82 Tap chi GAN MAT VIET NAM so 32-2015
Khang sinh dy phong va nhiem trung vet mo trong phiu thuat no!
soi cat tui mat
Prophylactic treatment by antibiotics and wound infections in laparoscopic cholecystectomy
Biii Manh Con
Tom tat
Muc dich: Khao sat mdt sd yeu td vd viec sii dung khang sinh du phdng va nhiem tning vet md trong phau thuat npi soi cat tui mat.
Phmmg phap: Tien ciiu cat ngang md ta Ket qua: Tdng sd trudng hpp 612. Nara/nu = 1/4.100% cac benh nhan dupc danh gia ASA I, n . 100%) cac bac sT phau thuat cd kinh nghi?m tir 10 nam trd len. Cac rdi loan Iam sang sau md dupc
ghi nhan: dau vet md, sdt, dau + sdt, tu dich sau md, .... Cd 8,2% benh nhan dupc danh gji bi nhiem triing vet md tai thdi diem xuat vien.
Ket luan: Ty le nhiem tning vet md dupc danh gia tai thdi diem xuat vien la 8,2%. Day la k ^ qud sdm ciia nghien cuu. Su dung khang sinh du phdng diing va hpp ly la dieu can thidt, tuy nhien can phai xem xet them cac yeu td ve tinh trang benh nlmn, cham sdc benh nhan trudc va sau md, tay nghe ciia bac sT phiu thuat
Abstract
Purpose: Surveying a number of factors on wound infection and the use of prophylactic anti- biotics in surgical laparoscopic cholecystectomy.
Methods: A cross-sectional descriptive study.
Results: The total number of cases 612. Male / female ^ 1/4. 100% of patients were evaluated ASA I, n . 100% of surgeons widi at least 10 years' experience. The postoperative clinical disorders are recognized: incision pain, fever, pain + fever,
Dat v i n d£
Nhiem khuan vet md (NKVM) la hau qua khdng mong mudn thudng gap nhit va la nguyen nhan quan trpng gay tii vong d ngudi benh dupc phau thuat tren toan thd gidi.
Nhiem khuin vet md (NKVM hay nhiem khuin tai viing mo, nhiem khimn tai vi tri md) la nhiing nhilm khuin tai vi tri phau thuat trong thdi gian tii khi md cho den 30 ngay sau md vdi phau thuat khdng cd cay ghep va cho tdi mot nam sau md vdi p h i u thuat cd ciy ghep bd phan gia (phau thuat implant). [4], [5], [6], [11].
fluid after surgery,.... 8.2 % of patients were eva- luated as wound in fection at the time of discharge.
Conclusions: The rate of wound infection was assessed at the time of discharge was 8.2%. Here are the early results of the study. Using proper and reasonable prophylactic antibiotics is essential.
However, it is necessary to consider additional factors in the patient's status and care about pa- tients before and after surgery as well as the skill of surgeons.
Ca, 10 chiic hen k^ -
Caquanldioangctrthe
Hinh 1: Vi tri nhiim trdng vit mo fSJ
Cac phiu thuit ngoai khoa thudng dupc chia sinh khac nhau. Khing sinh du phdng thudng thanh 4 nhdm: sach, sach nhiem, nhiem va bin, dupc dat ra trudc cac tnrdng hpp phiu tiiuat "sach tiiy theo loai phau thuat cd hudng sir dung khang - nhidm". Trong tnrdng hop md "sach" thi ky
Tap chi GAN MAT VIET NAM s^ 32-2015 83 thuat va kinh nghiem phiu tiiuat la b i ^ phap tdt
nhat dd cd dupc mpt ty le nhiem tning tiiip ngoai tru trudng hop ciy ghep mdt vat the la. Trong tiirdng hpp md nhidm hay bin thi khang smh thudng cd vai trd didu tii. Thdi didm diing khang sinh dir phdng la vin dd miu chot. Khang sinh can hien dien trong mau va cac md vao liic cd the bi nhiem triing. Nhu vay khdng the xem vide sii dung khang sinh sau phau thuat la bien phap ngan ngua thich dang \i nguy co cac tai bien do nhiem trung tuang duong vdi trudng hpp khdng dxing khing sinh dy phdng. Do dd hieu luc cua viec dung khang sinh du phdng bang khang sinh chu yeu la do thudc duac dua vao co the trudc liic phau thuat. Mpt lieu khang sinh bang dudng tiem chich vao liic din me hay tdi da 30 - 45 phut trudc md thdng thudng cho phep dat ndng dp d md can thiet trong liic phau thuat. Neu cudc phau thuat keo dai (> 3 gid) hay mat mau nhieu thi mot lieu thii hai can cho them khi dang khi phiu thuat. \^ec cho Idiang sinh sdm each khoang 2 gid trudc Iiic rach dao cd the din den tinh trang ndng dp thudc ti"ong md giam qua thap. [I], [3], [5], [8]. Sdi tiii mat la benh ly phd bien, phau thuat cat tiii mat ndi soi la tieu chuan vang trong dieu tri benh ly nay, day la phiu thuat "sach- nhiem" dupc chi djnh dung khang sinh du phdng trong thdi gian phau thuat. Tai Benh vien Bmh Dan, day !a phiu thuat dupc thuc hien hang ngay tai khoa ngoai gan mat.
Do vay chiing tdi thuc hi?n nghien ciiu nay nham danh gia:
*©anh gia hieu qua cua viec su dung khang sinh du phdng va tinh ti^g nhidm tiling vet md trong phiu thuat ndi soi cat tiii mat cd trieu chiing do sdi tai benh vien Binh dan tii 11/2010 den 11/2014"
Muc tieu chuyen biet
ti> Xac dinh mdt sd d^c diem ve lam sang va can lam sang, ti le bien chiing nhilm triing sau phiu thuat d cac benh nhan ti-en.
£;> So sanh viec sii dung khang sinh 1 lieu va 2 lidu vdi tinh trang nhiem tiling vet md sau phau tiiuat khi xuit vien.
pbuffng phAp nghien cihi Loai nghiin cim
Hdi ciiu, cat ngang md ta.
n = — • — ^
d
a = 0,05, Z = 1,96, d= 0,05, ti le nhidm tiling dukidnp=10%
Vay cd mau can =s 138 tivdng hpp.
Cho den nay, y van vln chua thdng nhat ve thdi gian dung khang sinh du phong, nhung da sd cac tac gia deu thdng nhit rang tiidi gian dung ngan nhat neu cd the. \^ec keo dai khang sinh du phdng se khdng lam tang hieu qua ma cd the lam tang nguy ca chpn loc chung khang thudc, nguy co chiu tac dyng phu va chi phi tdn kem. Nhieu nghien ciiu cho tiiay hieu qua cua mdt lieu khang sinh duy nhat cho trudc md cho thay cd hieu qua tijong duang nhu khang sinh dy phdng dung keo dai hon.
Nguyen tac sir dung khang sinh dy phdng:
^ Mdt loai khang sinh, cd phd bao tnim chiing vi khuan gay nhidm trimg.
0 Tiem mach liic bat diu tien me.
O Sir dung khang sinh du phdng giiip lam giam ti le nhiem trung cua phau thuat. Lieu khdi dau trong vdng I gid trudc phiu thuat hoac ciing luc vdi tidn me va cham dut ti-ong vdng 24gid.
£^ Duy tri ndng dp khang sinh hieu qua trong sudt cudc md. Ddi vdi cudc md chuang trinh, viee duy tri ndng dp nay khdng keo dai qua 12 gid sau mo. Ddi vdi cuoc md cap cim, cd the tiem Hdu thii hai sau Ueu dau 12 gid.
Khang sinh dupc cho vao ngay hau phiu thu hai ti-d ve sau khdng dupc xem la khang smh phong ngira. Cd mdt sd nghien cdu dd nghi keo dai tiep tuc khang smh den 72 gid sau phiu thuit.
Tuy nhien da sd nghien ciiu nhan thiy dung khang sinh dy phdng keo dai khdng cd lpi ma lam tang kha nang khang thuoc ciia khdng sinh va tang chi phididutii. [2],[8],[10].
Ueu chuan chgn benh (cdc benh nhdn thoa mdn cdc dieu kien):
i=> Tat ca cac trudng hop benh nhan viem tiii mat do sdi.
i=> dupc md chuang tiinh cit tiii mat ndi soi.
84 Tap chi GAN MAT VIET NAM s^ 32-2015
£p cd diing khang sinh du phdng: 1 tieu hoac 2 lieu.
O trong thdi gian tir 11/2010 ddn 11/2014.
Ueu chu&n logi trie (cdc benh nhdn chi cdn thda mdn 1 trong cdc dieu kien):
O Benh nhan chuydn md hd hay benh nhan cd tlii mat vidm ma can diing khang sinh dieu tri dupc danh gia trong luc md cua bac sT phau thuat.
£;> Benh nhan di img khang sinh dy phdng ban diu phai chuydn qua diing mdt loai khang smh thudc nhdm khac.
c? Benh nhan giam mien dich nhu: dai thao dudng, sir dung Corticoid, benh nhan nhiem virus HIV...
Cdc tnr&ng hgfp duac ghi nh^n id nhiem trdng sau phdu thuat:
i=> Benh nhan sdt sau phau thuat, cd bach cau tang, chu yeu la da nhan trung tinh.
£? Tu dich dudi gan qua sieu am kiem tra.
10 Nhiem tning vet md.
Bdnh gid kit qua:
Theo dinh nghia cua t6 chuc CDC (center for disease control and prevention)
- Nhiem trung tren be mat vdt md.
- Nhiem tning sau ben trong ciia vet md.
- Nhiem trimg cac ca quan hay cac khoang cua vi tri rao.
Trieu chiing cua nhidm tiling vet md: dd va dau xung quanh vi tri duoc phau thuat, dan luu ra dich due tir vi tri dupc phau tiiuat, sdt.
Do vay, chiing tdi danh gia tinh trang nhiem triing benh nhan dya vao cac tieu chimn ciia CDC va:
0 Ket qua tot: khi BN hoan toan khdng cd nhiem tning.
0 Ket qua trung binh: khi benh nhan cd bidn chiing va dap ling vdi dieu tri ndi khoa.
O K^t qua xau: khi cin md lai.
Phdn tich vd xu ly sd lieu
Tit ca sd lieu dupc ma hda, nhip va tinh toan dya vao phin mem SPSS. Sir dung cac phep kiem Chi binh phuang va Fisher. Khic biet cd y nghia thdng ke khi p< 0,05.
Ket qua
Tdng sd trudng hap nghien cuu: 612 ca Tile nam/nii =122/490-1 :4 Tudi:
> 60 tu6i
< 60 tu6i
Soca 99 513
Ty 18 (%) 16,2 83,8 Nhdn xet: phdn lan benh nhdn co do tudi nhd han 60.
Ly do n h a p vi^n Dau nhe ha suon phai (HSP) Dau HSP + S6t T6ng
8 5 lirgng (n) 605
7 612
T y l e ( % ) 98,9
1,1 100 Nhgn xet. phdn ldn benh nhdn nhap vien vdi trieu chung dau nhe vimg hg sudn phdi.
(cdc trieu chimg dau HSP, sot duac ghi nhdn trong phdn tien sir).
Cdc benh ly mgn tinh kem theo ghi nhgn trong tan su
Tien can Tim mach (cao huyet ajj, nhoi mau c a tim cu, thieu nang vanh, suy tim) Tieu duong Ho hap (benh phoi man tmh)
Khong T5ng
So lirgng
(n) 14 6 2 590 612
T y l l
(%)
2,3 1 0,3 96,4
100
Nhgn xet: phdn lan cdc benh nhdn khong co cdc benh ly mgn tinh kem theo.
Tri^u chimg lam sdng chinh khi khdm:
Tap chi GAN MAT VIET NAM so 32-2015 Tri§u chung
Dau HSP nhe+ sflt + vang da nhe Chi CO dau nhe HSP DauHSP + s6t Tong
S6 lu-yng (n) 2 601
9 612
Tylf(%) 0,3 98,2
1,5 100 Nhgn xet: trieu chung Idm sdng chuyeu Id dau
hg suanphdi. Cdc trudng hop co sot, vdng da nhe Tinh trgng binh nhan tru&c mo theo ASA:
dufrc theo doi vd tu het giai dogn tien phdu, cdn can thiep npi khoa.
Dac tinh Nam
NO
ASM ASAn ASAl ASAn
S6 Imjng (n) 115
7 475
15
Tyle(%) 18,8
1,1 77,6
2,5 Nhdn xet: cdc benh nhdn deu duoc ddnh gid o
muc ASA I, II
22 truong hgp co ASA II Id do co cdc vdn de ve tim mgch, tieu duang, benh ly ho hdp nhung nhe vd dugc ghi nhdn trong tien cdn.
Thai gian mo
Nhdn xet: co 22,4% truong hgp co dan luu sau mo.
Bdc si phau thudt kinh nghiem
Thoi gian 30 phiit-60 phut
>60phut Tong
So linjng (n) 549
63 612
Ty le(%) 89,7
10,3 100
Solimng 10 nam -20 nam
> 20 nam T6ng
So Iwgng (n) 164 448 612
Ty If (%) 26,8 73,2 100 Nhdn xet: 73,2% truong hgp dugc bdc si co kinh niem > 20 ndm thuc hien.
Thai gian nam viin sau md Nhdn xet: thai gian mo 30 phut - 60 phiit
chiem phdn lan.
Bat din luu sau md:
Dan lull sau mo CodJnliru Khong dSn lira T6ng
So luvng (n) 137 475 612
Tj'Ie(%) 22,4 77,6 100
Thoi gian nam vien sau md
< 3 ngay 3 ngay - 1 tuan Tong
So luvng (n) 565 47 612
Tylf(%) 92,3 7,7 100 Nhdn xet: 15 truong hgp co thai gian ndm vien tir 3 ngdy -1 tudn.
86 Tap chi GAN MAT VIET NAM so 32-2015 Cdc biin chirng sau mo ngi soi cat tui mgt
Cac roi loan Dau vet mo
set
Dau + sot Tu dich sau mo Dau + chay dich vet mo Tong
So lirong (n) 28
9 7 21 13 78
Tyl«(%) 4,5
1,5 1,1 3,4 2,2 12,7
Nhdn xet: co 78 trudng hgp (chiem ly le 12,7%) co cdc bien chimg hay roi loan Idm sdng sau phdu thudt.
Tinh trgng binh nhdn tru&c xuat viin:
D^c tinh
Nam
Nu
t6t Trung binh
xau
tat Trung binhX4u
S6 luong (n) 105
17 0 457
33 0
Ty le (%) 17,2 2,7
0 74,7
5,4 0
Nhdn xet: 50 trudng hgp (8,2%) xudt vien dirge ddnh gid Id trung binh, cdc trudng hgp con Igi dugc ddnh gid Id tot.
Khang sinh 1 hay 2 lieu va ^ h trang benh nhan liic xuat vien:
Tinh trang
T6t Trung bmh
Tdng
Khang sinh 1 lieu
So lu-gng (n) 260
23 283
Tyle(%) 42,4
3,8 46,2
2 lieu So luvng (n)
302 27 329
Tyle(%) 49,3
4,5 53,8
P
P
>0,05
Nhdn xet: Khong co sitT khac biet ve viec sir dung khdng sinh du phdng 1 lieu hay 2 lieu
Tap chi GAN MAT VIET NAM so 32-2015 87 Ban luan
Nghien cuu ciia chiing tdi gdm 612 benh nhan phiu tiiuat npi soi cat tiii mat cd tiieu chiing do sdi cd diing khang sinh dy phdng tai benh vien Binh din tij 11/2010 ddn 11/2014.
Tudi: b?nh sdi mat cd tiid gap d mpi dp tudi, tir 20-80 tudi va tinong bmh khoang 45-55 tudi. Tan sd mac benh sdi mat cao nhat d dp tudi 60-70.
Trong nghien ciiu nhdm tudi tu < 60 chiem uu the.
Nhdm tir 60 tudi trd len chiem ti le 16,2%, day la nhdm tudi can phai luu y vi kha nang chiu dyng mdt cudc md kem hon, tinh trang nang cua sdi dudng mat tang theo dp tudi, va thudng cd nhiing benh man tinh di kem theo. [7],
Gidi tinh: ti le nam : nu ^ 1 : 4 ndi len tinh uu flie ve gidi nti cua benh sdi tiii mat va phii hpp vdi ti le ciia nhieu cudc n ^ d n ciiu trudc [9]. Gia thidt dat ra dupc chap nhan la: ndi tiet td nii (Oestro- gen) lam tang choelesterol trong dich mat, mat khac progesterol lam giam kha nang co bdp cua tiii mat din den su ii tre d tiii mat lam tang nguy CO tao sdi.
Hau het benh nhan nhap vien vdi ly do dau bung am i vimg ha sudn phai (chiem ty le 98,9%).
Chi cd 7 benh nhan (1,1%) la nhap vien vi dau vimg ha sudn phai va cd sdt. Ket qua nay cho thay hau het cac benh nhan nhap vien khdng phai d tinh trang cap ciiu vi tat ca cac benh nhan trong nghien ciiu dupc sap xep theo hen nhap vien, md chuang tiinh cat tui mat npi soi.
Cac benh ly man tinh kem theo dupc ghi nhan qua tien sii va sau khi khim lam sang, can lam sang benh nhan: tim mach, tidu dudng, hd hap;
tuy nghien vdi ty le khdng nhidu.
Vd trieu chdng lam sang khi kham chi cd 2 benh nhan (0,3%) la cd bidu hien ciia tinh ti-ang nhidm trimg dudng mat (dau, sdt, vang da), 9 bdnh nhan (1,5%) cd tiieu chiing dau va sdt. Ket qua nay mdt lin nua cho thiy hiu hdt cac bdnh nhan nhap vien vdi tinh trang lam sang dn, cam giac khd chiu vimg ha sudn phai la nguyen nhan chinh khidn benh nhan kham benh va dupc chi dinh phau thuat. Didu nay cho thiy can phai cd chi dinh dimg ddi vdi cac tiirdng hpp viem tiii mat do sdi dupc md chuang tiinh, benh nhan phai thyc sy cd
tri|u chiing dau viing ha sudn phai hay sdi tiii mat cd tiieu chung tiii mdi cd chi dmh phiu tiiuat.Tinh trang lam sang benh nhan trudc md (danh gia theo ASA): cac benh nhan deu cd tmh trang dn, dupc danh gia ASA 1, n.
Trong nghien ciiu nay, thdi gian md tii 30 phiit - 60 phiit (89,7%). Chi cd 10,3% cd thdi gian md keo dai tien 60 phiit. Nguyen nhan thdi gian keo dai la do mdt sd tmang hpp vach tiii mat viem day, chay mau trong Iiic phau tich tam giac gan mSX hay bdc tach giudng tiii mat, do roi sdi trong liic lay tiii mat. Phan ldn cac trudng hpp khdng can dat dan luu dudi gan (77,6%), mdt sd tiudng hpp can dat din luu do bac sT phau thuat nhan dinh se cd dich tiet ra dudi gan va de theo doi cac tai bien va bien chiing cd the xay ra.
Dau vdt md (28 tiirdng hpp, 4,5%): cac tiudng hpp nay deu dupc cho paracetamol giam dau va tat ca cac tmdng hpp ddu dn sau do 1 - 2 ngay hau phau.
Sdt (9 trudng hop, 1,5%): 9 trudng hpp sdt ngay dau hau phau, dupc dimg paracetamol va tiJ het sdt ngay sau do, cac trudng hpp nay dupc thd cdng thiic mau va sd lupng bach cau da nhan trung tinh khdng tang. 2 trudng hpp sdt keo dai 3 ngay, cdng thiic mau cd bach cau tang (chii yeu la da nhan trung tinh), benh nhan nay dupc ddi khang sinh manh (Cefaclosporin the he 3 + metronidazole), sau dd tinh trang cai thien va xuat vien d ngay thu 7 hau phau.
Dau + sdt cd 7 tmdng hpp keo dai 3 ngay, cdng thiic mau cd bach cau tang (chii ydu la da nhan trung tinh), ca 7 trudng hpp nay dupc ddi qua khang sinh dieu tri, va benh dn tai thdi diem xuat vien.
Tu dich sau md (21 tiiidng hpp, 3,4%): Cd 21 tiirdng hpp sieu am kidm tia phat hien tia dich dudi gan sau md. 15 trudng hpp cd dat din luu va 6 tiirdng hpp khdng dat din luu. Ca 21 trudng hpp lam sang deu dn. Cac trudng hap c6 dat d§n luu dupc xoay ndi din luu. Tat ca trudng hpp nay ddu dupc giii lai 3 - 5 ngay de flieo ddi va cho xuit vidn.
Dau + chay dich vet mo (13 tiirdng hpp, 2,2%): 4 tiirdng hpp chay dich tai noi dat dan luu, 7 trudng hpp la tai Id ti-ocart d rdn: Cac trucmg hpp nay dupc cho thay bang vdt md 3 lin ti-en ngay, ddi khang sinh manh (Cefaclosporin ttid he
88 Tap chi GAN MAT VIET NAM s^ 32-2015 3 + meti-onidazole). Tinh ti-ang iam sang cd cai thipn, vdt md khd lanh tdt va cho xuat vien hau phSu ngay 6-7.
Chung tdi ghi nhan cac trudng hpp sdt cd bach cau tang, tu dich sau md, dau, sdt va chay dich vet md la mdt tinh trang nhiem tning sau md: 50 trudng hpp. Do vay cac tiirdng hpp nay deu dupc danh gia la trung binh. Tuy nhien cac trudng hpp nay dupc didu tri va ddu cai thien lam sang tdt d thdi diem xuat vien.
Trong nghien ciiu nay, ngoai viec danh gia hieu qua dy phdng cua khang sinh, chiing tdi cdn quan tam ddn viec cd nen sii dung lieu thu hai cua khang sinh trong 48 gid hau phiu. Vi su dung 1 lidu hay 2 hdu trudc va sau phau thuat thi deu cd muc dich la dy phdng, nen theo nhieu nghien ciiu va theo y van, van de y diic cd the dupc chip nhan. Chung tdi hdi ciiu lay them sd heu nay va chia thanh 2 nhdm:
Nhdm 1: sii dui^ khang sinh 1 lieu trudc phau thuat.
Nhdm 2 : su dung khang smh bao gdm I tieu trudc va 1 hdu sau phiu thimt.
Chiing tdi ghi nhan cd 283 bdnh nhan dupc sir dung khang sinh dy phdng 1 lieu trudc phau thuat va 329 benh nhin dupc sii dung khang sinh 1 hdu tmdc va 1 Ueu sau phau thuat. Khi so sanh 2 nhdm nay vdi tinh trang bdnh nhan trudc xuat vien, chiing tdi thay khdng cd su khac biet giira 2 nhdm.
Vi nghien cuu nay la so sanh cat ngang md ta, nen chiing tdi chi dua ra nhan dinh tren. De chiing minh dieu nay rd hon, can cd nhiing nghien ciiu vdi cd mau Idn hon, nhiing thiet kd nghien ciiu phii hop hon.
Ty le nhidm tiling vet md dupc danh tai thdi diem xuat vien la 8,2%. Day la kdt qua sdm cua nghien ciiu.
Ket luan
Ty Id nhidm tning vet md dupc danh gia tai thdi diem xuat vien la 8,2%. Day la ket qua sdm cua nghien cuu. Su dung khang sinh dy phdng diing va hop ly la didu can thiet, tuy nhien cSn phai xem xet them cac yeu td ve tinh ti-ang benh nhan, cham sdc benh nhan trudc va sau md, tay nghe ciia bac sT phiu thuat.
Tai li^u tham khao
1. American Society of Healtii-System Pharma- cists (1999). ASHP tiierapeutic guidelines on antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 56:1839-88.
2. Bratzler D. W., Houck P M.(2004). Antimicro- bial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project. CID ,38:1706-1713.
3. Calise P., Capussotti L. et al (2009). Periopera- tive antibiotic Prophylaxis in adults outline of the principal recommendations national refer- ence guidelines. Minerva anestesiologica. Vol 75, no 9:543-547.
4. Finlay J, "a review of the antimicrobal activity of clavuclanate" (2003), journal of antimicrobal chemotherapy, 18 - 23.
5. "Hudng din phdng ngua nhidm khuan vet md"(2012), QD-BYT367I.HaNdi.
6. Nguyin Van Kinh (2010), "Bao cao su dung khang sinh va khang khang sinh tai 15 benh vien Viet nam", benh vien Nhiet Ddi.
7. Nguyen Thanh Long, Le Van NghTa (2005),
"Dich te hpc benh sdi mat", Nghien cuu ung dung tien bg khoa hgc cong nghe trong chdn dodn vd dieu tri sdm benh soi mat, De tai khoa hpc cap nha nudc, Chuang trinh khoa hpc va cdng nghe phuc vy cham sdc va bao ve siic khde cdng ddng, tr. 8-31.
8. Mai Phuang Mai, "Khang sinh dy phdng tiDug phau thuat".
9. Le Quang NghTa, Nguyen Thuy Oanh, Le Thi Thuin (1990), 'Tdm lupc cac tiiay ddi smh ly tren ca the cua ngudi nhidu tudi", Benh ngogi khoa cua ngudi nhieu tuoi, Hdi y dupc hpc thanh phd Hd Chi Minh va benh vien Binh Dan,y. 12-15.
10. Scottish intercollegiate guidline network SIGN (2008). Antibiotic prophylaxis in sur- gery. Edinburgh: SIGN.
11. Western Austi-alian therapeutics advisory group (2008). Surgery antibiotic prophylaxis abdominal surgery, estem Australian Thera- peutics
