TINH HINH CHI DINH THUOC DIEU TRI BENH TIEU CHAY
A5 TRE EM TAI M O T SO BENH VIEN MIEN BAC VIET NAM
Pham Phddng Thiiy, Le Thj Hoan, Nguyen Tran Giang Hddng, Kim Bao Giang, Hoang Van Minh, VCi Thj Vdng TrUdng Dai hoc Y Ha Noi
Muc tieu: nghien cdu nay difdc tie'n banh nhim md ta thUc hanh chi dinh thudc dieu trj cho tre mic tieu chay cap lai khoa nhi mot so benh vien cac tuyen. Doi ttfgng va phtfang pbap nghien cffu: nghien cifu duac tie'n hanh tai 1 benh vien tuyen trung uang, 3 benh vien tuyen tinh dai dien cho 3 viing miSn bic va 6 benh vien tuyen huyen tai cic tinh nghien cdu. 352 ho sa benh nhi difgc chan doin tieu chay cap tai khoa nhi benh vien cic tuyen da dugc phan tich. Ket qua: nghien cdu cho thay so thud'c trung binh trong 1 benh an la 4,5 ( 95%o do tin cay: 4,4 - 4,6) tifOng dd'i cao. Chi djnh thud'c cho tre bj tieu chay chung d cac tuyen pho bie'n nbat la nhdm thudc ORT (94,2%); nhdm thud'c vitamin va men lieu hda (91,8%), thud'c eim tieu chay (70,7%), djch truyen (66,5%), tiep theo la cic thuoc khang sinh (49,1%). Chat khoang chi dUOc chi dinh 2,6% tnfdng hgp. Chi djnh sd dung khing sinh trong so tre mic tieu chay tai luyen huyen la 89% cao ban tuyen tinh (51,6%), cao ban tuyen trung uang (15,1%) mdt each cd y nglva thd'ng ke. Ket luan: cd tlnb hinh lam dung thud'c ndi chung va khang sinh ndi rieng trong dieu tri tieu chay cap, dac biet d benh vien tuyen huyen.
Td khoa: chi djnh thud^c, tieu chay cap, khang sinh, benh vien cac tuyen
I D A T V A N D E '^'"'^ dddng cua tre sau nay. Bi nhiem vi sinh vat gay benh theo ed ehe xam nhap, ehe do Benh tieu c h l y la nguyen nhan hang dau \
dieu trj va dinh dddng khdng hdp ly la nhdng gay benh tat va tif veng cho tre em d cac nddc , , , ., ^
yeu td nguy ed chuyen td tieu c h l y cap sang dang phat trien, ngddi ta ddc tinh tren the gidi
tieu ehay keo dai [3].
hang nam cd 500 trieu tre em dddi nam tudi
mle it nha't mot ddt tieu ehay va 4 trieu tre em ™ '^u I d Chdc Y t l The' Gidi va chddng dtfdi 5 tudi hang nam chet vi benh tieu c h l y . trinh Idng ghep va xuf tri tre benh (IMCl) cua Tieu chay la nguyen nhan thd hai gay td vong Viet Nam da phd bie'n phac dd d i l u tri va eham cho tre em sau n h i l m khuan hd ha'p cap tinh, sdc benh nhi tieu c h l y tai nha eung nhd tai ed 80% td vong do tieu c h l y x l y ra d tre dddi 2 sd y te. Tuy nhien d e nghien cdu gan day mdi tudi. Ci nddc ta binh quan 1 tre dddi 5 tudi mdi chi tap tmng v i o tinh hinh q u I n ly d i l u tri benh nam mac td 0,8 - 2,2 dax tieu chay. Tieu chay nhan tai nha. Thdng tin v l thdc trang dieu tri la nguyen nhan hang dau gay suy dinh dddng, benh nay tai benh vien cdn ban che. Nghien anh htfdng tdi sd tang trddng eua tre. Benh tieu cdu nay dddc tien hanh vdi muc tieu:
c h l y la mdt van de toan c l u , la g i n h nang kinh ^ ^ ^^ ff^^^ /,^n/, ^f^j ^j^h thuoc dicu trj to dd'i vdi cae nddc dang phat t r i l n [1 ]. ^/,o ^^* ^,- f,-^„ ^^^^y ^ - p f^,- i^/j^^ „^,- „ , ^ , ^ -
Vdi viee ap dung rdng rai lieu p h l p bdi phu benb vien cac tuyen.
dich dddng ucmg, ty le tif vong do tieu chay cap
; , , , , . ,- . . . , . , , . , I I . D O I T U O N G V A P H U O N G P H A P da giam dang ke. luy nhien, tieu chay cap co
Ihe chuyen sang tieu c h l y keo dai, gay I n h N G H I E N C U U
hu'dng xau tdi tinh trang sdc khde va tinh trang 1. Thie't ke nghien cud (NC): NC md ta cat ngang.
TCNCYH Phu truang 70 (5) -2010
2. Dd'i tddng nghien cifu
fid sd benh nhi dddc chan dean mac tieu ehay cap d i l u trj tai e l e benh vien d c tuyen.
trong khoing thdi gian 2 nam trddc thdi diem b i t dau tien hanh nghien cdu.
Ihdi gian nghien cdd: td t h i n g 10/2008 den thring 1/2010.
3. Dja diem nghien cii'u
Tuyen trung ddng: benh vien Bach Mai.
Tuyen tinh: 3 benh vien (Benh vien tinh Ha Nam - vung Ddng bang sdng Hong, Benh vien tinh Viet Tri - vung Ddng B l e , Benh vien tinh Hoa Binh - vung Tay Bae).
Tuyen huyen: tai mdi tinh dddc lifa chon, 2 benh vien huyen dddc d i l u tra.
4. C9 mau va chon mau
Cd mau dddc ddc tinh la 124 benh I n nhi eho mdi tuyen dda vao edng thdc sau:
6 ' ' X /?
'^ = Z i - X
i\-a/2Trong dd:
Z--, .0/.?= 1-96 (vdi a = 0,05); c: do chinh xac tddng dd'i = 25%; p: ty le benh an dat yeu clu sd dung thud'c hdp ly, an toan = 50%.
5. Ky thuat va cong cu thu thap thdng tin C I c benh I n dddc lifa chpn ngau nhien tif tdng sd benh an eua benh. C I c benh an dddc d c nghien edu vien ghi chep lai dda tren mau phieu thd'ng nha't da p h l t trien san, bao gdm mot sd'thdng tin chinh sau:
- Thdng tin v l dac diem c l nhan benh nhi tieu c h l y .
- Thdng tin v l tinh hinh ehi djnh thucjc.
- Thdng tin ve tinh hinh ehi djnh thudc khang sinh trong dieu trj tieu c h l y .
6. Quan ly va phan tich so lieu
Sd' lieu dddc nhap vao may tinh bang phan mem Microsoft Office Access. Phan mem Stata 10 dddc sif clung trong xd ly va phan tich sd' lieu.
III. KETQUA
Bangl. Dac dicm phan bo do tudi, gidi va thdi gian nam vien cua tre bj tieu chay cap tai benh vien (BV) cac tuyen
BV Tuyen huyen (n = 104) %
BV Tuyen tinh (n = 122) %
BV Tuyen trung ddng (n = 126) %
Chung (n = 352) %
, - ' •
1 udi
Gidi
< 2 tudi
> 2 tudi Nam
90,0 10,0 51,0
91,6 8,4 64,2
93,6 6,4 57,8
91,9 8,1 58,1
> 0,05
<0,05 Nd
1 hdi gian n l m vien trung binh (ngay)
49,0 35,8 42,2 41,9
4,6 (4,0 - 5,2)*
5,3 (4,6 - 6,0)*
6,0 (1,5 10,0)*
5,3
(3,7 - 5,9)* > 0,05
*; 95% do tin ciy
Tre < 2 tuoi chie'm ty le Idn (91, 9%o) trong tong so tre cd chan doin tieu chay cap d benh vien a ca 3 luyen. Thdi gian nam vien trung binh ciia tre d benh vien cac tuyen Pa 5,3 ngay (95%o dc) tin cay: 3,7 - 6,9). Khdng cd sif khac biet mot each cd y nghia thdng ke ve thdi gian nam vien Irunp, binh giifa benh vien cic luyen.
Bang 2. So thudc trung binh trong 1 benb an
sd thud'c trung binh
Tuyen huyen 4,7 (4,4 - 4,9)*
Tuyen tinh 4,4 (4,2 - 4 , 7 ) *
Tuyen trung ddng 4,4
(4,2 - 4 , 5 ) *
Chung 4,5 (4,4 - 4,6)*
P
> 0 , 0 5
*; 95%o do tin cay.
Sd thud'c trung binh trong 1 benh an tai benh vien cac tuyen la 4,5. Khdng cd sU khac biet ve so thudc trung binh gida benh vien cac tuyen vdi p > 0,05.
Bang 3. Cbi djnh nhdm thudc trong dicu trj tieu chay cap tai benh vien cac tuyen
Cac thudc
BV tuyen BV tuyen BV tuyen huyen tfnh trung dOng (n = 104) 7o (n = 122) % (n = 126) %
Chung (n = 352) % ORT
Djeh truyin bdi phu nddc va dien g i l l
Vitamin va men tieu hda Khang sinh
Thud'c e l m tieu c h l y Cha't khoang
Thudc khae
93,0 29,8 81,7 89,0 70,0 0,0 54,0
95,8 83,3 100,0
51,6 47,5 4,1 47,5
93,6 80,9 92,1 15,1 93,7 3,2 57,9
94,2 66,5 91,8 49,1 70,7 2,6 38,7
> 0,05
< 0 , 0 5
< 0,05
< 0 , 0 5
< 0,05
< 0 , 0 5
> 0 , 0 5 Chi dinh thudc cho tre bi tieu chay chung d cac tuyen pho bie'n nha't la thud'c ORT (94,2%);
thud'c vitamin va men tieu hda (91,8%o); cac thuoc cam tieu chay la 70,7%o; dich truySn boi phu nifdc va dien glal (66,5%o), va thud'c khing sinh (49,1). Cac thud'c khac nhU Paracetamol, Effralgan, Dimedron, Gardenal ciUdc chi dinh 38,7%o tnfdng hdp. Ghat khoang dUdc chi dinh 2,6%o.
100%
90%
80%
70%
60%
50%
40%
30%
20% f 10%
0%
47.2%
52.8%
16.2%
83.8%
10.5%
89.5%
31 8%
68.2%
-
D 2 nhom KS
D l nhomKS
Chung T\iy?n huy?n Tiiy?n t?ih
Bieu do 1. So nhom khang sinb trong benb an co cbi djnh sff dung khang sinb Tuy?n trung
irons
TCNCYH Phu truang 70 (5) -2010
Tai tuyen huyen chi dinh cd 2 thud'c khang sinh trd len trong tong benh an cd chi djnh Sif dung khang sinh chiem ty le kha cao 47,2%o, cao han so vdi tuyen tinh (16,2%o) va tuyen trung Udng (10,5%o) mot each cd y nghia thong ke (p > 0,05).
IV. BAN LUAN
sd thud'c trung binh trong mdt ddn thude tai mot sd benh vien e l c tuyen la 4,5. Theo khuyen d o cda To chdc Y te The gidi trong mdt ddn thud'c ehi c i n 1 - 3 loai thud'c, 1 loai thud'c ehinh v l 1 - 2 loai thud'c hd trci [9]. Nghien edu cua ehung tdi phu hdp vdi mdt so nghien cdu gan day cho tha'y sd thud'c trung binh trong mot ddn thudc van edn k h i eao so vdi khuyen eao cua "To ehde Y te The gidi.
Theo p h l e dd d i l u tri tieu c h l y cap ciia To chdc Y te "The gidi, bdi phu nddc va dien g i i i b i n g dddng ud'ng la mdt chi dinh quan trong giup tre dd phdng thie'u hut nddc va dien g i i i [5]. Qua nghien cdu cua ehung tdi cho tha'y e l e tuyen da ehi djnh nhdm thud'c thiet ye'u cho tre bj tieu ehay theo khuye'n cao cua To chdc Y te The gidi, the hien la ca 3 tuyen nhdm thud'c ORT ddcic ehi djnh rat phd bien (94,2% cac trddng hcJp). Luy nhien ty le chi djnh su' dung dich truyin bdi phu nddc v l dien giai trong so tre mac tieu c h l y tai tuyen huyen: 29,8% tha'p hdn tuyen tinh: 83,3% va tuyen trung ddng:
80,9%. "Trong khi dd Xy le tre mat nddc nang tai tuyen huyen la 6,0%, tuyen tinh la 1,6% va tuyen trung ddng I I 4,8%. Ket q u i ehe tha'y tinh trang bii djeh bang dddng tTnh mach dddng nhd cao hdn rat n h i l u sd vdi ty le benh nhan mat nddc nang. Cd the day I I do thdi quen phdng tinh trang mat nddc nang hdn chd tre cda d c can bd y te tai d e tuyen hoac do I p ldc cua ngddi nha.
Men tieu hda va vitamin khdng d i l u trj nguyen nhan gay tieu c h l y nhdng la thud'c hd
trc? dieu trj tieu chay cap [1]. Qua d i l u tra ta tha'y t^ le d c tuyen suf dung vitamin v l men tieu hda ehiem ty le k h i eao, ehdng td thay thud'c cae tuyen da chi djnh dung thudc hd tro d i l u trj tieu chay theo khuye'n eao eua To chdc Y te The gidi [5].
Chi djnh chat khoang chung eho e l 3 tuyen chiem ty le rat tha'p 2,6%. "Fheo H.A.Gathrie (1 989) kem cd t i c dung giiip tai tao te bao rupt bj mat trong khi bj tieu c h l y cap, giup cho qua trinh hdi phuc sau tieu c h l y cap nhanh hdn
[1 0]. G i n day To chu'c Y te "The gidi da khuye'n d o can sd dung Zn trong d i l u tri benh nhi tieu c h l y [6]. Tuy nhien viec ehi djnh Zn eho benh nhi tieu c h l y tai e l 3 tuyen d i u edn rat han che (2,6%).
Chi djnh thude nhdm e l m tieu chay cao d tuyen huyen, tuyen tinh, tuyen trung ddng lln Iddt la 70,0%; 47,5%, 93,7% chie'm ty le rat cao. Tuy nhien day I I nhdm thud'c khdng ddcJe khuye'n cao dung eho trd bj tieu ehay.
"Ty le su' dung khang sinh tai tuyen huyen la 89,0 % eao hdn tuyen tinh la 51,6% eao hcJn tuyen trung ddng la 1 5 , 1 % . Theo TCYT'IG da khuyen d o khdng dung khang sinh mil hoac dung thddng quy eho tre em [7]. Ke't qua nghien cdu ve ty le chi djnh k h i n g sinh d tuyen trung ddng tddng td vdi ty le suf dung k h i n g sinh trong nhdm benh nhan bi tieu chay (14,5%) trong nghien edu "Tinh hinh sd dung khang sinh trong khoa nhi benh vien Bach Mai nam 2003" [4].
Ty le chi djnh sd dung khang sinh d tuyen tinh va tuyen huyen rat cao (89,0% va 51,6%), eo the tuyen tinh va tuyen huyen ed sd lam dung k h i n g sinh.
Tai tuyen huyen ty le ehi djnh sd dung cd 2 nhdm khang sinh trd len trong sd ddn thudc cd ehi djnh suf dung khang sinh chiem ty le khdng nhd 47,2%, cao hdn so vdi tuyen tinh va tuyen trung ddng ( l l n Iddt la 16,2% va 10,5%). Theo
khuyen cao cua "To ehde Y te The gidi khdng nen dung khang sinh thddng quy cho tre bj tieu ehay [7].
V. KET LUAN VA KHUYEN NGHj
So thud'c trung binh trong 1 benh I n d d c tuyen v i n edn k h i cao, td 4,4 - 4,6 thud'c.
Chi dinh thud'c bdi phu djch cho tre bj tieu chay bang dddng ud'ng (ORT) d d c tuyen k h i phd bien, tuan thu p h l e dd d i l u trj tieu chay.
Tuy nhien ty le ehi dinh nhdm dich t r u y i n bdi phu nddc va dien giai, thude e l m tieu chay van edn kha eao, l l n Iddt la 70,9 va 66,5%.
Trong khi chi dinh chat k h o i n g ehiem ty le rat thap (2,6%).
Cd su' lam dung k h i n g sinh trong d i l u trj tieu chay cap tre em, dac biet d benh vien tuyen huyen. "Ty le sd dung khang sinh tai tuyen huyen, tuyen tinh v l tuyen trung ddng chiem ty le Idn l l n Idcft la 89,0%; 51,6% va 1 5, 1 %.
C i n cd elc bien p h l p tang cddng ehi dinh thucK an toan hdp ly trong d i l u trj benh tieu ehay d trc- em nhd: tuyen truyen v l tac dung d i l u trj tieu chay cua kem, chi djnh k h i n g sinh hdp ly va han che ehi djnh thud'c e l m tieu c h l y .
TAI LIEU THAM KHAO
1. Bo mon Nhi - Trddng D H Y H N (2009);
Bai giang nhi khoa - Tap 1; Nha xuat b i n Y khoa; 305 - 3 2 1 .
2. Nguygn Yon Binh (2003); "Nghien cdu 1 sd vi sinh vat gay benh tieu ehay cap d tre em
td 3 t h i n g tudi den 5 tudi tai benh vien Xanh Pdn - Ha Ndi v l tinh k h i n g thud'c cua chung".
2 4 - 2 6 .
3. Nguyen Gia Khanh va cong sd (1996)."Cac yeu to nguy cd lam sang, d i l u trj va dd phdng benh tieu c h l y kee d i i d tre em Ha Ndi, Bd Y te, Vien b i d ve sdc khde ba me tre em"; Nha xua't b i n Y hee, 30 - 34.
5. Nguyen Hong Son (1999); "Tim hieu d c ye'u td lien quan den tieu c h l y cap d tre em dddi 5 tudi cua 2 xa Yen My va Lien Minh, Thanh Tri, Hi N d i " . Chuyen d l td't nghiep bac sTy khoa, 7, 28, 2 1 , 38.
6. Sasaka wa.c (1995): Molecular basis of pathogenicity of Shigella. Rev.Med.Mierobial6 (4), 2 5 7 - 2 6 6 .
7. WHO, C D D Program(1990): A manual for the treatment of diarrhea - for use by physicans and other senior health workers. Geneva: WL10:
1 - 10.
8. World Health Organization (1991);
Guideline for cholera control CDD/S[r;R/REV.2.
9. World Health Organization (1993);
Instructor manual, strong thening the teaching of diarrhoeal diseases in medical school. Geneva, C D D / S E R / 9 3 , 1.
10. WHO (1997), management og the child with cough or difieult breathing. A guide for income countries, lUATLD., 5.
1 1 . World Health Organization (1998); The World Health Report 1998, Geneva 1998.
Summary
PRESCRIBING PRACTICE FOR CHILDREN WITH ACUTE DIARRHEA IN PEDIATRIC WARD IN SOME HOSPITALS IN THE NORTH OF VIETNAM
Objective: This study aims to describe prescribing - practice for children with acute diarrhea in pcxiiatric ward in some hospitals at all level. Methods: The study was carried out in a national hospital, 3 provincial hospitals, which are representative for 3 regions in North Vietnam, and 6 district hospitals of study provinces. A cross - sectional study was applied to analyze 352 patient - records of
TCNCYH Phil truang 70 (5) -2010
children with acute diarrhea in pediatric ward. Results: The average number of drugs per prescription is high (4.5; 95% Cl: 4.4 - 4.6). ORT (94.2%), vitamin and enzyme (91.8%), anti - diarrhea (70.7%), transfusion solutions (66.5%), and antibiotics (49.1%) were common drugs prescribed for children with acute diarrhea. Mineral was prescribed only in 2.6% of all eases. The rate of antibiotic prescription for acute diarrhea was 89% in district hospitals, 51.6% in provincial hospitals and 15.1%
in national hospital. Conclusions: Over - prescription of drugs and antibiotics for acute diarrhea among children persists.
Keywords: prescription, acute diarrhea, antibiotics, hospital at all level
TINH HINH SLfC KHOE BENH TAT VA LOI SONG CUA NCaCfl DAN 5 HUYEN BA vi - HA NOI NAM 2009
• •
Tran Quynh A n h \ Nguyen Phddng H o a \ Nguyen Van Yen^, Nguyen Ngoc HiJng\ Vu Thj Vdng^
^Trddng Dai hoe Y Ha Ndi; ^Sd Y te Ha Npi
Day la mot nghien cdu phd'i hdp giufa TrUdng Dai hoc Y Ha Noi va TrUdng Dai hoc NU Ewha Han Qudc. Muc tieu: md ta tinh hinh sdc khde benh tat va mdt so hanb vi nguy cd lien quan den ldi sdng Ciia ngUdi dan d huyen Ba VI - Ha Ndi nam 2009. Doi ttfgng va phtfang phap nghien cffu: md ta cit ngang ngUdi trUdng thanh tren 18 tuoi, tong so cd 960 ngUdi da tU nguyen tham gia vao nghien cifu. Sd lieu dugc thu thap bing bd cau hdi thiet ke sin. Xd ly ya phan tich so lieu bang cac phin mem Access va SPSS. Thuat toin khi binh phuang (;f) dugc sd dung nhim so sanh sU khic biet gitfa cic nhdm. Ket qua: (1) Ve tinh hinh sdc khde ciia ngUdi dan: Ty le sdc khde binh thudng 72%. Ty le sdc khde rat tdt va td't d nam cao ban nO (7,4%o va 12,2% so vdi 2,7%o va 7,2%o), khac biet cd y nghia thong ke vdi p <
0,05. Ty le ngUdi cd bleu hien trieu chdng cua benh hd hap va benh tuin hoan tha'p (6% va 9%). Ty le tu khai bio dugc chin doin mic tang huye't ap, rd'i loan chuyen hda md mau rat thap (5,3% va 1%), chUa cd trUdng hdp nao da tdng dugc chan doan li mic dii thio dUdng. (2) Ve cac hanh vi nguy cd Hen quan de'n ldi sd'ng: 50,5% nam gidi hien tai dang hiit thud'c la. T'y le phu nU hut thud'c la thu dong la 27%. T'y le nam gidi hien dang ud'ng ruau la 77%. Ty le khdng tap the due deu dan cao, gin 90%.
Tif khoa: sdc khoe, benh tat, Idi sdng, hanh vi nguy cd
I n»AT»/A'».i n«r dich mdi nhd cum A H 1 N 1 , SARS. Cd nhdng
I. DAT V A N DE ' b benh tddng ehdng da khd'ng che ddcJc nay lai
Thdng tin v l tinh trang sdc khde v l benh tat bung phat nhd ta. Nguyen nhan eua benh dich cd y nghTa rat quan trong trong viec d i n h g i l dddc cho la do sd bung nd dan sd, d n h i l m mdi thdc trang sdc khde va phan anh nhu c l u v l trddng, thie'd cac cdng trinh ve sinh, nddc cham sdc sdc khde eua ngddi dan. Trong nhdng sach... va ca do xu the toan c l u hda hien nay.
nam g i n day, eung vdi sd p h l t trien eua n l n Ben canh dd, d e benh khdng n h i l m trung kinh te - xa hdi cua da't nddc, md hinh sdc eung cd ty le mac cao trong edng ddng nhd tang khde, benh tat eua ngddi dan da ed n h i l u thay huyet ap, d i i thao dddng, beo phi. Nhdng van ddi. CIc benh n h i l m trung chda cG cd xu hddng d l sdc khde nay d i u cd lien quan den e l c thdi giam, ben canh dd xua't hien them nhdng benh quen trong cude sd'ng nhd thdi quen ud'ng rddu,
