Ban hnh km theo Quyt nh 4068/Q-BYT ca B trng B Y t

H v tn BN: ....
Logo Ngy sinh: ...................... Gii: ..
a ch: ..
QUY TRNH CHUYN MN S phng: ... S ging: .
PHU THUT GY 1/3 GIA 2 XNG M BN/S HSBA: .
CNG CHN NGI LN
Lu : nh du s la chn ( : c/ X : khng) vo . Khoang trn nu la chn ni dung;
(X)
xem thm chi tit ni dung trong ph lc x tng ng.
1. NH GI TRC KHI VO QUY TRNH
Tiu chun Gy 1/3 gia thn xng chy v mc Gy kn
a vo: Bnh nhn > 18 tui
Tiu chun Gy h Bnh nhn l TE
loi ra: Gy xng bnh l Tnh trng ton thn cha cho php phu
thut
Tin s: Tin s d ng Ghi r:...
Can thip ngoi khoa Ghi r:...

2. QUY TRNH CHN ON V X TR

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 Ban hnh km theo Quyt nh 4068/Q-BYT ca B trng B Y t

3. NGUYN TC CHN ON V IU TR
Nguyn tc iu tr
1. Nn chnh phc hi hon chnh gii phu
2. C nh vng chc, ng k thut.
3. Tp vn ng ch ng + vt l tr liu, Phc hi chc nng sau m.
4. Theo di v phng nga, iu tr cc bin chng.
4. CHN ON V PHN LOI
CHN ON
Lm sng Bin dng chi C ng bt thng
Sng im au chi
Cn lm sng XQ cng chn Thng Nghing: gy 1/3 gia 2 xng cng chn
PHN LOI
Theo AO cho cc trng hp gy kn
A B C
(Xng chy gy n gin) (Xng chy gy c mnh ri) (Xng chy gy phc tp)
A1: Gy ngang B1: Gy xon vn c mnh ri C1: Gy cho xon nhiu mnh
A2: Gy cho vt < 30 B2: Gy c mnh ri cho vt C2: Gy hai tng
A3: Gy cho vt > 30 B3: Gy c nhiu mnh ri nh C3: Gy vn c mt on
xng
5. PHN TNG NGUY C
Nguy c thp Nguy c trung bnh Nguy c cao
A B C
DIN TIN BNH V X TR TRC PHU THUT
DU HIU N1 N2 N3 Nn
Ton thn
Huyt p
Mch
Du hiu sinh tn
Nhit
Nhp th
Tri gic
Lm sng
Cc du hiu ton thn khc (nn, i, ho, to bn)
Chi gy
Chn p khoang
Tc mch mu do m
Ri lon dinh dng
Tn thng mch mu, thn kinh
Tng qut
Tng phn tch t bo mu
Thi gian mu chy mu ng (TS-TC) hoc
Prothrombin (PT, TQ)
ng huyt
SGOT, SGPT
Cn lm sng
Creatinin/mu
Tng phn tch nc tiu
o in tim (ECG)
XQ tim phi thng
Nhm mu ABO, RhD
in gii
iu tr Theo phc iu tr TRC phu thut gy hai xng cng chn (ph lc 1)
Chm sc Cp 3

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 Ban hnh km theo Quyt nh 4068/Q-BYT ca B trng B Y t

6. PHU THUT CHNG TRNH (PH LC 3)

Phng php phu thut Kt hp xng bng np vt; ng inh ni ty c cht
Phng php v cm Gy t ty sng Gy m ni kh qun Khc:...
Chn on sau phu thut Ph hp Khng ph hp C th:.
Tai bin / Bin chng Khng C C th:.
Thi gian phu thut Np vt: 90ph 120ph; ng inh ni ty: 60ph 90ph
DIN TIN BNH V X TR TI PHNG M
DU HIU Gi Gi Gi Gi Gi
Ton thn
Huyt p
Mch
Du hiu sinh tn
Nhit
Nhp th
Lm sng
Tri gic
Cc du hiu ton thn khc
Chi gy
Tnh trng chy mu vt m
TD mch mu chn
Cn lm sng Cc cn lm sng c ch nh trong phng m (nu c)
1. Khng sinh
2. Gim au sau m
iu tr
3. iu tr cc bin chng (phc lc 3)
4. iu tr theo cc phc ca phng m khi xy ra bnh l ton thn.
Chm sc Cp 3
DIN TIN BNH V X TR SAU PHU THUT
DU HIU N1 N2 N3 Nn
Ton thn
Huyt p
Mch
Du hiu sinh tn
Nhit
Nhp th
Tri gic
Cc du hiu ton thn khc (nn, i, ho, to bn)
Chi gy
au vt m
Lm sng Tc mch mu do m
Chi gy Ri lon dinh dng
Chn p khoang
Chy mu
Vt m
Nhim trng
Gp dui c bn chn
Gp dui cc ngn chn
Tnh trng vn Gp dui gi
ng chi
Ch ng
Th ng
Cng thc mu
Cn lm sng
XQ cng chn( thng-nghing)
iu tr Theo phc iu tr SAU phu thut gy hai xng cng chn (ph lc 1)
Chm sc Cp 3

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 Ban hnh km theo Quyt nh 4068/Q-BYT ca B trng B Y t

7. XUT VIN
Vt m kh Gim sng n
Tiu chun xut vin Ht au XQ kim tra tt
Vn ng ch ng chi gy c
Khng c du nhim trng vt m Kt thc quy trnh
Tnh trng xut vin
Vn ng ch ng chi gy tt
Hng iu tr tip theo Ung thuc theo n Ch vn ng
Thay bng vt thng hng VLTL, Phc hi chc nng sau m
ngy Theo di v x tr cc bin chng
8. QUN L V T VN BNH NHN
Thng tin GDSK VT L TR LIU, PHC HI CHC NNG SAU M ( ph lc 3 )
HNG DN IU TR SAU PHU THUT ( ph lc 4)
Hn ti khm: ngy..thng..nm..; Phng khm s:

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 Ban hnh km theo Quyt nh 4068/Q-BYT ca B trng B Y t

9. PH LC

Ph lc 1:
PHC IU TR PHU THUT
GY 1/3 GIA 2 XNG CNG CHN NGI LN

1. Ch nh:
+ Tt c cc trng hp tr A1.
+ Nn b bt tht bi.

2. Chng ch nh:
+ Nhim trng da gn xng gy.
+ Mc cc bnh ni khoa cha iu tr n nh.
+ Gy xng chy tr em

3. iu tr trc phu thut:

+ Gim au: paracetamol liu 15mg/kg/ln x 4ln, Idarac 200mg 1v x 2 ln/ ngy
+ Chng ph n.
+ Bt ng tm thi xng gy.
+ Khng sinh tnh mch d phng trc m: Cephalosporin th h I, II liu 1 2 g/ ln trc m 30
60ph
+ Theo di v x tr hi sc sau phu thut:
+ Theo di tri gic, cc du hiu sc do thuc t hoc m v cc du hiu sinh tn, ton thn khc.
+ Tnh trng chy mu vt m
+ Vn ng chi m
+ Khi c xy ra tai bin, bin chng ton thn th c iu tr theo cc phc ca Khoa phu thut
gy m hi sc.
+ Cc du hiu ton thn nht l cc du hiu sc phn v do thuc t hoc m.

4. iu tr sau phu thut: tip tc iu tr ti khoa CTCH

+ Khng sinh tnh mch (Cephalosporin I, II :liu 2-4g /ngy, chia 2 ln): 3 - 5 ngy.
+ Ung khng vim (Alphachymotrypsine 2 v x 3ln/ngy): 5 ngy.
+ Ung gim au (Paracetamol 500mg 1 v x 3 ln/ngy) : 5 ngy.
+ Ung Meloxicam 15mg 1v x 1 ln / ngy x5 ngy
+ Hoc Etoricoxib 60mg 1v x 2 ln/ngy x 5 ngy
+ Hoc Celecoxib 200mg 1 v x 2l/ ngy x 5 ngy
+ Ung vitamine (Vitamine C, Vitamine A): 5 ngy.
+ Calci D 500mg 1 v x 2 ln/ngy x 5 ngy
+ Dch truyn: nu bnh nhn n ung km
+ C xy ra tai bin, bin chng:
+ Ty tng loi tai bin hay bin chng xy ra m khi c nhng iu tr thm cho ph hp.

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 Ban hnh km theo Quyt nh 4068/Q-BYT ca B trng B Y t

Ph lc 2:
QUY TRNH PHU THUT
1. QUY TRNH PHU THUT NG INH NI TY XNG CHY

I. NH NGHA:
L quy trnh phu thut nn kn xng gy di mn hnh tng sng, sau ng inh xui dng t
li c chy ,cht vt u xa v u gn xng gy.Nu nn kn tht bi, rch da m gy, nn v
ng inh tng t nh nn kn.

II. CHUN B:
- Phu thut vin chnh/ph: bc s chuyn khoa chn thng chnh hnh.
- Phng tin: dng c, my C-Arm, trang thit b phu thut, thuc.
- Ngi bnh:
+ Cc xt nghim thng quy.
+ Gii thch cho ngi bnh v li ch v nguy c, tai bin phu thut.
+ Bnh nhn hoc ngi nh ng v k cam kt phu thut.
+ Khm tin phu, chuyn khoa v duyt m.
+ Chun b bnh nhn trc m.
+ a bnh nhn vo Khoa phu thut gy m hi sc.
- H s bnh n: hon chnh theo quy nh ca B Y t.

III. CC BC TIN HNH:

1. V cm: T ty sng
2. K thut:
- St trng da
- Tri sng.
- Ga r hi i bn m.
- Nn kn di mn hnh tng sng
- Rch da 2cm bc l b trc mm chy.
- Khoan, doa lng ty xng chy.
- ng inh ni ty xui dng.
- Cht vt u xa.
- Kim tra gy di mn hnh tng sng.
- Cht vt u gn.
- X ga r cm mu.
- Khu vt m theo lp.

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 Ban hnh km theo Quyt nh 4068/Q-BYT ca B trng B Y t

2. QUY TRNH PHU THUT NP VT THN XNG CHY

I. CH NH:
- Gy nhiu mnh, c mnh 3, 4.
- Gy cho xon.

II. CHNG CH NH:

- Gy h nng.
- Gy h nhim trng.

III. CHUN B
- Phu thut vin v bc s ph m.
- Kp gy m v y t dng c.
- B dng c kt hp xng cng chn, np vt.

IV. CC BC TIN HNH

- Gy m ton thn hoc t ti ch.
- St trng, tri xng v khun, Garo 1/3 di i.
- Rch da dc thn xng chy pha ngoi mo chy 1cm.
- Bc l gy, nn xng.
- t np vt pha ngoi m bo 4 vt trn gy v 4 vt di gy.
- t dn lu, khu vt m theo lp.

V. IU TR SAU PHU THUT

- Gc chn np Braun.
- Rt dn lu sau 48 gi.
- Khng sinh ton thn.
- Gim au, gim vim, gim ph n.
- Tho np sau 1 nm ri n 2 nm.

VI. TAI BIN V X TR

- Nhim trng: Tng liu hoc thay khng sinh
- Chy mu sau m: Bng p nu khng c c th m vt m cm mu
- Hoi t da mt trc: ct lc da hoi t, khu da th 2 hoc xoay cn - da vng ln cn che xng
- Chm lin xng hoc khng lin xng: kt hp xng li v ghp xng hoc ghp xng n
thun

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 Ban hnh km theo Quyt nh 4068/Q-BYT ca B trng B Y t

Ph lc 3:
VT L TR LIU, PHC HI CHC NNG SAU PHU THUT

Nguyn tc :
- To iu kin tt nht cho qu trnh lin xng.
- Gim sng, gim au, chng ri lon tun hon, chng kt dnh khp, nga hi chng au vng
(hi chng ri lon dinh dng giao cm phn x- hi chng Sudeck).
- Duy tr tm vn ng khp, nga teo c.
Mc tiu iu tr Chng trnh iu tr
Giai on sau phu thut: Giai on sau phu thut:
- Gim sng n, ci thin tun hon, - Tun 1: t th tr liu: nng cao chn khi nm hn
chng teo c, gim au v tr tim 4cm, Ch ng tp c ng gp dui
- Chng kt dnh cc c vng cng gi, hang, cc ngn chn. C chn, Co c tnh nh
chn, gia tng tm vn ng khp nhng cc c vng cng chn, i.
gi, khp c chn, duy tr tm vn - T tun th 3, i nng, chu lc mt phn tng
ng khp hng, ngn chn, phc dn chi phu thut trong khong 10 -12 tun
hi chc nng sinh hot.

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 Ban hnh km theo Quyt nh 4068/Q-BYT ca B trng B Y t

Ph lc 4:
HNG DN IU TR SAU PHU THUT

1. S dng thuc:
Khng sinh tnh mch (Cephalosporin I, II :liu 2-4g /ngy,chia 2 ln): 3 - 5 ngy.
Ung khng vim (Alphachymotrypsine 2 v x3 ln/ngy ): 5 ngy.
Ung gim au (Paracetamol 500mg 1v x 3 ln/ngy: 5 ngy.
Ung Meloxicam 15mg 1v x 1 ln / ngy x 5 ngy
Hoc Etoricoxib 60mg 1v x 2 ln/ngy x 5 ngy
Hoc Celecoxib 200mg 1 v x 2l/ ngy x 5 ngy
Ung vitamine (Vitamine C, Vitamine A): 5 ngy.
Calci D 500mg 1 v x 2 ln/ngy x 5 ngy
Omeprasol 20mg 1 v/ngy (d phng vim d dy - t trng khi dng NSAIDs)

2. Ch sinh hot:
+ Nhng vic nn lm:
Nm ngh ngi, k cao chi phu thut hn tim 4cm
Tp vn ng ch ng ngay sau m
T tun th 3, i nng, chu lc mt phn tng dn chi phu thut trong khong 10 -12 tun
(vi KHX bng np vis); i nng chng chn chu lc sau 1-2 tun (vi ng nh ni ty c cht)
Chp XQ kim tra sau 2, 6, 12 tun, v mi 6 12 tun.
+ Nhng vic khng nn lm:
Khng nng vt nng.
Trnh ht thuc l, ung ru, bia.
+ Sau ba thng, cc hot ng sinh hot c nhn c th tr v nh bnh thng.

3. Ch dinh dng:
+ n thc n nh, nhiu rau v tri cy hoc ung sa, trnh n thc n qu cng v dai.
+ Khng n cc cht gy kch thch trong thng u sau phu thut.

4. Ch theo di, ti khm:

+ Ti khm theo nh k: sau 2, 6, 12 tun, v mi 6 12 tun.
+ Ti khm ngay nu c du hiu:
au m khng sau khi dng thuc.
Sng n vt m.
Chy dch vt m.
+ Tho np vt sau 24 thng
+ Tho inh sau 12 thng

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