{"id":134254,"date":"2025-08-22T16:14:12","date_gmt":"2025-08-22T09:14:12","guid":{"rendered":"https:\/\/vnras.com\/drug\/?p=134254"},"modified":"2025-08-22T16:15:42","modified_gmt":"2025-08-22T09:15:42","slug":"tiep-can-benh-nhan-viem-phoi-nhap-vien-khong-dap-ung-voi-dieu-tri","status":"publish","type":"post","link":"https:\/\/vnras.com\/drug\/tiep-can-benh-nhan-viem-phoi-nhap-vien-khong-dap-ung-voi-dieu-tri\/","title":{"rendered":"TI\u1ebeP C\u1eacN B\u1ec6NH NH\u00c2N VI\u00caM PH\u1ed4I NH\u1eacP VI\u1ec6N KH\u00d4NG \u0110\u00c1P \u1ee8NG V\u1edaI \u0110I\u1ec0U TR\u1eca"},"content":{"rendered":"

Vi\u00eam ph\u1ed5i l\u00e0 nguy\u00ean nh\u00e2n th\u01b0\u1eddng g\u1eb7p g\u00e2y nh\u1eadp ICU v\u00e0 l\u00e0 nguy\u00ean nh\u00e2n nhi\u1ec5m tr\u00f9ng th\u01b0\u1eddng g\u1eb7p nh\u1ea5t t\u1ea1i ICU. H\u1ea7u h\u1ebft b\u1ec7nh nh\u00e2n \u0111\u00e1p \u1ee9ng v\u1edbi \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh th\u00edch h\u1ee3p trong 48-72 gi\u1edd. Kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 tri\u1ec7u ch\u1ee9ng l\u00e2m s\u00e0ng dai d\u1eb3ng ho\u1eb7c di\u1ec5n ti\u1ebfn x\u1ea5u \u0111i – nh\u01b0 s\u1ed1t, suy h\u00f4 h\u1ea5p, gi\u1ea3m kh\u1ea3 n\u0103ng oxy ho\u00e1 m\u00e1u v\u00e0\/ho\u1eb7c t\u1ed5n th\u01b0\u01a1ng tr\u00ean h\u00ecnh \u1ea3nh h\u1ecdc – v\u1edbi t\u1ef7 l\u1ec7 20-30%. Nhi\u1ec1u y\u1ebfu t\u1ed1 c\u00f3 th\u1ec3 g\u00f3p ph\u1ea7n g\u00e2y kh\u00f4ng \u0111\u00e1p \u1ee9ng v\u1edbi \u0111i\u1ec1u tr\u1ecb. Y\u1ebfu t\u1ed1 “v\u1eadt ch\u1ee7”, bao g\u1ed3m suy gi\u1ea3m mi\u1ec5n d\u1ecbch, b\u1ec7nh ph\u1ed5i m\u1ea1n, ho\u1eb7c vi\u00eam ph\u1ed5i h\u00edt c\u00f3 th\u1ec3 l\u00e0m cho v\u1ea5n \u0111\u1ec1 kh\u00f4ng \u0111\u01b0\u1ee3c gi\u1ea3i quy\u1ebft. Ngo\u00e0i ra, c\u0169ng c\u00f3 th\u1ec3 do li\u1ec1u kh\u00e1ng sinh kh\u00f4ng \u0111\u00fang, t\u00e1c nh\u00e2n kh\u00f4ng \u0111i\u1ec3n h\u00ecnh ho\u1eb7c kh\u00e1ng thu\u1ed1c (ch\u1eb3ng h\u1ea1n nh\u01b0 nhi\u1ec5m khu\u1ea9n \u0111a kh\u00e1ng, lao, ho\u1eb7c n\u1ea5m), c\u1ea7n chi\u1ebfn l\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh thay th\u1ebf. Bi\u1ebfn ch\u1ee9ng nhi\u1ec5m khu\u1ea9n huy\u1ebft li\u00ean quan \u0111\u1ebfn vi\u00eam ph\u1ed1i (vd, tr\u00e0n m\u00f9 m\u00e0ng ph\u1ed5i) ho\u1eb7c kh\u00f4ng (vd, vi\u00eam t\u00fai m\u1eadt c\u1ea5p kh\u00f4ng do s\u1ecfi) c\u00f3 th\u1ec3 c\u1ea7n \u0111\u01b0\u1ee3c lo\u1ea1i tr\u1eeb. Sau c\u00f9ng, b\u1ec7nh l\u00fd kh\u00f4ng do nhi\u1ec5m tr\u00f9ng (vd, thuy\u00ean t\u1eafc ph\u1ed5i, b\u1ec7nh l\u00fd \u00e1c t\u1ec9nh, ARDS th\u1ee9 ph\u00e1t ho\u1eb7c vi\u00eam m\u1ea1ch) c\u00f3 th\u1ec3 bi\u1ec3u hi\u1ec7n gi\u1ed1ng ho\u1eb7c g\u00e2y vi\u00eam ph\u1ed5i c\u1ea7n ph\u1ea3i \u0111\u01b0\u1ee3c xem x\u00e9t. M\u1eb7c d\u00f9 vi\u00eam ph\u1ed5i kh\u00f4ng \u0111\u00e1p \u1ee9ng v\u1edbi \u0111i\u1ec1u tr\u1ecb l\u00e0 th\u01b0\u1eddng g\u1eb7p, nh\u01b0ng c\u00f2n thi\u1ebfu nhi\u1ec1u b\u1eb1ng ch\u1ee9ng m\u1ea1nh v\u00e0 ti\u1ebfp c\u1eadn ph\u1ea7n l\u1edbn c\u00f2n d\u1ef1a v\u00e0o ph\u00e1n \u0111o\u00e1n l\u00e2m s\u00e0ng. B\u00e1c s\u0129 l\u00e2m s\u00e0ng n\u00ean \u0111\u00e0nh gi\u00e1 li\u00ean t\u1ee5c b\u1ec7nh s\u1eed v\u00e0 kh\u00e1m l\u00e2m s\u00e0ng, xem l\u1ea1i d\u1ecbch t\u1ec5 vi sinh v\u00e0 xem x\u00e9t c\u1eadn l\u00e2m s\u00e0ng h\u00ecnh \u1ea3nh h\u1ecdc kh\u00e1c ch\u1eb3ng h\u1ea1n nh\u01b0 CT ng\u1ef1c. N\u1ed9i soi ph\u1ebf qu\u1ea3n ho\u1eb7c x\u00e9t nghi\u1ec7m l\u1ea1i m\u1eabu \u0111\u1eddm h\u1ed7 tr\u1ee3 x\u00e1c \u0111\u1ecbnh t\u00e1c nh\u00e2n g\u00e2y b\u1ec7nh ho\u1eb7c c\u00e1c nguy\u00ean nh\u00e2n kh\u00f4ng do nhi\u1ec5m tr\u00f9ng. Trong b\u00e0i vi\u1ebft n\u00e0y, ch\u00fang t\u00f4i \u0111\u01b0a ra h\u01b0\u1edbng d\u1eabn x\u00e9t nghi\u1ec7m c\u0103n nguy\u00ean v\u00e0 qu\u1ea3n l\u00fd vi\u00eam ph\u1ed5i kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb.<\/p>\n

\"Ti\u1ebfp
Ti\u1ebfp C\u1eadn B\u1ec7nh Nh\u00e2n Vi\u00eam Ph\u1ed5i Nh\u1eadp Vi\u1ec7n Kh\u00f4ng \u0110\u00e1p \u1ee8ng V\u1edbi \u0110i\u1ec1u Tr\u1ecb<\/figcaption><\/figure>\n

GI\u1edaI THI\u1ec6U<\/h2>\n

Vi\u00eam ph\u1ed5i l\u00e0 m\u1ed9t trong nh\u1eefng nguy\u00ean nh\u00e2n th\u01b0\u1eddng g\u1eb7p nh\u1ea5t khi\u1ebfn b\u1ec7nh nh\u00e2n nh\u1eadp ICU v\u00e0 l\u00e0 nhi\u1ec5m tr\u00f9ng th\u01b0\u1eddng g\u1eb7p nh\u1ea5t t\u1ea1i ICU.<\/p>\n

Sau khi \u0111i\u1ec1u tr\u1ecb h\u1ed7 tr\u1ee3 v\u00e0 \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh ban \u0111\u1ea7u, \u0111\u00e1p \u1ee9ng l\u00e2m s\u00e0ng c\u1ee7a vi\u00eam ph\u1ed5i kh\u00f4ng ph\u1ea3i ngay l\u1eadp t\u1ee9c. B\u00e1c s\u0129 l\u00e2m s\u1ea3ng ph\u00e1t hi\u1ec7n 48-72 gi\u1edd \u0111\u1ea7u l\u00e0 quan tr\u1ecdng \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh di\u1ec5n bi\u1ebfn c\u1ee7a b\u1ec7nh. H\u1ea7u h\u1ebft b\u1ec7nh nh\u00e2n vi\u00eam ph\u1ed5i nh\u1eadp vi\u1ec7n \u0111\u00e1p \u1ee9ng v\u1edbi \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh v\u00e0 ph\u1ee5c h\u1ed3i ngay, nh\u00ecn chung di\u1ec5n bi\u1ebfn kh\u00f4ng bi\u1ebfn ch\u1ee9ng. Tuy nhi\u00ean, m\u1ed9t t\u1ec9 l\u1ec7 b\u1ec7nh nh\u00e2n c\u00f3 th\u1ec3 kh\u00f4ng \u0111\u00e1p \u1ee9ng v\u00e0 \u0111i\u1ec1u tr\u1ecb th\u1ea5t b\u1ea1i, l\u00e0m t\u0103ng nguy c\u01a1 t\u1ec9 l\u1ec7 t\u1eed vong, c\u00f3 th\u1ec3 tr\u00ean 40%. Thi\u1ebfu d\u1eef li\u1ec7u d\u1ecbch t\u1ec5 v\u1ec1 nh\u00f3m b\u1ec7nh nh\u00e2n kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb v\u00e0 \u00edt c\u00f3 b\u1eb1ng ch\u1ee9ng v\u1ec1 ti\u1ebfp c\u1eadn t\u1ed1t nh\u1ea5t trong nh\u1eefng t\u00ecnh hu\u1ed1ng n\u00e0y. C\u00e1c h\u01b0\u1edbng d\u1eabn hi\u1ec7n t\u1ea1i kh\u00f4ng cung c\u1ea5p khuy\u1ebfn c\u00e1o qu\u1ea3n l\u00fd \u0111i\u1ec1u tr\u1ecb nh\u00f3m b\u1ec7nh nh\u00e2n n\u00e0y.<\/p>\n

\u0110\u1ecaNH NGH\u0128A B\u1ec6NH NH\u00c2N KH\u00d4NG \u0110\u00c1P \u1ee8NG \u0110I\u1ec0U TR\u1eca<\/h2>\n

M\u1eb7c d\u00f9 vi\u00eam ph\u1ed5i m\u1eafc ph\u1ea3i trong c\u1ed9ng \u0111\u1ed3ng m\u1ee9c \u0111\u1ed9 n\u1eb7ng kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb \u0111\u00f3ng vai tr\u00f2 quan tr\u1ecdng trong l\u00e2m s\u1ea3ng, nh\u01b0ng c\u00e1c nghi\u00ean c\u1ee9u v\u1ec1 \u0111\u1ecbnh ngh\u0129a v\u00e0 nguy\u00ean nh\u00e2n c\u00f2n nhi\u1ec1u h\u1ea1n ch\u1ebf. Vi\u00eam ph\u1ed5i m\u1eafc ph\u1ea3i trong c\u1ed9ng \u0111\u1ed3ng m\u1ee9c \u0111\u1ed9 n\u1eb7ng n\u00ean \u0111\u01b0\u1ee3c xem l\u00e0 kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb n\u1ebfu kh\u00f4ng c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng trong v\u00f2ng 72 gi\u1edd \u0111\u1ea7u \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh th\u00edch h\u1ee3p. B\u1ec7nh nh\u00e2n SCAP kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb c\u00f3 th\u1ec3 bi\u1ec3u hi\u1ec7n nhi\u1ec1u tri\u1ec7u ch\u1ee9ng \u0111\u00e1ng lo ng\u1ea1i bao g\u1ed3m s\u1ed1t nhi\u1ec1u h\u01a1n ho\u1eb7c s\u1ed1t dai d\u1eb3ng, ho, c\u00f3 \u0111\u1eddm v\u00e0 kh\u00f3 th\u1edf. H\u01a1n n\u1eefa di\u1ec5n bi\u1ebfn l\u00e2m s\u00e0ng x\u1ea5u \u0111i \u0111\u1eb7c tr\u01b0ng v\u1edbi huy\u1ebft \u0111\u1ed9ng kh\u00f4ng \u1ed5n \u0111\u1ecbnh, t\u00ecnh tr\u1ea1ng h\u00f4 h\u1ea5p x\u1ea5u \u0111i, t\u00ecnh tr\u1ea1ng gi\u1ea3m oxy ho\u00e1 m\u00e1u x\u1ea5u \u0111i, ho\u1eb7c ph\u00e1t tri\u1ec3n c\u00e1c bi\u1ebfn ch\u1ee9ng n\u1eb7ng nh\u01b0 ARDS l\u00e0 c\u00e1c bi\u1ec3u hi\u1ec7n th\u01b0\u1eddng g\u1eb7p. Ngo\u00e0i ra, X-quang ng\u1ef1c v\u00e0 CT ng\u1ef1c c\u00f3 th\u1ec3 cho th\u1ea5y kh\u00f4ng c\u1ea3i thi\u1ec7n ho\u1eb7c th\u00e2m nhi\u1ec5m ti\u1ebfn tri\u1ec3n. C\u00e1c ch\u1ec9 s\u1ed1 x\u00e9t nghi\u1ec7m nh\u01b0 BC, CRP v\u00e0 PCT, ho\u1eb7c kh\u00f4ng v\u1ec1 \u0111\u01b0\u1ee3c b\u00ecnh th\u01b0\u1eddng ho\u1eb7c ti\u1ebfp t\u1ee5c t\u0103ng.<\/p>\n

\"H\u00ecnh
H\u00ecnh 1.<\/strong> \u0110\u1ecbnh ngh\u0129a vi\u00eam ph\u1ed5i kh\u00f4ng \u0111\u00e1p \u1ee9ng v\u1edbi \u0111i\u1ec1u tr\u1ecb<\/figcaption><\/figure>\n

M\u1ed9t b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c xem l\u00e0 kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb sau \u00edt nh\u1ea5t 48-72 gi\u1edd \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh th\u00edch h\u1ee3p; vi\u1ec7c x\u00e1c \u0111\u1ecbnh kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb \u0111\u01b0a ra t\u1eeb qu\u00e1 tr\u00ecnh \u0111\u00e1nh gi\u00e1 l\u1ea1i to\u00e0n di\u1ec7n c\u00e1c tri\u1ec7u ch\u1ee9ng l\u00e2m s\u00e0ng, k\u1ebft qu\u1ea3 x\u00e9t nghi\u1ec7m \u2013 \u0111\u1eb7c bi\u1ec7t l\u00e0 c\u00e1c d\u1ea5u \u1ea5n sinh h\u1ecdc, k\u1ebft qu\u1ea3 vi sinh v\u00e0 t\u00ecnh tr\u1ea1ng kh\u00f4ng c\u1ea3i thi\u1ec7n ho\u1eb7c th\u1eadm ch\u00ed ti\u1ebfn tri\u1ec3n th\u00eam c\u1ee7a c\u00e1c t\u1ed5n th\u01b0\u01a1ng th\u00e2m nhi\u1ec5m tr\u00ean h\u00ecnh \u1ea3nh h\u1ecdc.<\/em><\/span><\/p>\n

B\u1ea3n ch\u1ea5t vi\u00eam ph\u1ed5i th\u1edf m\u00e1y (VAP) kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb gi\u1ed1ng v\u1edbi vi\u00eam ph\u1ed1i c\u1ed9ng \u0111\u1ed3ng n\u1eb7ng. l\u00e0 kh\u00f4ng c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng trong v\u00f2ng 72 gi\u1edd \u0111\u1ea7u \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh th\u00edch h\u1ee3p (H\u00ecnh 1). Ch\u1ec9 \u0111i\u1ec3m l\u00e2m s\u00e0ng \u0111\u00e1ng tin c\u1eady nh\u1ea5t \u1edf b\u1ec7nh nh\u00e2n VAP kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb l\u00e0 kh\u00f4ng c\u1ea3i thi\u1ec7n t\u1ec9 l\u1ec7 PaO2:FiO2 trong v\u00f2ng 3 ng\u00e0y \u0111\u1ea7u (B\u00e1ng 1). S\u1ed1t \u00edt \u0111\u1eb7c hi\u1ec7u nh\u01b0ng ch\u1ec9 \u0111i\u1ec3m cho ti\u1ebfn tr\u00ecnh vi\u00eam kh\u00f4ng \u0111\u01b0\u1ee3c gi\u1ea3i quy\u1ebft, m\u1ed9t nguy\u00ean nh\u00e2n trong s\u1ed1 \u0111\u00f3 l\u00e0 vi\u00eam ph\u1ed5i ch\u01b0a \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb \u0111\u1ee7. T\u0103ng dai d\u1eb3ng v\u00e0\/ho\u1eb7c t\u0103ng nhi\u1ec1u h\u01a1n ch\u1ec9 s\u1ed1 CRP ho\u1eb7c PCT sau 3-4 ng\u00e0y \u0111i\u1ec1u tr\u1ecb c\u0169ng li\u00ean quan \u0111\u1ebfn \u0111i\u1ec1u tr\u1ecb th\u1ea5t b\u1ea1i. Tuy nhi\u00ean, PCT kh\u00f4ng gi\u1ea3m ho\u1eb7c t\u0103ng l\u00ean trong qu\u00e1 tr\u00ecnh \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh kh\u00f4ng d\u00f9ng \u0111\u1ec3 \u0111\u1ecbnh h\u01b0\u1edbng n\u00e2ng b\u1eadc ho\u1eb7c \u0111i l\u00e0m th\u00eam x\u00e9t nghi\u1ec7m ch\u1ea9n \u0111o\u00e1n. M\u1ed9t RCT v\u1ec1 n\u00e2ng b\u1eadc kh\u00e1ng sinh \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 gi\u00e1 tr\u1ecb PCT cao dai d\u1eb3ng ho\u1eb7c t\u0103ng l\u00ean so v\u1edbi th\u01b0\u1eddng quy cho th\u1ea5y \u0111\u1ecbnh h\u01b0\u1edbng theo PCT g\u00e2y t\u1ed5n th\u01b0\u01a1ng nhi\u1ec1u c\u01a1 quan h\u01a1n v\u00e0 k\u00e9o d\u00e0i th\u1eddi gian n\u1eb1m ICU so v\u1edbi ch\u0103m s\u00f3c th\u01b0\u1eddng quy, m\u00e0 kh\u00f4ng c\u1ea3i thi\u1ec7n t\u1ec9 l\u1ec7 s\u1ed1ng s\u00f3t. T\u0103ng b\u1ea1ch c\u1ea7u v\u00e0 th\u00e2m nhi\u1ec5m ph\u1ed1i tr\u00ean h\u00ecnh \u1ea3nh h\u1ecdc l\u00e0 c\u00e1c \u0111\u1eb7c \u0111i\u1ec3m c\u1ee7a vi\u00eam ph\u1ed5i kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb nh\u01b0ng kh\u00f4ng \u0111\u1eb7c hi\u1ec7u cho vi\u00eam ph\u1ed5i.<\/p>\n

T\u1ed1c \u0111\u1ed9 thanh th\u1ea3i t\u00e1c nh\u00e2n h\u00f4 h\u1ea5p kh\u00e1c nhau t\u00f9y v\u00e0o vi sinh v\u1eadt. C\u1ea5y n\u1ed9i kh\u00ed qu\u1ea3n th\u01b0\u1edfng \u00e2m t\u1ec9nh sau li\u1ec1u kh\u00e1ng sinh \u0111\u1ea7u ti\u00ean \u1edf b\u1ec7nh nh\u00e2n nhi\u1ec5m HI ho\u1eb7c ph\u1ebf c\u1ea7u. Tuy nhi\u00ean, c\u1ea5y c\u00f3 th\u1ec3 v\u1eabn d\u01b0\u01a1ng t\u1ec9nh v\u00e0i ng\u00e0y \u0111\u1ebfn v\u00e0i tu\u1ea7n \u1edf b\u1ec7nh nh\u00e2n nhi\u1ec5m Pseudomonas aeruginosa<\/em> m\u1eb7c d\u00f9 c\u00f3 c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng. \u0110i\u1ec1u n\u00e0y cho th\u1ea5y b\u1ec7nh nh\u00e2n mang m\u1ea7m b\u1ec7nh m\u1ea1n t\u00ednh h\u01a1n l\u00e0 nhi\u1ec5m tr\u00f9ng dai d\u1eb3ng v\u00e0 l\u00e0m cho vi\u1ec7c c\u1ea5y tr\u1edf \u00edt c\u00f3 gi\u00e1 tr\u1ecb trong \u0111\u1ecbnh h\u01b0\u1edbng so v\u1edbi \u0111\u00e1p \u1ee9ng l\u00e2m s\u00e0ng.
\nCho \u0111\u1ebfn hi\u1ec7n t\u1ea1i, ch\u01b0a c\u00f3 nghi\u00ean c\u1ee9u n\u00e0o \u0111\u00e1nh gi\u00e1 s\u00e2u v\u1ec1 s\u1ef1 kh\u00e1c bi\u1ec7t trong c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng, sinh b\u1ec7nh h\u1ecdc v\u00e0 c\u0103n nguy\u00ean vi sinh khi nhi\u1ec5m tr\u00f9ng \u0111\u01b0\u1ee3c gi\u1ea3i quy\u1ebft gi\u1eefa vi\u00eam ph\u1ed5i c\u1ed9ng \u0111\u1ed3ng n\u1eb7ng v\u00e0 vi\u00eam ph\u1ed5i th\u1edf m\u00e1y. Tuy nhi\u00ean, t\u1eeb g\u00f3c \u0111\u1ed9 sinh l\u00fd b\u1ec7nh, \u0111\u1ecbnh ngh\u0129a nhi\u1ec5m tr\u00f9ng \u0111\u01b0\u1ee3c gi\u1ea3i quy\u1ebft c\u00f3 th\u1ec3 kh\u00e1c nhau gi\u1eefa hai nh\u00f3m. \u0110\u1ea7u ti\u00ean, c\u0103n nguy\u00ean vi sinh ch\u1ecbu tr\u00e1ch nhi\u1ec7m g\u00e2y vi\u00eam ph\u1ed5i l\u00e0 kh\u00e1c nhau. Vi\u00eam ph\u1ed5i c\u1ed9ng \u0111\u1ed3ng n\u1eb7ng th\u01b0\u1eddng do c\u00e1c vi sinh v\u1eadt nh\u1ea1y v\u1edbi kh\u00e1ng sinh \u0111i\u1ec1u tr\u1ecb \u0111\u1ea7u tay, b\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c k\u00ec v\u1ecdng \u0111\u00e1p \u1ee9ng nhanh v\u1edbi kh\u00e1ng sinh ph\u1ed5 h\u1eb9p, \u0111i\u1ec1u n\u00e0y l\u00e0m cho t\u1ec9 l\u1ec7 \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh th\u00edch h\u1ee3p cao h\u01a1n. \u0110i\u1ec3m th\u1ee9 hai li\u00ean quan \u0111\u1ebfn m\u1ee9c \u0111\u1ed9 n\u1eb7ng c\u1ee7a t\u1ed5n th\u01b0\u01a1ng t\u1ea1i ch\u1ed7 \u1edf ph\u1ed5i, s\u1ef1 hi\u1ec7n di\u1ec7n c\u1ee7a nhi\u1ec5m tr\u00f9ng huy\u1ebft ho\u1eb7c s\u1ed1c nhi\u1ec5m tr\u00f9ng, v\u00e0 trong m\u1ed9t s\u1ed1 tr\u01b0\u1eddng h\u1ee3p g\u00e2y suy \u0111a c\u01a1 quan.<\/p>\n

Trong m\u1ed9t nghi\u00ean c\u1ee9u \u0111a trung t\u00e2m g\u1ea7n \u0111\u00e2y \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n vi\u00eam ph\u1ed5i c\u1ed9ng \u0111\u1ed3ng n\u1eb7ng, t\u1ec9 l\u1ec7 \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh th\u00edch h\u1ee3p l\u00e0 97%. M\u1ed9t nghi\u00ean c\u1ee9u kh\u00e1c t\u1ea1i Ch\u00e2u \u00c2u \u1edf b\u1ec7nh nh\u00e2n VAP, t\u1ec9 l\u1ec7 \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh th\u00edch h\u1ee3p th\u1ea5p h\u01a1n, 68%. Nghi\u00ean c\u1ee9u ENIRRIS bao g\u1ed3m c\u00e1c t\u1ec9nh tr\u1ea1ng nhi\u1ec5m tr\u00f9ng \u0111\u01b0\u1eddng h\u00f4 h\u1ea5p d\u01b0\u1edbi m\u1eafc ph\u1ea3i trong b\u1ec7nh vi\u1ec7n ho\u1eb7c trong ICU cho th\u1ea5y t\u1ec9 l\u1ec7 t\u1eed vong 90 ng\u00e0y cao h\u01a1n khi vi\u00eam ph\u1ed5i do c\u00e1c t\u00e1c nh\u00e2n \u0111a kh\u00e1ng.<\/p>\n

H\u1ee3p l\u00fd khi \u0111\u1ec1 xu\u1ea5t \u0111\u1ecbnh ngh\u0129a kh\u00f4ng \u0111\u00e1p \u1ee9ng trong vi\u00eam ph\u1ed5i c\u1ed9ng \u0111\u1ed3ng n\u1eb7ng v\u00e0 HAP\/VAP bao g\u1ed3m s\u1ed1t dai d\u1eb3ng, kh\u00f4ng c\u1ea3i thi\u1ec7n kh\u1ea3 n\u0103ng oxy ho\u00e1 m\u00e1u ho\u1eb7c di\u1ec5n bi\u1ebfn x\u1ea5u \u0111i, t\u1ed5n th\u01b0\u01a1ng h\u00ecnh \u1ea3nh h\u1ecdc ti\u1ebfn tri\u1ec3n, v\u00e0 c\u00e1c ch\u1ec9 s\u1ed1 vi\u00eam nh\u01b0 CRP ho\u1eb7c PCT cao ho\u1eb7c t\u0103ng l\u00ean \u1edf ng\u00e0y 3 so v\u1edbi gi\u00e1 tr\u1ecb n\u00ean.<\/p>\n

T\u1ea6N SU\u1ea4T KH\u00d4NG \u0110\u00c1P \u1ee8NG \u0110I\u1ec0U TR\u1eca?<\/h2>\n

Trong vi\u00eam ph\u1ed5i c\u1ed9ng \u0111\u1ed3ng n\u1eb7ng, m\u1ed9t l\u00fd do th\u01b0\u1eddng g\u1eb7p g\u00e2y nh\u1eadp ICU l\u00e0 \u0111i\u1ec1u tr\u1ecb th\u1ea5t b\u1ea1i. Ngay c\u1ea3 khi \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh th\u00edch h\u1ee3p v\u1edbi h\u01b0\u1edbng d\u1eabn v\u00e0 \u0111i\u1ec1u tr\u1ecb h\u1ed7 tr\u1ee3 \u0111\u1ea7y \u0111\u1ee7, t\u00ecnh tr\u1ea1ng kh\u00f4ng \u0111\u00e1p \u1ee9ng v\u1eabn t\u01b0\u01a1ng \u0111\u1ed1i th\u01b0\u1eddng g\u1eb7p. C\u00e1c nghi\u00ean c\u1ee9u cho th\u1ea5y t\u1ec9 l\u1ec7 kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb \u1edf b\u1ec7nh nh\u00e2n SCAP t\u1ea1i ICU dao \u0111\u1ed9ng t\u1eeb 15% \u0111\u1ebfn 30%. Kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb li\u00ean quan \u0111\u1ebfn k\u1ebft c\u1ee5c l\u00e2m s\u00e0ng x\u1ea5u bao g\u1ed3m k\u00e9o d\u00e0i th\u1eddi gian n\u1eb1m vi\u1ec7n v\u00e0 t\u1ec9 l\u1ec7 t\u1eed vong cao h\u01a1n. C\u00e1c y\u1ebfu t\u1ed1 nh\u01b0 tr\u00ec ho\u00e3n d\u00f9ng kh\u00e1ng sinh ho\u1eb7c d\u00f9ng kh\u00f4ng th\u00edch h\u1ee3p, nhi\u1ec5m vi khu\u1ea9n \u0111a kh\u00e1ng, suy gi\u1ea3m mi\u1ec5n d\u1ecbch, v\u00e0 thang \u0111i\u1ec3m \u0111\u00e1nh gi\u00e1 m\u1ee9c \u0111\u1ed9 n\u1eb7ng cao h\u01a1n (vd, SOFA, s\u1ed1c nhi\u1ec5m tr\u00f9ng, suy h\u00f4 h\u1ea5p c\u1ea5p t\u00ednh) g\u00f3p ph\u1ea7n \u0111\u00e1ng k\u1ec3 v\u00e0o t\u1ec9 l\u1ec7 kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb.<\/p>\n

HAP\/VAP \u0111\u1eb7t ra nh\u1eefng th\u00e1ch th\u1ee9c \u0111i\u1ec1u tr\u1ecb ph\u1ee9c t\u1ea1p h\u01a1n, \u0111\u1eb7c bi\u1ec7t l\u00e0 \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n nguy k\u1ecbch, n\u01a1i m\u00e0 t\u1ec9 l\u1ec7 nhi\u1ec5m tr\u00f9ng \u0111a kh\u00e1ng cao h\u01a1n. M\u1eb7c d\u00f9 t\u00e1c \u0111\u1ed9ng l\u00ean k\u1ebft c\u1ee5c v\u1eabn ch\u01b0a r\u00f5 r\u00e0ng, nh\u01b0ng \u0111i\u1ec1u tr\u1ecb th\u1ea5t b\u1ea1i th\u01b0\u1eddng g\u1eb7p h\u01a1n \u1edf HAP\/VAP so v\u1edbi SCAP. T\u1ec9 l\u1ec7 kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb trong HAP\/VAP dao \u0111\u1ed9ng t\u1eeb 20% \u0111\u1ebfn 40%, t\u00f9y thu\u1ed9c v\u00e0o qu\u1ea7n th\u1ec3 nghi\u00ean c\u1ee9u v\u00e0 t\u00e1c nh\u00e2n. C\u00e1c y\u1ebfu t\u1ed1 nh\u01b0 s\u1ef1 hi\u1ec7n di\u1ec7n c\u1ee7a Pseudomonas aeruginosa<\/em> v\u00e0 Acinetobacter baumannii<\/em>, t\u1ec9 l\u1ec7 \u0111\u1ec1 kh\u00e1ng kh\u00e1ng<\/p>\n

sinh v\u00e0 b\u1ec7nh n\u1ec1n nh\u01b0 COPD v\u00e0 suy gi\u1ea3m mi\u1ec5n d\u1ecbch li\u00ean quan \u0111\u1ebfn \u0111i\u1ec1u tr\u1ecb th\u1ea5t b\u1ea1i. M\u1ed9t ph\u00e2n t\u00edch t\u1ed5ng h\u1ee3p \u0111\u01b0\u1ee3c c\u00f4ng b\u1ed1 g\u1ea7n \u0111\u00e2y v\u1ec1 chi\u1ebfn l\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb HAP kh\u00f4ng th\u1edf m\u00e1y, bao g\u1ed3m 39 RCTs v\u00e0 4807 b\u1ec7nh nh\u00e2n, x\u00e1c nh\u1eadn t\u1ec9 l\u1ec7 HAP \u0111i\u1ec1u tr\u1ecb th\u1ea5t b\u1ea1i cao (t\u1eeb 30% \u0111\u1ebfn 45%). Li\u00ean quan \u0111\u1ebfn VAP, c\u00e1c tr\u01b0\u1eddng h\u1ee3p case-mix v\u00e0 \u0111\u1ecbnh ngh\u0129a ch\u1ea9n \u0111o\u00e1n l\u00e0 quan tr\u1ecdng trong x\u00e1c \u0111\u1ecbnh t\u1ec9 l\u1ec7 th\u1ea5t b\u1ea1i l\u00e2m s\u00e0ng. C\u0169ng nh\u01b0 HAP kh\u00f4ng th\u1edf m\u00e1y, t\u1ec9 l\u1ec7 \u0111i\u1ec1u tr\u1ecb th\u1ea5t b\u1ea1i kho\u1ea3ng 30%. \u0110i\u1ec1u th\u00fa v\u1ecb l\u00e0 ph\u00e1c \u0111\u1ed3 theo kinh nghi\u1ec7m carbapenem li\u00ean quan \u0111\u1ebfn l\u00e0m gi\u1ea3m t\u1ec9 l\u1ec7 th\u1ea5t b\u1ea1i v\u00e0 t\u1ec9 l\u1ec7 t\u1eed vong trong VAP; tuy nhi\u00ean t\u00e1c \u0111\u1ed9ng n\u00e0y kh\u00f4ng \u0111\u01b0\u1ee3c quan s\u00e1t trong c\u00e1c th\u1eed nghi\u1ec7m c\u00f3 m\u1ee9c \u0111\u1ed9 b\u1ec7nh n\u1eb7ng h\u01a1n v\u00e0 c\u0169ng kh\u00f4ng li\u00ean quan \u0111\u1ebfn vi\u1ec7c ph\u00e1t hi\u1ec7n c\u0103n nguy\u00ean Pseudomonas<\/em>.<\/p>\n

Y\u00caU T\u1ed0 QUAN TR\u1eccNG \u0110\u1ec2 X\u00c1C \u0110\u1ecaNH KH\u00d4NG \u0110\u00c1P \u1ee8NG \u0110I\u1ec0U TR\u1eca?<\/h2>\n

Th\u1eddi gian m\u00e0 c\u00e1c tri\u1ec7u ch\u1ee9ng vi\u00eam ph\u1ed5i kh\u1ecfi ch\u1ee7 y\u1ebfu ch\u1ecbu \u1ea3nh h\u01b0\u1edfng b\u1edfi y\u1ebfu t\u1ed1 n\u1ed9i t\u1ea1i c\u1ee7a v\u1eadt ch\u1ee7, \u0111\u1eb7c bi\u1ec7t l\u00e0 mi\u1ec5n d\u1ecbch. C\u00e1c b\u1ec7nh l\u00fd nh\u01b0 \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng, b\u1ec7nh \u00e1c t\u1ec9nh, suy gi\u1ea3m mi\u1ec5n d\u1ecbch v\u00e0 b\u1ec7nh giai \u0111o\u1ea1n cu\u1ed1i th\u01b0\u1eddng l\u00e0m suy gi\u1ea3m ch\u1ee9c n\u0103ng b\u1ea1ch c\u1ea7u h\u1ea1t, c\u0169ng nh\u01b0 mi\u1ec5n d\u1ecbch trung gian t\u1ebf b\u00e0o v\u00e0 mi\u1ec5n d\u1ecbch d\u1ecbch th\u1ec3, \u1ea3nh h\u01b0\u1edfng \u0111\u1ebfn ti\u1ebfn tr\u00ecnh ph\u1ee5c h\u1ed3i. C\u00e1c y\u1ebfu t\u1ed1 kh\u00e1c nh\u01b0 gi\u1ea3m kh\u1ea3 n\u0103ng h\u1ecd v\u00e0 thanh th\u00e1i ch\u1ea5t nh\u1ea7y trong COPD, suy dinh d\u01b0\u1ee1ng, h\u00edt m\u1ea1n t\u00ednh, gi\u1ea3m kh\u1ea3 n\u0103ng l\u00e0m s\u1ea1ch \u0111\u01b0\u1eddng th\u1edf trong nghi\u1ec7n r\u01b0\u1ee3u, c\u00e1c b\u1ec7nh l\u00fd th\u1ea7n kinh, v\u00e0 suy gi\u1ea3m kh\u1ea3 n\u0103ng d\u1eabn l\u01b0u h\u1ec7 b\u1ea1ch huy\u1ebft ph\u1ed5i v\u00e0 ph\u1ee7 ph\u1ed1i trong suy tim \u0111\u1ec1u li\u00ean quan \u0111\u1ebfn l\u00e0m ch\u1eadm qu\u00e1 tr\u00ecnh h\u1ed3i ph\u1ee5c trong vi\u00eam ph\u1ed1i. Th\u00f4ng th\u01b0\u1eddng, b\u1ec7nh nh\u00e2n c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng trong v\u00f2ng 48-72 gi\u1edd \u0111i\u1ec1u tr\u1ecb, nh\u01b0ng h\u1ecd v\u00e0 m\u1ec7t m\u1ecfi c\u00f3 th\u1ec3 k\u00e9o d\u00e0i l\u00ean \u0111\u1ebfn 2 tu\u1ea7n \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n \u0111ang c\u1ea3i thi\u1ec7n\/\u0111\u00e1p \u1ee9ng (B\u1ea3ng 1).<\/p>\n\n\n\n\n\n\n
Ti\u00eau chu\u1ea9n<\/th>\n\u00a0K\u1ef3 v\u1ecdng gi\u1ea3i quy\u1ebft<\/strong><\/td>\n<\/tr>\n
L\u00e2m s\u00e0ng<\/td>\nS\u1ed1t, t\u00ecm nhanh, th\u1edd nh\u00e1nh, kh\u00f3 th\u1edf 148-72 gi\u1edd
\nHuy\u1ebft \u0111\u00f4ng kh\u00f4ng \u1ed5n \u0111\u1ecbnh, t\u00ecnh tr\u1ea1ng oxy h\u00f3a m\u00e0u x\u1ea5u \u0111i
\n(PaO2\/FiO2), ARDS
\nM\u1ed9t m\u00f4i v\u00e0 h\u1ecd l\u00ean \u0111\u1ebfn 2 tu\u1ea7n<\/td>\n<\/tr>\n
X\u00e9t nghi\u1ec7n<\/td>\nPCT, CRP, BC, Lactat cao \u0111\u1ea1i tr\u00e0ng<\/td>\n<\/tr>\n
H\u00ecnh \u1ea3nh h\u1ecdc<\/td>\nH\u00ecnh \u1ea3nh h\u1ecdc x\u1ea5u \u0111i
\nTh\u1eddi gian \u0111\u1ec3 gi\u1ea3i quy\u1ebft th\u00e2m nhi\u1ec5m ph\u1ed1i
\n4 tu\u1ea7n trong h\u1ea7u h\u1ebft c\u00e1c tr\u01b0\u1eddng h\u1ee3p
\n10 tu\u1ea7n trong tr\u01b0\u1eddng h\u1ee3p vi\u00eam ph\u1ed5i n\u1eb7ng<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

B\u1ea3ng 1.<\/strong> Ti\u1ebfp c\u1eadn vi\u00eam ph\u1ed5i kh\u00f4ng \u0111\u00e1p \u1ee9ng v\u1edbi \u0111i\u1ec1u tr\u1ecb<\/p>\n

C\u00e1c y\u1ebfu t\u1ed1 kh\u00e1c \u1ea3nh h\u01b0\u1edfng \u0111\u1ebfn th\u1eddi gian h\u1ed3i ph\u1ee5c trong vi\u00eam ph\u1ed5i bao g\u1ed3m m\u1ee9c \u0111\u1ed9 n\u1eb7ng \u1edf th\u1eddi \u0111i\u1ec3m bi\u1ec3u hi\u1ec7n v\u00e0 t\u00e1c nh\u00e2n nghi ng\u1edd. C\u00e1c tr\u01b0\u1eddng h\u1ee3p n\u1eb7ng nh\u01b0 \u1edf nh\u1eefng ng\u01b0\u1eddi b\u1ecb s\u1ed1c nhi\u1ec5m tr\u00f9ng, vi\u00eam ph\u1ed5i \u0111a th\u1ee7y ho\u1eb7c ho\u1ea1i t\u1eed, ho\u1eb7c suy h\u00f4 h\u1ea5p c\u1ea7n th\u1edf m\u00e1y, nh\u00ecn cung c\u1ea7n th\u1eddi gian ph\u1ee5c h\u1ed3i l\u00e2u h\u01a1n. C\u00e1c t\u00e1c nh\u00e2n nh\u1ea5t \u0111\u1ecbnh c\u0169ng l\u00e0m ch\u1eadm t\u1ed1c \u0111\u1ed9 c\u1ea3i thi\u1ec7n l\u00e2m s\u1ea3ng. V\u00ed d\u1ee5, vi\u00eam ph\u1ed5i do Lao \u0111\u00e1p \u1ee9ng ch\u1eadm h\u01a1n v\u1edbi \u0111i\u1ec1u tr\u1ecb th\u00edch h\u1ee3p so v\u1edbi ph\u1ebf c\u1ea7u, vi\u00eam ph\u1ed5i Mycoplasma<\/em> ho\u1eb7c vi\u00eam ph\u1ed5i Chlamydia<\/em>. T\u00e1i l\u01b0\u1ee3ng vi khu\u1ea9n v\u00e0 s\u1ef1 hi\u1ec7n di\u1ec7n c\u1ee7a nhi\u1ec5m khu\u1ea9n huy\u1ebft trong vi\u00eam ph\u1ed5i ph\u1ebf c\u1ea7u v\u00e0 nhi\u1ec5m Legionella<\/em> th\u01b0\u1eddng c\u00f3 t\u1ed1c \u0111\u1ed9 ph\u1ee5c h\u1ed3i ch\u1eadm h\u01a1n so v\u1edbi nhi\u1ec5m tr\u00f9ng m\u00e0 kh\u00f4ng c\u00f3 nhi\u1ec5m tr\u00f9ng huy\u1ebft.<\/p>\n

TI\u1ebeP C\u1eacN B\u1ec6NH NH\u00c2N VI\u00caM PH\u1ed4I KH\u00d4NG \u0110\u00c1P \u1ee8NG \u0110I\u1ec0U TR\u1eca – CH\u1ea8N \u0110O\u00c1N PH\u00c2N BI\u1ec6T<\/h2>\n

Khi \u0111\u1ed1i m\u1eb7t v\u1edbi b\u1ec7nh nh\u00e2n kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb, \u0111\u1ed9i ng\u0169 ch\u0103m s\u00f3c t\u00edch c\u1ef1c ph\u1ea3i xem x\u00e9t 3 kh\u1ea3 n\u0103ng (H\u00ecnh 2): 1) d\u1ef1 \u0111o\u00e1n v\u1ec1 th\u1eddi gian d\u1ef1 ki\u1ebfn c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng kh\u00f4ng th\u1ef1c t\u1ebf; 2) \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh kh\u00f4ng th\u00edch h\u1ee3p do kh\u00e1ng thu\u1ed1c, nhi\u1ec5m c\u00e1c t\u00e1c nh\u00e2n kh\u00e1c nh\u01b0 trong b\u1ec7nh vi\u1ec7n ho\u1eb7c ki\u1ec3m so\u00e1t \u1ed5 nhi\u1ec5m tr\u00f9ng kh\u00f4ng \u0111\u1ee7 (vd, tr\u00e0n m\u00f9 m\u00e0ng ph\u1ed5i); 3) nhi\u1ec5m virus ho\u1eb7c b\u1ec7nh l\u00fd kh\u00f4ng do nhi\u1ec5m tr\u00f9ng.<\/p>\n

\"Xe\u0301t
H\u00ecnh 2.<\/strong> X\u00e9t nghi\u1ec7m v\u00e0 ch\u00e2n \u0111o\u00e1n ph\u00e2n bi\u1ec7t trong vi\u00eam ph\u1ed5i kh\u00f4ng \u0111\u00e1p \u1ee9ng v\u1edbi \u0111i\u1ec1u tr\u1ecb<\/figcaption><\/figure>\n
\n

Th\u1eddi gian ph\u1ee5c h\u1ed3i k\u00ec v\u1ecdng<\/h3>\n

X\u00e1c \u0111\u1ecbnh th\u1eddi gian ph\u1ee5c h\u1ed3i k\u00ec v\u1ecdng \u1edf b\u1ec7nh nh\u00e2n vi\u00eam ph\u1ed5i nguy k\u1ecbch kh\u00f4ng ph\u1ea3i l\u00e0 khoa h\u1ecdc ch\u00ednh x\u00e1c; tuy nhi\u00ean, n\u00f3 ph\u1ee5 thu\u1ed9c v\u00e0o nhi\u1ec1u y\u1ebfu t\u1ed1 \u0111\u01b0\u1ee3c \u0111\u1ec1 c\u1eadp tr\u01b0\u1edbc \u0111\u00f3. Ch\u1eadm tr\u1ec5 \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh theo kinh nghi\u1ec7m ho\u1eb7c h\u1ed3i s\u1ee9c kh\u00f4ng \u0111\u1ee7 l\u00e0 c\u00e1c y\u1ebfu t\u1ed1 nguy c\u01a1 c\u00f3 th\u1ec3 thay \u0111\u1ed5i \u0111\u01b0\u1ee3c \u1ea3nh h\u01b0\u1edfng l\u00e0m ch\u1eadm qu\u00e1 tr\u00ecnh ph\u1ee5c h\u1ed3i v\u00e0 k\u1ebft c\u1ee5c b\u1ea5t l\u1ee3i. Trong khi th\u1ea5t b\u1ea1i \u1edf m\u1ed9t b\u1ec7nh nh\u00e2n SCAP l\u00e2m s\u1ea3ng \u1ed5n \u0111\u1ecbnh sau 72 gi\u1edd \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh tr\u01b0\u1edbc \u0111\u00f3 \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 “\u0111i\u1ec1u tr\u1ecb th\u1ea5t b\u1ea1i”, khung th\u1eddi gian n\u00e0y c\u00f3 th\u1ec3 l\u00e0 qu\u00e1 d\u00e0i \u0111\u1ec3 ch\u1edd \u0111\u1ee3i tr\u01b0\u1edbc khi \u0111\u00e1nh gi\u00e1 l\u1ea1i ch\u1ea9n \u0111o\u00e1n \u1edf b\u1ec7nh nh\u00e2n nguy k\u1ecbch. V\u00ec th\u1eddi gian ph\u1ee5c h\u1ed3i kh\u00f4ng th\u1ec3 d\u1ef1 \u0111o\u00e1n ch\u00ednh x\u00e1c \u0111\u01b0\u1ee3c, b\u00e1c s\u0129 l\u00e2m s\u00e0ng ch\u0103m s\u00f3c b\u1ec7nh nh\u00e2n nguy k\u1ecbch \u0111\u01b0\u1ee3c ch\u1ea9n \u0111o\u00e1n vi\u00eam ph\u1ed5i kh\u00f4ng \u0111\u00e1p \u1ee9ng trong v\u00f2ng 72 gi\u1edd \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh ho\u1eb7c l\u00e2m s\u00e0ng x\u1ea5u \u0111i tr\u01b0\u1edbc 72 gi\u1edd n\u00ean \u0111\u01b0\u1ee3c xem x\u00e9t l\u1ea1i ch\u1ea9n \u0111o\u00e1n ban \u0111\u1ea7u v\u00e0 t\u00ecm c\u00e1 nguy\u00ean nh\u00e2n nhi\u1ec5m tr\u00f9ng v\u00e0 kh\u00f4ng nhi\u1ec5m tr\u00f9ng (B\u1ea3ng 1 v\u00e0 H\u00ecnh 2).<\/p>\n

Ti\u1ebfp c\u1eadn ch\u1ea9n \u0111o\u00e1n<\/h3>\n

\u0110\u00e1nh gi\u00e1 l\u1ea1i ch\u1ea9n \u0111o\u00e1n ban \u0111\u1ea7u<\/em><\/strong><\/p>\n

Gi\u1ea3 s\u1eed c\u00e1c h\u01b0\u1edbng d\u1eabn t\u1ea1i khu v\u1ef1c \u0111\u01b0\u1ee3c tu\u00e2n th\u1ee7, \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh kh\u00f4ng th\u00edch h\u1ee3p hi\u1ebfm khi l\u00e0 nguy\u00ean nh\u00e2n g\u00e2y ra th\u1ea5t b\u1ea1i l\u00e2m s\u00e0ng trong CAP nh\u01b0ng th\u01b0\u1eddng g\u1eb7p h\u01a1n trong HAP\/VAP, v\u00ec li\u00ean quan \u0111\u1ebfn nguy c\u01a1 nhi\u1ec5m khu\u1ea9n \u0111a kh\u00e1ng. H\u01b0\u1edbng d\u1eabn c\u1ee7a ATS\/IDSA trong c\u1ea3 CAP v\u00e0 HAP\/VAP x\u00e1c \u0111\u1ecbnh c\u00e1c y\u1ebfu t\u1ed1 nguy c\u01a1 nhi\u1ec5m khu\u1ea9n \u0111a kh\u00e1ng (H\u00ecnh 2). Trao \u0111\u1ed5i gi\u1eefa ph\u00f2ng vi sinh, d\u01b0\u1ee3c s\u0129 v\u00e0 b\u00e1c s\u0129 l\u00e2m s\u00e0ng l\u00e0 r\u1ea5t quan tr\u1ecdng \u0111\u1ec3 nhanh ch\u00f3ng x\u00e1c \u0111\u1ecbnh b\u1ec7nh nh\u00e2n \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh kh\u00f4ng th\u00edch h\u1ee3p. Ngo\u00e0i l\u1ef1a ch\u1ecdn \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh theo kinh nghi\u1ec7m, \u0111i\u1ec1u quan tr\u1ecdng l\u00e0 c\u1ea7n \u0111\u00e1nh gi\u1ea3 \u0111i\u1ec1u tr\u1ecb \u0111\u1ee7. Li\u1ec1u thu\u1ed1c n\u00ean \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 l\u1ea1i \u1edf b\u1ec7nh nh\u00e2n nguy k\u1ecbch tr\u1ea3i qua nh\u1eefng s\u1ef1 thay \u0111\u1ed5i \u0111\u00e1ng k\u1ec3 v\u1ec1 d\u01b0\u1ee3c l\u1ef1c h\u1ecdc \u1edf c\u1ea3 th\u1ec3 t\u00edch ph\u00e2n b\u1ed1 v\u00e0 t\u1ed1c \u0111\u1ed9 thanh th\u1ea3i thu\u1ed1c so v\u1edbi ng\u01b0\u1eddi b\u1ec7nh \u00edt n\u1eb7ng h\u01a1n. Ngo\u00e0i ra, truy\u1ec1n kh\u00e1ng sinh ng\u1eaft qu\u00e3ng so v\u1edbi li\u00ean t\u1ee5c t\u00f9y v\u00e0o thu\u1ed1c v\u00e0 n\u00ean ki\u1ec3m tra kh\u1ea3 n\u0103ng ng\u1ea5m thu\u1ed1c. Khai th\u00e1c k\u0129 b\u1ec7nh s\u1eed c\u0169ng g\u1ee3i \u00fd kh\u1ea3 n\u0103ng nhi\u1ec5m c\u00e1c vi khu\u1ea9n kh\u00f4ng th\u01b0\u1eddng g\u1eb7p v\u00e0 nhi\u1ec5m n\u1ea5m g\u00e2y vi\u00eam ph\u1ed5i n\u1eb7ng c\u00f3 th\u1ec3 kh\u00f4ng \u0111\u00e1p \u1ee9ng v\u1edbi ph\u00e1c \u0111\u1ed3 \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh th\u00f4ng th\u01b0\u1eddng (H\u00ecnh 2). V\u00ec d\u1ecbch Covid-19, t\u1ec9 l\u1ec7 ph\u00e1t hi\u1ec7n vi\u00eam ph\u1ed5i n\u1eb7ng \u0111o c\u0103n nguy\u00ean virus kh\u00f4ng \u0111\u00e1p \u1ee9ng v\u1edbi \u0111i\u1ec1u tr\u1ecb vi\u00eam ph\u1ed1i theo kinh nghi\u1ec7m, bao g\u1ed3m c\u00fam (c\u00f3 ho\u1eb7c kh\u00f4ng c\u00f3 nhi\u1ec5m khu\u1ea9n \u0111\u1ed3ng m\u1eafc), RSV, v\u00e0 sau c\u00f9ng l\u00e0 HSV v\u00e0 CMV t\u00e1i ho\u1ea1t \u0111\u1ed9ng.<\/p>\n

Bi\u1ec3n ch\u1ee9ng nhi\u1ec5m tr\u00f9ng huy\u1ebft<\/strong><\/em><\/p>\n

Kh\u00f4ng \u0111\u00e1p \u1ee9ng c\u0169ng c\u00f3 th\u1ec3 do nhi\u1ec5m tr\u00f9ng huy\u1ebft \u0111\u1ed3ng m\u1eafc tr\u1ef1c ti\u1ebfp li\u00ean quan \u0111\u1ebfn vi\u00eam ph\u1ed5i ho\u1eb7c \u0111\u1ed9c l\u1eadp v\u1edbi nhi\u1ec5m tr\u00f9ng ph\u1ed5i. Bi\u1ebfn ch\u1ee9ng nhi\u1ec5m tr\u00f9ng huy\u1ebft do vi\u00eam ph\u1ed5i bao g\u1ed3m nhi\u1ec5m tr\u00f9ng ph\u1ed1i th\u1ee9 ph\u00e1t, tr\u00e0n d\u1ecbch m\u00e0ng ph\u1ed5i, tr\u00e2n m\u00f9 m\u00e0ng ph\u1ed5i, \u00e1p xe ph\u1ed5i, v\u00e0 vi\u00eam ph\u1ed5i ho\u1ea1i t\u1eed. Tr\u00e0n d\u1ecbch khu tr\u00fa ho\u1eb7c dai d\u1eb3ng th\u01b0\u1eddng c\u1ea7n \u0111\u1eb7t d\u1eabn l\u01b0u \u0111\u1ec3 ki\u1ec3m so\u00e1t \u00f4 nhi\u1ec5m khu\u1ea9n, th\u01b0\u1eddng c\u1ea7n k\u1ebft h\u1ee3p h\u00ecnh \u1ea3nh h\u1ecdc can thi\u1ec7p v\u00e0 ph\u1eabu thu\u1eadt l\u00f2ng ng\u1ef1c. C\u00e1c bi\u1ebfn ch\u1ee9ng nhi\u1ec5m tr\u00f9ng huy\u1ebft kh\u00e1c kh\u00f4ng tr\u1ef1c ti\u1ebfp do vi\u00eam ph\u1ed5i nh\u01b0ng c\u00f3 th\u1ec3 gi\u1ed1ng v\u1edbi vi\u00eam ph\u1ed5i kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb bao g\u1ed3m vi\u00eam n\u1ed9i t\u00e2m m\u1ea1c, h\u1ed9i ch\u1ee9ng Lemierre, vi\u00eam t\u00fai m\u1eadt kh\u00f4ng do s\u1ecfi, vi\u00eam \u0111\u1ea1i tr\u00e0ng Clostridium difficile<\/em> ho\u1eb7c c\u00e1c nhi\u1ec5m tr\u00f9ng m\u1eafc ph\u1ea3i trong b\u1ec7nh vi\u1ec7n.<\/p>\n

Ch\u1ea9n \u0111o\u00e1n sai<\/strong><\/em><\/p>\n

Trong m\u1ed9t nghi\u00ean c\u1ee9u th\u1ef1c hi\u1ec7n t\u1ea1i ICU, 19% b\u1ec7nh nh\u00e2n nh\u1eadp vi\u1ec7n v\u1edbi ch\u1ea9n \u0111o\u00e1n vi\u00eam ph\u1ed5i sau c\u00f9ng l\u00e0 b\u1ec7nh l\u00fd kh\u00f4ng do nhi\u1ec5m tr\u00f9ng. C\u00f3 nhi\u1ec1u b\u1ec7nh l\u00fd kh\u00f4ng nhi\u1ec5m tr\u00f9ng c\u00f3 th\u1ec3 gi\u1ed1ng v\u1edbi vi\u00eam ph\u1ed5i ti\u1ebfn tri\u1ec3n n\u1eb7ng ho\u1eb7c kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb nh\u01b0 suy tim, t\u00e2n sinh, xu\u1ea5t huy\u1ebft ph\u1ebf nang lan to\u00e0, vi\u00eam ph\u1ed5i k\u1ebd c\u1ea5p, vi\u00eam ph\u1ed5i t\u0103ng b\u1ea1ch c\u1ea7u \u00e1i toan, thuy\u00ean t\u1eafc ph\u1ed1i, vi\u00eam m\u1ea1ch, v\u00e0 vi\u00eam ph\u1ed5i t\u1ed5 ch\u1ee9c ho\u00e1 (H\u00ecnh 2). M\u1ed9t ch\u1ea9n \u0111o\u00e1n kh\u00e1c th\u01b0\u1eddng b\u1ecb b\u1ecf s\u00f3t l\u00e0 s\u1ed1t do thu\u1ed1c. Danh s\u00e1ch kh\u00e1ng sinh li\u00ean quan \u0111\u1ebfn s\u1ed1t do thu\u1ed1c d\u00e0i v\u00e0 ch\u1ea9n \u0111o\u00e1n n\u00e0y n\u00ean \u0111\u1eb7c bi\u1ec7t nghi ng\u1edd khi c\u00f3 s\u1ef1 hi\u1ec7n di\u1ec7n c\u1ee7a t\u0103ng b\u1ea1ch c\u1ea7u \u00e1i toan.<\/p>\n

Ch\u1ea9n \u0111o\u00e1n \u0111\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n vi\u00eam ph\u1ed5i kh\u00f4ng \u0111\u00e1p \u1ee9ng v\u1edbi \u0111i\u1ec1u tr\u1ecb<\/h3>\n

Xem x\u00e9t l\u1ea1i ti\u1ec1n s\u1eed c\u1ee7a b\u1ec7nh nh\u00e2n<\/strong><\/em><\/p>\n

Trong b\u1ed1i c\u1ea3nh th\u1ea5t b\u1ea1i \u0111i\u1ec1u tr\u1ecb, vi\u1ec7c xem x\u00e9t l\u1ea1i ti\u1ec1n s\u1eed b\u1ec7nh c\u1ee7a b\u1ec7nh nh\u00e2n c\u00f3 th\u1ec3 \u0111\u1eb7c bi\u1ec7t h\u1eefu \u00edch \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh m\u1ed9t nguy\u00ean nh\u00e2n nhi\u1ec5m tr\u00f9ng g\u00e2y vi\u00eam ph\u1ed5i c\u00f3 th\u1ec3 b\u1ecb b\u1ecf s\u00f3t, ho\u1eb7c \u0111\u1ec3 ph\u00e1t hi\u1ec7n c\u00e1c y\u1ebfu t\u1ed1 nguy c\u01a1 cho th\u1ea5y s\u1ef1 hi\u1ec7n di\u1ec7n c\u1ee7a m\u1ed9t t\u00e1c nh\u00e2n kh\u00e1ng thu\u1ed1c cao. V\u00ed d\u1ee5, ti\u1ec1n s\u1eed ti\u1ebfp x\u00fac v\u1edbi \u0111\u1ed9ng v\u1eadt ho\u1eb7c \u0111i du l\u1ecbch c\u00f3 th\u1ec3 cung c\u1ea5p manh m\u1ed1i v\u1ec1 m\u1ed9t nguy\u00ean nh\u00e2n hi\u1ebfm g\u1eb7p g\u00e2y vi\u00eam ph\u1ed1i (xem H\u00ecnh 2).
\nTi\u00ean s\u1eed nhi\u1ec5m, ho\u1eb7c \u0111\u00e3 \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh l\u00e0 mang m\u1ea7m b\u1ec7nh qua c\u00e1c x\u00e9t nghi\u1ec7m t\u1ea7m so\u00e1t, v\u1edbi t\u1ee5 c\u1ea7u v\u00e0ng kh\u00e1ng methicillin<\/em> (MRSA) ho\u1eb7c Pseudomonas aeruginosa<\/em>, c\u0169ng nh\u01b0 ti\u1ec1n s\u1eed d\u00f9ng kh\u00e1ng sinh t\u0129nh m\u1ea1ch trong v\u00f2ng 30 ng\u00e0y qua, n\u00ean l\u00e0m d\u1ea5y l\u00ean ngh\u0129 ng\u1edd v\u1ec1 kh\u1ea3 n\u0103ng vi\u00eam ph\u1ed5i do t\u00e1c nh\u00e2n \u0111a kh\u00e1ng thu\u1ed1c.<\/p>\n

H\u00ecnh \u1ea3nh h\u1ecdc<\/strong><\/em><\/p>\n

H\u00ecnh \u1ea3nh X-quang trong vi\u00eam ph\u1ed5i th\u01b0\u1eddng \u0111\u01b0\u1ee3c ph\u00e2n ra ba nh\u00f3m ch\u00ednh: vi\u00eam ph\u1ed5i khu tr\u00fa kh\u00f4ng theo ph\u00e2n th\u00f9y ho\u1eb7c theo th\u00f9y ph\u1ed5i, vi\u00eam ph\u1ebf qu\u1ea3n ph\u1ed5i \u0111a \u00f4, vi\u00eam ph\u1ed5i k\u1ebd khu tr\u00fa ho\u1eb7c lan t\u1ecfa. \u1ede nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng, h\u01b0\u1edbng d\u00e2n c\u1ee7a ATS\/IDSA kh\u00f4ng khuy\u1ebfn c\u00e1o ch\u1ee5p X-quang ng\u1ef1c theo d\u00f5i th\u01b0\u1eddng quy. Tuy nhi\u00ean, trong nh\u1eefng tr\u01b0\u1eddng h\u1ee3p c\u00f3 bi\u1ec3u hi\u1ec7n l\u00e2m s\u00e0ng kh\u00f4ng \u0111i\u1ec3n h\u00ecnh d\u00f9 c\u00f3 b\u1eb1ng ch\u1ee9ng vi\u00eam ph\u1ed5i tr\u00ean h\u00ecnh \u1ea3nh h\u1ecdc, n\u00ean ch\u1ee5p l\u1ea1i X-quang ng\u1ef1c \u0111\u1ec3 lo\u1ea1i tr\u1eeb c\u00e1c ch\u1ea9n \u0111o\u00e1n kh\u00e1c. Ngo\u00e0i ra, vi\u1ec7c ch\u1ee5p l\u1ea1i X-quang c\u00f3 th\u1ec3 cho th\u1ea5y s\u1ef1 ti\u1ebfn tri\u1ec3n c\u1ee7a b\u1ec7nh, nh\u01b0ng quan tr\u1ecdng h\u01a1n l\u00e0 c\u00f3 th\u1ec3 ph\u00e1t hi\u1ec7n c\u00e1c \u1ed5 d\u1ecbch (hi\u1ebfm g\u1eb7p l\u00e0 \u00e1p xe, th\u01b0\u1eddng g\u1eb7p h\u01a1n l\u00e0 tr\u00e0n d\u1ecbch m\u00e0ng ph\u1ed5i), \u0111i\u1ec1u n\u00e0y c\u00f3 th\u1ec3 ch\u1ec9 ra vi\u1ec7c ki\u1ec3m so\u00e1t \u00f4 nhi\u1ec5m khu\u1ea9n ch\u01b0a hi\u1ec7u qu\u1ea3 (xem H\u00ecnh 2), nh\u01b0 trong tr\u01b0\u1eddng h\u1ee3p tr\u00e0n m\u00f9 m\u00e0ng ph\u1ed5i c\u1ea7n ph\u1ea3i d\u1eabn l\u01b0u. S\u1ef1 c\u1ea3i thi\u1ec7n tr\u00ean h\u00ecnh \u1ea3nh X-quang th\u01b0\u1eddng ch\u1eadm h\u01a1n so v\u1edbi c\u00e1i thi\u1ec7n l\u00e2m s\u00e0ng, c\u00f3 th\u1ec3 k\u00e9o d\u00e0i t\u1eeb v\u00e0i ng\u00e0y \u0111\u1ebfn v\u00e0i tu\u1ea7n. \u1ede b\u1ec7nh nh\u00e2n d\u01b0\u1edbi 50 tu\u1ed5i v\u00e0 nh\u1eefng ng\u01b0\u1eddi b\u1ecb vi\u00eam ph\u1ed5i nh\u1eb9 \u0111\u1ebfn trung b\u00ecnh, c\u00e1c t\u1ed5n th\u01b0\u01a1ng th\u00e2m nhi\u1ec5m tr\u00ean X-quang th\u01b0\u1eddng h\u1ed3i ph\u1ee5c trong v\u00f2ng 4 tu\u1ea7n.<\/p>\n

Ng\u01b0\u1ee3c l\u1ea1i, t\u1ed5n th\u01b0\u01a1ng ph\u1ed1i c\u00f3 th\u1ec3 l\u00ean \u0111\u1ebfn 10 tu\u1ea7n \u1edf b\u1ec7nh nh\u00e2n l\u1edbn tu\u1ed5i, nh\u1eefng ng\u01b0\u1eddi c\u00f3 nhi\u1ec1u b\u1ec7nh \u0111\u1ed3ng m\u1eafc v\u00e0 COPD, ho\u1eb7c vi\u00eam ph\u1ed5i n\u1eb7ng. X-quang ch\u1eadm ti\u1ebfn tri\u1ec1n \u0111\u01a1n \u0111\u1ed9c kh\u00f4ng ph\u1ea3i l\u00e0 ch\u1ec9 \u0111i\u1ec3m c\u1ee7a \u0111i\u1ec1u tr\u1ecb th\u1ea5t b\u1ea1i.<\/p>\n

Si\u00eau \u00e2m ph\u1ed1i c\u00f3 tr\u1ecdng \u0111i\u1ec3m c\u0169ng mang l\u1ea1i l\u1ee3i \u00edch v\u00ec n\u00f3 nh\u1ea1y h\u01a1n X-quang ng\u1ef1c trong ph\u00e1t hi\u1ec7n tr\u00e0n d\u1ecbch m\u00e0ng ph\u1ed5i v\u00e0 \u0111\u1eb7c \u0111i\u1ec3m c\u1ee7a d\u1ecbch g\u1ee3i \u00fd c\u00f3 s\u1ef1 hi\u1ec7n di\u1ec7n c\u1ee7a tr\u00e0n m\u00f9 m\u00e0ng ph\u1ed5i. Si\u00eau \u00e2m ph\u1ed1i c\u00f2n tr\u00e1nh \u0111\u01b0\u1ee3c chi ph\u00ed v\u00e0 tia x\u1ea1 trong CT – \u0111\u00f2i h\u1ecfi chuy\u00ean gia k\u0129 thu\u1eadt v\u00e0 \u00edt hi\u1ec7u qu\u1ea3 trong \u0111\u00e1nh gi\u00e1 s\u00e2u v\u1ebb m\u00e0ng ph\u1ed5i.<\/p>\n

\u0110\u1ed1i v\u1edbi c\u00e1c tr\u01b0\u1eddng h\u1ee3p vi\u00eam ph\u1ed5i kh\u00f4ng gi\u1ea3i quy\u1ebft \u0111\u01b0\u1ee3c ho\u1eb7c di\u1ec5n ti\u1ebfn l\u00e2m s\u00e0ng x\u1ea5u \u0111i, l\u00e0m l\u1ea1i h\u00ecnh \u1ea3nh h\u1ecdc – \u0111\u1eb7c bi\u1ec7t l\u00e0 CT ng\u1ef1c – \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o m\u1ea1nh. CT c\u00f3 th\u1ec3 gi\u00fap x\u00e1c nh\u1eadn l\u1ea1i ch\u00e2n \u0111o\u00e1n vi\u00eam ph\u1ed5i v\u00e0 ch\u1ea9n \u0111o\u00e1n ph\u00e2n bi\u1ec7t kh\u00e1c ho\u1eb7c b\u1ec7nh \u0111\u1ed3ng m\u1eafc c\u00f3 th\u1ec3 gi\u1ea3i th\u00edch t\u1ec9nh tr\u1ea1ng k\u00e9m \u0111\u00e1p \u1ee9ng c\u1ee7a b\u1ec7nh nh\u00e2n, nh\u01b0 ph\u00f9 ph\u1ed5i, thuy\u00ean t\u1eafc ph\u00f4i, c\u00e1c b\u1ec7nh l\u00fd vi\u00eam, vi\u00eam ph\u1ed5i t\u1ed5 ch\u1ee9c ho\u00e1 ho\u1eb7c b\u1ec7nh l\u00fd \u00e1c t\u00ednh. CT ng\u1ef1c c\u00f3 \u0111\u1ed9 ph\u00e2n gi\u1ea3i cao \u0111\u01b0\u1ee3c \u0111\u1ecdc v\u1edbi b\u00e1c s\u0129 ch\u1ea9n \u0111o\u00e1n h\u00ecnh \u1ea3nh c\u00f3 th\u1ec3 \u0111\u1eb7c bi\u1ec7t h\u1eefu \u00edch trong ph\u00e2n bi\u1ec7t nguy\u00ean nh\u00e2n nhi\u1ec5m tr\u00f9ng v\u00e0 kh\u00f4ng nhi\u1ec5m tr\u00f9ng. CT c\u00f2n gi\u00fap x\u00e1c \u0111\u1ecbnh ki\u1ec3u h\u00ecnh t\u1ed5n th\u01b0\u01a1ng (vd, th\u1ee7y ph\u1ed1i, t\u1ed5n th\u01b0\u01a1ng k\u1ebd, n\u1ed1t) v\u00e0 c\u00f3 th\u1ec3 ph\u00e1t hi\u1ec7n c\u00e1c bi\u1ebfn ch\u1ee9ng nh\u01b0 khoang, \u00e1p xe, tr\u00e0n m\u00f9 ho\u1eb7c \u0111i c\u0103n, gi\u00fap \u0111\u1ecbnh h\u01b0\u1edbng ch\u1ea9n \u0111o\u00e1n v\u00e0 can thi\u1ec7p \u0111i\u1ec1u tr\u1ecb (H\u00ecnh 2).<\/p>\n

X\u00e9t nghi\u1ec7m<\/strong><\/em><\/p>\n

\u0110\u1ed1i v\u1edbi b\u1ec7nh nh\u00e2n vi\u00eam ph\u1ed5i n\u1eb7ng kh\u00f4ng \u0111\u00e1p \u1ee9ng v\u1edbi \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh, l\u00e0m x\u00e9t nghi\u1ec7m (c\u1ea3 nh\u00f3m nguy\u00ean nh\u00e2n nhi\u1ec5m tr\u00f9ng v\u00e0 kh\u00f4ng nhi\u1ec5m tr\u00f9ng) – x\u00e9t nghi\u1ec7m m\u00e1u, n\u01b0\u1edbc ti\u1ec3u, d\u1ecbch r\u1eeda ph\u1ebf qu\u1ea3n c\u00f3 th\u1ec3 h\u1ed7 tr\u1ee3 x\u00e1c \u0111\u1ecbnh c\u0103n nguy\u00ean (H\u00ecnh 2). Theo d\u00f5i CRP v\u00e0 PCT trong \u0111\u00e1nh gi\u00e1 \u0111\u00e1p \u1ee9ng v\u00e0 \u0111\u1ecbnh h\u01b0\u1edbng th\u1eddi gian s\u1eed d\u1ee5ng kh\u00e1ng sinh. N\u1ed9i soi v\u00e0 l\u1ea5y d\u1ecbch r\u1eeda ph\u1ebf qu\u1ea3n c\u00f3 th\u1ec3 cung c\u1ea5p th\u00f4ng tin ch\u1ea9n \u0111o\u00e1n \u1edf tr\u00ean 40% b\u1ec7nh nh\u00e2n ICU vi\u00eam ph\u1ed5i \u0111i\u1ec1u tr\u1ecb th\u1ea5t b\u1ea1i. Trong tr\u01b0\u1eddng h\u1ee3p ngh\u1ec9 ng\u1edd l\u00e2m s\u00e0ng b\u1ec7nh l\u00fd kh\u00f4ng nhi\u1ec5m tr\u00f9ng, n\u00ean l\u00e0m x\u00e9t nghi\u1ec7m t\u1ef1 mi\u1ec5n (vd, ANA, anti-DNA ss v\u00e0 ds, c-ANCA, v\u00e0 p-ANCA, anti-GBM), x\u00e9t nghi\u1ec7m n\u01b0\u1edbc ti\u1ec3u, x\u00e9t nghi\u1ec7m BAL v\u00e0 d\u00f2ng ch\u1ea3y t\u1ebf b\u1ea3o.<\/p>\n

C\u1ea7n l\u00e0m g\u00ec v\u1edbi kh\u00e1ng sinh \u0111i\u1ec1u tr\u1ecb?<\/h3>\n

Kh\u00f4ng c\u00f3 d\u1eef li\u1ec7u RCT h\u01b0\u1edbng d\u1eabn ti\u1ebfp c\u1eadn \u0111i\u1ec1u tr\u1ecb b\u1ec7nh nh\u00e2n kh\u00f4ng \u0111\u00e1p \u1ee9ng. Do \u0111\u00f3, b\u00e1c s\u0129 l\u00e2m s\u00e0ng ph\u1ea3i d\u1ef1a r\u1ea5t nhi\u1ec1u v\u00e0o chuy\u00ean m\u00f4n y khoa v\u00e0 ph\u00e1n \u0111o\u00e1n l\u00e2m s\u00e0ng. N\u1ebfu vi\u1ec7c xem x\u00e9t d\u1eef li\u1ec7u l\u00e2m s\u00e0ng c\u00f3 li\u00ean quan cho th\u1ea5y m\u1ed9t ch\u1ea9n \u0111o\u1ea3n thay th\u1ebf ho\u1eb7c t\u00e1c nh\u00e2n kh\u00e1c ho\u1eb7c t\u00e1c nh\u00e2n kh\u00e1ng thu\u1ed1c, c\u00f3 th\u1ec3 c\u1ea7n \u0111i\u1ec1u ch\u1ec9nh kh\u00e1ng sinh \u0111i\u1ec1u tr\u1ecb, n\u00e2ng b\u1eadc \u0111i\u1ec1u tr\u1ecb \u0111\u1ec3 bao ph\u1ee7 t\u00e1c nh\u00e2n \u0111a kh\u00e1ng ho\u1eb7c th\u00eam thu\u1ed1c bao ph\u1ee7 t\u00e1c nh\u00e2n kh\u00f4ng \u0111i\u1ec3n h\u00ecnh ho\u1eb7c c\u00e1c t\u00e1c nh\u00e2n kh\u00e1c.<\/p>\n

Nhi\u1ec5m tr\u00f9ng nghi\u00eam t\u1ecdng h\u01a1n do \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh kh\u00f4ng ph\u00f9 h\u1ee3p c\u00f3 th\u1ec3 x\u1ea3y ra n\u1ebfu t\u00e1c nh\u00e2n g\u00e2y b\u1ec7nh kh\u1ea3ng v\u1edbi lo\u1ea1i kh\u00e1ng sinh ban \u0111\u1ea7u \u0111\u01b0\u1ee3c ch\u1ecdn, n\u00eau ban \u0111\u1ea7u vi khu\u1ea9n nh\u1ea1y c\u1ea3m nh\u01b0ng ph\u00e1t sinh kh\u00e1ng thu\u1ed1c trong qu\u00e1 tr\u00ecnh \u0111i\u1ec1u tr\u1ecb, ho\u1eb7c n\u1ebfu kh\u00e1ng sinh \u0111\u01b0\u1ee3c ch\u1ecdn kh\u00f4ng \u0111\u1ea1t n\u1ed3ng \u0111\u1ed9 \u0111\u1ee7 cao t\u1ea1i nhu m\u00f4 ph\u00f4i. C\u00e1c y\u1ebfu t\u1ed1 nguy c\u01a1 nhi\u1ec5m tr\u00f9ng kh\u00e1ng thu\u1ed1c ngay t\u1eeb \u0111\u1ea7u kh\u00e1c nhau t\u00f9y theo c\u0103n nguy\u00ean vi sinh, do \u0111\u00f3 vi\u1ec7c \u0111\u00e1nh gi\u00e1 c\u00e1c y\u1ebfu t\u1ed1 nguy c\u01a1 d\u1ecbch t\u1ec5 h\u1ecdc v\u00e0 l\u00e2m s\u00e0ng c\u1ee7a t\u1eebng c\u00e1 nh\u00e2n l\u00e0 r\u1ea5t quan tr\u1ecdng. V\u00ed d\u1ee5, ph\u1ebf c\u00e2u kh\u00e1ng ceftriaxone \u00edt g\u1eb7p \u1edf Hoa K\u1ef3 nh\u01b0ng l\u1ea1i th\u01b0\u1eddng g\u1eb7p h\u01a1n \u1edf \u0110\u00e0i Loan v\u00e0 H\u00e0n Qu\u1ed1c, c\u00e1c y\u1ebfu t\u1ed1 nguy c\u01a1 bao g\u1ed3m ti\u1ec1n s\u1eed \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh nhi\u1ec1u l\u1ea7n cho nhi\u1ec5m tr\u00f9ng \u0111\u01b0\u1eddng h\u00f4 h\u1ea5p. V\u00ec li\u1ec1u cao beta-lactam th\u01b0\u1eddng \u0111\u01b0\u1ee3c s\u1eed d\u1ee5ng trong \u0111i\u1ec1u tr\u1ecb vi\u00eam ph\u1ed1i m\u1eafc ph\u1ea3i trong c\u1ed9ng \u0111\u1ed3ng (CAP) t\u1ea1i Hoa K\u1ef3, n\u00ean kh\u1ea3 n\u0103ng kh\u00e1ng ceftriaxone d\u1eabn \u0111\u1ebfn \u0111i\u1ec1u tr\u1ecb vi\u00eam ph\u1ed5i th\u1ea5t b\u1ea1i l\u00e0 th\u1ea5p. M\u1eb7t kh\u00e1c, vi\u1ec7c s\u1eed d\u1ee5ng kh\u00e1ng sinh di\u1ec7t khu\u1ea9n so v\u1edbi kh\u00e1ng sinh kim khu\u1ea9n kh\u00f4ng ph\u1ea3i l\u00e0 y\u1ebfu t\u1ed1 nguy c\u01a1 d\u1eabn \u0111\u1ebfn kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb. \u0110i\u1ec1u n\u00e0y \u0111\u00e3 \u0111\u01b0\u1ee3c ch\u1ee9ng m\u00ecnh qua m\u1ed9t ph\u00e2n t\u00edch g\u1ed9p g\u1ea7n \u0111\u00e2y tr\u00ean 42 nghi\u00ean c\u1ee9u, cho th\u1ea5y kh\u00f4ng c\u00f3 s\u1ef1 kh\u00e1c bi\u1ec7t v\u1ec1 t\u1ef7 l\u1ec7 kh\u1ecfi b\u1ec7nh l\u00e2m s\u00e0ng gi\u1eefa b\u1ec7nh nh\u00e2n \u0111i\u1ec1u tr\u1ecb b\u1eb1ng thu\u1ed1c di\u1ec7t khu\u1ea9n v\u00e0 thu\u1ed1c kim khu\u1ea9n.<\/p>\n

Nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 th\u1eddi gian n\u1eb1m vi\u1ec7n k\u00e9o d\u00e0i, \u0111\u00e3 s\u1eed d\u1ee5ng kh\u00e1ng sinh nhi\u1ec1u, s\u1ed1ng t\u1ea1i c\u01a1 s\u1edf \u0111i\u1ec1u tr\u1ecb c\u1ea5p t\u1ec9nh d\u00e0i h\u1ea1n, ho\u1eb7c \u0111ang s\u1ed1ng ho\u1eb7c m\u1edbi \u0111i du l\u1ecbch \u0111\u1ebfn nh\u1eefng khu v\u1ef1c c\u00f3 t\u1ef7 l\u1ec7 kh\u00e1ng thu\u1ed1c cao (vd, \u00c2n \u0110\u1ed9 ho\u1eb7c Nam M\u1ef9) c\u00f3 th\u1ec3 c\u00f3 nguy c\u01a1 nhi\u1ec5m c\u00e1c vi khu\u1ea9n Gram \u00e2m \u0111a kh\u00e1ng nh\u01b0 c\u00e1c ch\u00fang ESBL, \u0111\u1eb7c bi\u1ec7t l\u00e0 E. coli, K. pneumoniae, K. oxytoca<\/em> ho\u1eb7c P. mirabillis<\/em>, th\u01b0\u1eddng c\u1ea7n \u0111i\u1ec1u tr\u1ecb b\u1eb1ng carbapenem. Trong tr\u01b0\u1eddng h\u1ee3p c\u00e1c ch\u00fang Enterobacteriales c\u00f3 gen ampC trong qu\u00e1 tr\u00ecnh \u0111i\u1ec1u tr\u1ecb b\u1eb1ng cephalosporin th\u1ebf h\u1ec7 3 d\u1eabn \u0111\u1ebfn s\u1ea3n xu\u1ea5t ampC beta-lactamase, th\u01b0\u1eddng c\u1ea7n \u0111i\u1ec1u tr\u1ecb b\u1eb1ng cefepime ho\u1eb7c carbapenem. Ngo\u00e0i ra, Pseudomonas aeruginosa<\/em> kh\u00e1ng thu\u1ed1c m\u1ee9c cao c\u00f3 th\u1ec3 c\u1ea7n \u0111i\u1ec1u tr\u1ecb b\u1eb1ng carbapenem, ceftolozane\/tazobactam ho\u1eb7c ceftazidime\/avibactam. Nh\u1eefng b\u1ec7nh nh\u00e2n \u0111ang di\u1ec5n ti\u1ebfn x\u1ea5u tr\u00ean l\u00e2m s\u00e0ng, c\u00f3 c\u00e1c y\u1ebfu t\u1ed1 nguy c\u01a1 k\u1ec3 tr\u00ean v\u00e0 ch\u01b0a \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb nh\u1eb1m v\u00e0o c\u00e1c vi khu\u1ea9n n\u00e0y ho\u1eb7c c\u00f3 kh\u1ea3 n\u0103ng \u0111\u00e3 nhi\u1ec5m ch\u00fang trong qu\u00e1 tr\u00ecnh n\u1eb1m vi\u1ec7n, c\u00f3 th\u1ec3 c\u1ea7n t\u0103ng c\u01b0\u1edfng \u0111i\u1ec1u tr\u1ecb ngay l\u1eadp t\u1ee9c, \u0111\u1eb7c bi\u1ec7t n\u1ebfu b\u1ec7nh nh\u00e2n \u0111ang suy s\u1ee5p. N\u1ebfu c\u00e1c vi khu\u1ea9n kh\u00f4ng \u0111\u01b0\u1ee3c ph\u00e2n l\u1eadp t\u1eeb m\u1eabu b\u1ec7nh ph\u1ea9m \u0111\u01b0\u1eddng h\u00f4 h\u1ea5p, kh\u1ea3 n\u0103ng ch\u00fang l\u00e0 nguy\u00ean nh\u00e2n g\u00e2y di\u1ec5n bi\u1ebfn l\u00e2m s\u00e0ng c\u1ee7a b\u1ec7nh nh\u00e2n l\u00e0 th\u1ea5p.<\/p>\n

T\u01b0\u01a1ng t\u1ef1, vi\u1ec7c th\u00eam vancomycin ho\u1eb7c linezolid \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb MRSA th\u01b0\u1eddng \u0111\u01b0\u1ee3c c\u00e2n nh\u1eafc \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 di\u1ec5n bi\u1ebfn l\u00e2m s\u00e0ng x\u1ea5u \u0111i. Nguy c\u01a1 m\u1eafc MRSA trong th\u1eddi gian n\u1eb1m vi\u1ec7n thay \u0111\u1ed5i t\u00f9y t\u00ecnh hu\u1ed1ng, nh\u01b0ng nh\u00ecn chung l\u00e0 hi\u1ec3m n\u1ebfu c\u00e1c bi\u1ec7n ph\u00e1p ki\u1ec3m so\u00e1t nhi\u1ec5m khu\u1ea9n \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n t\u1ed1t. Gi\u00e1 tr\u1ecb ti\u00ean \u0111o\u00e1n \u00e2m c\u1ee7a x\u00e9t nghi\u1ec7m t\u1ea7m so\u00e1t MRSA \u1edf m\u0169i (b\u1eb1ng PCR ho\u1eb7c c\u1ea5y) kh\u00e1 cao; do \u0111\u00f3, n\u1ebfu k\u1ebft qu\u1ea3 t\u1ea7m so\u00e1t MRSA \u1edf m\u0169i \u00e2m t\u1ec9nh, th\u00ec h\u1ee3p l\u00fd \u0111\u1ec3 ng\u1eebng ho\u1eb7c kh\u00f4ng th\u00eam kh\u00e1ng sinh \u0111i\u1ec1u tr\u00ec MRSA.<\/p>\n

M\u1ed9t l\u01b0u \u00fd b\u1ed5 sung li\u00ean quan \u0111\u1ebfn nh\u1eefng b\u1ec7nh nh\u00e2n kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb l\u00e0 v\u1eabn \u0111\u1ec3 l\u1ef1a ch\u1ecdn thu\u1ed1c v\u00e0 li\u1ec1u kh\u00e1ng sinh ph\u00f9 h\u1ee3p. V\u00ed d\u1ee5, n\u1ebfu vancomycin \u0111\u01b0\u1ee3c k\u00ea \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb MRSA nh\u01b0ng ph\u1ea3i m\u1ea5t 4 ng\u00e0y m\u1edbi \u0111\u1ea1t \u0111\u01b0\u1ee3c n\u1ed3ng \u0111\u1ed9 \u0111i\u1ec1u tr\u1ecb, th\u00ec c\u00f3 th\u1ec3 quan s\u00e1t th\u1ea5y t\u00ecnh tr\u1ea1ng l\u00e2m s\u00e0ng x\u1ea5u \u0111i ho\u1eb7c kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb. T\u01b0\u01a1ng t\u1ef1, n\u1ebfu daptomycin \u0111\u01b0\u1ee3c b\u1eaft \u0111\u1ea7u v\u00ec l\u00fd do kh\u00e1c, th\u00ec kh\u00f4ng th\u1ec3 k\u1ef3 v\u1ecdng thu\u1ed1c n\u00e0y \u0111i\u1ec1u tr\u1ecb \u0111\u01b0\u1ee3c vi\u00eam ph\u1ed5i do MRSA v\u00ec n\u00f3 b\u1ecb surfactant b\u1ea5t ho\u1ea1t. T\u00ecnh tr\u1ea1ng d\u00f9ng li\u1ec1u d\u01b0\u1edbi m\u1ee9c \u0111i\u1ec1u tr\u1ecb \u0111\u1ed1i v\u1edbi kh\u00e1ng sinh beta-lactam nh\u1eafm v\u00e0o vi khu\u1ea9n gram \u00e2m x\u00e2y ra kh\u00e1 th\u01b0\u1eddng xuy\u00ean, m\u1eb7c d\u00f9 \u1edf b\u1ec7nh nh\u00e2n ICU b\u1ecb nhi\u1ec5m khu\u1ea9n huy\u1ebft, d\u01b0\u1ee3c \u0111\u1ed9ng h\u1ecdc v\u00e0 \u0111\u01b0\u1ee3c l\u1ef1c h\u1ecdc c\u1ee7a thu\u1ed1c c\u00f3 th\u1ec3 b\u1ecb thay \u0111\u1ed5i, d\u1eabn \u0111\u1ebfn t\u0103ng th\u1ea3i tr\u1eeb kh\u00e1ng sinh. V\u00ec l\u00fd do n\u00e0y, nhi\u1ec1u ICU \u01b0u ti\u00ean s\u1eed d\u1ee5ng c\u00e1c thu\u1ed1c beta-lactam theo d\u1ea1ng truy\u1ec1n li\u00ean t\u1ee5c ho\u1eb7c truy\u1ec1n k\u00e9o d\u00e0i.<\/p>\n

Nhu c\u1ea7u th\u00eam kh\u00e1ng sinh \u0111\u1ec3 bao ph\u1ee7 c\u00e1c t\u00e1c nh\u00e2n vi khu\u1ea9n kh\u00f4ng \u0111i\u1ec3n h\u00ecnh ho\u1eb7c kh\u00f4ng ph\u1ea3i vi khu\u1ea9n ph\u1ee5 thu\u1ed9c v\u00e0o t\u00ecnh tr\u1ea1ng l\u00e2m s\u00e0ng v\u00e0 mi\u1ec5n d\u1ecbch c\u1ee7a b\u1ec7nh nh\u00e2n, c\u0169ng nh\u01b0 k\u1ebft qu\u1ea3 h\u00ecnh \u1ea3nh v\u00e0 x\u00e9t nghi\u1ec7m vi sinh. Nh\u00ecn chung, nhu c\u1ea7u th\u00eam c\u00e1c thu\u1ed1c n\u00e0y l\u00e0 hi\u1ec3m v\u00e0 th\u01b0\u1eddng ch\u1ec9 \u0111\u01b0\u1ee3c c\u00e2n nh\u1eafc \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n suy gi\u1ea3m mi\u1ec5n d\u1ecbch n\u1eb7ng. Vi\u1ec7c th\u00eam thu\u1ed1c \u0111i\u1ec1u tr\u1ecb vi khu\u1ea9n kh\u00f4ng \u0111i\u1ec3n h\u00ecnh ch\u1ee7 y\u1ebfu nh\u1eafm v\u00e0o Legionella spp<\/em>., c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c c\u00e2n nh\u1eafc n\u1ebfu ch\u01b0a \u0111\u01b0\u1ee3c ch\u1ec9 \u0111\u1ecbnh ban \u0111\u1ea7u \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n nguy c\u01a1 cao. B\u00e1c s\u0129 l\u00e2m s\u00e0ng c\u1ea7n l\u01b0u \u00fd t\u00ecnh h\u00ecnh d\u1ecbch t\u1ec5 \u0111\u1ecba ph\u01b0\u01a1ng li\u00ean quan \u0111\u1ebfn c\u00e1c \u0111\u1ee3t b\u00f9ng ph\u00e1t Legionella<\/em> v\u00e0 nh\u1eadn th\u1ee9c r\u1eb1ng x\u00e9t nghi\u1ec7m kh\u00e1ng nguy\u00ean n\u01b0\u1edbc ti\u1ec3u ch\u1ec9 ph\u00e1t hi\u1ec7n L. pneumophila<\/em> type 1, v\u1ed1n chi\u1ebfm 80-90% ca b\u1ec7nh, nh\u01b0ng v\u00ec c\u00e1c nh\u00f3m huy\u1ebft thanh kh\u00e1c v\u00e0 c\u00e1c lo\u00e0i Legionella<\/em> kh\u00e1c (vd L. micdadei<\/em>) c\u0169ng c\u00f3 th\u1ec3 g\u00e2y b\u1ec7nh, n\u00ean \u0111\u1ed9 nh\u1ea1y c\u1ee7a x\u00e9t nghi\u1ec7m n\u00e0y c\u00f3 th\u1ec3 th\u1ea5p h\u01a1n con s\u1ed1 tr\u00ean. \u0110\u00e1nh gi\u00e1 to\u00e0n di\u1ec7n bi\u1ec3u hi\u1ec7n l\u00e2m s\u00e0ng v\u00e0 ti\u1ec1n s\u1eed d\u1ecbch t\u1ec5 c\u1ee7a b\u1ec7nh nh\u00e2n l\u00e0 \u0111i\u1ec1u thi\u1ebft y\u1ebfu \u0111\u1ec3 x\u00e1c \u0111\u1ecbnh c\u00e1c t\u00e1c nh\u00e2n g\u00e2y b\u1ec7nh hi\u1ebfm g\u1eb7p g\u00e2y vi\u00eam ph\u1ed5i c\u1ed9ng \u0111\u1ed3ng kh\u00f4ng \u0111\u00e1p \u1ee9ng, t\u1eeb \u0111\u00f3 c\u00f3 th\u1ec3 c\u1ea7n li\u1ec7u ph\u00e1p kh\u00e1ng sinh tr\u00fang \u0111\u00edch, th\u01b0\u1eddng d\u01b0\u1edbi d\u1ea1ng ph\u1ed1i h\u1ee3p. Vi\u00eam ph\u1ed5i do n\u1ea5m ti\u1ebfn tri\u1ec3n nhanh v\u00e0 vi\u00eam ph\u1ed5i do PJP hi\u1ebfm g\u1eb7p v\u00e0 \u00edt x\u1ea3y ra \u1edf b\u1ec7nh nh\u00e2n kh\u00f4ng suy gi\u1ea3m mi\u1ec5n d\u1ecbch ho\u1eb7c kh\u00f4ng c\u00f3 c\u00e1c t\u00ecnh tr\u1ea1ng suy gi\u1ea3m mi\u1ec5n d\u1ecbch \u0111\u00e1ng k\u1ec3; tuy nhi\u00ean, vi\u1ec7c b\u1ed5 sung thu\u1ed1c kh\u00e1ng n\u1ea5m v\u00e0\/ho\u1eb7c TMP\/SMX t\u01b0\u01a1ng \u1ee9ng c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c c\u00e2n nh\u1eafc \u1edf b\u1ec7nh nh\u00e2n suy gi\u1ea3m mi\u1ec5n d\u1ecbch c\u00f3 k\u1ebft qu\u1ea3 h\u00ecnh \u1ea3nh h\u1ecdc v\u00e0 x\u00e9t nghi\u1ec7m vi sinh ph\u00f9 h\u1ee3p. C\u1ea7n l\u01b0u \u00fd r\u1eb1ng c\u00e1c t\u00e1c nh\u00e2n g\u00e2y b\u1ec7nh do virus, \u0111\u1eb7c bi\u1ec7t l\u00e0 c\u00fam, RSV v\u00e0 SARS-CoV-2 c\u00f3 th\u1ec3 g\u00e2y vi\u00eam ph\u1ed5i, bao g\u1ed3m c\u1ea3 vi\u00eam ph\u1ed5i th\u00f9y v\u00e0 c\u00f3 th\u1ec3 l\u00e2y cho b\u1ec7nh nh\u00e2n \u0111ang n\u1eb1m vi\u1ec7n; n\u1ebfu c\u00e1c t\u00e1c nh\u00e2n n\u00e0y \u0111\u01b0\u1ee3c x\u00e1c \u0111\u1ecbnh qua x\u00e9t nghi\u1ec7m h\u00f4 h\u1ea5p t\u00ecm virus, c\u1ea7n kh\u1edfi \u0111\u1ea7u thu\u1ed1c kh\u00e1ng virus th\u00edch h\u1ee3p. Ngo\u00e0i ra, CMV v\u00e0 HSV t\u00e1i ho\u1ea1t \u0111\u00e3 \u0111\u01b0\u1ee3c ph\u00e1t hi\u1ec7n th\u01b0\u1eddng xuy\u00ean \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n nguy k\u1ecbch ph\u1ea3i th\u1edf m\u00e1y (HSV th\u01b0\u1eddng g\u1eb7p h\u01a1n) v\u1edbi m\u1ee9c \u0111\u1ed9 \u1ea3nh h\u01b0\u1edfng kh\u00e1c nhau \u0111\u1ebfn k\u1ebft c\u1ee5c l\u00e2m s\u00e0ng. Tuy nhi\u00ean, hi\u1ec7n ch\u01b0a c\u00f3 khuy\u1ebfn c\u00e1o r\u00f5 r\u00e0ng v\u1ec1 gi\u00e1 tr\u1ecb c\u1ee7a \u0111i\u1ec1u tr\u1ecb kh\u00e1ng virus trong nh\u1eefng t\u00ecnh hu\u1ed1ng n\u00e0y. Cu\u1ed1i c\u00f9ng, nhi\u1ec5m mycobacteria hi\u1ec3m khi l\u00e0 nguy\u00ean nh\u00e2n g\u00e2y suy h\u00f4 h\u1ea5p c\u1ea5p, nh\u01b0ng lao k\u00ea v\u1eabn c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c c\u00e2n nh\u1eafc v\u00e0 \u0111i\u1ec1u tr\u1ecb \u1edf nh\u1eefng b\u1ec7nh nh\u00e2n ph\u00f9 h\u1ee3p.<\/p>\n

Khi kh\u00f4ng c\u00f3 d\u1ea5u hi\u1ec7u l\u00e2m s\u00e0ng x\u1ea5u \u0111i ho\u1eb7c ch\u1ea9n \u0111o\u00e1n c\u00f2n ch\u01b0a r\u00f5 r\u00e0ng, vi\u1ec7c kh\u00f4ng n\u00e2ng b\u1eadc ho\u1eb7c th\u1eadm ch\u00ed l\u00e0 ng\u1eebng kh\u00e1ng sinh trong khi ti\u1ebfp t\u1ee5c \u0111\u00e1nh gi\u00e1 b\u1ec7nh nh\u00e2n l\u00e0 \u0111i\u1ec1u h\u1ee3p l\u00fd. N\u1ebfu t\u00e1c nh\u00e2n g\u00e2y b\u1ec7nh tr\u01b0\u1edbc \u0111\u00f3 \u0111\u00e3 \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb \u0111\u1ea7y \u0111\u1ee7, vi\u1ec7c k\u00e9o d\u00e0i li\u1ec7u tr\u00ecnh \u0111i\u1ec1u tr\u1ecb v\u01b0\u1ee3t qu\u00e1 th\u1eddi gian khuy\u1ebfn c\u00e1o hi\u1ec7n t\u1ea1i h\u1ea7u nh\u01b0 kh\u00f4ng mang l\u1ea1i l\u1ee3i \u00edch v\u00e0 ch\u1eafc ch\u1eafn l\u00e0m t\u0103ng nguy c\u01a1 g\u00e2y h\u1ea1i. Nh\u00ecn chung, trong ICU, vi\u1ec7c thi\u1ebfu bao ph\u1ee7 kh\u00e1ng sinh l\u00e0 hi\u1ebfm g\u1eb7p do th\u01b0\u1eddng s\u1eed d\u1ee5ng ph\u00e1c \u0111\u1ed3 bao ph\u1ee7 r\u1ed9ng (v\u00ed d\u1ee5 cefepime ho\u1eb7c piperacillin\/tazobactam vancomycin), v\u00e0 c\u00e1c t\u1ec9nh hu\u1ed1ng \u0111\u00e3 \u0111\u1ec1 c\u1eadp tr\u01b0\u1edbc \u0111\u00f3 nh\u00ecn chung l\u00e0 kh\u00f4ng th\u01b0\u1eddng g\u1eb7p. N\u1ebfu kh\u00e1ng sinh \u0111\u01b0\u1ee3c m\u1edf r\u1ed9ng ho\u1eb7c c\u00e1c thu\u1ed1c kh\u00e1ng sinh kh\u00e1c \u0111\u01b0\u1ee3c th\u00eam theo kinh nghi\u1ec7m, c\u1ea7n \u0111\u00e1nh gi\u00e1 l\u1ea1i h\u00e0ng ng\u00e0y v\u1ec1 s\u1ef1 c\u1ea7n thi\u1ebft c\u1ee7a c\u00e1c thu\u1ed1c n\u00e0y. Quy\u1ebft \u0111\u1ecbnh n\u00e0y n\u00ean d\u1ef1a tr\u00ean c\u00e1c x\u00e9t nghi\u1ec7m ch\u1ea9n \u0111o\u00e1n b\u1ed5 sung, bao g\u1ed3m vi\u1ec7c l\u1ea5y m\u1eabu c\u1ea5y \u0111\u01b0\u1eddng h\u00f4 h\u1ea5p, t\u1ed1t nh\u1ea5t l\u00e0 qua d\u1ecbch r\u1eeda ph\u1ebf nang, ph\u01b0\u01a1ng ph\u00e1p n\u00e0y c\u0169ng cho ph\u00e9p l\u1ea5y m\u1eabu c\u1ea7y Legionella, PCR PJP, kh\u00e1ng nguy\u00ean galactomannan (\u0111\u1ed9 nh\u1ea1y cao h\u01a1n so v\u1edbi huy\u1ebft thanh), beta-D-glucan, nhu\u1ed9m soi v\u00e0 x\u00e9t nghi\u1ec7m lao\/n\u1ea4m, c\u0169ng nh\u01b0 panel \u0111a t\u00e1c nh\u00e2n virus h\u00f4 h\u1ea5p. N\u1ebfu carbapenem ho\u1eb7c c\u00e1c kh\u00e1ng sinh ch\u1ed1ng gram \u00e2m th\u1ebf h\u1ec7 m\u1edbi \u0111\u01b0\u1ee3c b\u1eaft \u0111\u1ea7u theo kinh nghi\u1ec7m, ch\u00fang n\u00ean \u0111\u01b0\u1ee3c ng\u1eebng ngay khi k\u1ebft qu\u1ea3 c\u1ea5y tr\u1ea3 v\u1ec1 kh\u00f4ng \u1ee7ng h\u1ed9 vi\u1ec7c ti\u1ebfp t\u1ee5c. N\u1ebfu kh\u00f4ng x\u00e1c \u0111\u1ecbnh \u0111\u01b0\u1ee3c ch\u1ea9n \u0111o\u00e1n nhi\u1ec5m tr\u00f9ng, c\u1ea7n c\u00e2n nh\u1eafc ng\u1eebng kh\u00e1ng sinh v\u00e0 theo d\u00f5i ch\u1eb7t ch\u1ebd, kh\u00f4ng n\u00ean ch\u1ec9 \u0111\u1ecbnh m\u1ed9t c\u00e1ch t\u00f9y ti\u1ec7n li\u1ec7u tr\u00ecnh d\u00e0i ng\u00e0y khi d\u1eef li\u1ec7u c\u1ea5y kh\u00f4ng \u1ee7ng h\u1ed9 vi\u1ec7c ti\u1ebfp t\u1ee5c \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh ph\u1ed5 r\u1ed9ng.<\/p>\n

Vi\u1ec7c ra quy\u1ebft \u0111\u1ecbnh h\u1ee3p l\u00fd v\u1ec1 s\u1eed d\u1ee5ng kh\u00e1ng sinh cho nh\u1eefng b\u1ec7nh nh\u00e2n kh\u00f4ng \u0111\u00e1p \u1ee9ng v\u1edbi \u0111i\u1ec1u tr\u1ecb ban \u0111\u1ea7u l\u00e0 m\u1ed9t qu\u00e1 tr\u00ecnh ph\u1ee9c t\u1ea1p, do s\u1ef1 kh\u00e1c bi\u1ec7t v\u1ec1 y\u1ebfu t\u1ed1 nguy c\u01a1 c\u1ee7a t\u1eebng b\u1ec7nh nh\u00e2n, ti\u1ec1n s\u1eed ph\u01a1i nhi\u1ec5m v\u00e0 c\u00e1c ch\u1ea9n \u0111o\u00e1n ph\u00e2n bi\u1ec7t ch\u1ed3ng l\u1ea5p, c\u00f3 th\u1ec3 l\u00e0 nguy\u00ean nh\u00e2n nhi\u1ec5m tr\u00f9ng ho\u1eb7c kh\u00f4ng nhi\u1ec5m tr\u00f9ng. \u0110i\u1ec1u n\u00e0y \u0111\u00f2i h\u1ecfi b\u00e1c s\u0129 ph\u1ea3i t\u00e1i \u0111\u00e1nh gi\u00e1 l\u00e2m s\u00e0ng m\u1ed9t c\u00e1ch th\u1eadn tr\u1ecdng, \u0111\u1ed3ng th\u1eddi c\u00e2n nh\u1eafc gi\u1eefa l\u1ee3i \u00edch v\u00e0 nguy c\u01a1 khi thay \u0111\u1ed5i ho\u1eb7c ng\u1eebng \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh. Nh\u1eadn th\u1ee9c r\u00f5 r\u00e0ng m\u1ecdi th\u1ee9 kh\u00e1ng sinh \u0111\u1ec1u ti\u1ec1m \u1ea9n nguy c\u01a1 l\u00e0 y\u1ebfu t\u1ed1 then ch\u1ed1t trong qu\u00e1 tr\u00ecnh \u0111\u01b0a ra quy\u1ebft \u0111\u1ecbnh.<\/p>\n

T\u00c0I LI\u1ec6U THAM KH\u1ea2O<\/h2>\n

Povoa P. Coelho L, Carratala J, Cawcutt K, Cosgrove SE, Ferrer R, Gomez CA, Klompas M. Lisboa T, Martin-Loeches I, Nseir S, Salluh JIF, Scherger S, Sweeney DA, Kalil AC. Correction: How to approach a patient hospitalized for pneumonia who is not responding to treatment? Intensive Care Med. 2025 Aug;51(8):1570-1571. doi: 10.1007\/s00134-025-08027-4. Erratum for Intensive Care Med. 2025 May:51(5):893-903. doi: 10.1007\/s00134-025-07903-3. PMID: 40658251; PMCID: PMC12317881.<\/p>\n","protected":false},"excerpt":{"rendered":"

Vi\u00eam ph\u1ed5i l\u00e0 nguy\u00ean nh\u00e2n th\u01b0\u1eddng g\u1eb7p g\u00e2y nh\u1eadp ICU v\u00e0 l\u00e0 nguy\u00ean nh\u00e2n nhi\u1ec5m tr\u00f9ng th\u01b0\u1eddng g\u1eb7p nh\u1ea5t t\u1ea1i ICU. H\u1ea7u h\u1ebft b\u1ec7nh nh\u00e2n \u0111\u00e1p \u1ee9ng v\u1edbi \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh th\u00edch h\u1ee3p trong 48-72 gi\u1edd. Kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 tri\u1ec7u ch\u1ee9ng l\u00e2m s\u00e0ng dai d\u1eb3ng ho\u1eb7c di\u1ec5n ti\u1ebfn […]\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-134254","post","type-post","status-publish","format-standard","hentry","category-y-te-suc-khoe"],"acf":[],"_links":{"self":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts\/134254","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/comments?post=134254"}],"version-history":[{"count":3,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts\/134254\/revisions"}],"predecessor-version":[{"id":134326,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/posts\/134254\/revisions\/134326"}],"wp:attachment":[{"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/media?parent=134254"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/categories?post=134254"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/vnras.com\/drug\/wp-json\/wp\/v2\/tags?post=134254"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}