SIÊU ÂM NỘI SOI CAN THIỆP.
I/. Sơ lược về siêu âm và máy siêu âm
1/. Siêu âm
Siêu âm là một loại dao động cơ học được truyền đi trong một môi trường vật chất nhất định.Năng lượng cơ học này tác động vào các phân tử vật chất của môi trường làm cho chúng dao động khỏi vị trí cân bằng, mặt khác do tương tác mà các phân tử bên cạnh nó cũng chụi ảnh hưởng và dao động theo, tạo thành sóng lan truyền cho tới khi hết năng lượng. chính vì vậy siêu âm không thể truyền ở môi trường chân không như các sóng điện từ.
Âm thanh được chia thành 3 loại dựa theo tần số. Những âm thanh có tần số duới 16 Hz mà tai người không thể nghe được là hạ âm. Các sóng âm có dải tần từ 16 Hz đến 20.000 Hz được gọi là âm thanh, còn siêu âm có tần số trên 20.000 Hz. Như vậy về bản chất siêu âm cũng không có gì khác với các dao động cơ học khác và nó cũng được đặc trưng bởi một số đại lượng vật lý như: tần số, biên độ , chu kỳ…
– Chu kỳ là khoảng thời gian thực hiện một nén và dãn. Đơn vị th¬ường được tính bằng đơn vị đo thời gian( s, ms…)
– Biên độ là khoảng cách lớn nhất giữa 2 đỉnh cao nhất và thấp nhất.
– Tần số ( f ) là số chu kỳ giao động trong 1 giây, đơn vị đo là Hz
– Bước sóng(λ) là độ dài của 1 chu kỳ giao động. Bước sóng th¬ường được đo bằng đơn vị đo chiều dài như mm, cm
– Tốc độ siêu âm ( c ) là quãng đường mà chùm tia siêu âm đi được trong 1 đơn vị thời gian, th¬ường được đo bằng m/s.
– Năng lượng siêu âm ( P ) biểu thị mức năng l¬ượng mà chùm tia siêu âm truyền vào cơ thể. Giá trị này phụ thuộc vào nguồn phát , trong siêu âm chẩn đoán để đảm bảo an toàn các máy thường phát với mức năng lượng thấp vào khoảng 1mw đến 10mw. Tuy nhiên trong các kiểu siêu âm thì siêu âm Doppler thường có mức năng lượng cao hơn. ở các máy siêu âm hiện đại người sử dụng có thể chủ động thay đổi mức phát năng lượng để nâng cao hơn tính an toàn cho bệnh nhân, nhất là đối với thai nhi và trẻ em.
– Cường độ sóng âm là mức năng lượng do sóng âm tạo nên trên 1 đơn vị diện tích. Thường được đo bằng đơn vị W/cm2. Cường độ sóng âm sẽ suy giảm dần trên đường truyền nhưng tần số của nó không thay đổi. Người ta còn tính cường độ sóng âm tương đối đo bằng dB. Khác với cường độ sóng âm, đại lượng này là một giá trị tương đối, nó cho biết sự khác nhau về cường độ siêu âm tại 2 vị trí trong không gian.
2/. Quá trình lan truyền sóng âm trong cơ thể
Chùm tia siêu âm đi qua tổ chức xương và mô mềm có 43% năng lượng bị phản xạ trở lại và chỉ có 57% năng lượng tiếp tục đi qua. Tương tự như vậy nếu bề mặt phân cách là không khí và mô mềm thì R= 0,998, hay hệ số truyền âm chỉ còn 1- 0,998 = 0,002 hay =0,2%. Do đó khi thực hành chúng ta phải tạo môi trường chất lỏng ( gel siêu âm ) giữa đầu dò và cơ thể để chùm tia siêu âm có thể xuyên vào trong cơ thể, mà không bị phản xạ trở lại.
Trong môi trường có cấu trúc đồng nhất, sóng âm lan truyền theo đường thẳng, và bị mất năng lượng dần gọi là suy giảm. Sự suy giảm theo luật nghịch đạo của bình phương khoảng cách. Sự hấp thu quan trọng của năng lượng âm gặp vật chất tạo nhiệt. Tuy nhiên sự mất năng lượng trong siêu âm không giống bức xạ tia X, vì ở đây còn có hiệu ứng quang từ hoặc hiệu ứng Compton. Vận tốc truyền sóng âm phụ thuộc vào độ cứng và tỷ trọng của môi trường vật chất xuyên qua, trong cơ thể người: mỡ 1450; nước 1480; mô mềm 1540; xương 4100 m/s.
3/. Máy siêu âm chẩn đoán :
– Phát sóng âm: Sóng âm được tạo ra do chuyển đổi năng lượng từ điện thành các sóng xung tương tự như phát xạ tia X, phát ra từ các đầu dò, có cấu trúc cơ bản là gốm áp điện (piezo-electric).
Sóng phản hồi sẽ thu nhận bởi đầu dò, sau đó được xử lý trong máy và truyền ảnh lên màn hình (display), hoặc ghi lại trên phim, giấy in hoặc trên băng đĩa từ. Tất nhiên các sóng phản hồi không được thu nhận bởi đầu dò sẽ bị biến mất theo luật suy giảm.
– Đầu dò (Transducer – Probe): làm nhiệm vụ vừa phát vừa thu sóng âm phản hồi.
Tùy theo máy và hãng sản xuất, các đầu dò quét được nhờ một hệ thống cơ khí hay điện tử, với chùm thăm dò theo hình chữ nhật hay rẽ quạt.
Một máy siêu âm
II/. Tính năng tác dụng , hình thái , kích thước đầu dò siêu âm ổ bụng
Đầu dò siêu âm ổ bụng phổ biến nhất là đầu dò quét điện tử cầm tay. Các tinh thể gốm áp điện được xếp thành một dãy theo chiều ngang (tuyến tính), được mở ra một cửa sổ (aperture) tương đối lớn do số lượng tinh thể từ 4 đến 10, chùm sóng âm khi phát ra khá rộng. Các đầu dò siêu âm hiện đại còn dùng Piezo polimer với cộng hưởng đa tần.
Một đầu dò siêu âm ổ bụng thường gặp …
Đầu dò thường có kích thước 75 x 17 với mặt cong lồi R150.
III/. Dụng cụ nguyên bản
Đầu dò siêu âm ổ bụng chứa nhiều miếng gốm áp điện (piezo-eletric), khi có dòng điện xoay chiều tần số cao khích thích vào miếng gốm này làm cho nó co giãn và phát ra xung siêu âm, ngược lại khi miếng áp điện rung lên do sóng siêu âm dội trở về sẽ tạo ra một xung động (tính thuận nghịch). Sóng siêu âm lan truyền vào các mô trong cơ thể, gặp các mặt phẳng sẽ tạo ra các sóng âm dội trở về (echo). Mỗi âm dội mà đầu dò thu nhận được sẽ chuyển thành tín hiệu điện, từ tín hiệu này sẽ được chuyển thành tín hiệu trên màn hình, và tất cả chùm sóng âm quét tạo nên hình ảnh siêu âm của ổ bụng.
Sử dụng trong chuyên môn tiết niệu, siêu âm cho phép thăm dò chẩn đoán từ thận đến bàng quang và các nội mô có liên quan.
Hình siêu âm thận bình thường
IV/. Dụng cụ siêu âm nội soi can thiệp
1/. Nguyên tắc :
Dựa trên lâm sàng thăm dò ổ bụng, hình ảnh đã qua máy tính xử lý cho phép xác định các nội mô, nội tạng cần can thiệp hóa sinh. Do đó chúng ta có thể đưa dịch sinh lý, thuốc điều trị dạng lỏng vào, làm sinh thiết v.v… một cách trực tiếp trên nội mô, nội tạng đó. Hiệu quả can thiệp dựa vào siêu âm lâm sàng sẽ tương tự như các phương tiện nội soi khác nhưng giản đơn, trực quan hơn nhiều.
2/. Ứng dụng :
Dụng cụ ghép một ống dẫn hướng với đầu dò siêu âm cho phép đưa mũi tiêm đến nội mô, nội tạng một cách chính xác với sự hỗ trợ của hình ảnh siêu âm. Các thao tác tiếp theo sẽ đem lại các hiệu quả y khoa cần thiết.
V/. Quá trình gia công : các công đoạn , các loại máy để gia công
1/. Vật liệu : Thép mạ Crôm 100 um theo đúng tiêu chuẩn y tế.
2/. Gia công :
– Ốp thân + ốp hông : máy đột – dập.
– Định vị + bộ ghép nối : máy tiện + hàn.
– Mạ Crom : máy mạ CrO3
VI/. Thử nghiệm trên máy siêu âm
VII/. Những sai lệch có thể xảy ra khi thử
Nếu liên kết các chi tiết không đúng sẽ làm ảnh hưởng đến khả năng thu phát siêu âm, làm lệch hướng các chùm siêu âm phản xạ. Điều này làm cho người thao tác siêu âm nội soi không đưa ống dẫn hướng đến chính xác nơi cần can thiệp.
VIII/. Cách khử sai.
1/. Ghép nối ốp hông chính xác, siết chặt ốc định vị vừa phải để không ảnh hưởng đến cấu trúc đầu dò (biến dạng, nứt vỡ v.v…)
2/. Chỉnh lý bộ ghép nối liên kết ống dẫn hướng với ốp hông, khử bớt độ “rơ” cơ khí.
3/. Vệ sinh kỹ khu vực liên kết khớp nối, tránh tàn dư của dịch, chất nhầy …, cặn đóng gây khó khăn cho thao tác nội soi can thiệp. Ngoài ra, ống dẫn hướng sẽ xuyên qua ổ bụng bệnh nhân nên cần làm sạch, vô trùng đến mức độ cần thiết.
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