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NHIEM TRUNG VET THlAlNG ti CHO VA GIAI P H A P K H A C PHUC
Nhiem trung vet thuang tten cho chu ygu la nhiem trimg ngoai idioa. Bii viet ciia chiing toi chi gidi ban trong vin dg nay.
Ngurdi ta gpi mpt qua trinh nhiem tning la nhilm tning ngo^i khoa, khi hieu qua phong tri nd dat dupc tdt nhat bang phuong phip ngo^i khoa, ket hop voi nhimg chit khang khuin va khang sir phit sinh benh khac.
Nhiem tning ngoai khoa xuat hien do su x i m nhip cua vi khuan, ddi khi la virus ho|c vi nam v i o CO thi ddng vit Sir phat sinh v i phat trien cua nhiem tning ngoai khoa, v l nguygn tic, khong khac nhirng qua trinh nhiem tning khac.Tuy nhign, nhilm tning ngo^i khoa xuat hien tten nen nhiing t i n thitong.
Thdng thudng, nhilm trung ngop khoa dupc bat dau tai cho x i m nhip ciia tic nhin gay benh va phin ldn c i c trudng hpp diln ra nhir mdt qua trinh khu tni cip tinh hay man tinh (nhilm trung ngoai khoa cyc bo). Trong trudng hpp t i c nhin c6 tinh giy benh m^nh va dpc luc cao ma co thg lai thilu hyt phan img thich iing phdng ve, co thg din d i n sir lan toa ciia mam benh, dua tdi xuat hien nhilm triing ngoai khoa toan than (nhiem tning huylt hoac nhilm ddc t l huylt).
Nhiem trung vet thucmg tten cho chu y l u la nhiem tning ngoai khoa hilu khi, doi khi l i nhilm tning ngoai khoa ySm khi hoac nhiem trung ngoai khoa thoi rua.
I. NHIEM TRUNG NGO^I KHOA HIEU KHI (NHIEM TRUNG MU)
Su ton thuong da va niem m^c thudng la tiln d l cho su phat trign nhiem trung mu. Chinh dilu do da tao dilu ki^n cho su x i m nhap v i o co thi c i c loai vi khuan: Staphylococcus, Streptococcus, Crypto-
VU Nhu Qudn Hgc viin Nong nghiep Viet Nam
coccus. Bacillus pyocyaneus, E. coli v i mot vii loai vi khuin sinh mil khac. Dac biet, nhimg qua trinh nhiSm trung mu thudng dupc giy ra bdi cac chung vi khuan Staphylococcus.
0 chd, dgng nhiem trung nay fhudng xay ra hern so vdi nhilm triing n g o ^ khoa yem khi; nd co dac tinh ngoai sinh l i chu ygu va phin ldn cic ttudng hop diln ra d cue bp, tign triln cip tinh, trong tnrdng hpp nang fhi bien chiing thanh nhilm triing toin than; sinh mu l i net djc tnmg.
1.1. Can bgnh hpc
Vdi dieu kien tu nhign d nude ta, q u i trinh nhiem tning vet thuong tten cho xay ra nhir t h i nao, vdi nhung loai vi khuin n i o xam nhip,... con qua it cac nghien ciiu.
Vu Nhu Quan va Chu Dice Thang (2010) da liy mau tii 60 vgt thuong nglu nhign v i 8 vit thirang nhin tao d dpng vat, vao cac thdi digm khac nhau de nuoi cay, phin lap, xic djnh thdi gian xam nhap ciia vi khuan vio vet thuang v i thinh phan loai vi khuin c6 mat ttong no. Ket qua dupc trinh biy tai bang dudi diy.
Ket qua nghien ciiu tren ciia tic gia bii bio cho thay.
Vi khuin x i m nhip v i o vit thuong rat nhanh, sau 24 gid bi v i t thuang; 100% so mau kiem tra (kg ca vet thuong ngiu nhign v i vit thuong nhan tao) deu bi nhilm khuin. Khi dpng vat bi thuong dong thdi xay ra su nhilm b i n v i t thuang do v i t gay thuang tich tic dpng, cung dat, cit, bui, nude, vit la khic,...roi vao ttong chiing. Vi sinh vat deo bam tten cic chat bin dd va ngay c i tten I6ng, da ciia vat nuoi, da lip tiic xam nhip vao vet thuang,
Cic loai vi khuin thudng ggp Irong vet thuong d dpng vgt la: E. coli, Staphylococcus, Streptococcus va Klebsiella; trong dd Staphylococcus c6 ty Ie nhiem cao
KHOA HOC KY T H U A T THtr Y T A P XXIV SO 8 - 2017
Bang 1. Cac loai vi khuan co trong v^t thiFong Lo^i vet
thipcng Vit thu-ang nglu nhien
Vet thu-ang nh§n tgo
Thai gian bj thipong Chi tieu 1. So mlu 2. Loai vi khuin:
E. coli Staphylococcus Streptococcus
Klebsiella 1. So m l u 2. Loai vi khuin:
E. coli Slapliyiococcus
Streptococcus Klebsiella
Trong 24 gid*
16 So mlu du-ong tinh
4 8 4 6
8 So mlu du-ong tinh
1 4 3 3
TJie
(%)
25,00 60,00 25,00 37,50
T^ie
(%)
12,50 50,00 37,60 37,50
24-48 gia- 26 So mlu du-ong tinh
10 16 12 12
8 S6mlu du>ang tinh
2 4 3 2
Tyie 38,46
(%)
61,54 46,15 46,15
TJiS
(%)
25,00 50,00 37,50 25,00
4 8 - 7 2 18 S6 mlu du-ffng tinh
6 16 12 10
8 S6mlu duang tinh
2 7 6 4
gio-
I f i§
(%)
33,33 88,89 66,67 55,56
TJie
25,00 87,50 75,00 50,00 (Nguon trich dan: Tgp chi Khoa hgc ky thudt thii y - Tap XVIl-sd 3-2010-tr. 63-70) nhat d mpi thdi diem. Cic loii vi khuin tten deu la dang
vi khuan Meu khi, neng E. coli li d^ing yem khj tuy ti^n.
Cac mau nghien cuu dupc liy tir nhihig vit thuoi^ ndng, hd m i ^ g , it md bio chit,,.. mdi trudng vet thuong l i hieu khi, chua liy duoc n ^ d cic vet thuong yem khi.
Nhin chung, ty le nhilm khuin d cac vit ihuong ngau nhien cao hon so vdi cac vit ihuong nhin tao, rd ret nhit l i cac miu liy vio thdi diem 24 - 48 gid va muon hoD.
Ty le nhilm ciia cic loii vi khuan rigng biet, theo thdi gian cd su khac biet rd r?t, cd xu hudng ngiy cang tang. 6 nhiing vit thuang ngau nhien ttong v6ng 24 gid, ty Ie miu nhilm E coli la 25%, Staphy- lococcus la 50%, Streptococcus l i 25%, Klebsiella Ii 37,50%. Vdi nhdm v i t thuong xiy ra trong vong 24 - 48 gid, ty le tuong ung Ii: 38,46%; 61,54%; 46,15%;
46,15%. V i o thdi dilm 72 gid sau hi thuong, ty I?
nhiem cic loai vi khuan tten tucmg ung Ii: 33,33 %;
88,89%; 66,67%, 55,56%.
1.2. Tyi^u chihig
Ehidi sii t i c dpng cua cic vi khuin hilu khi, ttong mo b i o xuat hien nhiing I tdn thuong v i hoai tur, ca thi phin ling lai bang qui trinh viem mu cap tinh.
Vi^c chi ra ranh gidi giiia cac qua trinh xay ra do boat dpng sdng ctia nhiing tic nhan gay b?nh v i phan dng vidm ciia ca thi (xuat hi^n vi dilu do) l i khdng c6
the. Nhiem trung mu cd the xay ra mot each em dem hay dii dpi, ic li^t.
L2.L Thi im dim
The niy diln ra ttgn nln viem binh thuong ciia ca thi. Hing rio hat dupc hinh thanh c6 gii tn ve mit sinh hpc, cd k h i nang bao vay, khong che mam benh va doc td ciia chiing.
Nhilm tning mu dien ra mot cich em dgm vdi su dinh vi d nhilm tning the hien ro; su hoai tu mo bao la tdi thieu; su phan huy mo b i o (kilu men-mii) CO gidi han; vung phu viem va thim nhilm tg bao cd ranh gidi xic djnh; khong co bieu hi?n vigm hach lympho, viem mach lympho.
Dong vat cd thi hi s6t nhe (tang 0,5 - l^C); ddi khi, thin nhiet chi dumg d mite cao cua su binh thudng. Nhip hd hip, nhip tira nhanh hon ddi chiit;
ddng vat hi lie c h l khong nhieu, khdng cd bien chung ning ng, con vat d l ding khoi benh.
1.2.2. The du dgi, dc lift
Trong trudng hpp bj nhilm vi khuan cd dpc luc cao (vit cin ciia ddng vat an thit, bi thuang khi loi qua vung ao tu, nude dong) cong vdi tinh phin img manh ciia ca the (viem tang phin iing), qua trinh nliiem triing mii dien ra mpt cich dii ddi. Trong viing cira nhilm quan sit thiy hien tupng hoai tii luy tien
KHOA HQC KY THUAT THO Y T A P X X I V SO 8 - 2017
(vung ho^i td ngiy cing md rdng), phu viem nang, viem hach lympho, viem mach lympho, nghen mach mau. Trong 6 tdn thuong, su hinh thinh md b i o hat bl tri hoan (hinh thanh v i phat trign rat cham chap), cd nhiing chd nd hoin toin khdng hinb thinh. Chinh dieu dd da tao digu kien cho su xam nhip cda t i c nhin kich thich v i o nhung md b i o linh ra^inh d xung quanh, dan den su phd bien (lan rpng) cua q u i trinh nhigm trung
Nhiing vit chit phin giii t^i d nhiera tning dupc hap thu vio mau, din den thih ttang nhiem ddc nang ciia CO thi, tii kich thich dot ngpt nhiing bp phin ngoai vi v i trung tira ciia h$ thong thin kinh, gay roi loan ding k l boat dong ciia than Vinh dinh dudng, lim giira phin iing thuc b i o ciia bach ciu, lim xau di chuc nang bio v§ cua hg thing md lign kit, q u i trinh dinh khu (co dmh) ciia d nhiera tning bi ngan ttd; vi vay, trong tien trien du dpi cua nhilm trung mii cip tinh, ludn ludn cd tinh nguy hidm ciia su bien thinh nhiera tning ngoai khoa toan than (nhiem tning huyet).
Su hap thu ddc to v i o raiu, sin phim phin hiiy ciia protid md bao v i vi khuan, dio den su lie che tao miu cua tuy xuong; do do, khdi lupng hong ciu v i hemoglobin trong miu giira. Trong huygt tuong, hira lupng globulin tang len, con khdi lupng albumin lai giim xudng. Quan sit thiy tang m ^ sd lupng bach ciu v i su dich chuyen cong thiic bach cau ve bgn ttai, den dgng nhin hinh giy; ddng thdi giim sd lupng bach cau ai toan v i bach cau da nhan ldn.
Tien trien dit dpi cda nhilm trung mu cip tinh giy ra su lie che mgnh cua con benh, thin nhiet giu ben viing d miic cao (sit cao liSn mign), tan s6 mach Sap v i ho hap nhanh hon, dau nhieu hon, roi loan tinh ngon mi^ng v i q u i trinh tieu hda.
1.3. Dilu tri vet thuwng cd mu
Su nhiem trdng vet thuang inh hudng rit ldn d i n qua trinh linh ciia vet thuong. Khi bi nhiem tning, vet thuong khdng linh dupc theo dang linh tien phit (linh thdi ky I), luc niy vit thuang lanh dupc la nhd su tien ttien cua phin iing vigm (lanh theo dgng linh thir phit - linh thdi ky II), thdi gian linh ciia nd keo dii hon nhilu ( 3 - 4 tuin) so vdi dang lanh thdi ky I (7 - 10 ngiy). Nhiem trung cing ngng, thdi gian lanh vet thuong cing k6o dii, tham chi cd thi k i t thuc bang cii chet ciia con vit. Dieu trj vit thuang nhiem trimg rail phai phii hpp vdi su biln dli trong vet thuong.
1.3.1. Trong pha thu nhdt cua qud trinh vet thuffng Trong pha niy nhit thilt phii sit dung tdng hpp cic bien phip nhim huang tdi d l phdng nhilm trung, giii phdng vit thuong khdi md b i o chit bang each sir d\ing kgt hpp cic phuang phip vo tning hda hpc, vit 1^ hpc v i smh hpc trudc v i sau khi xii ly ngogi khoa vet thuang. Trong do cin phai thanh toin cic hang, d, tiii; logi bo nbiing mo b i o chdt bang con dudng cit tiing phan; khi can thilt co thg md rpng vet thuang d i m bao cho su thoit dich-mii ty do (khong tich ty ttong vet thuong).
Riia bing dung dich sit tning: Can cii vao kit qua kiem tra vet thucmg, cho phep chiing ta lua chpn dung dich sit trung thich hpp se cho k h i nang dieu tri c6 higu q u i han. N l u pH cua vit thuong < 7, ddng cic dung djch sit tning cd phin img kilm de nia (natri hydro carbonat 4 - 5%, cloramin B 2%, nude x i phong 5%,...). Neu pH ciia vet thuang > 7, dung cic dung dich sit triing cd phin iing acid nh? de nia (nude oxy gii 3%, thulc tim 0,5 - 1%, cloracid 2%,...). Vet thuong cd hien tupng thiiy thilng nang nia bang cic dung djch uu fntong (raagnesi sulfat 20 - 40%, natri sulfat 20 - 40%, natri clorid 5%, tiiulc tim 5%,...). Vet thuong cd nhieu mu, dimg rivanol 0,1%. Vet thuong sau, mieng h^p, dung thuoc tim 1%, nude oxy gii 3%.
Sau khi da xii Iy ngoai khoa vet thuong, cira miu cin than, cho v i o ttong xoang cua nd hon hpp bpt kim h i m su phit triln ciia vi khuin hogc dat dan luu vdi cac huyln dich, dung dich uu tnrang. Xoang vit thuong rong dat dan luu mem, vet thuong siu dat dan luu dng.
1.3.2. Trong pha thu hai cua qud trinh vet thuffng Sii dung rapt each hpp Iy tai cyc bp bdn hpp: pix liquida 3 phin, xeroform 3 phin, diu than dau 94 phan; cd thi thay thi bing h§n hpp gim; ichthyol, bismuth subnittat v i diu ca. Khi c6 mat rad hgt vdi sic thii nhpt nhgt sii dyng acid lieu p h ^ ; khi quan sit thiy md hgt cd dgng cac hat Idn vdi miu do, sir dyng kilm Ii§u phip. Bing cich do se tang cudng dupc q u i trinh tigu nude v i cii tbifn su tao hgt va bieu bi hda vit thucmg.
Khi thilu su digu tri thich ding, ttong vung vet thuang xuit hi?n phu manh v i tham nhiem tg bio, ria vit thuong ttd nen cang v i khong it khi hi lit ra ngoii; ttong vit thuang tich liiy khoi lupng ldn mu, rao b i o chit; sd vimg vit thuang con vgt cd cam giic dau manh; co thi xuit hien nhung dau hiSu cua viSm
KHOA HOC tCY THUAT THtJ Y T J P XXIV SO 8 - 2017
hgch va mgch lympho; d cho, thio ohiet tang cao 2"C v i ban oua; mgch d | p nhaoh han mpt cich ding ke, ho hip nong va nhanh han.
Khi vit thuang cd bilu hi?n nhu tten, khang sinh la chi djnh bat bupc ket hpp vdi sulphanilamid v i nhiing l i ^ phap khic (bao gdm cic bien phip chdng nhilm khuin va dilu tri trifu chiing).
n . NHIEM TRUNG NGOAI KHOA YEM KHI
Nhiem trimg ngoai khoa y i m khi thudng phat tnIn d nhiing vit dam, vet thuang ngau nhien dap nit, vet thigo, vet thuong hda khi v i ngay c i khi xit IJ rdn cho chd radi sinh. Nhiem triing yIm khi cd the xuit Men dudi da, va dac bi^t nhilm trimg ttong ca, do khi tiem nhiiog chl phim vacxin khdng tuan thu cac nguygn t i c vd tning.
Do vi khuan yIm khi cd mgt trong 95% miu dit v i 100% miu phin, nSn phii hilu ring: Vet thuang ngau nhien tten cho, dgc bif t d vimg chin ludn luon cd su xam nhap ciia vi khuin yem khi; mac dii the, nhilm trirng ngoai khoa yem khi 6 cho tuang doi hilm.
Vet thuang h?p hay co dp hd mieng nhd, mac dii nhilm bin dit va phan rat nang, nhung it khi phit triln nhilm tning yIm khi, nlu dupc xii Iy ngoai khoa kip thdi (md rpng vit thucmg, rita vit thuang bing cac dung dich thudc tim, oxy gii,...); bdi vi, vi khuin yIm khi se hi chit sau 10 phut do t i c dpng ciia khdng khi.
2.1. Can bf nh hpc
Nhiem triing ngoai khoa yira khi thudng giy ra bdi cac loii vi khuan: Clostridium perfringens, Cl.
oedematiens, CL novyi, Ci histolyticum, CL septicum).
Cd hing logt nhung dilu ki?n thiic diy nhigm tning ngoai khoa yIm khi phit triln: Nhiing vet dam va vet tiem vdi Id vao h$p; su co mat ciia nhung co bi gian hay vd; tdn tgi vit gay thuong tich hay ngogi vat khac; rich hay nghen dpng mach lan cung cip mau cho vung tdn thuong; ur dpng Gnh mach hay cd mat u miu ldn; mit miu q u i nhilu; budc diy ga-rd liu 6 chin; s\r suy yeu hogt dpng ciia tim v i nhung dieu kien khac dan din su thieu o-xy md bio v i tao nhiing dilu kien yIm khi ttong vit thuang.
Ngoii ra cdn do: Su thiia hay thilu vitamin, nhiem Ignh, suy ki?t toin than, tii kich thich h?
thdng than kinh, dgc bi^t vi^c xit 1^ ngogi khoa v i
chong vi khuan q u i mudn hay khong diy du, tham chi khdng tign binh ddi vdi nhimg vet thuang d i p nat, gly xuong hd m i lai bang bd q u i kin se tao dilu ki§n cho phit trign nhiem tning ngoai khoa ygm khi.
Md b i o chet ttong v i t thuang cang nhilu, ldp ca vung ton thuang cing day, vet thuang cing sau thi su nhigm trung yem khi phat trign cing nhanh v i thudng xuygn bon, trong khi nhung digu kien khic la nhu nhau.
Cin phai nhan manh rang, co thg dpng vat ndi chung, chd ndi rieng khdng thg san xuat duac diy dil khang the doi vdi nhilm tning yIm khi, phan dng viem ciia nhilm trung yIm khi thg hign yeu dt; cdn khi hi hoai thu khi v i phii hoi, phan img viem bi nen xudng; do dd, qua trinh nhiem triing yem khi xuit hi?n, phit trien dii dpi va khuech tin rapt cich nhanh chdng.
Theo the hi^n tn^u chiing lim sang, nhigm trung ngogi khoa yem khi dupc chia ra: ap-xe khi, hogi thu khi v i ngay c i udn vin.
2.2. Tri^u chirng 2.2.1. Ap-xe khi
Ci cho, tai cho tiem hay chpc thara dd cd tiie xuat hien ip-xe khi. Dieu nay xay ra, trudc tien do nhung cue fibrin, tilp theo la su tang smh ciia tic nhan gay b?nh (thi hien ro tai c h l xam nhip diu tien ciia chung). Ap-xe khi gap d bit k^ bp phan n i o ciia co the, tuy nhien, nd thudng xuit hien 6 cho co cd cau tnic nhung bd ldn.
Phin biet vdi ip-xe giy ra bdi vi khuin sinh mil, ip-xe khi hinh thinh rat nhanh, trieu chiing viera tai cyc bp khdng thg hien ro nhung con vat sdt rat cao, lie che mgnh, nhip tim va nhip thd deu cham. Bang phep go, nghe thay i m "fring"; con khi sd, cim nhgn thiy su nen chat ding ke xung quanh ap-xe; an v i o nghe cd i m "vd tdc". Khi chich ip-xe khi, tit no cd djch mii miu dd-xira chay ra, co mui thdi va lin cic bpt khi; diy va thinh ciia ip-xe chac, khdng bang phing, lit bing ciu true hinh long nhung ldn.
Sir dung kip thai khing sinh v i sulfamid, md ngay nhiing ip-xe da hinh thinh (chin), riia d nhigm tning bing dung dich uu truong cua mudi an (5 - 10%) dupc ham ndng tdi 40**C, cd bd sung thuoc tim din 0,5 - 1%, hay nude oxy gia tdi 3%; ngay c i tudi lau dai mpt each hpp ly bang cic chit chda cio (cloracid, cloramin vdi dung djch thuoc tim v i dac
KHOA HQC KY THUAT THU Y TAP XXIV SO 8 - 2017
biet dung dich clorhexidin 0,2%) cho hieu qua digu tri tich cue.
2.2.2. Hogi thu khi
Tie nhin gay b^nh ciia hogi thu khi, theo nghien cuL ciia nhieu tic gii, co tdi 92 - 100% tmdng hpp la do Cl. perfringens, 21 - 35% do Cl oedematiens, 4 - 12 % do Cl septicum, rit it (0,6%) do Cl. histolyticum.
Ddi khi trong hpp phan cua no c6 c i tic nhin giy nhiem tning thdi: B. putrificus v i B. sporogenes.
Giai dogn diu ciia b§nh, ttong vimg vet thuang xuit hien dau du dpi vdi hi^n tupng phu khdng dau, Ignh, ldn din Ign; da ttong viing phii trd len cang thing. Qua 1 vai gid, tigng "lao xao" khi gan lien vdi viing phli. Vet tiiuong hd mi^ng mgnh, su tiet dich khdng ding ke, thinh v i diy cd raiu xim-bin hay niu-dd, mui chua khd chiu.
Khi nhiem trimg hdn hpp, su tiet djch nhigu hem, no cd miu ciia cao long tu thit vdi miii thoi. Md b i o bi chia cat ro ring, co mau vang-xanh. Nhung co bi tdn thuong cd mau thit ludc, tiep theo chuyln thanh miu den-nau. Nhihig miu cit ra cua md bio nii trong nude hay dung dich mudi an 10%. Khi ego long, nghe thiy am "kim loai".
Dpng vat bi lie che, dpt ngpt bd an, thin nhigt cao, nhip tim nhanh, mach yeu, nhip ho hip ciing nhanh hon, niem mac vai sic thai ving-vang.
Khi ttong 6 nhiem trimg cd vi khuin CL histolyti- cum, cac diu higu kg ttgn lien ket vdi su nheo ra nhanh chdng cua md lien kit, cin mac, ca, day chang. Co liic diu CO mau giara-bdng, sau dd theo mite dd tan riia bign thanh miu niu-dd nhgt.
Trong raiu, hira lupng hong cau giim, ttong khi hi?n tupng giam bach cau the hien rat ro, cdng thiic bach cau nghigng frai nhilu, bach ciu ii toan va bach cau don nhin ldn hau nhu khdng cd.
2 3 . Dilu tri v i t thirong nhiem trfing yIm khi Dilu tii nhilm tning ngogi khoa yem khi cin phii tong hpp vdi su tinh den nhung net sinh hpc die biet ciia cac vi khuan yem khi, hpp phan ciia chiing, sinh benh hpc v i nhung dgng the bifn benh. Trudc tien, ngudi ta sit dung cic bi^n phip dilu trj ngogi khoa dac thii ket hpp vdi dieu t4 sinh b?nh hpc v i lieu phip thim thiu-oxy hda. Chii ylu sao cho cic bien phip dilu tri cang dupc thuc hi^n cing sdm cing tit, trudc nhung bieu hien lira sing cua nhiem triing hoac vao giai dogn diu cua nd. Nhu thi, nhung dilu ki?n khdng
thuan Ipi ddi vdi vi khuin dupc tgo thinh, nhung qua trinh logn dudng than kinh v i hoai thu hi ngan trd vi khong lie chl nhiing luc lupng phdng ve cua ca the.
Thuc hien xit ly ngogi khoa cd y nghia dieu trj va du phdng Idn, ttong nhieu trudng hpp l i chii ylu.
Hoan toan can thilt xii ly ngogi khoa d nhOng vit thuang radi v i siu vdi vimg tdn thuang md co rpng ldn; nhilm bin bdi dat, phin.
Ngudi ta cich ly v i tien hanh nhiing Ii?u phip dieu tri dpng vgt cd nhiing dau higu lim sing cua nhilm tning yera kbi trong cic phdng riSng biet, khong lign quan vdi khu ndi tni khic cua ddng vat
Md rpng cic vet tiiuong sau, mieng hep; lay het cac cue raiu dong, cac rao bao chet, ngogi vgt co trong no.
Md ngay cac ip-xe khi da Mnh tiiinh (chin). Sau khi thuc hifn cac thu thuit ngoai khoa, cin thigt pbii thu dpn tit c i nhOng mo bao cat bo, dich ri, ngay ca nhung dung cu ngogi khoa sir dung 1 lin (bong, bang, vii ggc,.,.), tigu bdy theo dung qui dinh ciia ve sinh thi y.
Rita vet thuang, vet rad bang nude mudi uu truang (5 - 10%), dun ndng tdi 40''C, cd b l sung nude o-xy gii din 3%., thuoc tim din 1% hoac cloramin-T din 2%, vdi thdi gian nia keo dai 20 phiit.
Dat din luu mgm, t i m hon hpp gdm: lOOml muoi an 20%, 100ml nude o-xy gia 3%, 10ml diu ca hay diu thuc vat. Thay cho dat din luu, cd thg cho vao vet thuong, vet md hot kim khuin gdm: acid boric 6g, iodoform 2g, ampicillm 0,5g; hogc nhung bpt kim khuan khic.
Sii d\mg khing sinh v i sulfamid rapt cich hpp ly Dieu tri bang cic kich tiiicb phi dac hieu de ting siic de khing ciia dpng vit.
m . NHIEM TRUNG N G O ^ KHOA THOI RfA (NHIEM TRUNG THOI)
3.1. Can bfnh hpc
Nhilm tiimg ngogi khoa thoi riia phit trien dudi su inh hudng ciia nhung vi khuan yera khi tiiy ti^:
E. coli, B. putrificus, B. proteus vulgaris, B. sporo- genes,... ddi khi chung kit hop vdi Staphylococcus, Streptococcus.
Nhilm trimg dang niy dac trung biing sy phan hiy thoi riia mo bio vdi su tao thanh djch ri vigm cd raiii thoi, tin miu - dupc gpi ia mil thdi. Diu tign nd c6 raiu xim lln miu, sau dd bien flianh miu nude diing (nude lupc long Ipn).
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KHOA HOC K Y T H U A T T H U Y T A P XXIV S 6 8 - 2017
3.2. Sinb b|nh hpc
Nhirng vi khuin thoi riia ciia dudng mpt khi co su bien dgng v i su hiiy hogi ciia hang rao mdt, co the xim nhgp v i o mdi tnrdng bgn ttong ciia co the v i gay ra nhiem tning thdi npi sinh; trirang hpp nay it gap, quan sit dupc khi dpng vat bi long rupt hay mpt bl vit thuang.
Nhiera tning thdi riia ngoai sinh xuit hipn trong nhung vet thuong nang vdi su dap nit nhieu rad b i o vi tao thanh cac 6, tiii. Nhung vi khuin thdi rira sdng va sinh sin trong rad bio chit, chfing khdng xam nhip vao md b i o khde,
Nhu vay, d l phit triln nhilm tning thdi ngoai sinh, trudc tiSn cin cd nhiing mo bao chgt hay nhiing cue mau ddng hi phin hiiy, ttong khi su tuin hoin miu cyc bd bi roi loan va thigu byt o-xy ttong moi tnrdng vet thucmg.
Trong nhiing dieu kien nhu thi, dudi tic ddng cua nhirng men dupc tilt ra tir nhiing vi khuan thoi rua, xay ra su tan ra ciia nhirng rao bao chet, din din sy tich luy ptomain (nhora dpc t l thjt riia nhu cadaverine, muscarine v i putrescine) v i toxalbumin dpc (nhdra chit gay dpc te bio c6 ban chat protein), khi v i mii.
Nhiing sin phim cua su thdi riia md bao lam giim dpt ngpt phin iing viSm, su thuc bio, phin iing bao ve ciia mo bio cue bd v i lic che hoin toin su song ciia mo bio ttong vimg tie dpng true tilp.
Sau khi dupc hip thu vao raiu, chimg gay ra su nhilm dpc nang n l cho co the, lim giira dpt ngpt churc nang cua hg thong thin kinh va nhihig ca quan npi tang (giy ra su thoii hda-bign chat v i hoai tii trong cac ca quan npi tang)
3.3. Trieu chung
Diu tign nhilm trung thdi xuat hien ttong dang phii vigm liiy tiln. Khi vi khuan gay benh cd mat ttong vit tiiuong thi vio ngay tiiii 2 vit tiiuang bit diu tilt ra mii loang. Nhiing md bio chet bi nhGn ra, ra rupi cd mau xanh luc-xam va den-nau; su chay mau hiiy thanh mgch xuit hien.
Nhimg rao hat da dupc hinh thinh trudc do cung bl hogi tit va q u i trinh b^nh ly xay ra 6 ldp md b i o va CO quan nam siu hon. Gan, bao gin, co bj chet ttong khoing tiidi gian ngin, vung b^nh 1^* md rpng; nlu vit thuang d 4 chan, mdng cd thi bj bong ra.
Tit c i nhimg biln dli neu tten dan den su nhilm dpc nang cila ca the, than n h i ^ b^nh siic cao, nhip tira
va hd hap nhanh ban, trang thai chung ciia ddng vit bi lie che dot ngpt.
Tien lupng can than hay khdng thuin Ipi. Trong nhirng trudng hpp bj bd lieu, viec dieu tri khong co ket qui kha quan.
3.4. Dieu tri
Xem phan dieu tri nhiem triing ngoai khoa ygm khi.
IV. NHIEM TRUNG NGOAI KHOA DAC BIET
Mpt sd benh tmyen nhiem, ky sinh triing c6 lign quan dgn benh ly ngoai khoa hay ket qua chin doan, digu tri chiing dat dupc tot nhat bang phuong phip ngoai khoa, duac gpi la nhilm trung ngoai khoa dgc biet. Dien hinh l i benh uon vin (Tetanus).
Benh u6n van la bgnh tmyen nhiera c%) tinh chung cho nhigu loii vit nuoi va ngudi, do vi khuan Clostridium tetani xam nhap vao co the qua da v i nigra mac bi tdn thuang. Vi khuin tiet ngoai dpc to li tetanospasmm tic dpng dgn than kinh, gay co cimg ca vin va giat rung.
Benh uon van phin bo khip noi tten thg gidi, nhiing nude d vimg nhigt ddi gap nhieu hon. Benh thudng xay ra ttong nhimg viing nhat djnh, cd tinh chit le te, gpi la vimg udn van 6 nude ta do khi hgu nong im, benh xay ra gay tiiiet hai dang ke cho ngudi v i vit nudi.
Vi khuin Clostridium tetani la mpt tiuc khuin to, ngan, tiling hoac hai cong, bat mau Gram (+), yem khi triet dl; hinh thinh nha bao, khdng hinh thanh giip md.
Trong thign nhign, tit c i cac loai dpng vit c6 vii diu mic benh nhung mite dp cim thu la khac nhau:
ngua man cam nhat; tigp theo den ciru, trau, bo, Ipn;
chd v i meo it mic benh; loai chim khong mac benh.
Dpng vat mac benh d mpi liia tudi, thudng con non min cim ban
Nha bio ciia vi khuin phin bo rpng rai Irong dat, dudng tieu hoa v i phin cua dpng vgt; xam n h ^ vio CO thi chu ylu qua vit thuang; nhit l i khi bj thuang d bin chin, ke raong, bung; dac biet d vet thien, chd phau thuit, vet cat ron ciia ddng vat so sinh.
Nha b i o xam nhap vao vet thuang nhung de cd thi "niy m i m " thanh vi khuin, sinh sdi nay nd, tilt dpc to giy benh cin phai c6 2 dieu kien: ygm khi triet
lUlUAllQL. M i n U A l i n U 1 lAl-AAlV bU B - i U l /
de v i khong bj thuc bao; hai dieu ki?n niy cd dupc d cac vet thuang siu, mieng hep, ttong xoang hep c i a vet tiiuang cd nhieu mo bao dgp nit, cue miu dong hay ngogi vit.
Thdi gian nung b?nh tiiy ihupc vio khoing cich tu vi tri vet tiiuong tdi tmng ucmg thin kinh, dao dpng tir 3 - 2 1 ngay, thudng 8 ngay, d chd khoing vai tu&i; khi thdi gian nung b?nh cing ngan thi ty lg chgt cang cao Chd mac benh cd bilu hign giat rung quan sit rd d nhom co gin vit thuong; cic trieu chiing khac bieu hien md nhat (con benh bi ciing co, ciing ham, nudt khd khan, kho thd, dudi cong, lung tiling, bon chan thing-dau hi?u ciia co cimg co van). Khi con b?nh hi kich thich nhe v l thinh giac, thi giac deu cd bigu hien hoing hit, run riy, tiiira chi co giat va nga ra
Khi radi mac bgnh, than nhiet cua benh siic khdng tang, nhung liic gan chet, thin nhiet cd the tang 2 - 4°C, xic nong, mem; tim dap nhanh-ygu, kho tho, huylt ap tang, va md hdi khap co the, bi dai, bi ia. Do bi CO Cling him, con benh khong tu liy thiic an, nude udng dupc; benh tiln tnIn ttong vdng 1 - 2 tuin, con vgt se chit.
B?nh u l n van thudng cd tinh chat vung; vi vay, ttong viing uon van can chu y tiem phdng bgnh cho ngudi v i vit nudi. Khong tiem phdng dai tri cho vat nudi noi chung, chd ndi rieng; chi ngn tiem 1ml giai dpc t l dudi da trudc khi titign 1 tiiang va ttera mpt lin niia ngay sau khi tiiiln xong. Nhung con bi thuang nglu nhien hogc trudc khi tiiuc hien phiu thuat nao do, CO thi tiem huylt thanh khing ddc td u l n van, sau do tiera giai ddc t l d vi tri khac.
Khi do de cho chd, cin tiet tning cin tiign cic dung cy sit dung v i tay ngudi thuc hien thu thuit Cat diit diy ron d chd each thanh bung ciia nd 1cm, vuot khd cuing ron, sat tning n6 bang cdn lod 5% hay povidone iodine 5% (nen nhiing day ron vio cdc dung dung dich sat tning khoing 1 phiit); khdng nen thit diy ron lai.
Pbuang phip dieu tri:
Xu ly ngoai khoa vit thuang khong chgm ttg (xem phin dilu tri nhilm trung ngoai khoa yera Idii).
Tiem huylt thanh khang dpc to udn van v i giii dpc td uon vin. Huylt thanh phai dimg sdra mdi cd hieu qua (khdng ngn d l qui 12 gid sau khi hi thuang), khi con b?nh da Ign can co giat thi huyet thanh khdng CO tic dung. Sau khi tigm huylt thanh khang dpc to 1 tuan, tiem 3 - 4 raiii vacxin giii doc t l uon van (tiem dudi da, each ngiy tiem mpt lin, lieu lupng Iml/con),
Tiem khing sinh lilu cao hang ngiy: penicillin, cephalosporine, tettaxycline,...
Diing cic logi thulc ttin finh than kmh hay an thin (cloral hydrat, magnesi sulphat, aminazm,...).
Thudc ttp tira (camphora, caphein, adrenalin). Thu6c gian phg quan (ephedrin).
HO ly-cham soc tich cyc, ttong trucmg hop cin thiet, cho an udng bing 6ng thong.
V. su* DUNG KHANG SINH TRONG NHIEM TRUNG NGOAI KHOA
Hign nay ngudi ta da xac dinh rang, viec sir dimg khing sinh khdng cd can cii ttong nhiem irung ngoai khoa thudng mang lgi sy c6 hai nhieu han la c6 Ipi, mac dil chiing cd y nghia du phong va dieu tq dgc biet;
nhu khi sit dung khang sinh dai ngiy bang dudng cho udng c6 thi din dgn sy loan khuan ttong dudng dg diy-mdt va xuit hi^n sy d l khang ciia vi khuin,
Nhimg chi djnh sii dung khang sinh khong dieu kign, trudc tign phii k l din: Nhilm tning huyet, nhiing 6 hoai tii-mii kin gay ra sot-hip thu mu ro r?t;
ngay ca khi tdn thuang nhiem tning mu cac xoang giai phlu, nhiem frimg yIm khi, benh xg khuin va rapt vai tmdng hap nhiem n i m khac.
Sur dyng khing sinh sdm vdi sy tinh toin dgn tinh man cam vdi chiing ciia tie nhan giy nhiera trung cho phep dgt dupc higu qua dieu trj cao Hieu qui dieu tri cdn tang cao, nlu nhu tmdc 36 da tien hinh xii ly ngogi khoa vit thuang; ngay c i sau khi hut mu d nhung xoang kin v i rita chiing cin thgn bang cic dung dich sat tning. Hieu qui cua khing sinh dupc tang len dang k l nlu chiing ta tigm bap thit prodigiosin cho bgnh siic (lilu trung binh cbo chd 10 - 15mg).
Nong dp Iy tudng ciia khing sinh trong 6 nhiem trimg dat dupc khi dua cbiing vao dpng mach viing do.
Tuy nhifin, ciing cin phm noi ring, nong dd ciia khang sinh qui cao ttong ca thi se lie chg hd hip md bao, kim ham qua trinh phyc hli v i giira khang the tu nhign; dac bigt, khi sir dung chiing vdi tiidi gian dii. Khong thg dua khing sinh vio ca the vdi lieu t h ^ , vi vigc Iam d6 din din su xuit hien chiing kfaang khing sinh cua vi khuin.
Ligu trinh khing smh d nhiing trudng hpp benh nang thi keo dii han. Sii dyng thdi gian dai khing sinh nio do hay l i su ket hpp chiing cd thi tgo dilu kien phat triln bdi nhiem (superinfection). D I dieu dd khdng xiy ra, cin tiiay d l i khang sinh qua 5 - 7 ngay sit dyng hoac lau ban vdi sy kiem tta vi khuan
KHOA HQC KY T H U A T THtJ Y TAP XXIV SO 8 - 2017
hpc trudc khi thay ddi chiing (xic djnb tinh man cam vdi khang sinh ciia h? vi khuin ttong 6 benh).
Khi nhiem trung Staphylococcus v i nhirng t i c nhan khdng ro, sit dvmg: ampicilline, oxacillin, bicillin, lincoraycin, fiisidin,,.. Kgt hpp vdi nhiing khang sinh tic dpng den h? vi khuin Gram (-) nhu:
kanamycm, gentamycin, monomycin,...
Khing sinh cd t i c dyng tdt hon ca doi vdi B.
pyocyaneus li: kanaraycin, polymycin, gentamycin, carbecillin.
Trong nhilm tning cue bd v i toin thin gay ra bdi E. coli v i Proteus, hi§u q u i han c i l i ket hpp ampicillin vdi levomycetin, kanamycin, colistin.
5.1. Su dyng khang sinh t^i cho
Viec sii dung khang smh tgi chd (cyc bp) duoc thyc hien bang each: tudi, tam din luu mim, i p khan vai man dupc tim d i m dung dich hay huyln djch khang sinh va ngay c i bang cich bdi (thoa) thanh cua xoang bfnh ly sau khi da xir ly ngogi khoa (loai bo md bio chet, rita bang cic dung dieh sit triing).
Thudng sit dyng khang sinh k i t hpp vdi novo- cain, lieu phip phong bg (hay phong be ngan) dg tao tiianh d i m tham nhiem xung quang 6 nhiera trimg, sao cho dung dich dupc dua vao ngay c i phia dudi diy ciia nd.
Khi dilu tri dpng vat bj nhilm triing ngoai khoa, kit hpp mdt cich hpp ly khang sinh vdi sulfanila- mid (can thilt phai tinh dgn sy khdng phii hpp ciia sulfanilamid vdi novocain). Khi tac dpng ra nhieu mat khac nhau cua sy trao ddi chat tg b i o vi khuin, sulfanilamid inh hudng tdi vi khuan nhu Ii nhung chat hop lyc (syner^st) cua khang smh, sau khi tang cudng lan nhau tinh khang khuan ciia chiing.
5.2. Su dung Iching sinh t o i n t h i n
Cd hieu q u i lan nhit khi tiem khing sinh v i o dudi da, ea bap, tiiih mach, dpng mgch, dpng mgch chu. Khi su dyng, phan Ion cic loai khing sinh dupc hda tan bang dung dich novocain 0,25 - 0,5 %.
Khi tiem b i p cd thi bd sung mpt each hpp ly mau cua chinh con vat dupc dieu trj, dieu do tao dieu ki?n keo dai thdi gian tac dpng ciia khing sinh va cho phep r i t bdt sd l i n tiem ttong ngay.
Ngoii ra, hieu qua dieu tri ciia khing sinh dupc gin liln vdi hifu qua ciia li^u phap mau ty thin {au- tohaemotherapia).
Tiem tinh mach cdc thuoc sau xung ddng du(/c chu y:
Nhirng dung djch cua mudi novocain natri ben- zilpenicillin v i novocain moiphocyclin.
Erytromycin ascorbinat ttong dung dich nude muoi sinh ly hay glucose 5% (ty Ie pha: Img/ml dung mdi).
Oleandomicin pha ttong dung dich glucose 5%
(2mg/ml), tigm nhd giot (truyln) 3 lan trong ngay.
Tiem gentamycin sulfat v i o tlbh mgch khi nhilm tning raii nang.
Tigm dung djch khing sinh v i o npi bi (trong da) lam tang cao hira lupng ciia chiing ttong mach va hach lympho viing. C i c loai tetracyllin sau khi dupc hap thu v i o he thdng lyrapho c6 the tao thanh ttong do ndng dp cao hon d ranh gidi md b i o linh va benh ly, ttong viing vigm va ttong cic khoi u.
Tiem dudi da, tigm b i p thit: monomycin, ka- naraycin va gentamycin dam bao cho sy h i p thu nhanh chdng ciia chiing vao mau, tiep theo la su xam nhap v i o dich nao tiiy, dich phuc mac, dich khdp, djch phe mgc.
VI vay, xiing ding dupc sii dyng khang sinh Ifhdng nhiing chi khi nhigm triing ngoai khoa cue bp ma ngay ca khi nhigm triing ngoai khoa loan than (nhilm triing huyet). Cd y nghia dac biet ttong dieu tri nhilm triing huygt la tigm cham vio tinh mach morphocyclm pha ttong dung dich glucose 5%.
5.3. D I ph6ng x u i t hif n su* k h i n g k h i n g sinh ciia vi k h u i n
Sii dung rpng rai khang sinh ttong thu y vdi myc dich digu tri ma thieu sy giim sat day dii ciia cin bd thii y v i thilu nhiing chi dinh nghiem khac, dan den sy xuit hi?n nhiing chimg ben viing vdi khing sinh sii dung ciia vi khuan.
Tinh den nhung van de neu tren, khi su dung khdng sinh cdn chu y:
Su dyng khing sinh vdi myc dich dilu tri dudi sy kilm tta nghigm nggt ciia cin bp thii y, chi djnh dung khang sinb khi cin thilt.
Lua chpn khing sinh vdi sy can nhac tinh nhgy cam vdi chung ciia cac t i c nhan gay ra nhiem tning.
Nhit thilt phai sit dyng lieu Iy tudng v i con dudng dua thulc vio co thi, d i m b i o n i n g dp cd
KHOAHQCKY THUAT THO Y TAP XXIV SO 8 - 2017
hi?u qua digu tri cao ciia khang sinh ttong co the v i ttong I nhilm ttung.
Ket hpp dilu tri bing khang sinb vdi sulfanilamid va cac vitamin.
Khdng cho phep su dung khang smh thigu su kigm tta, v i dimg nhu nhiing chat kich thich tang ttpng vit nudi.
5.4. T i c dgng phy v i biln chihig khi dilu tri bang khing sinh
Dudi tic ddng ciia khang sinh, khi dilu tri nhiem tning ngogi khoa cip tinh, co thg lam ha than nhiet ve miic binh thudng (giam sit) va binh thudng hda phan ling ciia bach ciu, ngay c i lam giam va loai bo tneu chiing dau; tuy nhien, nhiing diu hi^u nay khdng luon ludn the hien trang tiiii chin thyc ciia qua trinh, do do b?nh cd thg keo dii hay tai phit.
Ngoai ra, dudi sy anh hudng cua khing sinh, ddi khi sau 2 tuin (cd thi sdm hon hay mupn hon) xuit hi?n phin img d; iing Khi sir dung khang sinh cyc bp, phin ling di iing tiig hign d dang vigm mieng (stoma- titis), tin thucmg eczema d da (tiiudng quan sat dupc d cho).
Cho uong khing sinh dii ngay, phit trien chiing logn khuan (dysbacteriosis) ttong tat c i dudng dg day-mot, din den mac bfnh nim Candida (Candidamycosis); khi do ludi cd raiu dd, tren ludi v i mdi xuit hien nhiing bdng nude nhd, sau d6 ludi bj den Igi, dupc bao phii bdi mpt ldp ming nham, nhung nil logt ndng xuit hien; qua trinh b^nh ly cdn dien ra d hiu, thanh quan, thuc quan va khi quin; cd the xuat hifn Candida huygt.
Nhiing qua trinh nhiem tning dai ding, sp suy nhupc ciia ca the, tic ddng cua tia sang, benh ciia he thing miu, rli loan trao ddi chat npi tigt va thigu cac vitamin,... tao dieu kien xuit hi^n b^nb Candida v i phin ling dj img. De ngan chan sy xuit hien thir phit cua nd, phii tinh toin mpt each hpp I^ khing sinh lieu phip vdi sir dyng cic logi vitamin: C, B,, B^, B^, K, PP (acid nicotinic).
Khi bi di img, phdi ngimg su dung khdng sinh vd sir dung cdc bien phdp duoi day.
Tiem dudi da mot trong so cac loai cocticosteroid nhu: hydrococtizon, prednizolon, dexamethason.
Cd thg sit dung ACTH kit hpp vdi tiem &ih mach 1 ttong sd dung dich khing hisamin: dimedrol (0,02
- 0,04g/ch6), tiem 2 - 3 lin /ngay. Diprazin (0,01 - 0,02g/chd), 2 - 3 lin/ngiy. Supractin sir dyng lieu nhu diprazin c6 hi^u qua tdt nhat.
Trong viing tigm khing sinh bi dj img, tigm mpt cich hpp Iy dung dich adrenalin 0,1% (0,2 - 0,5 ml/
chd) kit hpp vdi mdt ttong s i cic thudc khing hisla- min ke ttgn.
Neu dj ling giy ra bdi penicillin, ngudi ta tigm bip penicillinaza (300000 - 500000 Ul/chd).
Khi da phat triln Candida, can ngimg ngay vi?c sir dung khang sinh. Bdi nhiing d ton thuong bang dung dich con tim gentian. Cho udng iodua natri hay iodua kali (0,2g/kgTT) hoac dung djch lugol (0,5ml/kgTT).
Tiem tmh mgch canxi clorua 5% va sulfenilamid. Hieu qui Idn hem c i la tigm tiiih mach (nho giot) amphote- ricin kit hpp vdi nystatin v i levorin. Cho udng cac logi vitamin B, C, K. v i cac che phira khang histamm.
TAI LIEU THAM KHAO
1 Lg Anh Cudng (2009). Nghien ciru qud trinh sink hQC vet thucmg a mot so vgt nuoi vd bien phdp dieu tri. Luin van Thgc sy Khoa hpc Ndng nghiep Trudng Dai hpc Nong nghigp Hi N^i.
2 Nguyin Ba Hien, Huynh Thj My Lg, Lg Van Lanh, D l Thi Ngoc Thiiy, Dang Hiiu Anh (2012). Gido trinh B^nh truyen nhiem thu y. Nhi xuat ban Sai hpc Ndng nghigp H i N6i.
3. Huynh Van Khang (2003). B^nh ngogi khoa gia siic. Nhi xuit ban Nong nghiep. Hi Npi.
4. Vu Nhu Quan, Chu Dftc Thing (2010). Nghien cihi bien doi b^nh ly cue bd cita vet thuang & dong vdt vd bien phdp phong tri. Tapchi Khoa hpc Ky thugt Thii y. Tap XVn, s6 3-2010: 63-70. Hpi Thii y Vi, Ha Npi.
5. Va Nhu Quan, Chu Diic Thing (2010). Mot sd chi tieu ldm sdng, sinh ly mdu a cho mang vet thuang.
Tap chi Khoa hoc va Phat triln. Tgp 8, so 3: 458- 461. Trudng Dai hgc N6og nghigp H i Ndi.
6. Nguyen Thinh Tnmg (2010). Nghien cuu su bien doi mgt so chi tieu ldm sdng, chi lieu mdu cita cho khi mdc vet thucmg va thit nghi?m dieu trj. Lugn van Thgc sy Ndng nghiep. Trudng Dai hoc Nong nghiep Ha Npi.
7. Belov A. D., V.A. Lukianovxki, B.A. Baskirov, A.B. Exiutin, LK. Kalasnhic, M.V.Plakhotin (1990). Ngogi khoa thu y dgi cuong. Nha xuit bin Cdng NSng, Matxcava, CH Lien bang Nga ./.
