu ny c th dn n nhng tng tc thuc nghim trng khng c
kim sot.
Yu t di truyn [17], [20], [34]
Yu t di truyn quyt nh tc chuyn ha enzym. Nhng bnh nhn mang gen
chuyn ha chm c t l gp phi tng tc thuc thp hn so vi nhng ngi
mang gen chuyn ha nhanh.
Tnh trng bnh l [20], [34]
Mt s tnh trng bnh l ca bnh nhn c th lm cho bnh nhn c nguy c cao
gp tng tc thuc: bnh tim mch (lon nhp, suy tim sung huyt), i tho
ng, ng kinh, bnh l tiu ha (lot ng tiu ha, chng kh tiu), bnh v
gan, tng lipid mu, suy chc nng tuyn gip, bnh nhim HIV, bnh nm, bnh
tm thn, suy gim chc nng thn, bnh h hp (hen, bnh phi tc nghn mn
tnh). Nhiu bnh i hi bnh nhn buc phi dng nhiu thuc t c hiu
qu iu tr mong mun. V d, suy tim sung huyt, hi chng AIDS, bnh lao,
ng kinh hay bnh tm thn. Trong khi , nhiu thuc dng trong iu tr lao hay
cho bnh nhn mc hi chng AIDS v thuc chng ng kinh li c kh nng cm
ng hay c ch enzym chuyn ha, d gy tng tc vi cc thuc khc. Mt s tnh
trng bnh l khc i hi phi c iu tr bng nhng thuc c khong iu tr
hp. V d, lithium dng iu tr ri lon lng cc, thay i nh nng lithium
trong mu do tng tc thuc cng c th lm xut hin c tnh trn bnh nhn.
i tng bnh nhn c bit [17], [20], [34]
Ngi gi c t l gp tng tc thuc cao hn, do bnh nhn cao tui thng mc
bnh mn tnh hoc mc km nhiu bnh, dn n phi s dng nhiu thuc cng
lc v nhm i tng ny, c nhiu thay i sinh l do qu trnh lo ha (nh
chc nng gan thn suy gim). Ph n c nguy c b tng tc thuc cao hn so vi
nam gii. Bnh nhn bo ph hay suy dinh dng, thng c s thay i mc
chuyn ha enzym v th i tng ny nhy cm hn v d b nh hng bi tng
tc thuc hn. Nhng i tng khc c nguy c cao l nhng bnh nhn bnh
nng, bnh nhn mc bnh t min hay nhng tri qua phu thut ghp c quan.
Thuc c khong iu tr hp [20], [34]
Nhng thuc c th k n trong danh sch ny l: khng sinh aminoglycosid,
cyclosporin, digoxin, nhng thuc iu tr HIV, thuc chng ng, thuc iu tr
lon nhp tim (quinidin, lidocain, procainamid), nhng thuc iu tr ng kinh
(carbamazepin, phenytoin, acid valproic) v thuc iu tr i tho ng (insulin,
dn cht sulfonylure ng ung).
Liu dng v tnh cht dc ng hc ca thuc [20]
Nhiu tng tc thuc xy ra ph thuc nng ca thuc trong mu, do , liu
dng v tnh cht dc ng hc ca thuc quyt nh n vic xy ra tng tc v
hu qu ca tng tc .
1.1.5. ngha lm sng ca tng tc thuc

Tng tc thuc c th li hu qu trn bnh nhn nhiu mc khc
nhau, t mc nh khng cn can thip n mc nghim trng nh bnh mc km
hay t vong. iu c ngha rng khng phi tng tc no cng nghim trng v
c ngha lm sng. Tng tc thuc c ngha trn lm sng l nhng tng tc
thuc lm thay i tc dng iu tr hay c tnh ca thuc, cn thit phi c nhng
can thip y khoa hoc hiu chnh liu [35]. Do , theo kt qu nghin cu in vivo
hay in vitro, mt tng tc c th xy ra nhng cha chc tng tc c ngha
trn lm sng. Cc yu t quan trng nh gi mc ngha ca mt tng tc
thuc l: mc nghim trng ca tng tc, phm vi iu tr ca thuc v kh
nng s dng kt hp hai thuc trn lm sng [20], [35].
i vi mt thuc c khong iu tr hp, nh digoxin, mt thay i nh v
nng thuc cng c th gy ra mt tc ng ln trn lm sng. Ngc li, i
vi mt s thuc c khong iu tr rng, vic nng tng ln gp i hay thm
ch gp ba cng khng li hu qu trn lm sng, v d khng sinh ceftriaxon. V
vy, hu qu tng tc v hiu qu iu tr trn bnh nhn quyt nh mc

ngha lm sng ca mt tng tc thuc [20].
1.2. Kim sot tng tc thuc trong thc hnh lm sng

Tng tc thuc l mt trong nhiu yu t nh hng n p ng ca bnh
nhn vi iu tr. Nhim v ca ngi bc s l phi bit c trong n thuc ca
bnh nhn, tng tc c xy ra hay khng v mc nghim trng ca tng tc
[2]. Vi s lng khng l nhng tng tc thuc c m t, cng vi vic xut
hin rt nhiu thuc mi v nhng thng tin v tng tc thuc lin tc c cp
nht hin nay, bc s khng th nh ht tt c tng tc v trn thc t, iu ny l
khng cn thit v s tng tc thuc c ngha lm sng l khng nhiu. Bc s
thng cn n nhng s h tr t cc CSDL tra cu tng tc thuc, phn mm k
n c dng ti bnh vin hay t cc bng cnh bo xut bi cc nghin cu
khc nhau c cung cp nhng thng tin cn thit v mt tng tc c th.
1.2.1. Cc c s d liu tra cu tng tc thuc

Do hu qu to ln m tng tc thuc c th gy ra trn lm sng, nhiu c
s d liu (CSDL) chuyn v tra cu tng tc thuc c xut bn. Mt s c
s d liu tra cu tng tc thuc c uy tn trn th gii v Vit Nam c lit k
di y.
Bng 1.1. Mt s c s d liu tra cu v tng tc thuc
STT
Tn c s d liu
Tng tc thuc v ch
Loi CSDL
Sch
Drug Interaction Facts
Stockleys Drug Interactions
bn/Quc gia
hc/ Vit Nam
mm tra cu
ngoi tuyn
Nh xut
Ting Vit Nh xut bn Y
khi ch nh
Sch/phn
Ngn ng
Sch
Ting Anh
Wolters Kluwer
Health /M
Ting Anh Pharmaceutical
Press/Anh
4
Thsaurus des interactions
Sch
mdicamenteuses
Php
Evaluation of Drug
Sch
Publications/M
Sch
Drug Interactions: Analysis
Ting Anh Lippincott

Williams &
and Management
Wilkins/M
Micromedex DRUG-
Phn mm tra
REAX System
cu trc tuyn
MIMS Drug Interactions
Afssaps/Php
Ting Anh APhA
Interactions
Phn mm tra
8
Ting
Ting Anh Thomson

Reuteurs/M
Ting Anh
cu trc
UBM
tuyn/ngoi
Medica/c
tuyn
9
10
Drug Interactions Checker
Phn mm tra
(http://www.drugs.com)
cu trc tuyn
Drug Interaction Checker
Phn mm tra
(http://www.medscape.com)
cu trc tuyn
Ting Anh Drugsite Trust/

New Zealand
Ting Anh Medscape
LLC/M
Sau y l nhng CSDL c s dng trong nghin cu:

Bristish National Formulary [23]
British National Formulary l mt n phm chung ca Hip hi Y khoa Anh
v Hip hi Dc s Hong gia Anh, c xut bn 6 thng mt ln. BNF khng
phi l mt CSDL chuyn v tng tc thuc nhng Ph lc 1 ca BNF l phn
ring dnh cho tng tc thuc. Tng tc thuc c lit k theo th t bng ch
ci. M t v tng tc thuc kh n gin, ch bao gm tn hai thuc (hoc nhm
thuc) tng tc vi nhau v hu qu mt cch ngn gn ca tng tc. Nhng
tng tc thuc nghim trng c k hiu bng du chm trn (), c th km theo
cnh bo trnh s dng phi hp.
10
Drug Interaction Facts [34]

y l mt CSDL tra cu tng tc thuc uy tn ca tc gi David S. Tatro
do Wolters Kluwer Health pht hnh. Cun sch ny bao gm trn 1.800 chuyn
lun tng tc thuc thuc v tng tc thuc thc n v hn 20.000 thuc. Mi
chuyn lun bao gm: tn thuc (nhm thuc) tng tc, mc ngha, mc
nghim trng, d liu v tng tc, thi gian tim tng, hu qu, c ch, kim sot,
bn lun v ti liu tham kho. Mc ngha ca tng tc c nh gi da
trn mc nghim trng v d liu m t v tng tc nh sau:
Mc ngha
Mc nghim trng
D liu m t tng tc
c chng minh/ c kh nng/
Nghim trng
Trung bnh
Nh
Nghim trng/Trung bnh C th
nghi ng
nghi ng
nghi ng
Nh
C th
Bt k
Khng chc chn
Micromedex 2.0 DRUG-REAX System [42]

DRUG-REAX System l mt phn mm tra cu tng tc thuc trc tuyn
cung cp bi Thomson Reuteurs v cng l mt cng c tra cu c dng ph bin
ti M. Hin nay, phn mm ny cung cp thng tin v tt c cc dng tng tc:
tng tc thuc thuc, thuc thc phm chc nng, thuc thc n, thuc
ethanol, thuc thuc l, thuc bnh l, thuc thi k mang thai, thuc thi k
cho con b, thuc xt nghim v thuc phn ng d ng. Mi kt qu tra cu v
mt tng tc thuc bao gm cc phn sau: tn thuc (hoc nhm thuc) tng tc,
cnh bo (hu qu ca tng tc), kim sot, thi gian tim tng, mc nghim
trng (chng ch nh, nghim trng, trung bnh, nh, khng r), d liu v tng
tc (rt tt, tt, trung bnh, khng r), c ch, tm tt, m t tng tc trong y vn v
11
ti liu tham kho. Phn mm ny kh thun tin trong tra cu nhng cc bc s, c

s khm cha bnh cn mt khon ph kh ln c th s dng.
Stockleys Drug Interaction Pocket Companion 2010 [33]
y l phin bn thu gn ca cun Stockleys Drug Interaction dnh cho
nhng nhn vin y t khng c nhiu thi gian c v nghin cu su v tng
tc thuc. Cun sch ny bao gm hn 1500 chuyn lun v c tng tc thuc
thuc v tng tc thuc dc liu, khng lit k tng tc ca nhm thuc gy
m, thuc chng virus v thuc iu tr ung th. Mi chuyn lun bao gm: tn
thuc (nhm thuc) tng tc, mc ngha ca tng tc, tm tt cc bng chng
v tng tc v m t ngn gn cch kim sot tng tc. Nhn nh ngha ca
tng tc c phn ra thnh 4 mc v c th hin bi 4 k hiu nh sau:
K hin
: tng tc e da tnh mng hoc b chng ch nh bi nh sn
K hiu
: tng tc gy ra nhng hu qu nghim trng trn bnh nhn v
xut.
cn thit phi hiu chnh liu hoc theo di cht ch.

K hiu
: hu qu ca tng tc gy ra trn bnh nhn cha c khng
nh, v th nn ch dn cho bnh nhn v mt s phn ng c hi c th xy ra,

v/hoc cn nhc cc bin php theo di.
K hin
: tng tc khng c ngha trn lm sng hoc khng chc chn
v kh nng xy ra tng tc.

Thsaurus des interactions mdicamenteuses [40]
y l mt hng dn iu tr - dc hc v tng tc thuc, l mt ti liu
tham kho uy tn ti Php c xy dng v nh gi bi nhm chuyn gia v tng
tc thuc ca Cc qun l Dc Php (Afssaps), c ph duyt bi Hi ng qun
l thuc lu hnh trn th trng Php (Commision dAMM). Xy dng nn cun
sch ny, nhm tc gi da trn nhng nghin cu lm sng v tng tc (trn
ngi tnh nguyn khe mnh hoc trn bnh nhn) trc hoc sau khi thuc lu
hnh trn th trng, da trn nhng d liu trong y vn (ca lm sng n l, nhng
12
nghin cu khc) v da trn nhng d liu lm sng cha c cng b (Ngn

hng d liu v cnh gic dc c cung cp bi cc trung tm cnh gic dc
cc vng trn ton nc Php, d liu ca cc phng th nghim cha cng b). Cc
tng tc c lit k c phn ra thnh 4 mc : (1) chng ch nh (contreindication); (2) khng nn phi hp (association dconseille); (3) thn trng khi
phi hp (prcaution demploi); (4) cn ch ( prendre en compte).
Mc d cc CSDL l cng c c lc phc v tra cu tng tc thuc, tuy
nhin, bc s v dc s gp kh khn trong qu trnh tra cu gy ra bi s khng
ng thun gia cc CSDL khc nhau. Nhiu nghin cu trn th gii ch ra s
bt ng gia cc CSDL tra cu tng tc thuc trong lit k tng tc v nhn
nh mc nghim trng ca tng tc. Mt nghin cu tin hnh ti M thc
hin nh gi trn 4 CSDL l Drug Interaction Facts, Evaluation of Drug
Interactions, Drug Interactions: Analysis and Management, Micromedex DRUGREAX System ch ra rng ch 9% s tng tc nghim trng c lit k trong
c 4 CSDL, trn thc t, 71,7% tng tc c nhn nh l nghim trng trong duy
nht mt CSDL [8]. Tng t nh vy, mt nghin cu thc hin nh gi 4 CSDL
l Bristish National Formulary, ph lc tng tc thuc ca Vidal Php, Drug
Interaction Facts v Micromedex Drug-Reax cho thy s khng ng thun ca cc
CSDL ny v lit k v nhn nh mc nghim trng ca cc tng tc thuc
[38]. K c i vi hai CSDL l Micromedex v Drug Interaction Facts u c
xy dng ti M, mc tng ng l rt thp. S khng ng thun ny do cc l
do sau: (1) mi CSDL c nhng tiu ch khc nhau lit k cc thuc gy tng
tc; (2) mi CSDL s dng nhiu ngun thng tin khc nhau nh gi v cng
mt tng tc thuc; (3) cc CSDL khc nhau thng nhn nh khc nhau v kh
nng gy tng tc ca cc thuc thuc cng mt nhm iu tr; (4) n nay, h
thng chung phn loi mc nghim trng ca tng tc thuc v phng php
hon thin nht xc nh ngha lm sng ca cc tng tc vn cha c. V vy,
mt s tc gi xut vic xy dng mt qui trnh nh gi, thm nh mc
ngha lm sng ca cc tng tc thuc khng da vo bt c CSDL no. Mt
13
nghin cu thc hin ti H Lan [37] xut phng php nh gi mt tng

tc thuc da trn 4 tiu ch: (1) bng chng m t tng tc; (2) mc ngha
lm sng ca hu qu m tng tc c th gy ra trn bnh nhn; (3) cc yu t
nguy c (tng tc c th c bit nghim trng trn mt s i tng bnh nhn
c bit); (4) t l bnh nhn gp cc phn ng c hi nu s dng cp phi hp.
Sau , da trn nhng thng tin thu thp c v 4 tiu ch trn, mc ngha
lm sng ca tng tng tc c tho lun gia cc thnh vin trong nhm thc
hin.
1.2.2. Phn mm h tr k n cho bc s

Trn th gii, vi s pht trin mnh m ca cng ngh thng tin, vic a
cng ngh vo h tr bc s trong qu trnh iu tr bnh cho bnh nhn c p
dng t rt lu. Cui nhng nm 1970, tng v phn mm h tr k n ra i,
trong , c tch hp tin ch duyt tng tc thuc v a ra nhng cnh bo v
tng tc thuc bnh nhn c th gp [9]. Nhng phn mm nh vy gip gim
thiu sai st trong s dng thuc, nng cao hiu qu iu tr v gim t l tng tc
thuc gp trn bnh nhn [24]. Ti Vit Nam, vic p dng cng ngh thng tin
phc v cho s dng thuc ti cc bnh vin mi ch dng phm vi qun l hnh
chnh, ch mt s bnh vin tuyn trung ng, phn mm chuyn ngnh y dc v
phn mm qun l thuc mi c s dng. Nhng cc phn mm ny cha tch
hp chc nng qun l tng tc trong n thuc bnh nhn v cc phn mm duyt
tng tc thuc c s dng nh mt cng c tham kho khng chnh thc [1].
Tuy nhin, s h tr ny ca cc phn mm cng gy t nhiu kh khn cho
cc bc s. Vic phn mm h tr k n a ra qu nhiu cnh bo v nhng tng
tc khng c ngha trn lm sng lm bc s c xu hng b qua nhng cnh bo
c a ra [14], [22], [29] v rt nguy him nu bc s b qua c nhng cnh bo
v nhng tng tc thc s nghim trng. Theo kt qu ca mt nghin cu thc
hin ti Php, ch 334 trong s 613 cnh bo v tng tc thuc b cc bc s b qua
l nhng cnh bo chnh xc [27]. Mt nghin cu khc thc hin ti 6 Trung tm
14
lo khoa ti M ch ra rng 72% cnh bo v tng tc thuc b b qua l nhng

tng tc thuc nghim trng v ch c 20% s cnh bo ny b b qua vi l do
thch hp [15].
Hin nay, s lng cc CSDL tra cu tng tc thuc nh cc sch chuyn
kho, phn mm trc tuyn hay ngoi truyn l rt nhiu nhng liu cc CSDL ny
c m bo cht lng khng v cht lng n u l iu ng lo ngi. Thc
trng cht lng km ca cc phn mm tra cu tng tc thuc c ghi nhn.
Nhng phn mm ny khng c mt h thng cht ch phn loi tng tc thuc,
s dng nhng thng tin cha c nh gi hay kim nh lm c s a ra
cnh bo, v thng khng bao gm thc phm chc nng [21], [22]. Chnh nhng
thng tin sai lch hoc khng y ca nhng CSDL km cht lng s gy nh
hng xu n qu trnh iu tr cho bnh nhn.
Nhng kh khn c th gp phi trong qu trnh tra cu thng tin v tng
tc thuc u c ghi nhn qua nhiu nghin cu. Trong thc hnh lm sng,
cc vn ny khin bc s v dc s bi ri v mt nhiu thi gian tra cu y
vn nhm tm ra cu tr li xc ng cho mt vn . Trong khi , vic iu tr li
i hi bc s a ra quyt nh nhanh chng v chnh xc. V vy, vic xy dng
mt cng c gip cc bc s nm bt cc tng tc nghim trng m khng tn
nhiu thi gian l v cng cn thit.
1.2.3. Bng cnh bo v nhng tng tc nghim trng

Trn th gii, mt vi tc gi xut vic xy dng v ban hnh bng
cnh bo v nhng tng tc thuc nghim trng cho i tng bnh nhn c th.
C th nhc n nghin cu ca Malone v cng s xut 25 cp tng tc thuc
nghim trng c th gp phi cho i tng bnh nhn ngoi tr [26]. Hai tc gi
Hanstern v Horn cng xut danh sch 100 tng tc thc s quan trng cn ch
[18]. D n Multidisciplinary Medication Management Project (M) a ra
tng xy dng danh sch 10 tng tc thuc cn ch trong qu trnh chm sc
15
sc khe di ngy [10]. Ti Php, URCAM (y ban vng v bo him y t) cng

ban hnh khuyn co v nhng tng tc thuc chng ch nh nm 2004 [41].
Nh vy, vic xy dng mt danh sch ngn gn nhng tng tc thuc
thc s nguy him khng phi iu mi m trn th gii, v iu ny l rt thit
thc vi cc cn b y t trong thc hnh lm sng.
1.2.4. Mt s khuyn co chung kim sot tng tc thuc

Cho d tt c cc hn ch ca nhng ti liu tra cu tng tc thuc c
gii quyt th quan trng nht, trong vic kim sot tng tc thuc, vn l quyt
nh ca bc s. Kin thc chuyn mn v kinh nghim trn lm sng s gip bc s
a ra nhng bin php can thip hp l cho bnh nhn, da trn nhng cnh bo
c a ra bi cc CSDL, phn mm h tr k n hay bng cnh bo tng tc
thuc. Di y l mt s khuyn co chung kim sot tng tc thuc mt cch
hiu qu trn bnh nhn [17], [20], [32], [34], [36]:
Ghi nh kin thc c bn v tng tc thuc.
nh gi nguy c (tui, thay i sinh l, tnh trng bnh l, ung ru, ht
thuc, ch n, yu t thuc v mi trng) trn tng i tng bnh nhn
c th.
S dng CSDL tra cu tng tc thuc nh mt cng c tra cu, tham kho.
Nn tm kim thng tin t nhiu ngun khc nhau.
Ghi nh v thng xuyn cp nht danh sch nhng thuc d c kh nng
gy tng tc nh nhng cht cm ng hay c ch enzym, cng nh nhng
thuc c khong iu tr hp.
Hi bnh nhn v tt c nhng thuc bnh nhn ang s dng bao gm c
thuc c ngun gc dc liu dc c truyn, thc phm chc nng trc
khi k n. iu y l v cng quan trng v nhiu bnh nhn ngh rng
thc phm chc nng c tc dng nh, khng tng tc vi nhng thuc
thng thng hay thc phm chc nng khng gy ra nhng phn ng c hi
16
v chng c ngun gc t nhin hay n gin h ngh rng thc phm chc
nng khng phi l thuc.
S dng mt thuc thay th khng gy tng tc.
Nu thuc thay th khng sn c, nn dng thuc khc c kh nng gy
tng tc thp hn hoc c chuyn ha theo mt con ng khc.
Nu hai thuc tng tc buc phi s dng ng thi, s dng nhng phng
php gim thiu tng tc nh thay i dng bo ch, thi gian ung
thuc hp l, hiu chnh liu.
Theo di bnh nhn nu tng tc thuc c ngha lm sng c nguy c xy
ra trn bnh nhn.
Theo di bin i bt thng trn bnh nhn v tm hiu nguyn nhn xem
c phi bt ngun t tng tc thuc hay khng. Ch , vic bt u hoc
ngng s dng mt thuc c th lm xut hin nhng thay i ny.
Hng dn cho bc s v bnh nhn v nguy c xy ra tng tc v cc biu
hin, triu chng c th xut hin nu tng tc xy ra.
17
Chng 2. I TNG V PHNG PHP NGHIN CU

2.1. i tng nghin cu
2.1.1. Cc c s d liu tra cu tng tc thuc
thc hin ti ny, nhm nghin cu s dng 5 CSDL sau: (1) Ph
lc 1 Dc th Anh 61 (Bristish National Formulary 81) (BNF) [23]; (2) Drug
Interaction Facts 2010 (DIF) [34]; (3) Micromedex 2.0 DRUG-REAX System
(MM) [42]; (4) Stockleys Drug Interactions Pocket Companion 2012 (SDI) [33];
(5) Thsaurus des interactions mdicamenteuses (TIM) [40]. y u l 5 CSDL
chuyn tra cu v tng tc thuc c uy tn, l ti liu tham kho u tay ti cc
nc xut bn v c sn ti Trung tm DI & ADR Quc gia thi im thc hin
ti. i vi TIM, nhm nghin cu ch s dng ti liu ny trong trng hp mt
hot cht khng c mt trong 4 CSDL u.
2.1.2. Danh mc thuc

Thuc trong danh mc a vo nghin cu phi ph hp vi cc tiu chun
sau:
Tiu chun la chn:
-
S dng ti bnh vin Thanh Nhn ti thi im thng 11/2011.
S dng theo ng ton thn.
Tiu chun loi tr:

-
Thuc tc dng ti ch.
Thuc c ngun gc dc liu.
2.1.3. n thuc ngoi tr v bnh n ni tr

Tt c nhng n ngoi tr lu tr trong phn mm qun l ti khoa Dc
bnh vin Thanh Nhn trong 2 tun t 07/03 18/03/2011.
Tt c bnh n ca bnh nhn ang c iu tr c mt ti 19 khoa lm sng
ti bnh vin Thanh Nhn trong ngy 25/02/2012.
18
2.1.4. Nhm chuyn mn

Nhm chuyn mn bao gm:
13 bc s cng tc ti bnh vin Thanh Nhn;
2 dc s lm sng cng tc ti khoa Dc bnh vin Thanh Nhn;
2 dc s cng tc ti Trung tm DI & ADR Quc gia.
2.2. Phng php nghin cu

2.2.1. Xy dng danh sch tng tc thuc cn ch trong thc hnh lm sng
ti bnh vin Thanh Nhn
Vic xy dng danh sch tng tc thuc cn ch c thc hin qua ba
giai on. u tin, nhm nghin cu la chn nhng tng tc thuc c ngha
lm sng (tng tc thuc dn n hiu qu iu tr v/hoc c tnh ca mt thuc
b thay i ti mc cn hiu chnh liu hoc c bin php can thip y khoa khc
[35]) t cc CSDL, sau tin hnh tp hp thng tin trong y vn lin quan n cc
cp tng tc . Nhng tng tc la chn c nh gi bi nhm chuyn
mn, xut pht t tng thc hin theo qui trnh Delphi sa i [19]. y l quy
trnh ly kin ng thun gia cc nh chuyn mn c nhn nh v quan im
khc nhau v cng mt vn , vic nh gi c tin hnh c lp v qua nhiu
vng. Cui cng, cc dc s trong nhm chuyn mn tho lun v cht li danh
sch tng tc cui cng.
2.2.1.1. Giai on 1: Xy dng danh sch tng tc thuc c ngha lm sng

c ng thun gia cc CSDL tra cu tng tc thuc
Nhng tng tc thuc nghim trng gia cc hot cht c la chn t
nhng CSDL tra cu tng tc thuc. Do cc CSDL khc nhau c h thng phn
loi tng tc thuc khc nhau nn u tin nhm nghin cu quy c mc nh
gi tng tc thuc c ngha lm sng cc CSDL nh sau (bng 2.1).
19
Bng 2.1. Quy c mc nh gi tng tc thuc c ngha lm sng cc

CSDL
BNF
DIF
Mc
1
MM
SDI
TIM
Du
chm
ContraDu gch cho X (e
Contratrn/c th thm
indicated
da tnh mng hoc
indication
(Chng ch
cm t Avoid
chng ch nh)
(Chng
concomitant
ch nh)
Du chm than ! nh)
use
(Nghim
Mc
Major
(Nghim trng cn
trng/Trnh s
(Nghim
hiu chnh liu hoc
2
dng phi hp)
trng)
theo di cht ch)
Nhng tng tc thuc c chn phi tha mn hai tiu chun. Tiu chun
1 l ghi nhn v tng tc ny t mc ng thun gia cc CSDL. Trng hp
hot cht c mt trong 4 CSDL, tng tc ca hot cht c chn khi tng tc
ny c ghi nhn t nht bi 3/4 CSDL. Trng hp hot cht c mt trong 3
CSDL, tng tc ca hot cht c chn khi tng tc ny c ghi nhn t nht
bi 2/3 CSDL. Trng hp hot cht c mt trong 2 CSDL, tng tc ca hot cht
c chn khi tng tc ny c ghi nhn c 2 CSDL. Trng hp hot cht ch
c mt trong 1 CSDL, tng tc c chn ch khi c ghi nhn mc cao
nht. Tiu chun 2 l nhng cp tng tc p ng iu kin ca tiu chun 1 v
phi c ghi nhn t nht trong 1 CSDL mc cnh bo cao nht.
2.2.1.2. Giai on 2: Ly kin nh gi ca nhm chuyn mn v nhng tng tc

c chn giai on 1
Nhm chuyn mn bao gm 13 bc s i din cho cc khoa lm sng ti
bnh vin; 2 dc s ca khoa Dc v 2 dc s ca Trung tm DI v ADR Quc
gia. Mi thnh vin trong nhm c cung cp mt bn m t thng tin chi tit v
tng tc thuc la chn sau giai on 1 gm cc phn sau: (1) nhn nh ca cc
CSDL; (2) hu qu; (3) c ch; (4) x tr v (5) bn lun v cp tng tc. Tt c
thnh vin nhm chuyn mn tp trung li trong mt bui, ti , mt ngi i
din nhm nghin cu trnh by v nhn nh ca cc CSDL, hu qu, c ch, x tr
ca cc tng tc c la chn. Sau , mi thnh vin nhm chuyn mn nh
gi cc tng tc mt cch c lp theo 6 tiu ch (bng 2.2) theo thang im t 1
20
im (hon ton phn i) n 5 im (hon ton ng ) [11]. Ring tiu ch 6 ch

c nh gi bi 2 dc s ca Trung tm DI v ADR Quc gia theo thang im
ring [37] (bng 2.3). L do giai on ny ch gm 2 dc s ang cng tc ti
Trung tm DI v ADR Quc gia v h c iu kin tra cu nhiu ngun CSDL
thng tin thuc sn c.
Bng 2.2. Su tiu ch nh gi tng tc thuc ca nhm chuyn mn

STT
1
2
4
5
6
Tiu ch nh gi
Mc ph bin ca
tng tc
Mc nghim trng
ca tng tc
ngha ca tiu ch
Tng tc thng gp trn lm sng, quan trng
v c th gy hu qu bt li cho bnh nhn.
Khi xy ra tng tc, c th e da tnh mng
hay li nhng hu qu nghim trng khng hi
phc cho bnh nhn.
i tng bnh nhn Kh nng xy ra tng tc cao nhng i tng
bnh nhn c bit nh: chc nng cc c quan
c bit
suy gim (hp thu, phn b, chuyn ha, thi tr
thuc); ang dng cc thuc khc iu tr cc
bnh mc km.
Nhn thc v tng tc Bc s nm r v kh nng xy ra tng tc
trong iu tr.
Khi tng tc xy ra i hi bc s phi nh gi
Kim sot tng tc
nhanh v can thip kp thi x tr tng tc.
D liu m t tng tc S xut hin ca tng tc c m t bi nhng
bng chng lm sng ng tin cy.
Bng 2.3. Thang im nh gi tiu ch 6
1 im
2 im
3 im
4 im
5 im
Nghin cu dc lc hc thc hin trn ng vt, th nghim in

vitro vi kt qu ngoi suy mt cch hn ch trn ngi trong th
nghim in vivo, d liu cha c cng b.
Bo co ca lm sng cng b, nhng khng hon chnh (khng c
ti hoc ngng s dng thuc, xut hin nhng yu t khc gy nn
phn ng c hi).
Bo co ca lm sng m t y , c cng b; phn tch hi
cu v chui ca lm sng c bo co.
Th nghim c i chng, cng b, c thc hin trn bnh
nhn hoc ngi tnh nguyn khe mnh, vi nhng tiu ch nh gi
thay th.
Th nghim c i chng, cng b, c thc hin trn bnh
nhn hoc ngi tnh nguyn khe mnh, vi nhng tiu ch nh gi
21
c ngha lm sng.
Poster hay bn tm tt trong nhng hi tho khoa hc: 1 hoc 2 im, ph
thuc vo thng tin cung cp. Nu nhng thng tin ny cha c cng b
trong nhng tp ch uy tn trong vng 3 nm sau hi tho, thng tin ny c
nh gi l 1 im.
Thng tin t bn tm tt c tnh sn phm/bo co nh gi trn cng ng
ti chu u: 1, 2 hoc 3 im ph thuc vo thng tin cung cp.
Phn tch hi cu chui ca lm sng c bo co: 2 hoc 3 im, ph thuc
vo thng tin cung cp.
2.2.1.3. Giai on 3: Tho lun v cht li danh sch tng tc thuc cui cng
Da trn kt qu nh gi giai on 2, vi mc ch thu gn danh sch
tng tc, hai dc s ca khoa Dc - bnh vin Thanh Nhn v hai dc s ca
Trung tm DI v ADR Quc gia tip tc tho lun v ng thun kin cht li
danh sch tng tc thuc cui cng.
2.2.2. Xy dng hng dn x tr cho cc tng tc thuc trong danh sch cui
cng
Nhm nghin cu tp hp hng dn x tr cho cc tng tc thuc trong
danh sch cui cng t 4 CSDL l: (1) DIF [34]; (2) MM [42]; (3) Stockleys Drug
Interactions [32]; (4) Drug Interactions: Analysis and Management [17]. Sau , la
chn ra nhng kin v kim sot tng tc c ghi nhn nhiu CSDL nht v
xy dng phn kim sot tng tc theo nh hng chung nh sau:
Kim sot tng tc

thuc nghim trng
Chng ch nh?
C
Thay th bng thuc
no? v/hoc ngng
dng thuc tm thi
hay trong khong thi
gian no?
Khng
Hiu chnh liu nh th no?

v/hoc theo di nhng ch s
sinh ha no hay biu hin
lm sng no trn bnh nhn?
v/hoc cn thn trng hay
lu im g khi s dng cp
phi hp ny cho bnh nhn?
22
2.2.3. Xc nh tn sut gp phi nhng tng tc trong danh sch c xy

dng trong n thuc iu tr ngoi tr v bnh n ni tr ti bnh vin
Tt c nhng n thuc iu tr ngoi tr ca bnh nhn c bo him y t
trong hai tun t ngy 07/03 - 18/03/2011, lu tr trong phn mm qun l ca khoa
Dc - bnh vin Thanh Nhn v tt c bnh n c mt 19 khoa lm sng trong
ngy 25/02/2012 c r sot kim tra s xut hin cc tng tc thuc nm
trong danh sch tng tc thuc cn ch c xy dng. Ch tiu nh gi l s
tng tc c pht hin, s n c t nht mt tng tc v c th cc tng tc
c ghi nhn.
2.4. X l s liu
S liu c x l theo phng php thng k y hc bng phn mm SPSS
16.0 v Excel 2007. Trong giai on ly kin nh gi ca nhm chuyn mn, h
s tng quan trong nhm (intraclass correlation coefficient - ICC) ca tng tiu
ch nh gi c tnh bng phn mm SPSS 16.0, theo phng php c xut
bi Shrout v Fleiss [31]. y l mt ch s th hin mc ng thun ca cc
thnh vin trong nhm, v ch s ny cng gn 1 th mc ng thun cng cao,
c th nh sau [13]:
Gi tr ICC < 0,4: Mc ng thun km;
0,4 Gi tr ICC < 0,6: Mc ng thun trung bnh;
0,6 Gi tr ICC < 0,75: Mc ng thun cao;
Gi tr ICC 0,75: Mc ng thun rt cao.
23
Chng 3. KT QU NGHIN CU
3.1. Xy dng danh sch tng tc thuc cn ch trong thc hnh lm sng
Ti thi im thng 11/2011, 377 hot cht thuc 87 nhm thuc (theo phn
loi trong Ph lc 1 ca BNF) c s dng ti bnh vin Thanh Nhn ph hp tiu
chun la chn a vo nghin cu. Trong giai on 1 la chn nhng tng tc
nghim trng t cc CSDL, nhm nghin cu ghi nhn 78 tng tc p ng tiu
chun 1 (Ph lc 2) v 44 tng tc p ng hai tiu chun a vo nghin cu
giai on 2. Nhm chuyn mn bao gm 13 bc s n t 11 khoa lm sng (Tim
mch; Hi sc tch cc; Ni tit; Ni tng hp; Thn kinh; Thn tit niu; Ngoi
tng hp; Sn; Lin chuyn khoa; Tiu ha; Nhi); 2 dc s lm vic ti khoa Dc
bnh vin v 2 dc s lm vic ti Trung tm DI & ADR Quc gia. Kt qu nh
gi ca nhm chuyn mn v 44 tng ny c trnh by trong bng 3.1.
Bng 3.1. Danh sch 44 tng tc thuc c la chn trong giai on 1 v kt qu
nh gi ca nhm chuyn mn trong giai on 2
STT
Cp tng tc
Aspirin
1
2
Kali clorid
Digoxin
Heparin v heparin
trng lng phn t
thp
Spironolacton
Amiodaron
Khng sinh macrolid

(clarithromycin,
erythromycin)
Digoxin
Digoxin
Hydroclorothiazid
Spironolacton
Thuc i khng th
th angiotensin-II
Khng sinh aminosid
6
7
8
9
Furosemid
Spironolacton
Aspirin
Cc NSAID
10
11
12
13
Dn cht statin
(atorvastatin,
simvastatin)
Dn cht statin
(atorvastatin,
simvastatin)
Colchicin
Thuc c ch men
chuyn
Cc NSAID
Heparin v heparin
trng lng phn t
thp
Thuc chng nm
nhm azol
Khng sinh macrolid
(clarithromycin,
erthromycin)
Khng sinh macrolid
(clarithromycin,
1. Mc
ph
bin
2. Mc
nghim
trng
3. i
tng
bnh
nhn c
bit
4. Nhn
thc v
tng tc
5. Kim
sot
tng tc
6. D
liu v
tng tc
Tng im
ca 6 tiu ch
4.1
4.6
4.0
4.6
4.7
4.0
26.0
3.8
4.4
4.1
4.4
4.5
4.5
25.7
4.2
4.3
3.6
4.1
4.2
5.0
25.4
4.2
4.4
3.5
4.2
4.5
4.5
25.3
4.4
4.5
3.5
4.4
4.3
3.5
24.6
4.0
4.2
4.2
4.3
4.4
3.5
24.6
4.2
4.0
3.9
4.2
4.2
4.0
24.5
4.1
4.0
3.6
4.5
4.7
3.5
24.4
3.8
4.4
3.6
4.3
4.3
4.0
24.4
3.6
4.4
3.8
4.5
4.5
3.5
24.3
3.8
4.2
3.5
4.0
4.2
4.5
24.2
3.9
4.2
3.4
4.2
4.4
4.0
24.1
3.9
4.4
3.5
4.2
4.2
3.5
23.7
24
erythromycin)
14
Amiodaron
Diltiazem
Carbamazepin
Khng sinh macrolid

(clarithromycin,
erythromycin)
Simvastatin
15
16
Amiodaron
Dn cht alkaloid ca
la mch
3.8
4.4
4.2
4.1
4.4
2.5
23.4
3.8
3.9
3.5
3.8
3.9
4.5
23.4
3.8
4.1
3.4
3.8
3.9
4.0
23.0
3.6
4.2
3.4
3.9
4.2
3.5
22.8
19
Adrenalin
Khng sinh macrolid

(azithromycin,
clarithromycin,
erythromycin,
roxithromycin,
spiramycin)
Dn cht statin
(atorvastatin,
rosuvastatin,
simvastatin)
Propranolol
3.4
3.8
3.6
3.7
3.8
4.5
22.7
20
Fentanyl
Fluconazol
3.4
4.1
3.4
3.6
4.1
4.0
22.6
21
Diltiazem
Erythromycin
3.6
4.2
3.3
4.0
4.4
3.0
22.5
22
Nifedipin
Phenobarbital
4.0
4.2
3.2
4.1
4.1
2.5
22.1
23
Nhng thuc ko di on QT*
3.8
4.2
3.4
4.0
4.2
2.5
22.1
17
Dn cht firat
18
Isofluran
3.6
4.1
3.5
3.9
4.2
3.5
22.8
25
Clorpromazin
Thuc gin c khng

kh cc
(pancuronium,
vecuronium)
Propranolol
26
Cc NSAID
Methotrexat
Khng sinh aminosid
3.2
4.0
3.5
3.5
4.1
3.0
21.3
29
Aspirin
Thuc gin c khng

kh cc
(pancuronium,
piperonium,
rocuronium,
vecuronium)
Khng sinh
carbapenem
Methotrexat
3.5
3.9
3.1
3.7
3.5
3.5
21.2
30
Itraconazol
Vincristin
3.1
3.9
3.0
3.5
3.7
4.0
21.2
31
Acid ioxaglic
Metformin
4.0
4.5
3.4
2.9
4.2
2.0
21.0
Kali clorid
Thuc khng
cholinergic
(biperiden)
Sumatriptan
3.9
4.1
3.4
3.9
4.1
1.5
20.9
24
27
28
Acid valproic
32
3.6
3.6
3.1
3.5
3.6
4.5
21.9
3.5
3.7
3.1
3.6
3.8
4.0
21.7
3.4
3.8
3.3
3.6
4.1
3.5
21.7
3.5
3.8
3.1
3.6
4.0
3.5
21.5
3.5
4.0
2.9
3.5
3.8
3.0
20.7
34
Dn cht alkaloid ca
la mch
Co-trimoxazol
Methotrexat
3.2
3.7
3.2
3.2
3.8
3.5
20.6
35
Cc NSAID
Ketorolac
2.9
4.1
2.9
3.9
4.1
2.5
20.4
Dn cht alkaloid ca
la mch
Methotrexat
Thuc chng nm
nhm azol
Khng sinh penicilin
3.4
3.9
3.7
3.6
3.9
1.5
20.0
3.2
3.5
3.1
3.2
3.9
3.0
19.9
Thuc c ch chn
lc ti thu hi
serotonin (fluoxetin,
sertralin)
Ivabradin
Tramadol
3.0
3.8
3.1
3.2
3.8
3.0
19.9
3.2
3.6
2.7
3.4
3.6
2.5
19.0
3.3
3.8
3.3
3.1
3.8
1.5
18.8
33
36
37
38
39
40
Alfuzosin
Thuc c ch
CYP3A4 (diltiazem,
clarithromycin,
erythromycin,
itraconazol)
Itraconazol
25
41
Aspirin
Ketorolac
2.9
3.5
2.9
3.8
3.8
1.5
18.4
42
Ketorolac
Pentoxifylin
3.1
3.7
3.0
3.3
3.6
1.5
18.2
Thuc c ch ti thu
hi serotonin
(fluoxetin, sertralin,
venlafaxin)
Metoclopramid
Xanh methylen
2.4
3.5
2.8
3.2
3.4
2.5
17.8
2.8
3.4
2.6
3.1
3.2
1.0
16.1
Gi tr trung bnh
3.6
4.0
3.4
3.8
4.0
3.3
22.1
Gi tr nh nht
2.4
3.4
2.6
2.9
3.2
1.0
16.1
Gi tr ln nht
4.4
4.6
4.2
4.6
4.7
5.0
26.0
lch chun
0.4
0.3
0.4
0.4
0.3
1.0
2.3
0,816
0,688
0,644
0,814
0,734
0,818
43
44
H s ICC
Piribedil
* 3 cp tng tc ca nhng thuc ko di on QT l: (1) amiodaron khng sinh macrolid (azithromycin, clarithromycin,
erythromycin, spiramycin); (2) amiodaron khng sinh quinolon (levofloxacin, ofloxacin); (3) amiodaron thuc iu tr ri lon tm
thn (amisulpirid, clorpromazin, haloperidol).
Ghi ch: Cc tng tc c xp theo th t gim dn ca tng im 6 tiu ch nh gi.
Cc tng tc c tng im trung bnh nm trong khong 16,1 n 26,0 trn

tng im ti a l 30 im, trong cp tng tc aspirin heparin v heparin
trng lng phn t thp c s im cao nht. Trong su tiu ch, tiu ch 2 (mc
nghim trng) v tiu ch 5 (kim sot tng tc) c gi tr trung bnh cao nht, u
bng 4,0 im. iu cho thy nhm chuyn mn nhn nh 44 tng tc c
la chn vo giai on 2 l nhng tng tc c th li hu qu nghim trng v
cn c bin php can thip mnh kim sot tng tc. Tiu ch c khong bin
thin ln nht (t 1,0 n 5,0) l tiu ch v d liu m t tng tc, gi tr trung
bnh l 3,3 1,0. iu ny cho thy bng chng trong y vn ghi nhn v cc tng
tc khc nhau thng khng ng nht v c s lng v cht lng.
Nhng tng tc c la chn l nhng tng tc c tng im trung bnh
6 tiu chun 22,1 (gi tr trung bnh tng im 6 tiu ch ca 44 tng tc). Trong
23 tng tc p ng iu kin trn (nhng tng tc c s th t t 1 n 23 trong
bng 3.1), bn dc s trong nhm chuyn mn tho lun v thng nht b sung
vo danh sch ba tng tc l: (1) dn xut alkaloid ca la mch sumatriptan v
tng tc ca alkaloid ca la mch gy hu qu nghim trng v c bn CSDL
nghin cu u a ra khuyn co chng ch nh khi phi hp vi sumatriptan; (2)
ivabradin thuc c ch CYP3A4 v ivabradin l mt thuc mi, c s dng rt
ph bin ti khoa tim mch ca bnh vin Thanh Nhn; (3) acid ioxaglic
metformin v y l mt tng tc nghim trng c kh nng e da tnh mng v
26
c nguy c cao xy ra, cn thit phi tin hnh cnh bo ny. ng thi, nhm dc
s quyt nh loi b tng tc fentanyl fluconazol do vic s dng ng thi hai
thuc trn thc t l rt him gp. Nh vy, danh sch tng tc thuc cn ch
bao gm 25 tng tc, l nhng tng tc c lit k trong bng 3.2.
Bng 3.2. Danh sch 25 tng tc thuc cn ch trong thc hnh lm sng
ti bnh vin Thanh Nhn
STT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Cp tng tc
Metformin
Propranolol
Digoxin
Diltiazem
Simvastatin
Cc NSAID
Heparin v heparin trng lng phn t
thp
Cc NSAID
Heparin v heparin trng lng phn t
thp
Carbamazepin
Khng sinh macrolid (clarithromycin,
erythromycin)
Colchicin
erythromycin)
Dn cht alkaloid ca la mch
Khng sinh macrolid (azithromycin,
clarithromycin, erythromycin,
roxithromycin, spiramycin)
Sumatriptan
Dn cht firat
Dn cht statin (atorvastatin, rosuvastatin,
simvastatin)
Dn cht statin (atorvastatin, simvastatin) Khng sinh macrolid (clarithromycin,
erthromycin)
Dn cht statin (atorvastatin, simvastatin) Thuc chng nm nhm azol
Digoxin
Hydroclorothiazid
Digoxin
erythromycin)
Diltiazem
Erythromycin
Furosemid
Khng sinh aminosid
Ivabradin
Thuc c ch CYP3A4 (diltiazem,
itraconazol)
Kali clorid
Spironolacton
Nifedipin
Phenobarbital
Acid ioxaglic
Adrenalin
Amiodaron
Amiodaron
Amiodaron
Aspirin
Aspirin
27
23
24
25
Spironolacton
Thuc i khng th th angiotensin-II
Spironolacton
Thuc c ch men chuyn
Nhng thuc ko di on QT*:
(1) amiodaron khng sinh macrolid (azithromycin, clarithromycin, erythromycin,
spiramycin);
(2) amiodaron khng sinh fluoroquinolon (levofloxacin, ofloxacin);
(3) amiodaron thuc iu tr ri lon tm thn (amisulpirid, clorpromazin,
haloperidol)
H s ICC nh gi mc ng thun v nhn nh ca cc thnh vin

trong nhm chuyn mn c gi tr dao ng t 0,644 n 0,818, ph thuc vo tng
tiu ch, trong tiu ch 1 (mc ph bin ca tng tc) v tiu ch 6 (d liu
m t tng tc) c gi tr cao nht. Gi tr ICC cng gn 1 th mc ng thun
cng cao, do vy nhm chuyn mn t c mc ng thun cao trong vic
nh gi cc tng tc thuc.
3.2. Xy dng hng dn x tr cho cc tng tc thuc trong danh sch cui
cng
Nhm nghin cu xy dng mt bng m t v cch kim sot 25 tng
tc ny (c th trong Ph lc 3).
3.3. Xc nh tn sut gp phi nhng tng tc trong danh sch c xy
dng trong n thuc iu tr ngoi tr v bnh n ni tr ti bnh vin
Trong khong thi gian 2 tun t ngy 07/03 - 18/03/2011, nhm nghin cu
thu thp c 6737 n iu tr ngoi tr ca bnh nhn c bo him y t. Cc
n thuc c r sot pht hin cc tng tc nm trong danh sch 25 tng tc
thuc cn ch c xy dng. Kt qu thu c trnh by trong bng 3.3:
Bng 3.3. Tn sut k n v t l xut hin tng tc nm trong danh sch 25 tng tc
thuc cn ch c xy dng trong n iu tr ngoi tr t ngy 07/03-18/03/2011
Cp tng tc
TT
Thuc 1
Aspirin
Thuc 2
Heparin v heparin
trng lng phn t
thp
Tn sut
k n
thuc 1
(n)
Tn sut
k n
thuc 2
(n)
Tn sut
phi hp
2 thuc
(n)
T l so
vi tng s
n (%)
28
Kali clorid
Digoxin
4
5
Amiodaron
Digoxin
Thuc i khng th
th angiotensin-II
6
7
Furosemid
Thuc c ch men
chuyn
9 Aspirin
Heparin v heparin
10 trng lng phn t
thp
Dn cht statin
11 (atorvastatin,
simvastatin)
8
Dn cht statin
12 (atorvastatin,
simvastatin)
13 Colchicin
14 Amiodaron
15 Carbamazepin
16 Amiodaron
17
Dn cht alkaloid
ca la mch
18 Dn cht firat
19 Adrenalin
Spironolacton
Khng sinh
macrolid
(clarithromycin,
erythromycin)
Digoxin
Hydroclorothiazid
21
20
0
20
20
81
0
2
0
0.03
Spironolacton
305
Khng sinh
aminosid
37
Spironolacton
545
Cc NSAID
393
Cc NSAID
393
219
219
30
54
79
193
550
273
0.03
66
Thuc chng nm
nhm azol
Khng sinh
macrolid
(clarithromycin,
erthromycin)
Khng sinh
macrolid
(clarithromycin,
erythromycin)
Diltiazem
Khng sinh
macrolid
(clarithromycin,
erythromycin)
Simvastatin
Khng sinh
macrolid
(azithromycin,
clarithromycin,
erythromycin,
roxithromycin,
spiramycin)
Dn cht statin
(atorvastatin,
rosuvastatin,
simvastatin)
Propranolol
29
20 Diltiazem
Erythromycin
21 Nifedipin
Phenobarbital
22 Nhng thuc ko di on QT
Acid ioxaglic dng
Metformin
23
tim
Dn cht alkaloid
24
Sumatriptan
ca la mch
Cht c ch
CYP3A4 (diltiazem,
25 clarithromycin,
Ivabradin
erythromycin,
itraconazol)
54
162
5
1
0
0
0
0
0
0
769
59
14
508
Trong 6737 n thuc, nhm nghin cu pht hin c 4 n c tng

tc, trong , mi n ch c 1 tng tc thuc. Tn sut xut hin tng tc trn
tng s n l 0,059%. Cc tng tc lin quan n 2 cp tng tc l digoxin
hydroclorothiazid v dn cht fibrat dn cht statin.
Ngy 25/02/2012, nhm nghin cu thu thp c 543 bnh n ni tr c
18 khoa lm sng ti bnh vin Thanh Nhn (trong ngy 25/02/2012, khng c bnh
nhn lu ti khoa Phc hi chc nng v khoa Thn nhn to; nhm nghin cu
cng khng ly c bnh n ti khoa Cp cu do c im lu tr bnh n ca
khoa ny), thc hin r sot s xut hin 25 tng tc trong danh sch c xy
dng v thu c kt qu nh sau:
Bng 3.4. T l xut hin 25 tng tc trong danh sch tng tc cn ch c
xy dng trong n iu tr ni tr ti bnh vin Thanh Nhn ngy 25/02/2012
TT
Tn khoa lm sng
Thn tit niu
S bnh
n
S bnh n c
tng tc
T l tng
tc so vi s
bnh n ca
khoa (%)
21
Ni ngh nghip
26
7,69
Thn kinh
41
Tim mch
49
12,24
C th cp tng tc
Amiodaron
Levofloxacin;
Netilmicin
Furosemid
Kali clorid
Spironolacton;
Aspirin
Nadroparin;
30
Netilmicin Furosemid
5
6
Nhi
Lin chuyn khoa
55
42
0
0
0
0
Ngoi tng hp
33
3,03
Ngoi s no
51
1,96
Hi sc tch cc
22
9,09
10
11
Phu thut
Sn
2
26
0
0
0
0
12
Tiu ha
48
10,42
13
14
Ni tit
n nguyn s sinh
43
4
0
0
0
0
15
Ni tng hp
57
3,51
16
17
18
ng y
Phc hi chc nng
Thn nhn to
Tng
23
0
0
543
0
0
0
19
0
0
0
3,50%
Amikacin Furosemid
Enoxaparin Diclofenac
Kali clorid
Spironolacton;
Tobramycin Furosemid
Kali clorid Spironolacton
Netilmicin Furosemid
Bng 3.5. Nhng tng tc c pht hin trong bnh n ni tr

ti bnh vin ngy 25/02/2012
TT
Cp tng tc
S bnh n cha
T l so vi tng s tng
tng tc
tc b pht hin (%)
Amiodaron khng sinh quinolon
5,26
Furosemid khng sinh aminosid
31,58
Kali clorid spironolacton
10
52,63
Aspirin heparin v heparin trng
5,26
5,26
19
100
lng phn t thp

5
Cc NSAID - Heparin v heparin

trng lng phn t thp
Tng
31
Trong 543 bnh n r sot, nhm nghin cu pht hin c 19 bnh

n c tng tc, trong , mi bnh n ch c 1 tng tc thuc. T l gp 25 tng
tc trong bnh n ni tr ton bnh vin l 3,50%, trong , t l cao nht l khoa
Tim mch (12,24%) v khoa Tiu ha (10,42%). Trong 25 cp phi hp trong danh
sch tng tc c xy dng, ch 5 cp tng tc b pht hin (Bng 3.5), tng
tc gp nhiu nht l kali clorid spironolacton v furosemid khng sinh
aminosid.
32
Chng 4. BN LUN
Tng tc thuc thuc l mt trong cc vn thng gp trong thc hnh
lm sng, c th li hu qu nghim trng v nh hng xu n kt qu iu tr
trn bnh nhn [2], [4], [20]. Tuy nhin, bc s thng gp nhiu kh khn trong
qu trnh tra cu tng tc thuc v cht lng, s khng ng nht gia cc CSDL
[8], [38] v vic cc CSDL a ra cnh bo v qu nhiu tng tc thuc khng
thc s c ngha trn lm sng khin cc bc s, dc s c xu hng b qua
nhng cnh bo. Do , chng ti thc hin nghin cu vi mc ch xy dng mt
danh sch tng tc thuc ngn gn, d nh v nhng tng tc thc s
nghim trng v cn ch trong thc hnh lm sng ti bnh vin Thanh Nhn da
trn bng chng ghi nhn trong y vn v kin nh gi ca nhm chuyn mn bao
gm bc s v dc s.
4.1. Xy dng danh sch tng tc thuc cn ch trong thc hnh lm sng
xy dng danh sch tng tc thuc c ngha lm sng, nhiu phng
php c thc hin, nh nghin cu ca Malone v cng s (Hoa K) [26],
phng php ca Hansten & Horn (Hoa K) [18] xy dng danh mc 100 tng tc
ng ch nht, phng php xy dng danh sch 10 tng tc thuc cn ch
trong qu trnh chm sc sc khe di ngy bng cch iu tra nhn nh ca cc
cn b y t xut bi d n Multidisciplinary Medication Management Project
(M) [10], hng dn v nhng tng tc thuc chng ch nh ti Php do
URCAM (y ban vng v bo him y t) ban hnh nm 2004 [41]. Nhm nghin
cu la chn phng php ca Malone v cng s (2004) tin hnh do y l
phng php cho php p dng danh mc thuc s dng ti mi bnh vin xy
dng danh sch tng tc. ng thi, tng tc c la chn theo phng php
ny va da trn bng chng y vn va da trn kin nh gi ca bc s v dc
s - nhng cn b y t tip xc trc tip tham gia iu tr cho bnh nhn trn lm
sng.
33
So vi danh sch 25 tng tc nghim trng c a ra bi nghin cu ca

Malone, danh sch c nhm nghin cu xy dng khng c nhng tng tc ca
thuc chng ng ng ung, thuc c ch monoamin oxidase (IMAO), khng
sinh iu tr lao. S khc bit ny c gii thch do tnh n thi im hin ti,
bnh vin Thanh Nhn khng s dng cc nhm thuc ny, hai nghin cu c hai
danh mc thuc s dng khc nhau. Nh vy, vic xy dng danh mc tng tc
da trn bng chng y vn v c s ng thun kin ca nhm chuyn mn trn
lm sng ny c th m rng p dng ph hp vi cc khoa phng hay bnh vin
khc nhau. So vi danh sch xut bi d n Multidisciplinary Medication
Management Project, danh sch xut bi ti khng c 8 trn 10 tng tc,
trong 5 tng tc lin quan n warfarin, 1 tng tc lin quan verapamil y
l hai hot cht khng c s dng ti bnh vin. Hai tng tc cn li khng c
mt l thuc c ch men chuyn kali clorid v khng sinh quinolon theophyllin
l nhng tng tc p ng tiu chun 1 nhng khng p ng tiu chun 2 c
nhm nghin cu ra.
Nhm nghin cu hy vng bng cnh bo 25 tng tc thuc c xy dng
s gip bc s nm c nhng tng tc nghim trng trn lm sng mt cch
nhanh chng v d dng. Chng ti khng mong mun lm cc bc s, dc s
cnh gic qu mc, dn n hu qu khng ch nh nhng thuc ny cho bnh
nhn, mc d vic phi hp thuc l cn thit v em li hiu qu iu tr tt. Ch
cn thn trng v c bin php can thip ng n, bc s c th kim sot tt cc
tng tc trn. chnh l l do nhm nghin cu ng thi tin hnh xy dng
hng dn x tr 25 tng tc ny trong thc hnh lm sng.
4.2. Xc nh tn sut xut hin 25 tng tc trong n iu tr ngoi tr v
bnh n ni tr ti bnh vin
T danh sch tng tc xy dng c, chng ti tin hnh r sot n thuc
iu tr ngoi tr pht hin tng tc. Kt qu cho thy t l xut hin 25 cp
phi hp ny trong n thuc ngoi tr ch t 0,059%. Cc nghin cu khc xc
34
nh t l xut hin tng tc nghim trng trn i tng bnh nhn ngoi tr cng
cho kt qu kh thp. Trong nghin cu ca Peng v cng s (2003) [28], t l
tng tc c a ra ch di 1%. Cc tc gi ny xc nh tng tc c ngha
lm sng trong n thuc bnh nhn bng mt chng trnh duyt n trn my vi
tnh c s dng nhiu b lc phc tp v nh gi ca mt dc s lm sng. Cn
nghin cu ca Mahmood v cng s (2007) [25] xc nh t l xut hin 25
tng tc thuc xut bi Malone trn bnh nhn lo khoa ngoi tr, kt qu ca
nghin cu ny cao hn (ln n 2,15%). iu c th c gii thch bi hai l
do. Danh sch Malone xut l da trn nhng thuc dng cho bnh nhn ngoi
tr. Bn cnh , i tng nghin cu l bnh nhn cao tui, y l i tng c
nhiu yu t nguy c gp tng tc thuc nh dng nhiu thuc iu tr cc bnh
ng thi hoc thng mc bnh mn tnh. Vi nghin cu ca chng ti, t l xut
hin tng tc rt thp mt phn c th do cc thuc c mt trong danh sch cui
cng hu ht l nhng thuc dng cho bnh nhn ni tr v v th, t l k n cc
thuc ny cho bnh nhn ngoi tr l rt thp v t l xut hin tng tc li cng
thp hn na.
Hai cp tng tc c pht hin l tng tc ca dn cht fibrat
(gemfibrozil/fenofibrat) dn cht statin (simvastatin/atorvastatin) v tng tc ca
digoxin hydrochlorothiazid. Cp tng tc u tin xut hin trong n ca hai
bnh nhn, trong , mi bnh nhn khm bnh hai khoa lm sng khc nhau v
mi khoa, bnh nhn u c k n mt thuc iu tr ri lon lipid mu. Nh
vy, tng tc xy ra y l do bc s khng nm c nhng thuc m bnh
nhn c ch nh khi khm khoa khc. Hu qu ca tng tc l lm tng nguy
c mc bnh c hoc tiu c vn trn bnh nhn mc nghim trng. V cp
tng tc gia digoxin hydroclorothiazid, tng tc ny c th gy ra ri lon
in gii v y l mt trong nhng yu t nguy c dn n lon nhp tim. R rng,
c hai tng tc trn u c th gy ra nhng hu qu nghim trng v kim sot
tng tc ny, bc s cn pht hin c tng tc v ch ng tin hnh cc bin
php can thip trn bnh nhn. Vic xut hin tng tc ny trn i tng bnh
35
nhn ngoi tr, nhm bnh nhn khng c gim st thng xuyn bi cn b y t
c th gy nguy him cho bnh nhn.
Tn sut xut hin 25 tng tc c ngha lm sng trong bnh n ni tr
trong mt ngy l 3,50%. Kt qu ny c chnh lch ng k so vi nhng nghin
cu khc v mi nghin cu u c i tng khc nhau (ton bnh vin hay ch
mt s khoa lm sng), thi gian nghin cu khc nhau v quan trng nht l quy
c tng tc nh th no c coi l c ngha lm sng. Theo mt nghin cu
thc hin ti bnh vin Hu ngh nm 2004 [6], t l tng tc c ngha lm sng
(tng tc mc 1 theo phn loi ca MIMS Interactive) trn bnh nhn ni tr ti
3 khoa Tiu ha, Tim mch, Tit niu l 10,9%. iu ny c th l gii c do
nghin cu ny ch thc hin trn 3 khoa c c im bnh nhn dng nhiu thuc,
thng c t l bnh nhn gp tng tc thuc kh cao v tc gi ch la chn mt
CSDL l phn mm MIMS Interactive nhn nh mc nghim trng ca
tng tc. Cng tng t, mt nghin cu c thc hin ti ba khoa Ni tit, Tiu
ha, Tim mch bnh vin Bch Mai (2007) [5] a ra t l tng tc c ngha
lm sng theo nhn nh ca phn mm Martindale trn bnh nhn ni tr l
78,5%. Mt tng tc khc thc hin ti 3 khoa ni tr mt bnh vin ti Thy S
(2007) [39] a ra kt qu l 74% bnh nhn gp tng tc c ngha lm sng
theo nhn nh ca phn mm k n dng trong bnh vin, c nh gi li bi
mt dc s lm sng v c tham kho vi cun Stockleys Drug Interactions.
Nm cp tng tc c pht hin l: kali clorid spironolacton; furosemid
khng sinh aminosid; amiodaron khng sinh quinolon; aspirin heparin v
heparin trng lng phn t thp; cc NSAID heparin v heparin trng lng
phn t thp, trong tng tc gp nhiu nht l tng tc gia kali clorid v
spironolacton. C 5 tng tc ny khng phi l nhng tng tc chng ch nh
nhng u i hi bc s cn rt thn trng v theo di bnh nhn cht ch. Tng
tc gia kali clorid v spironolacton dn n nguy c tng nng kali mu, c th
gy ri lon nhp tim. ng lu , 9 trn 10 bnh n c 2 thuc ny u c mt
thuc li tiu furosemid, l mt thuc c tc dng tng o tho kali. Nh vy,
36
trong trng hp ny, cc bc s c th nhn thc c v tng tc v ch

ng phi hp cc thuc vi nhau nhm ngn nga ri lon in gii, ng thi
trnh mt tc dng ca thuc li tiu gi kali. iu quan trng l cn theo di nng
kali mu ca bnh nhn cht ch, trnh s tng nng kali mu qu mc. Tuy
nhin, ch nn phi hp spironolacton v kali clorid trong trng hp bnh nhn h
kali mu nghim trng, khng p ng vi mt trong hai thuc khi dng n c.
V cn c bit thn trng nhng bnh nhn c cc yu t nguy c (nh bnh
nhn cao tui, mc i tho ng hoc suy thn) [17]. Vi cp tng tc,
furosemid v khng sinh aminosid, c hai thuc u gy c tnh trn thn v thnh
gic nn khi phi hp hai thuc ny bc s cn kim tra nh k chc nng thn v
thnh lc ca bnh nhn. Cn amiodaron v levofloxacin u c tc dng ko di
on QT, v th tng tc ny c th dn n ri lon nhp tim v bc s nn trnh
s dng ng thi hai thuc ny. Trong trng hp cn thit phi hp, bc s cn
ht sc thn trng v theo di cht ch in tm ca bnh nhn. Vi tng tc
aspirin/diclofenac heparin trng lng phn t thp, nhng thuc ny u c tc
dng chng ng mu, v vy, s tng nguy c xut huyt. Bnh nhn s dng cp
phi hp ny cn c gim st biu hin chy mu cng nh cc ch s ng mu
thch hp. ng ch , trong iu tr, aspirin cng heparin hay heparin trng lng
phn t thp c ch nh trong trng hp d phng bin chng thiu mu cc b
nhng bnh nhn au tht ngc th khng n nh [32]. Mc d bc s c th ch
ng phi hp hai thuc ny nhm em li hiu qu iu tr cho bnh nhn, nhng
cng cn nm r hu qu ca tng tc ny c bin php theo di v x tr thch
hp.
Nghin cu mi ch dng li vic xc nh t l xut hin 25 tng tc ny
trong n thuc ca bnh nhn, ch khng xc nh t l phn ng c hi do cc
tng tc ny thc t gy ra trn bnh nhn. Tuy nhin, vi mc nghim trng
c ghi nhn trong y vn v theo nh gi ca nhm chuyn mn, vic xut hin
nhng tng tc ny trong n thuc bnh nhn cn c ht sc lu v thn
trng.
37
Trong iu kin tin hnh, nghin cu ny cn mt s hn ch nht nh. Th

nht, do c nm CSDL tham gia nghin cu u l nhng ti liu nc ngoi nn
mt s hot cht khng c lit k trong cc ti liu ny. Bn cnh , do cch ghi
nhn tng tc mi CSDL l khc nhau nn trong qu trnh thc hin, nhm
nghin cu c th mc sai st bc la chn nhng tng tc nghim trng. Th
hai, MM nhn nh mc nghim trng v mc tin cy ti liu ghi nhn ca
tng tc mt cch c lp, khng ch r mc ngha lm sng ca tng tc.
Nhm nghin cu la chn tng tc trong CSDL ny da theo mc nghim
trng (chng ch nh, nghim trng), khng phi da theo mc ngha lm sng
nh cc CSDL khc v iu ny c th l mt sai s trong vic xt ng thun vi
cc CSDL cn li. Th ba, nghin cu la chn ra nhng tng tc ch da trn
bng chng y vn v cha xt n iu kin lm sng xut hin tng tc , do ,
c th xy ra trng hp mt s tng tc c coi l nghim trng mt bnh
cnh lm sng nht nh khng xut hin trong danh sch ny. Th t, nhm chuyn
mn bao gm nhiu thnh vin khng phi nhng chuyn gia v tng tc thuc, v
gm nhiu bc s cc khoa lm sng khc nhau c c im s dng thuc khc
nhau nn rt c th bc s khng nm ht c tng tc ca nhng thuc h t s
dng. iu ny c th l yu t gy nhiu lm nh hng n kt qu nh gi
tng tc. Th nm, khi thc hin nh gi tng tc, tng thnh vin nhm chuyn
mn a kin nh gi ch quan da trn nhng thng tin v tng tc c cung
cp bi nhm nghin cu, do im s v mt tiu ch thng l khc nhau gia
tng ngi v gy ra s khng ng thun ca nhm chuyn mn. Vi vic s dng
qui trnh Delphi sa i, chng ti c th gim thiu ti a hn ch ny v thc t,
gi tr ICC gia 17 thnh vin l kh cao, cho thy nhn nh c a ra bi nhm
chuyn mn t mc ng thun cao.
Tnh n thi im ny, y l nghin cu u tin tin hnh xy dng mt

danh sch tng tc thuc cn ch c thc hin ti Vit Nam. Nghin cu
ra mt phng php lun thc hin xy dng bng cnh bo tng tc thuc
38
nghim trng, p dng cho khoa lm sng hoc bnh vin c th. Hai mi nhm
tng tc c xc nh u l nhng tng tc c kh nng li hu qu nghim
trng trn bnh nhn v c r sot trong n iu tr ngoi tr, ni tr ti bnh
vin. Mc d t l xy ra cc tng tc ny tng i thp, nhng cc bc s, dc
s cn rt thn trng v c bin php can thip nhm gim thiu hu qu trn bnh
nhn.
39
Chng 5. KT LUN V XUT

5.1. Kt lun
1. xy dng c danh sch 25 tng tc thuc cn ch trong thc hnh
lm sng ti bnh vin Thanh Nhn da trn c s bng chng ghi nhn trong y vn
v nh gi ca mt nhm chuyn mn bao gm cc bc s, dc s, ng thi
cng xy dng hng dn x tr cho nhng tng tc ny.
2. xc nh c tn sut xut hin 25 cp phi hp ny trong k n
ngoi tr bo him lu tr trong phn mm qun l ti khoa Dc bnh vin t
ngy 07/03 - 18/03/2011 l 0,059%. Trong tng s 6737 n, 4 n xut hin tng
tc lin quan n 2 cp phi hp l: digoxinhydroclorothiazid v dn cht fibrat
dn cht statin. T l xut hin nhng tng tc ny trong bnh n ni tr ti 18
khoa lm sng ngy 25/02/2012 l 3,50%. Trong tng s 543 bnh n, 19 bnh n
xut hin tng tc thuc c lin quan n 5 cp phi hp l: kali clorid
spironolacton, furosemid khng sinh aminosid, amiodaron khng sinh quinolon,
aspirin heparin trng lng phn t thp, cc NSAID heparin trng lng phn
t thp.
5.2. xut
- Nhng cp tng tc ny c xy dng da trn danh mc cc thuc s
dng ti bnh vin tnh n thi im thng 11/2011. Do , trong tng lai, khi
bnh vin b sung hay loi b hot cht, danh sch ny cn c cp nht v chnh
sa.
- Trong tng lai, bnh vin c th thit k cc bng cnh bo v 25 tng
tc c la chn dn ti cc khoa lm sng, ng thi tch hp danh sch
ny vo phn mm k n sp c trin khai trong ton bnh vin. Xa hn, nhm
nghin cu mong mun s xut bn mt quyn cm nang b ti c m t chi tit
bin php kim sot cc tng tc ny v pht cho tt c cc nhn vin y t ang
cng tc ti bnh vin.
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42.
Micromedex Healthcare Series [intranet database]. Version 2.0. Greenwood

Village, Colo: Thomson Reuters (Healthcare) Inc.
Ph lc 1: Danh sch hot cht s dng bnh vin Thanh Nhn ti thi
im thng 11/2012 theo phn loi ca Ph lc 1 trong BNF
STT
Nhm thuc
Thuc gy m
Thuc gy t
Thuc an thn - gy ng
- gii lo
Thuc dn cht opioid
Thuc iu tr ng kinh v
chng co git
Thuc iu tr ri lon
tm thn
STT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Hot cht
Isofluran
Ketamin
Propofol
Sevofluran
Thiopental
Bupivacain
Lidocain
Procain
Bromazepam
Clorazepat
Diazepam
Etifoxin
Lorazepam
Midazolam
Rotundin
Tetrazepam
Zolpidem
Codein
Dextromethorphan
Dextropropoxyphen (propoxyphen)
Fentanyl
Morphin
Pethidine
Tramadol
Carbamazepin
Gabapentin
Levetiracetam
Phenobarbital
Pregabalin
Topiramat
Acid valproic
Valpromid
Amisulprid
Clorpromazin
Haloperidol
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
Thuc chng trm cm
Thuc iu tr parkinson
10
Thuc i khng 5HT1
11
Thuc lm tng tr nh, iu tr

suy gim tr tu v hng cm
12
Thuc chn bta
13
Thuc kch thch chn lc

th th bta-2
14
Thuc kch thch chn lc

th th alpha-2
68
Thuc cng giao cm
69
70
71
72
73
74
15
Levomepromazin
Olanzapin
Sulpirid
Amitriptylin
Fluoxetin
Mirtazapin
Sertralin
Tianeptin
Venlafaxin
Diethazin
Levodopa
(Levodopa +) Benserazid
(Levodopa +) Carbidopa
Piribedil
Tolcapon
Dihydroergotamin
Ergometrin
Ergotamin
Sumatriptan
Cerebrolysin
Ginkgo biloba
Meclofenoxat
Piracetam
Raubasin (+ almitrin)
Vinpocetin
Atenolol
Bisoprolol
Carvedilol
Metoprolol
Propranolol
Salbutamol
Terbutalin
Methyldopa
Dobutamin
Dopamin
Ephedrin
Adrenalin
Isoprenalin
Noradrenalin
16
Thuc gin c
17
Thuc khng muscarinic
18
Thuc li tiu
19
Thuc chn knh canxi
20
Thuc c ch men chuyn
21
Thuc i khng th th
angiotensin II
22
Thuc gin mch nhm nitrat

hu c
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
Pseudoephedrin
Eperison
Mephenesin
Pancuronium
Pipecuronium
Rocuronium
Suxamethonium
Thiocolchicosid
Tolperison
Vecuronium
Atropin
Biperiden
Trihexyphenidyl
Trimebutin
Acetazolamid
Furosemid
Hydroclorothiazid
Indapamid
Spironolacton
Amlodipin
Diltiazem
Felodipin
Lacidipin
Lercanidipin
Nifedipin
Nimodipin
Captopril
Enalapril
Imidapril
Lisinopril
Perindopril
Quinapril
Ramipril
Candesartan
Irbesartan
Losartan
Telmisartan
Valsartan
Glyceryl trinitrat
Isosorbid mononitrat
23
Glycosid tim
115
Digoxin
24
Thuc chng lon nhp
116
Amiodaron
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
Buflomedil
Fructose-1,6-diphosphat
Heptaminol
Hydralazin
Ivabradin
Naftidrofuryl
Nicorandil
Pentoxifylin
Rilmenidin
Trimetazidin
Atorvastatin
Rosuvastatin
Simvastatin
Ciprofibrat
Fenofibrat
Gemfibrozil
Cimetidin
Famotidin
Nizatidin
Ranitidin
Esomeprazol
Lanzoprazol
Omeprazol
Pantoprazol
Rabeprazol
Amoxicilin (+ acid clavulanic)
Ampicilin (+ sulbactam)
Benzylpenicilin (pen G)
Cloxacilin
Oxacilin
Phenoxy methylpenicilin (pen V)
Piperacilin (+ tazobactam)
Cefaclor
Cefadroxil
Cefalexin
Cefamandol
Cefazolin
25
Thuc gin mch v cc thuc

khc tc ng ln h tim mch
26
Thuc iu tr ri lon lipid

mu nhm c ch HMG CoA
reductase
27
Thuc iu tr ri lon lipid

mu nhm fibrat
28
Thuc khng H2
29
Thuc chn bm proton
30
Khng sinh penicillin
31
Khng sinh cephalosporin
32
Khng sinh carbapenem
33
Khng sinh nhm aminosid
34
Khng sinh nhm phenicol
35
Khng sinh nhm

nitro-imidazol
36
Khng sinh nhm licosamid
37
Khng sinh nhm macrolid
38
Khng sinh nhm quinolon
39
Khng sinh nhm sulfamid
40
Khng sinh nhm tetracyclin
41
Khng sinh khc
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
Cefdinir
Cefepim
Cefixim
Cefoperazol
Cefotaxim
Cefotiam
Cefpodoxim
Cefradin
Ceftazidim
Ceftriaxon
Cefuroxim
Ertapenem
Imipenem (+ cilastatin)
Meropenem
Amikacin
Gentamicin
Netilmicin
Tobramycin
Cloramphenicol
Metronidazol
Secnidazol
Tinidazol
Clindamycin
Azithromycin
Clarithromycin
Erythromycin
Roxithromycin
Spiramycin
Ciprofloxacin
Levofloxacin
Acid nalidixic
Norfloxacin
Ofloxacin
Pefloxacin
Sulfamethoxazol + trimethoprim
Doxycyclin
Tetracyclin
Fosfomycin
Nifuroxazid
Nitrofurantoin
42
Thuc chng virus
43
Thuc dit giun, sn
44
Thuc chng nm
45
Thuc chng vim khng c

cu trc steroid (NSAID)
46
Thuc khng histamin
47
Thuc h ng huyt
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
Vancomycin
Acyclovir
Lamivudin
Albendazol
Mebendazol
Pyrantel
Fluconazol
Itraconazol
Nystatin
Celecoxib
Diclofenac
Ibuprofen
Ketoprofen
Ketorolac
Meloxicam
Naproxen
Piroxicam
Tenoxicam
Acetylleucin
Alimemazin
Betahistin
Chlorphenamin
Cinnarizine
Desloratadin
Diphenhydramin
Fexofenadin
Flunarizin
Hydroxyzin
Levocetirizin
Loratadin
Oxomemazin
Promethazin
Acarbose
Benfluorex
Glibenclamid
Gliclazid
Glimepirid
Insulin
Metformin
Rosiglitazon
48
Thuc iu tr ung thu

v iu ha min dch
49
Thuc cng ph giao cm
50
Thuc c ch kt tp tiu cu
51
Thuc chng ng mu
nhm heparin
52
Thuc khc tc ng ln mu
53
Mu v cc ch phm lin quan
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
Bleomycin
Carboplatin
Cisplatin
Cyclophosphamid
Cytarabin
Dacarbazin
Daunorubicin
Doxorubicin
Epirubicin
Etoposid
Filgrastim
Fluorouracil
Folinat/acid folinic
Glycyl funtumin
Hydroxycarbamid
Ifosfamid
Irinotecan
Mesna
Methotrexat
Mitomycin
Octreotid
Oxaliplatin
Pygeum africanum
Tamoxifen
Vincristin
Cholin alfoscerat
Galantamin
Neostigmin
Pyridostigmin
Acid acetylsalicylic (aspirin)
Clopidogrel
Enoxaparin
Heparin
Nadroparin
Carbazochrom
Chymotrypsin/alphachymotrypsin
Erythropoietin
Hyaluronidase
Acid tranexamic
Dextran
54
Thuc iu tr gt
55
Thuc tc dng ln c xng

nhm biphosphonat
56
Thuc cha tc nghn

ng th nhm xanthin
57
Thuc long m, long m
58
59
Thuc khng cn gip

Dn cht estrogen
60
Thuc glucocorticoid
61
62
63
64
65
Dn cht androgen
Dn cht progestogen
Hormon vng di i
Cc steroid tng ng ha
Hormon gip trng
66
Thuc khng gip trng
67
Hormon thy sau tuyn yn
68
Cht hp ph ng tiu ha
69
Thuc chng nn
70
71
Thuc bao vt lot

Thuc khng acid
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
Hydroxyethylstarch
Gelantin
Allopurinol
Colchicin
Acid alendronic
Acid zoledronic
Aminophyllin
Theophyllin
Acetylcystein
Ambroxol
Bromhexin
Eprazinon
Guaifenesin
Cacitonin
Estriol
Budesonid (+ formoterol)
Dexamethason
Fluticason
Hydrocortison
Methylprednisolon
Prednisolon
Testosteron
Progesteron
Somatostatin
Nandrolon
Levothyroxin
Benzylthiouracil
Carbimazol
Propylthiouracil
Thiamazol
Desmopressin
Oxytocin
Attapulgit
Diosmectit
Dimenhydrinat
Domperidon
Metoclopramid
Ondansetron
Sucralfat
Nhm phosphat
Nhm hydroxyd/magi hydroxid

Attapulgit/ magi carbonat/nhm
hydroxyd
Bisacodyl
Lactulose
Macrogol
Magi sulfat
Sorbitol
72
Thuc nhun trng
314
315
316
317
318
73
Thuc chng kch thch

nhu ng ng tiu ha
319
Loperamid
320
321
322
323
324
325
326
327
328
329
330
331
332
333
334
335
336
337
338
339
340
341
342
343
344
345
346
347
348
349
Alverin
Drotaverin
Papaverin
Scopolamin
L- ornithin/L-aspartat
Tidiacic arginin
Troxerutin
Canxi clorid/canxi gluconat
Kali clorid
Magnesium aspartat (+ kali aspartat)
Mannitol
Natri clorid/natri hydrocarbonat
Boron
Coban
ng
Flo
Km
Lysin
Mangan
Molypden
Nicken
St
Vanadi
Calcitriol
Acid folic
Mecobalamin
Sulbutiamin
Vitamin A
Vitamin B1 (Thiamin)
Vitamin B12 (Cyanocobalamin)
74
Thuc chng co tht
75
Thuc tc dng ln gan
76
Thuc lm bn thnh mch
77
Dung dch cn bng in gii
78
Khong cht
79
Vitamin
350
351
352
353
354
355
356
358
359
360
361
362
363
364
365
366
367
368
Vitamin B2 (riboflavin)
Vitamin B5 (acid pantothenic)
Vitamin B6 (pyridoxin)
Vitamin C (acid ascorbic)
Vitamin D
Vitamin E
Vitamin K
Vitamin PP (vitamin B3/niacin/acid
nicotinic)
Alfuzosin
Tolazolin
Almitrin
Diacerein
Glucosamin
Mazipredon
Nefopam
Paracetamol
Serratiopeptidase
Methoxsalen
Acid ioxaglic/meglumin
369
Misoprostol
370
371
372
373
374
375
376
377
Glutathion
Xanh methylen
Naloxon
Pralidoxim
Protamin
Amylase + papain + simethicon
Bacillus claussii
Lactobacillus acidophilus
357
80
Thuc chn alpha
81
Thuc kch thch h hp
82
Thuc gim au, chng vim

khc
83
84
85
Thuc iu tr vy nn
Thuc cn quang
Thuc tng t
prostaglandin E1
86
Thuc gii c
87
Thuc dng trong trng hp

ri lon tiu ha, tiu chy
Ph lc 2: 78 tng tc p ng tiu chun 1
TT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
Cp tng tc
Acid ioxaglic
Acid valproic
Adrenalin
Alfuzosin
Amiodaron
Amiodaron
Amiodaron
Amiodaron
Amisulpride
Amitriptylin
Amitriptylin
Amitriptylin
Aspirin
Aspirin
Metformin
Khng sinh carbapenem
Propranolol
Itraconazol
Lidocain
Digoxin
Diltiazem
Simvastatin
Thuc li tiu
Thuc c ch ti thu hi serotonin
Thuc cng giao cm
Tramadol
Ketorolac
Heparin v heparin trng lng phn
t thp
Aspirin
Methotrexat
Aspirin
Cc NSAID
Cc corticoid
Phenobarbital
Cc NSAID
Heparin v heparin trng lng phn
t thp
Cc NSAID
Ketorolac
Cc NSAID
Methotrexat
Carbamazepin
Diltiazem
Carbamazepin
Haloperidol
Carbamazepin
Simvastatin
Carbamazepin
Carbamazepin
Dextroproxyphen
Carbamazepin
Khng sinh macrolid
(clarithromycin, erythromycin)
Thuc i khng th th angiotensin- Spironolacton
II
Thuc c ch CYP3A4 (diltiazem,
Ivabradin
29
30
31
32
33
34
35
36
37
38
39
41
42
43
44
45
40
46
47
48
49
50
51
52
53
itraconazol, fluconazol)
Thuc c ch men chuyn
Thuc c ch men chuyn
(fluoxetine, sertraline)
(fluoxetine, sertraline, venlafaxine)
(fluoxetine, sertraline, venlafaxine)
Clopromazin
Cimetidin
Cimetidin
Ciprofloxacin
Clindamycin
Colchicin
Kali clorid
Spironolacton
Sumatriptan
Xanh methylen
Tramadol
Propranolol
Lidocain
Dn cht xanthin
Sucralfat
Pancuronium
Khng sinh macrolid
Co-trimoxazol
Methotrexat
Thuc chng nm nhm azol
Sumatriptan
Dn cht firat (ciprofibrat, fenofibrat, Dn cht statin (atorvastatin,
gemfibrozil)
rosuvastatin, simvastatin)
Dn cht statin (atorvastatin,
simvastatin)
simvastatin)
Diltiazem
simvastatin)
Dn cht xanthin
Khng sinh quinolon (ciprofloxacin,
norfloxacin, pefloxacin)
Digoxin
Diltiazem
Digoxin
Itraconazol
Digoxin
Hydrochlorothiazid
Digoxin
clarithromycin, erythromycin)
Digoxin
Spironolacton
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
Diltiazem
Diltiazem
Erythromycin
Felodipin
Felodipin
Fentanyl
Fluoxetin
Furosemid
Ginkgo biloba
Isofluran
Itraconazol
Kali clorid
Kali clorid
Ketorolac
Khng sinh aminosid
Khng sinh aminosid (amikacin,
gentamicin, tobramycin)
Khng sinh macrolid
Khng sinh penicillin
Khng sinh quinolon
Lidocain
Metoclopramid
Midazolam
Nhng thuc ko di on QT*
Nifedipin
Thuc i khng th th H2
Thuc chn bta giao cm

Erythromycin
Dn cht xanthin
Itraconazol
Phenobarbital
Haloperidol
Khng sinh aminosid
Ibuprofen
Thuc gin c khng kh cc
(pancuronium, vecuronium)
Vincristin
Spironolacton
Thuc khng cholinergic (biperiden)
Pentoxifyllin
Thuc gin c khng kh cc
Vancomycin
Midazolam
Methotrexat
Tenoxicam
Thuc chn bta giao cm (atenolol,
metoptolol, propranolol)
Piribedil
Phenobarbital
Tolazolin
* 3 cp tng tc ca nhng thuc ko di on QT l: (1) amiodaron khng sinh

macrolid (azithromycin, clarithromycin, erythromycin, spiramycin); (2) amiodaron
khng sinh quinolon (levofloxacin, ofloxacin); (3) amiodaron thuc iu tr ri lon
tm thn (amisulpirid, chlorpromazin, haloperidol).
Ghi ch:
Nhng tng tc c nh du mu xm l nhng tng tc p ng tiu chun
2 v a vo nghin cu su hn.
Ph lc 3: DANH SCH TNG TC THUC CN CH V BIN PHP X TR

TRONG THC HNH LM SNG TI BNH VIN THANH NHN
STT
Cp tng tc
Acid ioxaglic metformin
1
2
Adrenalin propranolol
Amiodaron digoxin
Amiodaron diltiazem
Amiodaron simvastatin
Bin php x tr
Ngng dng metformin tm thi: trc hoc ti thi im chp v trong vng 48 gi sau khi chp.
Bt u dng li metformin ch khi kim tra li chc nng thn tr v mc bnh thng.
- Thay th propranolol bng thuc chn bta chn lc (nh metoprolol) t nguy c gy ra tng
huyt p v chm nhp tim hn propranolol khi dng phi hp adrenalin.
- Theo di cht ch huyt p ca bnh nhn.
- Nu xy ra cn tng huyt p cp, c th kim sot bng clopromazin, nifedipin, aminophylin.
Nhp tim chm do phn x c th c kim sot bng atropin. Nu propranolol i khng tc
dng ca adrenalin trong iu tr sc phn v, s dng glucagon c th c hiu qu. Liu glucagon
cho ngi ln l 1-5 mg tim IV trong vng 5 pht, sau truyn t 5-15 mcg/ph ty theo p
ng. Liu glucagon cho tr em l 20-30 mcg/kg (ti a 1 mg) tim tnh mch, sau truyn 5-15
mcg/ph ty theo p ng.
- Gim 1/3 n 1/2 liu digoxin khi bt u s dng amiodaron v tip tc hiu chnh liu sau 1
hoc 2 tun, c th sau 1 thng (hoc cng c th hn) ngng dng amiodaron. Vic hiu chnh
liu da trn kinh nghim ca bc s nhng tt nht nn da vo vo nng digoxin trong huyt
thanh. Lu c bit trn bnh nhn nhi.
- Theo di cht ch cc biu hin c tnh ca digoxin trn bnh nhn (nh nn, bun nn, lon
nhp tim)
- Chng ch nh nhng bnh nhn mc hi chng suy nt xoang hoc blc nh tht mt phn.
- Theo di biu hin c tnh trn tim mch ca bnh nhn, c bit trong giai on dng liu tn
cng amiodaron.
- Liu simvastatin khng nn vt qu 20mg/ngy, tr trng hp li ch iu tr vt qu nguy c
vim c v tiu c vn cp.
- Theo di cht ch cc biu hin vim c, tiu c vn cp (au c, mi c, mm c) v nng
creatinin kinase (CK) ca bnh nhn. Ngng s dng simvastatin khi nng CK tng r rt hoc
khi nghi ng hoc chn on bnh nhn b vim c v tiu c vn cp.
Aspirin cc NSAID
(ketorolac, ibuprofen)
Aspirin heparin v heparin

trng lng phn t thp
(enoxaparin, nadroparin)
Cc NSAID - heparin v
heparin trng lng phn t
thp
Carbamazepam khng sinh

nhm macrolid
(clarithromycin,
erythromycin)
10
Colchicin - khng sinh

macrolid (clarithromycin,
erythromycin)
Dn cht alkaloid ca la
mch khng sinh macrolid
(azithromycin, clarithromycin,
erythromycin, roxithromycin,
spiramycin)
11
- Aspirin ketorolac: chng ch nh

- Aspirin gii phng nhanh ibuprofen: ibuprofen phi c dng trc aspirin 8 gi hoc sau 30
pht.
- Aspirin cc NSAID khc: khng cn can thip, tuy nhin, bc s cn lu tng tc c th xy
ra v c th dn n xut huyt tiu ha.
- Nn trnh phi hp hai thuc tr mt s trng hp c bit nh d phng bin chng thiu mu
cc b bnh nhn au tht ngc khng n nh.
- Khi cn thit phi hp hai thuc, cn theo di cht ch cc ch s xt nghim ng mu thch hp
v biu hin xut huyt trn bnh nhn. iu tr triu chng xut huyt nu xy ra.
- Tm ngng NSAID trc khi bt u s dng heparin hoc heparin trng lng phn t thp, nu
c th.
- Theo di cht ch cc du hiu chy mu trn lm sng (c bit l chy mu ng tiu ha) v
cc ch s xt nghim thch hp trn bnh nhn.
- Thay th clarithromycin / erythromycin bng azithromycin hoc cn nhc ngng s dng mt
trong hai thuc, c bit trnh phi hp erythromycin v carbamazepin.
- Hiu chnh liu carbamazepin hp l (khong 30 50% khi phi hp clarithromycin), tt nht
nn da vo nng thuc trong mu.
- Theo di nng carbamazepin v theo di cht ch du hiu c tnh ca carbamazepin trn
bnh nhn (ri lon vn ng, chng mt, ng g, th , mt tp trung, chng nhn i).
Trnh dng cp phi hp ny, c bit bnh nhn suy thn. Dng thuc khc thay th iu tr
gt hoc nhim khun.
- Nn trnh phi hp dn cht alkaloid ca la mch vi clarithromycin v erythromycin. Nu cn
thit phi hp, cn theo di cht ch nhng biu hin c tnh ca dn cht alkaloid ca la mch
(nn, bun nn, thiu mu cc b do co tht mch). C th phi gim liu ca cc alkaloid ca la
mch.
- Ch : Roxithromyxin c nguy c gy tng tc thp hn; spiramycin v azithromycin do khng
c ch CYP3A4 nn c th s khng gy ra tng tc. Tuy nhin, nu phi hp 2 thuc ny th
bnh nhn vn phi c theo di mt cch cht ch.
12
13
Dn cht alkaloid ca la
mch sumatriptan
Dn cht fibrat dn cht
statin (atorvastatin,
simvastatin, rosuvastatin)
14

simvastatin) - khng sinh
macrolid (clarithromycin,
erthromycin)
15

simvastatin) thuc chng
nm nhm azol (fluconazol,
itraconazol)
16
Digoxin hydrochlorothiazid
Chng ch nh dng ng thi hai thuc. Nu phi hp, hai thuc ny phi c dng cch nhau
ti thiu 24 gi.
- Atorvastatin: s dng liu thp nht c hiu qu, khuyn co liu khi u l 10mg.
- Simvastatin: liu ti a khi phi hp vi gemfibrozil l 10mg/ngy.
- Rosuvastatin: khuyn co liu khi u l 5mg v chng ch nh mc liu trn 40mg/ngy.
- Khuyn co chung: khi cn thit phi hp hai thuc, theo di triu chng ca vim c, tiu c
vn (au c, mm c, yu c) trn bnh nhn. Theo di ch s CK. Ngng dng thuc nu ch s
CK tng hoc trong trng hp bnh nhn c chn on hoc nghi ng b vim c hoc tiu c
vn.
- Simvastatin erythromycin / clarithromycin: chng ch nh phi hp. Thay th erythromycin /
clarithromycin bng azithromycin.
- Atorvastatin erythromycin / clarithromycin: nu ch dng khng sinh ch trong mt thi gian
ngn, tm dng ung atorvastatin. Nu cn thit phi hp, liu atorvastatin khng vt qu 20
mg/ngy. Theo di nhng biu hin au c v tiu c vn (au, yu hay mm c), c bit trong
thng u tin dng thuc v trong qu trnh tng liu ca 1 trong 2 thuc. Nu bnh nhn c
chn on/nghi ng bnh v c, tiu c vn, theo di nng CK v ngng dng tm thi nu nh
CK tng.
- Vi itraconazol: chng ch nh phi hp vi simvastatin; vi atorvastatin: ngng dng
atorvastatin nu ch dng itraconazol ch trong mt thi gian ngn. Nu cn thit phi hp, s dng
liu atorvastatin khng vt qu 40 mg/ngy.
- Vi fluconazol: thn trng khi s dng liu cao (trn 200mg/ngy)
- Khuyn co chung: khi cn thit phi hp hai thuc, theo di triu chng ca vim c, tiu c
vn (au c, mm c, yu c) trn bnh nhn. Theo di ch s CK. Ngng dng thuc nu ch s
CK tng hoc trong trng hp bnh nhn c chn on hoc nghi ng b vim c hoc tiu c
vn.
- Theo di nng kali v magi trong huyt tng v theo di cc biu hin ng c digoxin trn
bnh nhn (nn, bun nn, lon nhp tim).
- D phng tnh trng mt kali nghim trng bng cch s dng cc ch phm b sung kali hoc
dng nhng thuc li tiu gi kali hoc khuyn co ch n t natri / giu kali cho bnh nhn.
17
Digoxin khng sinh

macrolid (erythromycin,
clarithromycin)
18
Diltiazem erythromycin
19
Furosemid khng sinh

aminosid
20
21
Ivabradin - thuc c ch
CYP3A4 (diltiazem,
itraconazol)
Kali clorid - spironolacton
22
Nifedipin - phenobarbital
23
Spironolacton - thuc i
- Thay erythromycin / clarithromycin bng mt khng sinh khc (ngoi tr tetracyclin) nhng
bnh nhn phi dng digoxin thng xuyn. Hoc cn nhc vic s dng digoxin qua ng tim
do tng tc ny c th khng xy ra nu nh thuc khng qua rut.
- Theo di cht ch nng digoxin trong huyt thanh v nhng biu hin ng c digoxin trn
bnh nhn (nn, bun nn, lon nhp tim).
- Gim liu digoxin, nu cn thit
- Nu c th, nn trnh s dng cp ph hp ny.
- Nu phi hp, theo di khong QT ti thi im ban u v trong sut qu trnh dng ng thi 2
thuc ny.
- Hiu chnh liu diltiazem, nu cn thit.
- Trnh dng qu liu.
- Gim liu 1 hoc 2 thuc bnh nhn suy gim chc nng thn.
- Theo di chc nng thn v thnh gic ca bnh nhn thi im ban u v trong sut qu trnh
iu tr.
- Chng ch nh phi hp ivabradin vi clarithromycin, erythromycin ung, itraconazol,
diltiazem.
- C th phi hp ivabradin vi fluconazol nhng cn dng ivabradin liu khi u thp 2,5 mg
x 2 ln/ngy v theo di nhp tim ca bnh nhn.
- Ch phi hp hai thuc ny trong trng hp bnh nhn h kali mu nghim trng khng p ng
vi mt trong hai thuc khi dng n c. c bit thn trng nhng bnh nhn c cc yu t
nguy c (nh bnh nhn cao tui, mc i tho ng hoc suy thn)
- Nu phi hp, theo di cht ch nng kali trong huyt thanh v biu hin tng kali mu trn
bnh nhn (yu c, mt mi, d cm, nhp tim chm, sc v in tm bt thng), ng thi
khuyn co bnh nhn v ch n hp l, trnh dng thc n giu kali.
- Thay th nifedipin bng mt thuc iu tr tng huyt p khc.
- bnh nhn iu tr n nh bng nifedpin, theo di cc du hin gim hiu qu iu tr ca
thuc khi dng thm phenobarbital.
- Cn nhc vic dng nifedipin liu cao hn.
- Khng nn s dng cp phi hp ny nhng bnh nhn c Clcr < 30 mL/ph.
khng th th angiotensin-II
24
Spironolacton - thuc c ch
men chuyn
25
Cc thuc c nguy c ko di
khong QT:
(1) amiodaron khng sinh
macrolid (azithromycin,
spiramycin);
(2) amiodaron khng sinh
quinolon (levofloxacin,
ofloxacin);
(3) amiodaron thuc iu tr
ri lon tm thn (amisulpirid,
chlorpromazin, haloperidol).
- Theo di thng xuyn chc nng thn v nng kali trong huyt thanh ca bnh nhn, c bit
nhng bnh nhn c mt hoc nhiu yu t nguy c (dng ng thi vi nhng thuc c kh
nng tng nng kali mu, mc km i tho ng hay suy thn, bnh nhn dng spironolacton
vi liu >50mg/ngy; cao tui).
- S dng spironolacton liu thp nht c hiu qu. Liu khuyn co cho a s bnh nhn l 25
mg/ngy.
- Khng nn s dng cp phi hp ny nhng bnh nhn c Clcr < 30 mL/ph.
- Theo di thng xuyn chc nng thn v nng kali trong huyt thanh ca bnh nhn, c bit
nhng bnh nhn c mt hoc nhiu yu t nguy c (dng ng thi vi nhng thuc c kh
nng tng nng kali mu, mc km i tho ng hay suy thn, bnh nhn dng spironolacton
vi liu >50mg/ngy; cao tui).
- S dng spironolacton liu thp nht c hiu qu. Liu khuyn co cho a s bnh nhn l 25
mg/ngy.
- Trnh phi hp cc thuc ny.
- Nu phi hp, cn thn trng v theo di cht ch in tm ca bnh nhn.
Ph lc 4: Mu phiu m t tng tc dnh cho nhm chuyn mn
Phiu m t tng tc Cp tng tc s
Nhm thuc 1
Nhm thuc 2
Thuc 1
Thuc 1
Thuc 2
Thuc 2
M t tng tc theo
1
Nhn nh ca cc CSDL
v mc ca tng tc
BNF:
DIF:
MM:
SDI:
Hu qu ca tng tc
C ch tng tc
X tr tng tc
Bn lun
Ph lc 5: Mu phiu chm im ca nhm chuyn mn
Phiu nh gi tng tc
Ngi nh gi:
n v/Khoa, phng:
Ngy, ni thc hin:
nh gi 44 cp tng tc
im
Cp tng tc s 01
Thuc 1
Thuc 2
1. Mc ph bin ca tng tc
2. Mc nghim trng ca tng tc
3. i tng bnh nhn c bit
4. Nhn thc v tng tc
5. Kim sot tng tc
(Ghi ch: Bng nh gi tng t i vi 43 tng tc cn li)
Ph lc 6: Phiu ly thng tin n thuc iu tr ngoi tr c tng tc
Trung tm Quc gia v Thng tin thuc

v Theo di phn ng c hi ca thuc
Bnh vin Thanh Nhn
N THUC IU TR NGOI TR TUN T 07 18/03/2011

1. Thng tin c bn
1
2
3
M bnh nhn
Khoa, phng khm bnh
Ngy khm bnh
2. S dng thuc trn bnh nhn

STT
1
2
3
4
5
6
7
8
Thuc
3. Nhn xt
Trong n ny, c xut hin cp phi hp tng t nh nhng cp phi hp c lit
k trong Danh sch tng tc thuc cn ch ti bnh vin Thanh Nhn hay khng?
C
Nu c, l cp phi hp no?
1
2
3
Khng
Ph lc 7: Phiu ly thng tin bnh n ni tr c tng tc
Trung tm Quc gia v Thng tin thuc

v Theo di phn ng c hi ca thuc
Bnh vin Thanh Nhn
BNH N NI TR TRONG NGY 25/02/2012

1. Thng tin c bn
1
2
M bnh nhn
Khoa lm sng
2. S dng thuc trn bnh nhn

STT
1
2
3
4
5
6
7
8
Thuc
3. Nhn xt
Trong n ny, c xut hin cp phi hp tng t nh nhng cp phi hp c lit
k trong Danh sch tng tc thuc cn ch ti bnh vin Thanh Nhn hay khng?
C
Nu c, l cp phi hp no?
1
2
3
Khng

KL - Tuong Tac Thuong Gap

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B Y T

NGHIN CU XY DNG DANH SCH

NGHIN CU XY DNG DANH SCH

Ngi hng dn:

Cui cng, ti xin gi li cm n n b m. Nhng ngi c l khng hiu

2.2.3. Xc nh tn sut gp phi nhng tng tc trong danh sch c

DANH MC CC K HIU VIT TT

British National Formulary 81

Drug Interaction Facts 2010

Micromedex 2.0 DRUG-REAX System

Thuc chng vim khng c cu trc steroid

Stockleys Drug Intetactions Pocket Companion 2010

Thsaurus des interactions mdicamenteuses

Bng 1.1. Mt s c s d liu tra cu v tng tc thuc

Bng 2.1. Quy c mc nh gi tng tc thuc c

ngha lm sng cc CSDL

Bng 3.1. Danh sch 44 tng tc thuc c la chn trong

giai on 1 v kt qu nh gi ca nhm chuyn mn trong giai

Bng 3.2. Danh sch 25 tng tc thuc cn ch trong thc

trong danh sch 25 tng tc thuc cn ch c xy dng

Bng 3.5. Nhng tng tc c pht hin trong bnh n ni tr

bao gm bc s v dc s; ng thi xy dng hng dn x tr nhng tng tc

Chng 1. TNG QUAN

1.1.2. Dch t hc v tng tc thuc

1.1.3. Hu qu ca tng tc thuc

1.1.4. Yu t nguy c gy tng tc thuc

Nu bnh nhn c iu tr bi nhiu bc s cng lc, mi bc s c th khng

1.1.5. ngha lm sng ca tng tc thuc

vy, hu qu tng tc v hiu qu iu tr trn bnh nhn quyt nh mc

1.2. Kim sot tng tc thuc trong thc hnh lm sng

1.2.1. Cc c s d liu tra cu tng tc thuc

Drug Interaction Facts

Stockleys Drug Interactions

hc/ Vit Nam

Ting Vit Nh xut bn Y

Ting Anh Pharmaceutical

Thsaurus des interactions

Drug Interactions: Analysis

Ting Anh Lippincott

MIMS Drug Interactions

Ting Anh APhA

Ting Anh Thomson

Drug Interactions Checker

Drug Interaction Checker

Ting Anh Drugsite Trust/

Sau y l nhng CSDL c s dng trong nghin cu:

Drug Interaction Facts [34]

Nghim trng/Trung bnh C th

Khng chc chn

Micromedex 2.0 DRUG-REAX System [42]

ti liu tham kho. Phn mm ny kh thun tin trong tra cu nhng cc bc s, c

: tng tc e da tnh mng hoc b chng ch nh bi nh sn

: tng tc gy ra nhng hu qu nghim trng trn bnh nhn v

cn thit phi hiu chnh liu hoc theo di cht ch.

: hu qu ca tng tc gy ra trn bnh nhn cha c khng

nh, v th nn ch dn cho bnh nhn v mt s phn ng c hi c th xy ra,

: tng tc khng c ngha trn lm sng hoc khng chc chn

v kh nng xy ra tng tc.

nghin cu khc) v da trn nhng d liu lm sng cha c cng b (Ngn

nghin cu thc hin ti H Lan [37] xut phng php nh gi mt tng

1.2.2. Phn mm h tr k n cho bc s

lo khoa ti M ch ra rng 72% cnh bo v tng tc thuc b b qua l nhng

1.2.3. Bng cnh bo v nhng tng tc nghim trng

sc khe di ngy [10]. Ti Php, URCAM (y ban vng v bo him y t) cng