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S Y T QUNG NINH

BNH VIN BI CHY

THUYT MINH TI NGHIN CU


KHOA HC V PHT TRIN CNG NGH
ng dng chuyn giao k thut can thip ng mch vnh qua da
trong iu tr nhi mu c tim cp c ST chnh ln ti Bnh vin Bi
Chy.

C quan ch qun ti : S khoa hcv cng ngh tnh Qung Ninh


C quan ch tr ti :Bnh vin Bi Chy

H Long, thng 11- 2015

THUYT MINH TI NGHIN CU


KHOA HC V PHT TRIN CNG NGH1
I. THNG TIN CHUNG V TI.
1. Tn ti:
ng dng chuyn giao k thut can thip ng mch vnh qua da trong
iu tr nhi mu c tim cp c ST chnh ln ti Bnh vin Bi Chy.
2. M s:
3. Thi gian thc hin: 18 thng (n thng).
4. Cp qun l:
Nh nc
5. Kinh ph:

C s

Tnh

. Trong :

- T Ngn sch s nghip khoa hc:


+ Nm th nht:
+ Nm th hai:
- T ngun khc:
+ Nm th nht:
+ Nm th hai:
6. Thuc:

Chng trnh (ghi r tn chng trnh, nu c)


D n KH&CN2 (ghi r tn d n KH&CN, nu c)
ti c lp

7. Lnh vc khoa hc:


T nhin;

Nng, lm, ng

K thut (Cng nghip, XD, GT, ...);

Y dc.

nghip;
8. Ch nhim ti :
H v tn: Vn Thnh
Ngy, thng, nm sinh: 20/11/1963

Nam/ N: Nam

Hc hm, hc v: Bc s chuyn khoa Cp I


Chc danh khoa hc: .....Bnh vin Bi Chy
Chc v: Ph gim c Bnh vin.
1

Mu Thuyt minh ny dng cho ti nghin cu ng dng v trin khai thc nghim thuc cc lnh
vc khoa hc nu ti mc 7, trang 1 ca Thuyt minh. Thuyt minh c trnh by v in ra trn kh
giy A4.
2
Theo Quy nh tm thi v vic xy dng v qun l cc d n khoa hc v cng ngh (Quyt nh s
11/2005/Q-BKHCN ngy 25/8/2005 ca B trng B KH&CN)

in thoi: 033.3846566 (CQ); Mobile:

Fax: 033.3846566

Nh ring: Phng H Khu TP H Long Tnh Qung Ninh


9. Th k ti:
H v tn: Trn Vn Qu
Ngy, thng, nm sinh: 16/11/1983

Nam/ N: Nam

Hc hm, hc v: Thc s y khoa


Mobile:
E-mail:
Tn t chc ang cng tc: Khoa Tim mch Bnh vin Bi Chy
a ch t chc: T1K4 phng Ging y TP H Long Tnh Qung
Ninh.
a ch nh ring:
10. C quan ch tr ti :
- Tn t chc ch tr ti: Bnh vin Bi Chy tnh Qung Ninh.
in thoi: 0333846557

Fax: 0333846557

E-mail: @gmail.com
Website:
a ch: Phng Ging y, thnh ph H Long.
H v tn th trng c quan: Giang Quc Duy Gim c
S ti khon: 711A07937987
Kho bc nh nc thnh ph H Long
Tn c quan ch qun ti: S Y t tnh Qung Ninh; S Khoa hc
v Cng ngh tnh Qung Ninh.
11. Cc t chc phi hp chnh thc hin ti :
Bnh vin Tim H Ni. o to hng dn.
+ a ch: 92 Trn Hng o, qun Hon Kim - H Ni
+ in thoi:
+ Email:

12. Cn b thc hin ti:


Thi
gian lm

TT

H v tn, hc

T chc

hm hc v

cng tc

Ni dung cng vic

vic cho

tham gia

ti
(S
thng
2

quy i )

BSCKI. Vn
Thnh

Thc s Trn Vn
Qu

BSCKI. Vng Vn
Phng

Bc s inh Danh
Trnh

Bc s Hong Th
Duy

c ti liu, thu thp


thng tin v ti
Khoa
Vit cng
HSCC, Ph
Thu thp s liu
Gim c
Thng qua cng
BVBC
X l s liu v vit
ti
Bo v ti
c ti liu, thu thp
Khoa Tim thng tin v ti
mch,
Thu thp s liu
BVBC
X l s liu
Khoa Tim
mch,
BVBC

Khoa Tim
mch,
BVBC
Khoa Tim
mch,
BVBC

c ti liu, thu thp


thng tin v ti
Thu thp s liu
X l s liu
Tham gia can thip
Trc tip khm v iu
tr
nh gi kt qu sau
khi ra vin
Thu thp s liu
Tham gia can thip
Trc tip khm v iu
tr
nh gi kt qu sau
khi ra vin

18

18

18

12

12

Mt (01) thng quy i l thng lm vic gm 22 ngy, mi ngy lm vic gm 8 ting

Thu thp s liu

Bc s V Th Hng
Hnh

Khoa Tim
mch,
BVBC

iu dng Phm
Vn Tip

Khoa Tim
mch,
BVBC

iu dng
Nguyn Vn Ton

Khoa Tim
mch,
BVBC

K ton. Trn Th
Thy o

Phng Ti
Chnh K
Ton,
BVBC

Trc tip khm v iu


tr
nh gi kt qu sau
khi ra vin
Thu thp s liu
Chun b dng c can
thip
Chm sc bnh nhn
sau can thip ly s liu
Chun b dng c can
thip
Chm sc bnh nhn
sau can thip ly s liu
Tham gia mua sm
dng c, trang thit b.
Kim tra ha n,
chng t.

12

12

12

II. MC TIU, NI DUNG KH&CN V PHNG N T CHC


THC HIN TI
13. Mc tiu ca ti
ng dng k thut chp v can thip ng mch vnh qua da bng
h thng chp mch vnh k thut s xa nn (DSA) ti Bnh vin
Bi Chy.
nh gi kt qu can thip ng mch vnh qua da trong iu tr
nhi mu c tim cp c ST chnh ln ti Bnh vin Bi Chy.
xut mt s gii php ng dng phng php chp, can thip
ng mch vnh trn a bn tnh Qung Ninh.
14. Tnh trng ti:
Mi
K tip hng nghin cu ca chnh nhm tc gi
K tip nghin cu ca ngi kh
15. Tng quan tnh hnh nghin cu v lun gii s cn thit phi
nghin cu ti:
5

15.1. nh gi tng quan tnh hnh nghin cu thuc lnh vc ca


ti.
15.1.1. Trn th gii.
Mc d c nhiu tin b trong chn on v iu tr trong ba thp k qua, song
nhi mu c tim (NMCT) cp vn l mt vn sc kho cng ng quan trng cc
nc cng nghip v ngy cng tr nn quan trng hn cc nc ang pht trin.
Hng nm ti M c khong 1,5 triu bnh nhn phi nhp vin v NMCT cp khong
30%, t l t vong cao ti vin cng nh sau 1 thng v sau 1 nm l 5 10 % [18],
[31].
Theo bo co ca T chc Y t th gii (WHO 1999) t l t vong do
bnh tim thiu mu cc b mt s nc chu l:
Trung quc
: 8,6%
n
: 12,5%
Cc nc chu khc
: 8,3%
T l mc bnh cng nh t l t vong c lin quan n tui v gii. Cc
t l ny tng ln r rt theo tui v cng mt la tui th cao hn nam gii
[31].
15.1.2. Vit Nam
- Theo ti liu bo co cho bit c 2 trng hp NMCT ln u tin c
pht hin trc nm 1960 [6], [10], [14].
- Theo Trn Trinh, t l NMCT so vi tng s BN nm ti vin l: nm
1991: 3%; nm 1996: 6,1%; nm 1999: 9,5%; trong t l TV l 27,4%.
- Theo Nguyn Vn Tin: NMCT Vit Nam gp ch yu nam gii
87,2%, 49,3% tui lao ng (< 60 tui) v t l t vong cn cao
24,9%.
- Theo thng k ca Vin Tim mch Quc gia Vit nam:
+ Trong 10 nm (t 1980 n 1990) c 108 ca NMCT vo vin.
+ Nhng ch trong 5 nm (t 1991 n 1995) c 82 ca NMCT vo vin.
- Theo Phm Vit Tun v Nguyn Ln Vit, t l bnh tim thiu mu cc
b nhp vin ti Vin Tim mch Quc gia nm 2003 l 11,2%, nm 2007 l 24%
[13].
15.2. c im gii phu v sinh l ng mch vnh
15.2.1. Gii phu ng mch vnh
6

C hai ng mch vnh (MV): MV phi v MV tri xut pht gc


MC qua trung gian l nhng xoang Valsalva, v chy trn b mt ca tim [7].
15.2.1.1. ng mch vnh tri (xut pht t xoang Valsalva trc tri):
Sau khi chy mt on ngn (1-3 cm) gia M phi v nh tri, MV tri
chia ra thnh 2 nhnh: ng mch lin tht trc (MLTTr) v M m. on
ngn gi l thn chung MV tri (hnh 1.1) [7], [18], [31].
M M ON GN

Hnh 1.1. Gii phu ng mch vnh tri.


MLTTr: Chy dc theo rnh lin tht trc v pha mm tim, phn
thnh nhng nhnh vch v nhnh cho [6], [18], [31].
+ Nhng nhnh vch chy xuyn vo VLT.
+ Nhng nhnh cho chy thnh trc bn.
M m: Chy trong rnh nh tht, M m cho 2-3 nhnh b cung cp
mu cho thnh bn ca tht tri [6], [18], [31].
15.2.1.2. ng mch vnh phi
MV phi chy trong rnh nh tht phi. on gn cho nhnh vo nh
v tht phi ri vng ra b phi, ti ch thp ca tim chia thnh nhnh MLTS
v qut ngc tht tri (hnh 1.2) [6], [18], [31].

Hnh 1.2. Gii phu ng mch vnh phi.


15.2.1.3. Cch gi tn theo nghin cu phu thut ng mch vnh [6], [18],
[31].
* Thn chung MV tri: t l MV tri ti ch chia thnh MLTTr v M
m.
* ng mch lin tht trc chia lm 3 on:
+ on gn: t ch chia cho ti nhnh vch u tin
+ on gia: t nhnh vch u tin cho ti nhnh cho hai.
+ on xa: t sau nhnh cho th hai
* ng mch m chia lm 2 on:
+ on gn: t ch chia cho ti nhnh b 1
+ on xa: t sau nhnh b 1
* ng mch vnh phi chia lm 3 on:
+ on gn: 1/2 u tin gia l MV phi v nhnh tht phi
+ on gia: gia on gn v on xa
+ on xa: t nhnh b phi cho ti MLTS
15.2.2 Sinh l ti mu ca tun hon vnh
Tun hon vnh m bo ti mu cho tim hot ng nhng cng chu s
chi phi ca tim.
Tun hon vnh din ra trn mt khi c rng co bp nhp nhng nn
ng hc ca tun hon vnh cng thay i nhp nhng. V tm tht tri co bp
mnh hn tm tht phi nn tun hon vnh tm tht tri thay i theo chu
chuyn tim, mu ti cho tm tht tri ch c trong th tm trng, cn trong th
8

tm thu khng c mu ti. Cn tm tht phi mu ti u hn, khng theo


chu chuyn tim, tuy vy trong th tm thu cng b hn ch hn.
Trong mng tun hon vnh h thng ni thng gia cc ng mch c rt
t, v vy nu mt ng mch no b tc th s ti mu cho vng c tim tng
ng b ngng tr v nu tc nghn ny ko di s gy hoi t c tim.
C s khc bit v dng tun hon lp di ni tm mc v lp di thng
tm mc. Trong th tm thu, c tim co lm tng p sut ring phn trong c tim,
c bit l lp c di ni tm mc. C mt bc thang p sut tng dn t ngoi
vo trong, p sut khi c tim ny p mnh vo cc MV v mnh nht lp
di ni tm mc, v vy trong th tm thu dng mu n lp di ni tm mc
rt t so vi lp di thng tm mc [6], [18], [31].
15.3. i cng v nhi mu c tim cp
15.3.1. nh ngha
Nhi mu c tim l tnh trng hoi t mt vng c tim, hu qu ca thiu
mu cc b c tim cp tnh trong thi gian di do tc MV [6], [10], [18], [31].
Mt s yu t nguy c ca NMCT:
*Cc yu t nguy c c th thay i c:
- Huyt p cao.
- Ht thuc l.
- Tng Cholesterol mu- v/hoc tng Triglycerid mu.
- i tho ng.
- Bo ph.
- t hot ng th lc, cng thng tm l.
*Cc yu t nguy c khng thay i c:
- Tui cao.
- Gii.
- Yu t di truyn.
Lm sng nhi mu c tim cp:
au ngc vng trc tim
C 3 hon cnh pht hin theo kinh in:
-

Din bin ca mt cn au tht ngc khng n nh.

L bin chng t ngt ca cn au tht ngc n nh.

Thng l bin c u tin, gip pht hin ra bnh mch vnh (50%
cc trng hp).
9

a. Trng hp in hnh:
-

Xy ra t ngt, thng lc khng c gng sc.


V tr sau xng c, chn ngang gia ngc.

au d di lm bnh nhn lo u v c cm gic cht n ni.

Hng lan: cnh tay, hm di, thng v, ct sng lng, vai.

Thi gian au ko di (30 pht n nhiu gi), khng vi Trinitrin, c


th c lm du bi cc thuc gim au mnh.

Cc triu chng km theo c th gp: v m hi, kh th, hi hp nh


trng ngc, nn hoc bun nn, l ln.

Cc triu chng ri lon tiu ho thng gp trong trng hp NMCT


vng sau di.

b. Trng hp khng in hnh:


-

Th khng au: gp 10-15% bnh nhn khng au hoc au nh khng


in hnh, bnh nhn ch thy tc vng tim, thng gp bnh nhn
sau m, ngi gi, i tho ng, tng huyt p.

Tai bin mch mu no, ph phi cp:bnh nhn t ngt b ph phi


cp.

Cht t ngt: 80% trng hp cht t ngt ngi ln tui l do bnh


MV, c tin s suy vnh hoc khng c nguyn nhn. Nguyn nhn thng l
do rung tht hoc cn nhp nhanh tht, t khi do suy tim.
Mt s nghin cu nc ngoi cho thy NMCT ngi cao tui c
mt s im ring bit nh: tnh cht au tht ngc khng in hnh, thm ch
khng au ngc nh ngi tr m ch c biu hin mt xu, v m hi , tin
lng thng nng hn v thng km theo nhiu bnh phi hp.
15.3.2 Nguyn nhn v c ch bnh sinh trong nhi mu c tim
Nguyn nhn ch yu ca NMCT l do x va MV. Mt s nguyn nhn
khc nh: bt thng bm sinh, vim l MV do giang mai, bc tch MC,
thuyn tc MV trong hp hai l, Osler, hp van MC vi ho [6], [10], [18],
[31].
C th NMCT do co tht ko di hoc huyt khi t ly gii: thng gp
ngi tr, nghin ht thuc l, hoc c bnh l v ng mu [6], [10], [18], [31].

10

Mng x va v
Tiu cu kt dnh
Tiu cu hot ho
Huyt khi gy tc 1 phn
M au ngc khng n
nh

Tc vi mch NMCT khng c ST

Huyt khi gy tc hon ton M NMCT c ST

Hnh 1.3. C ch bnh sinh trong NMCT cp


15.3.3 nh hng ca thiu mu v ti ti mu i vi c tim
15.3.3.1 C tim thch nghi (Preconditioning)
Thut ng c tim thch nghi do Murry v cng s a ra u tin nm
1986, sau khi nghin cu c tim ch c gy thiu mu v ti ti mu 4 ln
thy chu c thiu mu ko di hn c tim khng b thiu mu trc [26].
15.3.3.2 C tim ng min (Myocardial Hibernating)
C tim c th thch nghi vi thiu mu mn tnh bng cch gim tnh co
bp, ph hp vi tnh trng gim ti mu v do vy bo tn kh nng sng.
Nu c cung cp mu y , c tim khi phc li c kh nng co bp [22].
15.3.3.3 C tim chong vng (Myocardial Stunning)
Chong vng c tim cc bnh nhn b bnh MV xy ra trong cc
trng hp: c tim b thiu mu thong qua, NMCT cp c ti ti mu sm,
hoc trong cc trng hp m tim m, v thay tim [19], [25], [26].
15.3.3.4 Tn thng ti ti mu (Reperfusion Injury)
Tn thng ti ti mu lm t bo c tim chong vng, tn thng ni
mc v vi mch, v tn thng t bo khng hi phc hoc hoi t [20], [22],
[25].
15.3.3.5 Ti cu trc tm tht (Ventricular Remodeling)
11

Theo sau s tc nghn ca MV, ti cu trc c th lm vng nhi mu


gin rng. Nhi mu gin rng c th xut hin trong khong thi gian vi ngy.
Nhng thay i vng c tim khng b nhi mu c th gy gin dn tht tri v
chc nng tht tri xu i nhiu hn. S tng dn th tch tht tri 20 - 40%
c ghi nhn sau 1 nm cc bnh nhn b NMCT rng [17].
15.3.4. iu tr NMCT cp
15.3.4.1. iu tr ni khoa
Nm bt ng, theo di monitor lin tc, v phi cho th oxy bo ho
oxy ng mch t trn 90%. Dng Morphine sulphate cho nhng bnh nhn c
biu hin ph phi cp, kch thch nhiu hoc khng gim mc au ngc sau
khi dng nitroglycerin [2], [6], [10], [16], [18], [30], [31].
* Thuc c ch ngng tp tiu cu
- Acid Salicylic
- Thienopyridine.
- Thuc c ch th th Glycoprotein IIb/IIIa ca tiu cu
* Cc thuc chng ng
- Heparin khng phn on.
- Heparin trng lng phn t thp
- Thuc c ch trc tip thrombin.
* Nhm thuc nitrate
* Thuc chn th th bta giao cm
* Thuc iu chnh ri lon lipid mu, n nh mng x va
* Thuc chn knh canxi.
* Thuc c ch men chuyn
* Cc thuc c ch th th angiotensin II.
15.3.4.2. iu tr tiu si huyt
iu tr tiu si huyt c ch nh cho nhng bnh nhn c biu hin
au tht ngc trong vng 12 gi k t lc khi pht, c km theo on ST chnh
ln (1mm 2 chuyn o ngoi vi, 2mm 2 chuyn o lin tip trc tim,
gi NMCT cp) v/hoc biu hin blc nhnh tri mi xut hin trn in tim.
Mun t hiu qu ti u, phi dng thuc tiu si huyt cng sm cng tt da
trn nhng tiu chun v in tim m khng cn i cc kt qu v men tim nh
creatinine kinase (CK) hay troponin.
12

* Cc thuc tiu si huyt: c chia lm 2 loi


- t chn lc vi fibrin: nhng thuc khng hoc t chn lc vi fibrin nh
streptokinase (SK), urokinase v Anisoylate plasminogen streptokinase activator
complex (APSAC) s hot ho plasminogen cho d plasminogen gn vi
fibrin trong cc ng hay cn t do lu hnh trong mu, v th cc thuc ny s
to ra tnh trng tiu si huyt ton th, lm gim plasminogen trong mu, xut
hin cc sn phm ging ho ca fibrinogen (FDP) vi nng cao, lm gim
nng -antiplasmin to ra tnh trng chng ng gip duy tr qu trnh hon
tan cc ng.
- Chn lc vi fibrin: l nhng cht hot ho plasminogen m (t-PAs) nh
alteplase, duteplase hay saruplase s hot ho plasminogen gn vi fibrin trn
b mt ca cc ng, chuyn plasminogen thnh plasmin. Phn t plasmin gn
sn vi fibrin bng lin kt lysine, nn qu trnh chuyn i ny hnh thnh thm
nhiu v tr tc dng mi, gn nhiu hn vi fibrin v plasminogen, to iu kin
thun li cho qu trnh tiu si huyt tip tc. Do vy, cc thuc chn lc vi
fibrin khng gy ra tnh trng tiu ng ton th.
Hiu qu ca iu tr ph thuc vo thi gian t khi khi pht au ngc
n khi c dng thuc tiu si huyt. Do phi dng thuc tiu si huyt
cng sm cng tt. Cc s liu t FTT (Fibrinolytic Therapy Trialists
Collaborative Group) tng hp t 9 nghin cu iu tr tiu si huyt bao gm
58 600 bnh nhn cho thy t l bin chng chung bao gm: t vong 10,5%,
chy mu no 1,0%, chy mu nng ngoi no 0,7%.
* Hn ch ca iu tr tiu si huyt

13

Mc d iu tr tiu si huyt c hiu qu, nhng ng tic l khng n


mt phn ba lng bnh nhn ph hp vi ch nh dng thuc. Sau khi
truyn thuc, < 50% cc ng mch th phm c m thng c dng chy t
mc TIMI-3, cha k ti vic hn mt phn ba cc ng mch trong s vn
cn hp nhiu, lu dn s tc li. Nguyn nhn l cc thuc tiu si huyt ch yu
c tc dng ho tan li fibrin ca huyt khi m khng lm thay i li giu
tiu cu, thuc khng th o ngc c qu trnh ngng tp tiu cu cng nh
khng c tc dng ln thrombin, cht hot ho tiu cu mnh nht.
15.3.4.3. Can thip ng mch vnh qua da
C 3 chin lc can thip MV trong NMCT cp [5], [14], [16], [24],
[27].
- Can thip MV th u (Primary infarct angioplasty): can thip nhnh MV
th phm gy NMCT trong vng 12 gi k t khi khi pht au ngc hay c cc
triu chng khc m khng c iu tr trc bng thuc tiu si huyt. Nhiu
th nghim ngu nhin so snh can thip MV th u vi iu tr thuc tiu si
huyt cho thy hiu qu sm v lu di tt hn nhm bnh nhn c can thip
MV th u.
- Can thip MV c to thun (Facilitated coronary angioplasty): can thip
thng quy cp cu nhnh MV gy nhi mu cng sm cng tt sau khi c
iu tr thuc tiu si huyt.
- Can thip MV cu vn (Rescue coronary angioplasty): can thip MV sm
sau khi iu tr thuc tiu si huyt tht bi.
* Can thip MV th u trong iu tr NMCT cp c on ST chnh ln
Ch nh loi I
+ Ch nh chung
Nn tin hnh can thip MV th u cho cc bnh nhn b NMCT cp c
on ST chnh ln trong vng 12 gi k t khi khi pht triu chng au ngc,
v c can thip trong vng 90 pht bi cc bc s c kinh nghim.
+ Ch nh c bit
1. Can thip MV th u c tin hnh cho cc BN <75 tui b NMCT
cp c on ST chnh ln, b sc tim trong vng 36 gi k t khi b NMCT ph
hp vi ti to mch, c th c tin hnh trong vng 18 gi sau khi b sc.
14

2. Can thip MV th u c tin hnh cng sm cng tt cho cc BN


b NMCT cp c suy tim huyt nng v/hoc ph phi cp trong vng 12 gi.
Ch nh loi IIa:
1. Can thip MV th u c th tin hnh cho mt s BN chn lc 75
tui b NMCT cp c on ST chnh ln, sc tim trong vng 36 gi k t khi b
NMCT ph hp vi ti to mch, c th c tin hnh trong vng 18 gi sau
khi b sc.
2. C th can thip MV th u cho cc BN b NMCT cp c on ST
chnh ln t 12 24 gi v c 1 c im sau: Suy tim huyt nng, tnh trng
huyt ng hoc in hc khng n nh, c bng chng vn cn thiu mu c
tim.
Ch nh loi IIb:
Cn cn nhc khi tin hnh can thip MV th u cho cc BN nhn
NMCT c on ST chnh ln ph hp vi iu tr TSH bi cc bc s c t kinh
nghim.
Ch nh loi III:
1. Can thip nhnh MV khng lin quan n vng nhi mu.
2. Can thip MV cho bnh nhn NMCT > 12 gi khng cn triu chng.
15.3.4.4. Phu thut bc cu ni ng mch vnh
Phu thut bc cu MV cp cu trong NMCT cp c ch nh cho
BN:
+ Tn thng thn chung MV tri
+ Tn thng c ba nhnh MV, v ng mch vnh h lu tt
+ Bnh van tim phi hp
+ C cc bin chng c hc do nhi mu c tim cp
+ Gii phu MV khng thch hp cho vic can thip MV qua da [2], [31].

15.4 Lun gii v vic t ra mc tiu v nhng ni dung cn nghin


cu ca ti
Qua s liu thng k s b trong nhng nm gn y ti Bnh vin
Bi Chy lng bnh nhn b nhi mu c tim cp cn phi chuyn ln
tuyn trn can thip ng mch vnh hng nm khong 40 ca mi nm, v
s ca mc bnh l tim mch ngy cng tng.
15

i vi bnh nhn nhi mu c tim, thi gian chnh l s sng cn


ca c tim, trong khi thi gian chuyn bnh nhn ln tuyn
trn mt 3-4h, t bo c tim s b hoi t d c chuyn ln tuyn
trn kp thi.
Hin nay, bnh vin c trang b h thng chp mch s ha xa
nn DSA phc v cho cc k thut can thip mch vnh, tim bm
sinh, ri lon nhp phc tp m trc y bt buc bnh nhn phi
iu tr ti bnh vin tuyn trn ... i ng cn b y bc s c o
to nng cao tay ngh, nhiu bc s c o chuyn su v can
thip tim mch v c s tr gip ca Bnh vin Tim H Ni, bnh
vin tim mch u ngnh ca Th .
Trc nhu cu i hi ngy cng cao ca cng tc chm sc sc khe cho
nhn dn trn a bn tnh, c bit trong lnh vc tim mch chuyn su th
vic trin khai ti ng dng chuyn giao k thut can thip ng mch
vnh qua da trong iu tr nhi mu c tim cp c ST chnh ln ti Bnh
vin Bi Chy, Qung Ninh l ht sc cn thit. Kt qu nghin cu s p
ng c cc mc tiu ra.
16. Lit k danh mc cc cng trnh nghin cu, ti liu c lin quan
n ti trch dn khi nh gi tng quan
TING VIT:
1.

L Th Kim Dung (2005), Nghin cu c im lm sng v cn lm sng


cc bnh nhn trn 70 tui b nhi mu c tim cp, LV Thc s,
HYHN.

2.

Nguyn Huy Dung v cng s (2004), "La chn cc phng php x l nhi
mu c tim". Ph trng tp ch tim mch hc Vit Nam, (38), trang 203 - 247.

3.

H Thng Dng v CS (2006), "Kt qu chp v can thip ng mch


vnh qua da bnh nhn trn 75 tui ti bnh vin Thng Nht thnh ph
H Ch Minh", K yu bo co khoa, trang 98.

4.

Phan Tun t (2008), "Nghin cu nhng yu t tin lng bnh nhn b


hi chng ng mch vnh cp", Tp ch Tim mch hc Vit Nam, (50), trang
42 52.
16

5.

Hi tim mch hc Vit Nam (2008), "Khuyn co 2008 ca Hi tim mch


hc Vit Nam v can thip ng mch vnh qua da", NXBYH, tr 507 510.

6.

Phm Gia Khi, Nguyn Ln Vit (2001), "Nhi mu c tim", Bi ging


bnh hc ni khoa tp 2, Nh xut bn Y hc, trang 84 85.

7.

L Thu Lin (1996), "Tun hon mch vnh", (Chuyn sinh l hc, B mn
sinh l), Trng i hc Y H ni, Nh xut bn Y hc, tr 75 79.

8.

Hn Nht Linh, Phm Gia Khi, (2011), "Nghin cu 1 s yu t tin


lng nng lin quan n t l t vong ngay sau 48 gi can thip ng
mch vnh qua da", Tp ch Tim mch hc Vit Nam, (58), trang 44 53.

9.

Nguyn Hng Sn, Phm Mnh Hng, (2010), "Nghin cu vai tr thang
im syntax trong tin lng bnh nhn sau can thip ng mch vnh qua
da", Tp ch y Tim mch hc Vit Nam (53), trang 21 37.

10. Nguyn Thch v cng s (2007), "Hi chng ng mch vnh cp v


nhi mu c tim cp", Nh xut bn Y hc, H Ni, trang 1-79.
11. Phm Vit Tun, Nguyn Ln Vit (2008), "Tm hiu m hnh bnh tt
bnh nhn iu tr ni tr ti Vin tim mch Vit Nam trong thi gian 5 nm
2003 - 2007", Lun vn thc s y hc i hc y H Ni.
12. Nguyn Quang Tun (2004), "Nghin cu phng php can thip ng
mch vnh qua da trong iu tr nhi mu c tim cp", Lun n TS,
HYHN.
13. Nguyn Th Bch Yn (2004), "Nghin cu ri lon vn ng vng v
chc nng tm thu tht tri sau nhi mu c tim bng siu m", Lun n TS,
YHN.
14. Hunh Trung Cang (2014), Kt qu 2 nm can thip ng mch vnh
qua da ti bnh vin a khoa Kin Giang, Tp ch Tim mch hc Vit Nam, s
68,2014., trang 161-169.

TING ANH:
15. ACC/AHA (2009), "Hng dn qun l bnh nhn nhi mu c tim c ST
chnh ln".
16. Alhaddad IA (1998), "Ti cu trc tht tri sau nhi mu c tim", Cardiac
Intensive Care, 265 272.
17. Antman EM (2001), "Nhi mu c tim cp", Heart Disease, 1114-1126.
18. Bolli R (1990), "C ch c tim chong vng", Circulation, 723 738.
17

19. Gerd H, Rainer S (2000), "Sinh l hc c tim ng min ", Trends


Cardiovasc Med, (10), 108 - 114.
20. Krone RJ, Shaw RE, Klein LW, et al (2003), "nh gi ca AHA/ACC v
Hi h thng phn loi tn thng can thip v ng mch vnh trong can thip
ng mch vnh hin nay ", Am J Cardiol, (92), 389 - 394.
21. Kusuoka H, MMarban E (1992), "C ch t bo chong c tim", Annu
Rev Physiol, (54), 243 256.
22. Saito S, Nguyen T, and Nobuyoshi M (2000), "Can thip nhi mu c tim
qua da. Qun l vn bnh l tim mch phc tp ", the consultants
approach, 37-56.
23. Thach NG, Shigeru S, Graeme S et al (2001), "Qun l nhi mu c tim
cp ST chnh ln ", Management of Complex Cardiovascular Problems, 25
67.
24. Topol EJ, (2008), "Nhi mu c tim cp: Chn on v iu tr sm",
Textbook of Cardiovascular Medicine.

17. Ni dung nghin cu khoa hc v trin khai thc nghim ca ti


v phng n thc hin.
Ni dung 1: Nghin cu ti liu, k thut ng dng phng php chp v
can thip ng mch vnh qua da. Kho st thc hnh ti bnh vin Trung
ng.
Thu thp thng tin v k thut, qui trnh ng dng phng php
phng php chp v can thip ng mch vnh qua da trn th gii v ti
Vit Nam.
Thu thp cc ti liu v kt qu trin khai ng dng ng dng
phng php chp v can thip ng mch vnh qua da ti Bnh vin Tim
H Ni.
Trn c s kt qu thu thp bc u nh gi c iu kin ng
dng phng php chp v can thip ng mch vnh qua da ti Bnh vin
Bi Chy.
* Vit Bo co chuyn 1: iu kin ng dng phng php chp v
can thip ng mch vnh qua da ti Bnh vin Bi Chy.
Ni dung 2: Thc hin ng dng phng php chp v can thip ng
mch vnh qua da; kt hp o to bc s v iu dng, k thut vin.
1/. C cn b ln Bnh vin Tim H Ni hc phng php chp v can
thip ng mch vnh qua da..
18

S lng bc s v iu dng vin c c i o to l thuyt:


04 bc s, 05 iu dng.
Thi gian i o to: 1 thng.
2/. Thu chuyn gia Bnh vin Tim H Ni o to ti bnh vin Bi
Chy.
S lng chuyn gia: 02 ngi.
S lng bc s, iu dng v k thut vin c o to v thc hnh:
04 bc s, 05 iu dng vin.
Thi gian o to ti bnh vin Bi Chy: D kin 20 ngy.
+ Hng dn thc hnh: --- ca chp v can thip. Trong : chp v can
thip mu --- ca, chp v can thip phi hp --- ca (c chuyn gia h tr)
v thc hnh can thip --- ca (c chuyn gia gim st).
* Hi tho ln 1: nh gi kt qu o to.
Thnh phn tham gia: Cc chuyn gia; Cc bc s Bnh vin Bi Chy;.
D kin:
Thi gian: 01 bui.
3/ Thc hnh ti bnh vin Bi Chy.
3.1. i tng nghin cu:
Tiu chun la chn bnh nhn: Chn tt c cc bnh nhn nhp
vin t thng ../2016 ../2017, c chn on nhi mu c tim cp c ST
chnh ln c chp v can thip mch vnh qua da ti Bnh vin Bi
Chy.
3.2. C mu nghin cu : d kin 30 bnh nhn.
Nm 2016 trin khai thc hnh 30 ca.
Nh vy, phn kinh ph cho qu trnh khm bnh khi nhp vin n
khi c ch nh chp v can thip ng mch vnh do bo him v gia nh
bnh nhn chi tr
3.3: Cc k thut s s dng:
a. Trang thit b v dng c bao gm:
+ Trang thit b hin c ca Bnh vin:
Trung tm can thip tim v mch mu
My chp mch s ha xa nn DSA Phillip.
+ Vt t cn mua: s lng b dng cc can thip mch vnh cn
dng c tnh
19

30 b dng c dng cho can thip ( guiding tr gip can thip,


dy dn ng cho bng v stent, bng nong, stent ng mch
vnh, b ht huyt khi, bm p lc)
b. Cch thc tin hnh chp v can thip: Theo hng dn ca chuyn
gia Bnh vin Tim H Ni.
Ni dung 3- Hon thin quy trnh k thut ng dng phng php
chp, can thip ng mch vnh qua da ti Bnh vin Bi Chy.
1/ a ra quy trnh k thut chp ng mch vnh.
2/ a ra quy trnh can thip ng mch vnh.
Xy dng bo co chuyn 3: Quy trnh k thut chp, can thip ng
mch vnh qua da ti Bnh vin Bi Chy.
Ni dung 4- Theo di, nh gi kt qu can thip v sau can thip:
1/ Theo di bnh nhn sau can thip nh gi kt qu. (Mu bnh n
nghin cu nh km)
Mc thnh cng can thip ng mch vnh
Kt qu in tm sau can thip mch vnh
Kt qu thnh cng v bnh nhn sau can thip
c im lm sng v cn lm sng bnh nhn c can thip
Cc bin c tim mch ln xy ra trong vin v ngn hn ( 6 thng)
Thu thp v x l s liu:
Trc tip thm khm ngi bnh trc, trong v sau can thip. Ghi
nhn xt vo bnh n mu nh gi cc ch tiu nghin cu.
X tr s liu: kim nh bng cc thut ton 2 , T-student, ng
dng phn mm SPSS17.
Xy dng bo co chuyn 2: Kt qu ng dng phng php chp
v can thip ng mch vnh qua da ti Bnh vin Bi Chy.
Ni dung 5 xut mt s gii php ng phng php chp v can thip
ng mch vnh qua da ti a bn tnh Qung Ninh.
Xy dng bo co chuyn 4: Mt s gii php trin khai nhn rng.
* Hi Tho Khoa hc ln 2: Gii thiu kt qu trin khai ti Bnh vin
Bi Chy v Hng dn quy trnh k thut ng dng ng dng phng
php chp v can thip ng mch vnh qua da ti Bnh vin Bi Chy.
Thnh phn:
+ i tng: Bc s, y t mt s bnh vin tuyn huyn trong tnh;
+ Thi gian: 01 ngy;
20

+ S lng ngi tham d: 50 ngi.


18. Cch tip cn, phng php nghin cu, k thut s dng.
* Cch tip cn:
Da theo cc ti liu hng dn ca nc ngoi, trng i Hc Y
H Ni , Bnh vin Tim H Ni v cc kt qu nghin cu ng dng ca
Bnh vin Tim H Ni.
Qua s liu thng k trong nhng nm gn y ti Bnh vin Bi
Chy, s lng bnh nhn c nhi mu c tim cp cn c chp v can
thip cp cu t 30-40 bnh nhn mi nm tng dn theo thi gian.
Tin hnh nghin cu thc nghim kt hp vi o to 4 bc s v
5 iu dng vin.
* Cc phng php nghin cu:
Phn tch ti liu
Phng php chuyn gia;
M t ct ngang tin cu.
Tin hnh cc xt nghim, chp chiu lm sng.
T chc hi tho khoa hc, ly kin chuyn gia.
Phng php thng k y hc nh gi kt qu iu tr.
* Cc K thut s dng:
Ch tiu nghin cu
Cc yu t dch t hc
Tui v gii
Nguyn nhn
Phn loi tn thng trn hnh nh chp ng mch vnh.
* K thut chp v can thip
ng vo ng mch
ng vo c th qua ng mch i hoc ng mch quay [14], [24].
La chn dng c
* Sheath
Sheath ng mch thng dng c ng knh 5F-8F [14], [24], [27].
*Chn ng thng can thip
- ng mch lin tht trc
ng thng can thip JL4 hay EBU 4 c la chn cho hu ht cc trng
hp. Nu l ca MV tri xut pht cao hay gc MC nh nn chn ng thng
21

JL3,5 hoc EBU 3.5. Khi trong thn chung MV tri, xoay nh ng thng
ngc chiu kim ng h s hng n ra trc. Nu thn chung ngn, nn chn
ng thng c u ngn trnh lm bt tc ng mch m [7], [14], [24], [27],
[31].
- ng mch m
Khi trong thn chung, xoay nh ng thng JL4 xui chiu kim ng
h s to c s ng trc n nh. ng thng JL5 hoc EBU 4.5 ph hp cho
nhng bnh nhn c gc MC gin [7], [14], [24], [27], [31].
- ng mch vnh phi
Vi MV phi hng i ngang, hng nh ra trc hay xung di th
ng thng JR4 l thch hp. C th dng ng thng Amplatz hay ng thng hnh
gy nh khc cn cu [7], [14], [24], [27], [31].
* Dy dn
* Bng nong
* Stent: Trn thc t c rt nhiu loi Stent nh:
+ Stent thng
+ Stent bc thuc heparin
+ Stent gii phng thuc chng ti hp ti ch
Hin nay ch loi Stent n ra bng bng c ph heparin v Stent gii
phng thuc chng ti hp c chng minh l c hiu qu nht [14], [24], [27],
[31].
18.1 Cc bc tin hnh
* Phng php a ng thng can thip vo ng mch vnh
ng thng can thip vi kch thc v hnh dng thch hp c y trt
trn dy dn vo quai MC, sau c li chn lc vo l MV cn can thip.
MV c chp cc t th cn thit thy r nht tn thng v hng i
vo ca dy dn cng nh cc dng c can thip khc [14], [24], [27], [31].
* Li dy dn qua tn thng
Vic la chn dy dn phi da vo gii phu MV, hnh thi tn thng
v kinh nghim ca phu thut vin. u ca dy dn c to hnh da theo
hnh thi ca mch ch. Dy dn phi a tht nh nhng qua tn thng, n
tn on xa ca MV h tr cho vic y bng [14], [24], [27], [31].
* Chn bng
22

ng knh bng c chn so vi MV l 1:1. ng knh M c


nh gi bng cch so snh mch ch vi ng thng (6F = 2 mm). Mc d nh
gi bng mt ng knh MV so snh km chnh xc hn k thut s, nhng
y l phng php n gin nht v c s dng rng ri nht [14], [24], [27],
[31].
* Phng php nong ng mch vnh bng bng
Bng c y trt trn dy dn n tn thng ch. Sau khi khng
nh v tr chnh xc bng chp MV vi thuc cn quang, bng c bm ln
t t bng bm p lc vi dung dch c pha 50% nc mui sinh l v 50%
thuc cn quang. p lc bm tng dn n khi bng n hon ton. Thi gian
bm bng t 10-60 giy. Cn theo di du hiu au ngc ca bnh nhn v s
thay i trn T. Sau mi ln nong, bng c rt v ng thng li dy dn
ti ch. MV c chp li nh gi s lu thng v mc hp tn lu.
Phi nh gi mt cch c h thng mc hp tn lu, huyt khi, bc tch, tc
nhnh bn, tc mch on xa, co tht, thng MV v khng c dng chy. Nu
bnh nhn n nh v mc hp tn lu trn phim chp < 30%, dng chy bnh
thng, khng b bc tch nhiu hay c huyt khi, tt c cc dng c c rt ra
ngoi v MV c chp li ln cui. Nu khng t kt qu mong mun phi
t Stent [14], [24], [27], [31].
* Phng php t Stent ng mch vnh (hnh 1.4)

Hnh1.4. Stent t trong lng ng mch vnh: A. ct dc; B. ct ngang


Tn thng c nong trc bng bng gim thiu nguy c gy bc
tch thnh MV, gip t Stent d dng hn, v cng cho php phu thut vin
nhn thy r v tr ca tn thng gc[14], [24], [27], [31].
18.2. C ch lm rng lng ng mch vnh
23

Lc cng ca bng nong trong lng MV s lm v cc huyt khi v


gy ra bc tch ni mc vi cc mc nt gy v tch ri ca mng x va
khi lp o gia khc nhau, lm cng lp o gia v lp o ngoi to ra vt
nt trong tn thng x va thnh knh cho mu chy qua [14], [24], [27],
[31].
18.3 Theo di bnh nhn sau can thip
Sau th thut cc bnh nhn cn c theo di 12 - 24 gi trong n v
chm sc bnh mch vnh. Sheath ng mch quay c rt ngay sau kt thc
th thut cn Sheath ng mch i c th c rt ra ngay sau th thut hoc 4
gi sau khi ngng truyn heparin. Bnh nhn phi nm bt ng trn ging t
nht 1 gi cho mi French kch thc ca sheath (6F = 6 gi) [14], [24], [27],
[31]
18.4. Bin chng
18.4.1. T vong trong bnh vin: bnh nhn t vong trong qu trnh nm vin
18.4.2. Nhi mu c tim xung quanh th thut
Nhi mu c tim mi khi c mt trong cc tiu chun sau:
- S tin trin ca on ST chnh ln, xut hin song Q mi t nht 2 chuyn
o trn cng vng chuyn o hoc xut hin blc nhnh tri hon ton mi.
- C bng chng hoi t c tim: CK-MB 3 ln hoc CK 3 ln bnh thng.
18.4.3. Phu thut
Hin tng khng c dng chy trong ng mch vnh No-Reflow
Nguyn nhn l do co tht vi mch, tc cc mch nh do huyt khi, mnh
x vahu qu ca thiu mu ko di. X tr: tim thuc gin mch vo MV
(Nitrate100-300mcg, Adenosin 30-40 mcg, Nikoradine 0,3 - 0,5mg) [14], [24].
18.4.4. Tc on xa ng mch vnh
Do huyt khi hoc mng x va bong ra khi nong MV bng bng hoc
t stent biu hin l hnh nh ct ngang on MV pha sau v tr can thip
hoc nhnh bn. X tr bng cch nong tip bng bng cho ti khi t kt qu ti
u, sau dng heparin ko di (48-72 gi) sau th thut [14], [24], [27], [31].
18.4.5. Huyt khi trong Stent
Huyt khi Stent l vn c hc, c th c phng bng k thut t
Stent ti u m khng cn mt ch thuc chng ng tch cc. t Stent ti
u l m bo Stent ph hon ton tn thng, p st hon ton vo thnh
24

mch, n hon ton v i xng. Nong thm bng bng vi p lc cao (> 15 atm)
l mt khu ch yu ca t Stent ti u [14], [24], [27], [31].
18.4.6. Thng ng mch vnh
Him gp (< 0,5%) sau nong bng bng hay t stent nhng l mt bin
chng nguy him e do tnh mng ngi bnh. Nguyn nhn ch yu l nong
bng bng qu to on mch xon vn nhiu hoc nong nhnh bn. X tr bng
t Cover stent hoc phi m bc cu ni ch vnh cp cu [14], [24], [27], [31].
18.4.7. Ri lon nhp tim
Cc RL nhp nng thng xut hin vo thi im bt u ti ti mu v
thng gp l nhp nhanh tht, rung tht hoc ri lon nhp chm.
RL nhp chm nng cn t to nhp tm thi. Rung tht hoc nhp nhanh
tht cn phi sc in chuyn nhp sau duy tr lidocain [14], [24], [27], [31].
18.4.8. Ti hp sau can thip
t Stent cho lng mch trn tru, rng hn, lm gim thiu s chun co li
ca thnh mch (thng < 8%), v lm gim s ti cu trc ca ng mch v t
l ti hp thp hn so vi nong bng bng. T l ti hp sau khi t Stent < 20%,
trong 85% ti hp xy ra trong vng 12 thng u, cn 15% ti hp xy ra
trong t 1 n 3 nm sau t Stent [14], [24], [27], [31].

* Tnh mi, tnh c o, tnh sng to:


y l bin php iu tr nhi mu c tim hiu qu v an ton nht
hin nay c p dng rng ri trn th gii v Vit Nam, nhng tnh
Qung Ninh cha thc hin c.
19. Phng n phi hp vi cc t chc nghin cu v c s sn xut
trong nc: Bnh vin Tim H Ni
20. Phng n hp tc quc t: Khng.
21. Tin thc hin ti :
TT
1

Ni dung, cng vic


ch yu cn c TH (cc
mc nh gi ch yu)
2

Sn phm
phi t

Thi gian

(bt u,
kt thc)

Ngi
thc hin

Xy dng cng chi tit

cng c hi
ng T thng qua.

1/20162/2016

CN ti

Thu thp thng tin lin quan Bo co chuyn


n vn nghin cu.
1

2/2016

CN ti
&CT vin
25

Mua thit b vt t

2/2016

Bnh vin
Bi Chy

C cn b ln Trung ng 04 bc s,
o to l thuyt
dng cn
o o
thuyt.
Hp ng thu chuyn gia Hp ng
o to phu thut (02 kt.
chuyn gia)

05 iu
b c
v l

2/2016

04bc s ,05
iu dng
c o to

c k

3/2016

Bnh vin
KKV Bi
Chy.

o to chp v can thip Kt qu o to


ti Bnh vin Bi Chy.
c 04 BS v 05
DV

3/2016

Chuyn gia

T chc Hi tho nh gi Bo co kt qu hi
kt qu o to.
tho.

4/2016

Bnh vin
KBC

Thc hnh can thip cho 30 ca


bnh nhn nhi mu c tim
c ST chnh nhp vin Bi
Chy

3/20163/2017

CN ti+
CTV

Theo di bnh nhn sau m S liu theo di


nh gi kt qu phu thut.

3-5/2017

nt

10

Vit bo co chuyn 2,3,4 Bo co chuyn

3-5/2017

nt

11

Tng hp, phn tch s liu S liu tnh ton


v tnh ton hiu qu kinh t

5/2017

nt

12

T chc hi tho gii thiu khong 50 ngi


kt qu nghin cu v quy
trnh k thut ng dng ng
dng phng php chp v
can thip ng mch vnh
qua da ti Bnh vin Bi
Chy.

5/2017

nt

14

Vit bo co tng hp

c H KHCN
thng qua

6/2017

CN ti

15

Nghim thu cp c s

BC t yu cu

6/2017

CN ti v

30 b dng c
can thip ng
mch vnh

26

trnh
tnh

KHCN

CT vin

III. SN PHM KH&CN CA TI

TT
1

3
4

Tn sn phm

Yu cu khoa hc
d kin t c
Bo co tng hp kt qu c H Khoa hc Cng ngh
thc hin ti.
tnh thng qua.
a DVD lu tr kt qu
ti.
Bo co chuyn
Chuyn 1: iu kin ng S liu y , trung thc
dng phng php chp v Phn tch su sc, c tnh khoa
can thip ng mch vnh hc.
qua da trong iu tr nhi
mu c tim c ST chnh ln
ti Bnh vin Bi Chy.

Ghi ch
10 quyn

02 quyn

Chuyn 2: Kt qu ng S liu y , trung thc


dng phng php chp v Phn tch su sc, c tnh khoa
can thip ng mch vnh hc
qua da trong iu tr nhi
mu c tim c ST chnh ln
ti Bnh vin Bi Chy.

02 quyn

Chuyn 3: Quy trnh


phng php chp v can
thip ng mch vnh qua
da trong iu tr nhi mu
c tim c ST chnh ln ti
Bnh vin Bi Chy.
Chuyn 4: Mt s gii
php trin khai nhn rng
o to 04 Bc s, 05 iu
dng cho Bnh vin Bi
Chy.
Bnh nhn c iu tr

Bo m tnh kh thi, ph hp vi
iu kin thc t

02 quyn

Bo m tnh kh thi, ph hp vi
iu kin thc t
c cp chng ch.
02 kp m lm ch k thut

02 quyn

30 bnh nhn

22. Kh nng v phng thc chuyn giao kt qu nghin cu:


Sau khi ng dng phng php chp v can thip ng mch vnh
qua da trong iu tr nhi mu c tim c ST chnh ln ti Bnh vin Bi
Chy. Nhm nghin cu s chuyn giao cho cc bnh vin trong tnh c
nhu cu p dng trn a bn tnh.
27

20. Cc li ch mang li v cc tc ng ca kt qu nghin cu


20.1. i vi lnh vc KH & CN c lin quan :
y l ti nghin cu ng dng phng php chp v can thip
ng mch vnh qua da trong iu tr nhi mu c tim c ST chnh ln ln
u tin tnh.
Gp phn thc y nghin cu cc phng php iu tr mi trong
iu tr cc bnh tim mch chuyn su cc bnh vin trn a bn tnh.
a ra cch nhn ton din v cc vn trong iu tr nhi mu
c tim cp.
20.2. i vi ni ng dng kt qu nghin cu
V phng din k thut v hiu qu s c dng tham kho cho
cc bnh vin khc ng dng phng php ny ph hp vi hon cnh
tnh Qung Ninh v ca Vit Nam .
C c phng php mi, gp phn p ng nhu cu chm sc sc
kho ngy cng cao ca nhn dn; nng cao cht lng phc v nhn dn,
nng cao uy tn bnh vin.
Bi dng, o to cn b KH & CN: o to c cc bc s c
kh nng tin hnh thnh tho chp v can thip ng mch vnh qua da.
Gp phn thc y phong tro nghin cu khoa hc trong bnh vin v
trong ngnh y t.
20.3. i vi kinh t x hi.
Sm tr bnh nhn v sinh hot bnh thng, gp phn n nh sm
v i sng x hi cho bnh nhn.
Gi tin ph hp vi cc bnh c mc thu nhp thp, nhng bnh
nhn lao ng nng.
V. KINH PH THC HIN TI V NGUN KINH PH
(Gii trnh chi tit xem ph lc km theo)

TT

Ni dung cc khon chi


Tng s:

Nm 2016

Nm 2017

1.200.000. 600.000.00
000 VND
0 VND

Tng s
1.800.000.
000 VND

Bao gm:
Kinh ph t SNKH
Khon I: Thu khon chuyn
mn.
Khon II: Thit b
Khon IV: Cc khon chi
khc
Ngun khc
28

H Long, ngy thng nm 2015


Ch nhim ti
(H, tn v ch k)

Vn Thnh

T chc ch tr ti
(H, tn, ch k, ng du)

Giang Quc Duy

29