CB Nuoc Dien Giai

8/14/2019 CB Nuoc Dien Giai

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NGOI KHOA LM SNG-2007

CN BNG NC V IN GII

1-Ri lon cn bng nc v natri:

1.1-Cn bng nc v natri:Nc chim 50% trng lng cth (TLCT) ph n v 60% TLCT nam gii. tr em,t l ny cao hn (tr nh nhi: 80%).

Nc trong cth bao gm nc ni bo (chim 2/3) v nc ngoi bo (chim 1/3).

Nc ngoi bo bao gm dch k (3/4) v huyt tng (1/4).

Tnh cht thm thu ca mt dung dch ni chung v dch cth ni ring c quyt nhbi s lng cc tiu phn hon tan chkhng phi bi khi lng ca chng. Trong ccngn dch ca c th, cc ion ng vai tr quan trng trong vic quyt nh tnh cht thmthu ca ngn dch .

Na+ l cation chnh ca dch ngoi bo. Na+ v cc anion ph thuc (HCO3- , Cl-) quyt nh90% tnh thm thu ca dch ngoi bo.

K+ l cation chnh ca dch ni bo. K+ cng c vai tr quan trong trong vic quyt nh tnhthm thu ca dch ni bo.

Trn lm sng, ri lon cn bng nc lun gn lin vi ri lon cn bng cc in gii, cbit l natri.

iu ho cn bng xut nhp nc c thc hin thng qua hai cch chnh: cch khtiu ho lng nc nhp v hormone ADH iu ho lng nc xut.

Na+c iu ho ch yu thn, di tc ng ca 3 yu t: huyt p, aldosterone vhormone li niu natri (ANP). Aldosterone l yu t chnh gip thn bo tn natri.

1.2-Tng natri huyt tng:

1.2.1-Nguyn nhn:

Gim th tch dch ngoi bo:

o Cth gim thu nhn: Ung th thc qun Hn m

Gim cm gic kht do tui gi, mc bnh tm thn, tn thng trung tmkht do chn thng, u bu, vim nhim

o Mt nc ngoi thn: Tiu chy Bng St nhiu m hi do vn ng qu mc

o Mt nc qua thn: Thuc li tiu Tiu ng cha kim sot

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Truyn manitol n qu nhiu protein

Tng th tch dch ngoi bo:

o Sai lm trong iu tr: truyn nhiu dung dch mui.o Ngc mui: nhm ln khi nui n tr nh, rt xung bin.

Th tch dch ngoi bo khng thay i: bnh l thng gp nht l i tho nht. i thonht c hai loi: i tho nht trung ng v i tho nht do thn.

1.2.2-Chn on:

Triu chng ca tnh trng tng p lc thm thu: gim sc c, d b kch thchNu nnghn, BN m sng, ng kinh, hn m v c cc tn thng thn kinh khng hi phc.

Triu chng ca s thay i th tch dch ngoi bo:

o Tng th tch dch ngoi bo: tng thn trng, mch cng v ny r, huyt p hitng, ph, rale khi nghe phi hoc ting gallo S3 khi nghe tim.

o Gim th tch dch ngoi bo: Gim nh (mt di 4% TLCT): kht, mch nhanh, nc tiu gim th tch

nhng ln hn 1000 mL/24 gi, t s BUN/creatinin ln hn 20, X-quangphi: gim tun hon phi.

Gim trung bnh (mt 4-8% TLCT): gim huyt p t th, Hct tng, nctiu t hn 1000 mL/24 gi.

Gim nng (mt 8-12% TLCT): sc, nc tiu t hn 500 mL/24 gi. Gim rt nng (mt hn 12% TLCT): lmhay hn m, tru mch, v niu.

1.2.3-iu tr:

1.2.3.1-Trng hp gim th tch:

Nguyn tc iu tr:

o Trc tin, khi phc li nng thm thu bnh thng ca dch tho Tip theo, khi phc li th tch bnh thng ca dch tho Sau cng, b sung cc in gii khc b mt v iu chnh ri lon kim toan nu c

nh gi lng nc thiu ht da vo lm sng, hay tnh ton theo cng thc sau:

Vthiu = tng lng nc cth x [(Na+ huyt tng/ 140) - 1]Vic nh gi lng nc thiu ht c thc hin mi ngy. Ch b trong ngy lngnc thiu ht theo tnh ton, cng vi lng duy tr (25-35 mL/kg/24 gi).

Trung bnh cn 2-3 ngy bi hon mt trng hp mt nc nng.

Xt nghim nng Na+ huyt thng thng xuyn bo m hiu qu ca vic iu tr.

Na+ huyt tng nn c h t t, khong 0,5 mEq/L/giv khng qu 10 mEq/L/24 giu tin.

Nu bnh nhn cn ung c, b nc qua ng ming. Trong trng hp thiu nc

trm trng hoc bnh nhn khng ung c, b nc qua ng tnh mch. Dung dchdng b l Glucose 5% hoc NaCl 0,45%.

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1.2.3.2-Trng hp tng th tch:

Nu BN b qu ti natri, ct ngay cc loi dch truyn gy qu ti, cho bnh nhn n chnht hon ton.

khi phc li th tch bnh thng, dng cc tc nhn li niu.

khi phc li nng thm thu bnh thng ca dch th, dng dung dch Glucose 5%hoc NaCl 0,45%.

1.3-Gim natri huyt tng:

1.3.1-Nguyn nhn:

Gim natri huyt tng, nng thm thu huyt tng bnh thng:

o Gim natri huyt tng gi to: gp trong nhiu trng thi bnh l trong c stng protid hoc lipid huyt tng.

o Gim natri huyt thong qua: bnh nhn ang c truyn cc dung dch glucose,manitol ng trng.

Gim natri huyt tng, nng thm thu huyt tng tng:

o Tng p lc thm thu huyt tng bnh nhn tiu ngo Bnh nhn ang c truyn cc dung dch glucose, manitol u trng

Gim natri huyt tng, nng thm thu huyt tng gim:

o Th tch dch ngoi bo gim: Nguyn nhn thng g p nht trn lm sng l s bi hon khng y

dch mt c cha nhiu natri (dch tiu ho) bng cc dung dch khng hoccha t natri (Glucose 5% hoc NaCl 0,45%).

Tiu chy Cc nguyn nhn khc:

Gim natri huyt ngi ung bia Chng nhc nng aldosterone Sau loi b tc nghn ng niu hai bn Tnh trng xut huyt

o Th tch dch ngoi bo tng: Suy tim huyt Xgan Hi chng thn h Giai on thiu niu ca hoi tng thn cp. Cc trng thi thng d hormone v thng thn: hi chng Cushing, hi

chng cng aldosterone nguyn pht v th pht

o Th tch dch ngoi bo khng thay i: Gim natri huyt hu phu: c th xy ra sau mt phu thut chng trnh

khng c bin chng, bnh nhn hon ton kho mnh trc . BNthng l n. Bnh thng c pht hin vo ngy hu phu 5-7. Natri

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huyt tng thng trong khong 125-130 mEq/L. a s trng h p BNkhng c triu chng g v khng cn phi c iu tr.

Hi chng tng tit khng thch hp ADH (SIADH) Cc nguyn nhn khc:

Ngc nc Kht bnh l Thuc li tiu thiazide Thiu ht kali Hi chng sau ct t ni soi tin lit tuyn: xy ra khi c s hp thu

mt s lng ng k cc cht trong dung dch rng (glycine,sorbitol, manitol).

1.3.2-Chn on:

Triu chng ph thuc vo s thay i nng thm thu huyt tng v th tch dchngoi bo.

Na+ huyt tng < 120 mEq/L: nhc u, nn i, nhn i, tri gic lm, dn ti hn m vxut hin cc cn co git.

Nn nghn chn on SIADH khi BN c:

o Tnh trng gim natri huyt tngo Nc tiu c c tng i (nng thm thu ln hn 300 mmol/kg)o Khng c biu hin ph, h huyt p t th hoc mt nc

Chn on xc nh SIADH bng cch nh lng ADH trong huyt tng hoc nc tiu.Hi chng sau ct t ni soi tin lit tuyn: nu dung dch rng l glycine, c th biu hin

bng cc triu chng tim mch v thn kinh: h huyt p, chm nhp tim, ri lon th lc vm tm thi.

1.3.3-iu tr:

1.3.3.1-Trng hp gim th tch:

Nguyn tc chung:

o Trc tin, khi phc li nng thm thu bnh thng ca dch tho Tip theo, khi phc li th tch bnh thng ca dch tho Sau cng, b sung cc in gii khc b mt v iu chnh ri lon kim toan nu c

Gim natri huyt tng mc nh (Na+ huyt tng = 120-135 mEq/L): dng dung dchNaCl 0,9%. Na+ huyt tng nn c tng t t, khong 0,3 mEq/L/giv khng qu 8mEq /L trong 24 giu tin.

Khi Na+ huyt tng < 120 mEq/L, nn s dng dung dch NaCl 3%, mc tng khong1-2 mEq/L/gicho n khi Na+ huyt tng ln n gii hn an ton (120-130 mEq/L).

Gim natri huyt trm trng (Na+ huyt tng < 110 mEq/L hoc bnh nhn lm, hn m,co git), c th cho php mc tng ti a 5 mEq /L/gicho n gii hn an ton.

1.3.3.2-Trng hp tng th tch:

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Nguyn tc chung:

o Gii hn mui v nc trong chn ung hng ngyo iu tr gim kali huyt v thc y s bi niu m trong bi niu nc vt tri

hn bi niu natri.

C th:o Lng nc nhp hng ngy nn thp hn lng nc tiuo Theo di thn trng hng ngy nh gi hiu quiu tro S dng thch hp thuc li tiu quai (furosemide) cng nhiu chnh s thiu ht

kali

1.3.3.3-iu trc hiu:

1.3.3.3.1-Bi hon nc v natri bnh nhn tiu ng b nhim ketone v tng plc thm thu:

Dung dch bt u nn l NaCl 0,9%. Trong 2-4 giu tin, tc truyn c duy tr 5mL/kg/ginu bnh nhn b thiu ht th tch nh (kht nc, kh nim mc hu hng), 10mL/kg/ginu thiu ht th tch trung bnh, 15 mL/kg/ginu thiu ht th tch trm trng(sc, hoi tng thn cp, nhim toan lactic).

Cc dung dch i phn tc dnh cho nhng trng hp sc nng (tc 10 mL/kg/gi,c th gp i nu khng thy hiu qu), v truyn cng lc vi dung dch NaCl 0,9%.

Sau 2-4 gi, gim tc truyn xung , tr trng hp huyt ng hc cha n nh.Chuyn sang truyn dung dch NaCl 0,45% nu Na+ huyt tng tng v bnh nhn khngc biu hin ph no.

Khi ng huyt gim xung ti mc 250 mg/dL, bt u truyn dung dch Glucose 5%.Sau 4 gi, nu bnh nhn khng nn i, bt u cho bnh nhn ung (100-200 mL/gi)ng thi gim lng dch truyn tng ng.

1.3.3.3.2-SIADH:

Ch yu l hn ch nc nhp hng ngy (800-1000 mL), cung cp mui kt hp viiu tr cn nguyn.

Dung dch mui u trng dnh cho nhng trng hp nng, c du chng thn kinh.

Demeclocycline l cht c ch tc dng ca ADH, c thc s dng trong thi gian di(600-900 mg/ngy).

Furosemide c tc dng i khng vi ADH (lm gim tnh u trng ca tu thn) c ths dng kt hp vi dung dch mui u trng trong trng hp cp cu.

2-Ri lon cn bng kali:

2.1-Cn bng kali:

S cn bng K+c thc hin thng qua hai cch thc: ti phn phi K+ gia ni v ngoibo, v cch bi tit K+ng ln xa.

S bi tit K+ng ln xa chu nh hng ca: aldosterone (thng qua bm Na+-K+), ionH+ (bm H+-K+), bm natri-kali ATPase v dng chy ca dch ng thn.

2.2-Tng kali huyt tng:2.2.1-Nguyn nhn:

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Tng K+ huyt tng gi to:

o Mu mu c lu tr trong mi trng lnh qu lu hay b tn huyt trc khi th.o Chng tng tiu cu hoc tng bch cuo Vn ng gng sc

Tng chuyn K+ ra ngoi bo:

o Tnh trng nhim toano Thiu ht insulino S dng tc nhn c ch beta adrenergico Ngc digoxin, succinylcholineo Lit chu k do tng K+ huyt tngo Cc trng thi tng p lc thm thu huyt tngo Tng thn nhit c tnh

Cth qu ti K+:

o Hoi t m lan rng (nhi mu mc treo, xon rut, vim tu hoi t)o Ho tr ung th (leukemia cp, lymphoma Burkitt)o Tng ph hu hng cu (tn huyt, xut huyt tiu ho, t mu trong cth)o Truyn mu ton phn c thi gian bo qun lu.

Gim bi tit K+ qua thn:

o Cc trng thi suy gim tc lc cu thn (suy thn)o Cc trng thi thiu ht mineralocorticoid: suy v thng thn nguyn pht v th

pht, hi chng nhc nng aldosterone bm sinh v mc phi.

2.2.2-Chn on:

in tm : thay i sm nht l sng T cao nhn, sau l sng P dt, khong PR kodi, phc b QRS dn rng, sng S m su, cui cng xut hin sng hnh sin, rung tht vkt thc bng ngng tim.

H thn kinh c: t nga, d cm, yu cv lit mm.

Tiu ho: nn i, tiu chy, i khi c biu hin lit rut.

2.2.3-iu tr:2.2.3.1-iu tr tng kali huyt tng trm trng (K+ huyt tng > 6,5 mEq/L hoc cthay i trn in tm ngoi sng T cao nhn):

Can-xi: dung dch s dng tt nht l calcium gluconate (tuy nhin c th dng calciumchloride) vi liu 10 mL dung dch 10% TM chm trong 2 pht. C th lp li sau 5 phtvi tng liu 30 mL.

Bicarbonate: thng dng dung dch u trng 8,4%, 1 ng 50 mL (50 mEq) cho mi lnTM chm, liu trung bnh 1-3 ng (50-150 mEq).

Insulin: c xem nh l tc nhn iu tr tng kali huyt ng tin cy nht, v l chn la

u tin trong nhng tnh hung e do tnh mng. Insulin c s dng kt hp viglucose. Liu s dng: insulin loi tc ng nhanh (Regular Insulin) tim mch 5 n v

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mi 15 pht, ng thi vi glucose (di dng dung dch 10%) liu 25-50 gm mi gi. Tcdng xy ra trong vng 15-30 pht. Tng liu ti thiu 50-100 gm glucose.

Tc nhn beta-adrenergic (epinephrine v albuterol): albuterol c th c pha vo dungdch Glucose (0,5 mg pha trong 100 mL Glucose 5% TTM 10-15 pht, thi gian tc dng20 pht) hoc s dng di dng kh dung (20 mg/4ml NaCl 0,9% trong 10 pht, thi giantc dng 30 pht).

2.2.3.2-iu tr tng kali huyt nh (K+ huyt tng = 5-6 mEq/L):

Sodium polystyrene (Kayexalate): c s dng qua ng ung hoc tht tho.

Ung: Kayexalate 40 gm ho tan trong dung dch sorbitol 10-20% 20-100 mL. Thi giantc dng 1-2 gi. C th lp li liu trn sau 2-4 gicho n khi nng K+ huyt tng trv bnh thng. Mi gram Kayexalate s ly ra khi cth 1mEq K+.

Tht tho: ho tan 50-100 gm Kayexalate trong 200 mL nc. Ch gi nc 30-45 phttrc khi x. Thi gian tc dng trung bnh 30-60 pht. Lp li liu trn sau 2-4 gicho nkhi nng K+ huyt tng trv bnh thng. Mi gram Kayexalate s ly ra khi cth0,5 mEq K+.

Thm phn: thm phn phc mc c thc trin khai nhanh hn thm phn mu, nhngkhng hiu qu bng. Ni chung c hai bin php thm phn u cn c thi gian chun b,do thm phn thng c chnh trong trng hp qu ti nng kali khng th sdng Kayexalate.

2.2.3.3-iu tr tng kali huyt tng mn tnh:

Ch yu l hn ch nhp kali.

Kayexalate v cc loi thuc li tiu mt kali (furosemide, thiazide) c th c ch trong mts trng hp.

2.2.3.4-iu trc hiu:

2.2.3.4.1-Lit chu k do tng kali huyt tng:

iu tr bng cc tc nhn beta-2 nh salbutamol (c kt hp hay khng vi acetazolamide).

2.2.3.4.2-Tng kali huyt tng do sdng thuc dn ckhcc succinylcholine:

Bin php phng nga l chnh yu:

o S dng barbiturate (c ch knh K+) trc khi s dng succinylcholine.o Khng s dng succinylcholine bnh nhn c tng kali huyt, thay

succinylcholine bng thuc dn ckhng kh cc (pancuronium, gallamine).iu tr trong thi gian phu thut: c th bng insulin-glucose hoc bicarbonate.

2.2.3.4.3-Cc trng thi thiu ht mineralocorticoid:

iu tr thay th bng fludrocortisone 0,1 mg/ngy.

2.2.3.4.4-Sdng thuc li tiu tit kim kali:

Ngng ngay thuc ang s dng (cn nhc n vic chuyn sang thuc li tiu gy li niukali khi vn cn chnh dng li tiu).

Hn ch cc ngun cung cp kali.

Tng cng tc lc cu thn.2.3-Gim kali huyt tng:

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2.3.1-Nguyn nhn:

Tng chuyn K+ vo ni bo:

o Tnh trng nhim kimo Thng d insulino S dng cc tc nhn beta adrenergico Ngc theophyllin, bariumo Lit chu k do h K+ huyt tng c tnh cch gia nho Lit chu k do h K+ huyt tng bnh nhn nhim c gipo Thiu ht magnesium

Cth tng nhu cu K+:

o Hi chng dinh dng trlio ang iu tr thiu mu nngo ang c truyn hng cu lng

Cth mt K+:

o Nn i ko dio Ht thng d dyo D tiu hoo Tiu chyo Cc phu thut chuyn lu niu-ng tiu hoo Nhim ketone v tng p lc thm thu huyt tng bnh nhn tiu ngo Cc trng thi thng d hormone v thng thn: hi chng Cushing, hi chng

cng aldosterone nguyn pht v th pht

o Tnh trng li niu sau tc nghno Bnh l toan ho ng thn tp 1 v 2

2.3.2-Chn on:

Tim: ri lon nhp tht, trong thng gp hn c l ngoi tm thu tht. BN c K+ huyttng < 3 mEq/L, c tin cn thiu mu c tim, ang c gy m s c nguy c lon

nhp tht cao.in tm : sng T dt, ST chnh xung, xut hin sng U, khong QU ko di. Nu K+huyt tng tip tc gim: sng T m, P o ngc, block nh tht, nhp nhanh kch pht,rung nh, rung tht v cui cng ngng tim.

Tiu ho: lit rut, to bn.

C vn: yu c, mt mi, hi chng bn chn khng ngh, au c v c th c du hiuchut rt. Lit cxut hin khi nng K+ huyt tng < 2,5 mEq/L. Thng lit cchi,nhng nu cthn mnh bnh hng, bnh nhn c th ri vo tnh trng suy h hp.

2.3.3-iu tr:

2.3.3.1-Phng nga gim kali huyt:

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Chnh:

o BN ang b suy tim nng ang phi dng mt s lng ln thuc li tiuo BN ang s dng digoxino BN suy gan nng, c nguy cdn n hn m gan nu thiu ht kalio BN ang s dng thuc gy mt kali nh corticoid hay carbanoxolono BN khng n ung c, th d chun b trc m, nhng ngy u sau phu thut

vng bng, t thng mi-d dy trong cc trng hp hp mn v hay tc rut

o S dng dung dch kim (NaHCO3) iu tr nhim toan vi tc nhanh hockhi lng ln

o Khi phc nhanh chng th tch tun hon bng cc dung dch khng hoc cha tK+.

C th phng nga thiu ht kali bng cc ch phm kali hoc cc tc nhn gim bi niu

kali nh thuc li tiu tit kim kali (spironolacton, triamterene, amiloride).2.3.3.2-Bi hon sthiu ht kali:

Chlorua kali: c thc s dng iu tr tt c cc hnh thi thiu ht kali.

Cung cp kali qua ng ung: 40-120 mEq/ngy, tu thuc vo mc thiu ht kali.

Bi hon thiu ht kali qua ng tnh mch ngoi bin:

o Dung dch c nng K+ khong 40 mEq/L l thch hp.o Dung dch dng pha ch phm K+ c th l NaCl 0,9% hoc Glucose 5%. Trong

trng hp khn cp ch dng dung dch NaCl v glucose y K+ vo trong t bo.

o Khng bi hon qu 240 mEq/ngyo Tc truyn khong 10 mEq/gi. Trong trng hp khn cp tc c th ln n

40 mEq /ginhng phi theo di in tm lin tc.

2.3.3.3-iu trc hiu:

2.3.3.3.1-H kali huyt do sdng tc nhn beta adrenergic, ngc theophylline, litchu k do h kali huyt bnh nhn nhim c gip:

S dng tc nhn block beta.

2.3.3.3.2-Bnh nhn c thc hin phu thut chuyn lu niu-ng tiu ho:

C th ch nh cc tc nhn c ch s h p thu Cl-

nh chlorpromazine (25-50 mg, 3ln/ngy) v nicotinic acid (400 mg, 3-4 ln/ngy).

iu tr bng phu thut dnh cho cc trng hp si niu hoc hp ming ni.

Khi c nhim trng ngc dng xy ra, cn chnh khng sinh thch hp.

C th gim bi niu canxi (gim tc hnh thnh si niu) bng thuc li tiu thiazide.

2.3.3.3.3-B sung kali bnh nhn tiu ng b nhim toan ketone v tng p lcthm thu huyt tng:

Sau khi c chn on xc nh v trin khai insulin v dch truyn tr liu, v nu lulng nc tiu ti thiu 30-60 mL/giv nng K+ huyt tng nh hn 5 mEq/L:

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o Nu nng K+ huyt tng ln hn 4 mEq/L v tc truyn dch ln hn 1lt/gi: KCl sc pha vo t lt dch truyn th 3 vi nng 20 mEq/L.

o Nu nng K+ huyt tng nh hn 4 mEq/L v tc truyn nh hn 1 lt/gi:c th pha KCl vi nng 40 mEq/L.

Tc truyn: 10-20 mEq/ginu K+

huyt tng ln hn 4 mEq/L, 20-30 mEq/ginu K+

huyt tng nh hn 4 mEq/L.

Cn nh lng K+ huyt tng mi 2-4 gi trong 12- 24 giu tin v thc hin ECGmi 30-60 pht trong 4-6 giu.

2.3.3.3.4-Cc trng thi thng dhormone v thng thn:

Hi chng cng aldosterone nguyn pht do u tuyn lnh tnh v thng thn mt bn:

o Tt nht l phu thut ct b u.o BN khng th phu thut c: spironolacton c chnh duy tr huyt p bnh

thng v iu chnh tnh trng thiu ht kali.

Hi chng cng aldosterone nguyn pht do tng sn v thng thn hai bn khng rnguyn nhn: c th c phu thut ct gim mt phn m v thng thn chc nng,nhng hu ht c iu tr bng spironolacton.

3-Ri lon cn bng can-xi:

3.1-Cn bng can-xi:

Trong huyt tng, can-xi tn ti di ba dng chnh : gn kt vi protein (canxi proteinat),kt hp vi cc ion khc to thnh cc h p cht khng phn ly (can-xi citrat, can-xi

bicarbonat) v ion Ca2+ t do.

Ch c ion Ca

2+

(chim khong 45% lng canxi huyt tng) l c hot tnh v mt sinh ltrong cth.

C 3 hormone ch yu iu ho chuyn ho ca can-xi trong c th: hormone tuyn cngip (PTH), vitamin D v calcitonin.

Hormone tuyn cn gip v vitamin D (1,25-OH2-D3) tng huy ng Ca2+ t xng, tng

hp thu Ca2+rut v thn.

Calcitonin c ch s huy ng Ca2+ t xng v tng bi tit Ca2+ qua nc tiu.

3.2-Tng can-xi huyt tng:

3.2.1-Nguyn nhn:

Cung cn gip nguyn pht:

o U tuyn cn gip lnh tnho Ung th tuyn cn gipo Hi chng tn sn a tuyn ni tit typ 1 (MEN 1: u tuyn cn gip, u tuyn yn, u

t bo o tu)

Cng cn gip th pht : p ng ca tuyn cn gip i vi cc bnh l gy gim can-xihuyt mn tnh nh suy thn.

Bnh l c tnh ca v, thn, tu xng v bch cu ...: y l nguyn nhn gy tng can-xi

huyt tng ph bin nht.Cc nguyn nhn lin quan n vitamin D:

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o S dng qu nhiu vitamin Do Tng sn xut 1,25-OH2 -D3 (gp trong sarcoidosis v cc bnh l m ht khc)o Cc bnh l ni tit : suy v thng thn nguyn pht, cng gip.

Cc nguyn nhn khc:

o Bnh tng can-xi huyt tng v gim can-xi niu c tnh cch gia nho Bt ng lu ngyo Li tiu thiazideo Hi chng kim sa: xy ra nhng ngi phi nhn mt lng ng k can-xi, th

d ung nhiu sa hoc dng cc tc nhn antacid h p th c nh can-xicarbonat.

3.2.2-Chn on:

Triu chng thng mh, v th hin nhiu h cquan khc nhau.

H tiu ho: bun nn, i ma, to bn, vim tu, lot d dy-t trng.

H thn kinh: biu hin bng tnh d b kch thch hay c ch.

Tiu nhiu, do bt thng trong cch gy c c nc tiu.

Tng canxi huyt trm trng c th dn n suy thn vi chng si niu hay thn ng vi.

in tm : khong QT ngn li km theo cc ri lon nhp

Nng PTH tng trong cng cn gip v gim trong cc bnh l cn li

3.2.3-iu tr:

3.2.3.1-iu tr tng can-xi huyt tng cp tnh:Khi phc li th tch tun hon v tng bi niu can-xi.

Khi th tch tun hon c khi phc, c th dng dung dch NaCl 0,9% (150-300mL/gi) kt hp furosemide (20 mg TM/4-6 gi).

Salmon calcitonin: 4 IU/kg TB hoc TDD mi 12 gi.

Glucocorticoid, pamidronate disodium, plicamycin, gallium nitrate: c ch nh trongtng can-xi huyt tng do cc bnh l c tnh.

Phosphat: ch dng trong trng hp khn cp v c th dn n cc bin chng nh h can-xi huyt (khi s dng qu liu), lng ng can-xi triphosphat nhiu ni trong cth.

Cimetidine: lm gim tnh acid ca dch v, do gim s hp thu can-xi rut.

Thm phn: c chnh trong trng hp suy thn.

3.2.3.2-iu tr tng can-xi huyt mn tnh:

Gii hn lng can-xi v tng lng NaCl trong thc phm (trung bnh 200 mEqNaCl/ngy).

Ung nc (trung bnh 2-3 lt ngy).

C th km theo mt thuc li tiu (furosemide hoc ethacrynic acid) v phosphat (ung)vi liu trung bnh (nhm gi cho nng phosphat huyt tng trong gii hn bnh

thng).

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Phu thut:

o c chnh cho cc trng hp cng cn gip nguyn pht.o Cn thm st c hai bn v tm c bn tuyn cn gip.o nguyn i vi tuyn bnh thng, ct b c tuyn c adenoma v ct gn trn

(7/8) tuyn b ph i.o i vi trng hp ung th tuyn cn gip, nu c chn on xc nh trc v

trong khi phu thut, phng php c la chn l ct b ton b tuyn v thugip cng bn km no hch c.

o Nu phu thut thnh cng, 95% BN s c nng can-xi huyt tng trv bnhthng.

Tc nhn c ch beta (propranolol): c chnh cho bnh nhn cng gip c tng can-xihuyt tng.

Chiu x: c th c hiu qu trong trng hp ung th xng th pht.

3.3-Gim can-xi huyt tng

3.3.1-Nguyn nhn

Thiu nng tuyn cn gip:

o Thiu nng tuyn cn gip nguyn pht: Khuym khuyt hoc thiu dng (bm sinh) tuyn cn gip Hi chng Di George: suy tuyn cn gip, suy v thng thn, thiu mu c

tnh.

o Thiu nng tuyn cn gip th pht: S ct b qu nhiu m tuyn cn gip trong phu thut tuyn gip: thng

gp nht

Ung th cc cu trc chung quanh xm ln tuyn cn gip X tr I131 trong iu tr cng gip

Chng mm xng:

o Chn thiu vitamin Do Hi chng km hp thu: xy ra sau ct d dy, rut non, gan hay cc bnh l tc

mt.

o Gim tng hp 25-OH-D3 (xgan)o Gim tng hp 1,25-OH2-D3thn (bnh ci xng ph thuc vitamin D typ 1, hi

chng Fanconi)

o khng t bo ch i vi tc ng ca vitamin D (bnh ci xng ph thucvitamin D tp 2)

Vim tu cp

Hi chng vi lp, hoi t t bo

Cc nguyn nhn khc:

o Suy thn mn

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o Truyn mu nhanh v vi khi lng lno Cc trng thi kim ho mu cp tnh (truyn bicarbonate, tng thng kh): nng

Ca2+ huyt tng gim nhng nng can-xi huyt tng bnh thng.

o Gim albumin huyt tng (nng can-xi huyt tng gim nhng nng Ca2+huyt tng bnh thng).

o Gim Mg2+ huyt tng3.3.2-Chn on:

H thn kinh : nng ny bn chn, t, nga, d cm. Tetany xut hin khi nng can-xihuyt tng gim xung ti mc 7 mg/dL. Biu hin u tin ca tetany ton thn l duhiu Trousseau hay du hiu co rt c bn tay chn. Khi mc can-xi huyt tng gimnhng cha gy tetany trn lm sng (tetany tim tng) ta c th pht hin bng cchtm du hiu Chvostek, hoc garrot cnh tay tm du hiu Trousseau.

in tm : khong QT ko di, cc ri lon nhp tht

Thiu nng tuyn cn gip: nng PTH huyt tng gim th p, nng can-xi huyttng gim, nng 1,25-OH2-D3 gim, nng phosphat tng.

3.3.3-iu tr:

3.3.3.1-Can-xi:

Gim can-xi huyt nh (nng can-xi huyt tng 6-7 mg/dL): iu tr bng can-xi quang ung, liu trung bnh hng ngy khong 1gm.

Gim can-xi huyt cp tnh hoc bnh nhn xut hin tetany: iu tr bng can-xi quang tnh mch. Hai ch phm ca can-xi dng trong iu tr gim can-xi huyt tng cptnh l can-xi clorua v can-xi gluconat. C th s dng dung dch can-xi gluconat 10% 10-

20 mL tim mch chm trong 5-10 pht, sau truyn tnh mch vi liu lng 1-2mg/kg/gitrong 4-6 gi. Khi nng can-xi huyt tng trv bnh thng, duy tr 0,3-0,5mg/kg/gi. Can-xi tim mch tt nht nn c tin hnh di s theo di bng in tm. Cn thn i vi bnh nhn b nhim toan hay bnh nhn hoc ang s dngdigitalis.

3.3.3.2-Vitamin D:

c chnh trong trng hp nhc nng tuyn gip cn gip, thiu vitamin D. Khi uvi canxiferol 30.000 UI/ngy hay dihydrotachysterol 0,25 mg/ngy hoc 1,25-OH2-D30,15-0,3 g/ngy.

3.3.3.3-Ch :iu chnh ri lon ca cc in gii khc km theo (c bit l magi v kali).

4-Ri lon cn bng kim toan:

4.1-Cn bng kim toan:

Bnh thng, nh vo qu trnh thi CO2 v cc acid cnh, cn bng H+c duy tr:

lng H+ sinh ra bng lng H+o thi.

Khi mt acid (HA) c a vo trong dch c th, cchiu ho cn bng H+ s dintin theo ba bc:

oBc u tin xy ra nhanh chng, nhhot ng ca cc h thng m trong dchcth:

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(*) H+ + A- + Na+ + HCO3- Na+ + A- + H2O + CO2

o Bc th hai xy ra chm hn, nhcch b tr ca h h hp: thi tt c CO2 rangoi qua phi.

oBc th ba l cch b tr ca thn, xy ra sau cng nhng hon ho: ti hp thuton b lng HCO3-c lc qua cu thn v b sung lng HCO3- hao ht (*)thng qua qu trnh bi tit cc acid chun c v bi tit amonium.

Gi tr bnh thng ca cc thng s lin quan n qu trnh cn bng H+ trong cth (khmu ng mch).

Thng s Gii hn bnh thng pH 7,35-

Nng H+ 45-35 nEq/LPaCO2 35-45 mmHg

PaO2 75-100 mmHg

HCO3- (# CO2 ton phn, TCO2 ) 22-26 mmol/L

Nhng thay i dn n s tng nng ion H+ ca dch cth (pH gim) c gi l tnhtrng nhim toan. Nhng thay i dn n s gim nng ion H+ ca dch c th (pHtng) c gi l tnh trng nhim kim.

C thnh gi cn bng kim toan da vo cng thc:

[H+] = 8.10-7 (0,03 PCO2 / [HCO3-] )

nh gi mt ri lon cn bng kim toan, chng ta da vo 3 yu t: pH (hay nng H+), p sut phn CO2 (PCO2) v nng HCO3

-.

Nh vy:o Nhim toan ([H+] tng): xy ra khi PCO2 tng (toan h hp) hoc [HCO3-] gim

(mt HCO3- hoc thm H+ , toan chuyn ho).

o Nhim kim ([H+] gim): xy ra khi PCO2 gim (kim h hp) hoc [HCO3] tng(thm cht kim hoc mt H+ , kim chuyn ho).

nh gi khuynh hng b tr:

bit c khuynh hng b tr din ra theo chiu hng no, tt nht l da vo cnbng Henderson-Hesselbalch:

pH = 6,1 + log ([HCO3

-] /0,03 PCO2) = 6,1 + log 20 = 7,4

Khi mt ri lon kim toan xy ra, trc tin mt trong hai yu t trn b thay i. Cchb tr hot ng nhm thay i yu t cn li sao cho t l [HCO3

-]/0,03 PCO2 khng thayi, lc pH dch cthc gigi tr 7,4 v ta ni hot ng b tr c hiu qu.

Hot ng b tr c hiu qu khi cc ri lon din tin mn tnh. Ngc li, nu ri londin tin cp tnh, thng chng nhanh chng trnn mt b.

Khong trng anion huyt tng (AG-anion gap):

AGht = Na+ - (Cl- + HCO3-)

Bnh thng khong trng anion huyt tng dao ng trong khong 12 2 mEq/L.

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Trong nhim toan chuyn ho, khong trng anion tng chng t c s tng nng cacc acid hu c(ni sinh hoc ngoi sinh).

Nhim toan chuyn ho m khong trng anion khng tng c gi l nhim toan chuynho tng chlor huyt tng, bi v mc gim ca HCO3

-c b tr bng mc tngtng ng ca Cl-.

4.2-Nhim toan chuyn ho:

4.2.1-Nguyn nhn:

Nhim toan chuyn ho c khong trng anion tng:

o Nhim toan lactic: Nhim toan lactic typ A (thiu oxy t bo): trng thi suy gim ti mu m

(xut huyt, suy tim, nhim trng huyt).

Nhim toan lactic typ B: vn ng qu mc, tnh trng nhim kim, suy gan,tiu ng, h ng huyt, cc bnh l c tnh (lymphoma, leukemia,

sarcoma, ung th v), ng kinh ton th, suy thn, cc loi thuc(phenformin, salicylate) v c cht (ethanol, ethylene glycol), mt s khimkhuyt c tnh cch di truyn (th d thiu PDH, pyruvate carboxylase,PEPCK)

o Nhim toan ketone: Nhim toan ketone trn BN tiu ng khng kim sot: hnh thi nhim

ketone quan trng nht.

Nghin ru mn Nhn i

o Cc nguyn nhn khc: ngc ethylene glycol, suy thnNhim toan chuyn ho c khong trng anion bnh thng:

o Toan ho do ng thno Cc bnh l gy mt HCO3- qua ng tiu ho:

Tiu chy cp tnh hay mn tnh D tiu ho Bnh nhn c t thng dn lu ng mt, ni tt rut non-rut non, rut

non-rut gi, bnh nhn c phu thut chuyn lu niu-tiu ho

o Cc loi thuc, cc loi dch truyn: Thuc li tiu c tc dng c ch carbonic anhydrase (acetazolamide) hay

tit kim kali (spironolactone, amiloride)

Truyn nhiu dung dch m c hm lng cationic amino acid cao (lysine,glutamine, arginine, histidine) hoc cc amino acid c gc sulfur(methionine, cysteine, cystine): dn n nhim toan tng chlor huyt tng.

Truyn dung dch NaCl ng trng vi s lng ln v tc nhanh. Cc loi thuc: amphotericin B, toluene

4.2.2-Chn on:

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Thng gp nht: nhp thnhanh v su.

Nhim toan cp tnh: c th c nhp thkiu Kussmaul.

Nhim toan cp tnh v trm trng: lmhoc hn m.

Nhim toan mn: mt mi, suy nhc.

Bun nn, i ma v au bng: c th xy ra c nhim toan cp v mn.

4.2.3-iu tr:

4.2.3.1-Nguyn tc chung:

Nhim toan chuyn ho mn tnh: ngn chn hay hn ch bt s tin trin ca cc bnh lcn nguyn v phng nga kh nng xy ra cc sang chn.

Nhim toan chuyn ho cp tnh: i hi phi c nhng bin php iu tr cp thi:

o Hn ch bt qu trnh d ho trong cc trng hp chn thng (bt ng, gim autt), phu thut (c gng chuyn sang phu thut chng trnh thay v cp cu)

hay nhim trng (dn lu, khng sinh).o iu chnh tnh trng mt nc v gim natri huyt km theo.o Gim bt tng lng H+ v phc hi li kho d trm ca cth bng dung dch

bicarbonate.

4.2.3.2-iu chnh nhim toan chuyn ho bng dung dch bicarbonate:

Mi trng hp pH di 7,2 u c chnh dng HCO3- ngn nga bin chng trn

chc nng co bp ca ctim.

Tnh ton lng HCO3-cn phi cho:

2 x [(0,2A x TLCT) +1/2(0,2A x TLCT)] = 0,6A x TLCT

(A l lng HCO3- cn thit nng nng HCO3

- ca 1 lt huyt tng ln n gi trmong mun)

Trn thc t lm sng khng cn thit phi b tt c lng HCO3- thiu ht.

HCO3- nn c s dng di dng dung dch ng trng. Pha 2 ng Natri Bicarbonate

8,4% (50 mEq/1 ng 50 mL) vo 500 mL dung dch Glucose 5% s cung cp cho bnh nhn100 mEq Na+, 100 mEq HCO3

- v 600 mL H2O.

4.2.3.3-iu tr nhim toan ketone bng insulin:

Insulin l chnh u tin v ngay sau khi xc nh chn on.Nguyn tc s dng insulin: phi dng loi insulin tc dng nhanh (Regular Insulin), quang tnh mch. Bt u bng 0,2 IU/kg tim mch, sau truyn tnh mch vi tc 0,1 IU/kg mi gi hay tim mch 0,1 IU/kg/gi. Dung dch truyn l NaCl 0,9%: pha100 IU insulin trong 500 mL NaCl 0,9% v truyn vi tc 10 git/pht.

nh lng ng huyt mi 2 gi. Nu cthp ng tt, ng huyt s gim 5-10% gitr ban u. Nu ng huyt khng gim, tng liu insulin ln gp i.

Khi ng huyt gim xung ti 250 mg/dL, gim phn na liu insulin ang s dng,ng thi bt u truyn thm dung dch Glucose 5% phng nga tai bin h ng

huyt. Hoc chuyn sang dng tim di da (c th s dng insulin NPH hoc Lente): khiu bng 15 IU, sau mi 4 ginh lng ng huyt v tip tc insulin vi liu lng

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gim dn (10 IU nu ng huyt 150-200 mg%, 5 UI nu ng huyt di 150 mg%.Chuyn sang chiu tr duy tr khi th ketone m tnh trong huyt tng (hoc trvgii hn bnh thng nu xt nghim nh lng: acetoacetate nh hn 1 mg/dL, beta-hydroxybutyrate nh hn 3 mg/dL).

4.3-Nhim kim chuyn ha:

4.3.1-Nguyn nhn:

Nhim kim chuyn ho c p ng vi chlor:

o Hp mn v, nn i ko di hoc ht thng d dy ko dio S dng thuc li tiu thiazide v li tiu quaio Hi chng nhim kim sau u thno Bnh tiu chy mt chlor bm sinho U nhung mao i trng

Nhim kim chuyn ho khng p ng vi chlor:o Cc trng thi thng d hormone v thng thn: hi chng Cushing, hi chng

cng aldosterone nguyn pht v th pht

o Cc nguyn nhn khc: Hi chng kim sa Chng nhim kim sau khi bt u n trli Bnh nhn c truyn mu khi lng ln (hoc cc dung dch c cha

lactate, acetate, citrate)

4.3.2-Chn on:Nhim kim nh: khng c triu chng.

Nhim kim trm trng (pH >7,5):

o Biu hin thiu oxy (do gim thng kh v gim phn ly oxy-hemoglobin)o Ri lon nhp tht v nhp trn thto Ng g, l ln tm thn, m sng, yu c, chut rto Nng can-xi huyt tng khng thay i nhng nng Ca2+ gim (do Ca2+ tng

gn kt vi protein huyt tng) c th dn n tetany.

Nng Cl- nc tiu:o 20 mEq/L: gp trong cc trng thi thng d hormone v thng thn, hi chngkim sa

4.3.3-iu tr hp mn v:

iu mu cht iu chnh ri lon v ni mi mt bnh nhn hp mn v (hay nn i,ht thng d dy ko di):

oB nc

o B Cl-

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o B K+o B Na+

Truyn nhanh dung dch NaCl 0,9% nu bnh nhn c du hiu thiu ht th tch dch ngoibo nng.

Theo di tnh trng tim mch v h hp v nh lng nng cc ion huyt tng nhiuln nh gi hiu quiu tr.

C th bt u bng truyn K+ (di dng mui KCl) cng lc vi dung dch NaCl nu nhtnh trng bnh nhn qu nng hoc bnh nhn sp sa c thng kh nhn to.

Nu tnh trng bnh nhn khng nng lm, NaCl v KCl c truyn vi tc chm hn,th d 1000 mL NaCl 0,9% v 40 mEq KCl mi 6 gi.

Cn lu rng: mt bnh nhn hp mn v c nng K+ huyt tng 2,5 mEq/L cn bihon khong 200 mEq K+.

Trnh dng dung dch lactate bi hon s thiu ht nc v c th lm cho tnh trng

nhim kim thm nng.Hn ch bt s mt thm HCl: c th kt hp vi cc anti-H2 nh cimetidine (300 mg TMmi 8 gi), ranitidine (100 mg TM mi 12 gi).

Trng hp bnh nhn b suy thn cp: iu chnh tnh trng nhim kim bng dung dchHCl hoc thm phn mu.

4.4-Nhim toan h hp:

4.4.1-Nguyn nhn:

Nhim toan h hp cp tnh:

o Nguyn nhn ngoi bin: Sc tim Thuyn tc ng mch phi Ph phi cp Ht phi d vt Vim phi ht Cn hen cp Co tht thanh qun Hi chng ngng thtrong lc ng Trn kh trn mu mng phi Mng sn di ng Hi chng suy h hp cp ngi ln Suy gim vn ng ca cc c h h p: do thuc hay cc c cht, bnh

nhc c, bnh l cdo h kali huyt tng , hi chng Guallain-Barr, unvn, chn thng ct sng c....

o Nguyn nhn trung ng: Chn thng, vim nhim h thn kinh trung ng

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Hot ng ca trung tm h hp bc ch do tc ng ca cc loi thuc gym, dn xut morphine hay cc cht gy ng khc...

Tng sn xut CO2: st cao, nhim trng, dinh dng bng ch nhiucarbohydrate... c th dn n nhim toan h hp trn ca bnh nhn csn bnh l v h hp.

Nhim toan h hp mn tnh:

o Bnh phi tc nghn mn tnh (COPD)o Suy thng kh ph nang mn tnh do h thn kinh trung ng bc ch (thuc, cc

sang thng vim nhim, u bu...), cc ri lon v thng kh trong lc ng (hichng Pickwick), cc ri lon chc nng thn kinh c(bnh l cnguyn pht hayth pht), cc bt thng v cu trc ca lng ngc (g, vo ct sng...).

4.4.2-Chn on:

Lm sng:

o Thnhanho Nhp tim nhanh, mch ny mnh, cao huyt po Da m (dn mch ngoi bin), nng u (dn mch no)o Hoa mt, l lno My git co Co git, hn mo Lon nhp tim

Xt nghim: PaCO2

ln hn 45 mmHg, nng HCO3

- huyt tng bnh thng hoc tngnh, pH < 7,35. Nu bnh nhn b thiu oxy km theo, PaO2 < 60 mmHg v bnh nhn slm vo tnh trng nhim toan nng n hn so vi nhim toan h hp n thun.

4.4.3-iu tr:

4.4.3.1-iu tr nhim toan h hp cp tnh:

Ba mc tiu chnh:

o iu chnh s thiu oxy: quan trng nhto Ci thin tnh trng u thno iu tr cc bnh l cn nguyn

Liu php oxy:

o Thiu oxy nh (PaO2 > 50 mmHg): iu tr bng cc liu php oxy thng dng, phbin nht l cho bnh nhn thoxy qua mt n Venturi. Thoxy qua mt n Venturic th gip duy tr FiO2 ln ti 50%, ng thi cn ci thin tnh trng u thn tthn so vi thoxy qua thng mi.

o Thiu oxy nng (PaO2 < 50 mmHg): thng kh nhn to.Dung dch bicarbonate: c chnh khi bnh nhn b nhim toan chuyn ho kt hp v

pH mu nh hn 7,2. Ch nn cho tng liu nh mt (1-2 ng NaHCO3 8,4% 50 mL).

Ht d dy. Ch bi hon li 1 lt dch vc ht ra bng 1 lt dung dch NaCl 0,9%(cng vi 40 mEq K+, vi iu kin bnh nhn khng c nhim toan chuyn ho km theo).

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C mt cch iu tr thay th vi tc dng tng t m khng cn phi bi hon dch, ldng cc antacid trung ho HCl trong dch v.

Cc bin php iu tr nguyn nhn:

o St cao: h st bng cc tc nhn vt l (lau mt, mn lnh...) hay dc l(acetaminophen).

o Khng sinh c ch nh cho nhng trng h p nhim trng, cng nh thucchng ng kinh dnh cho bnh nhn ng kinh.

o Naloxone: chnh cho nhng bnh nhn ngc cc dn xut ca morphine.o Cc tc nhn dn ph qun (v corticoid): l thuc la chn u tin i vi bnh

nhn ln cn hen cp tnh.

o C th loi c cht bnh nhn ngc barbiturate v cc cht gy ng khngphi barbiturate trong vng 4 giu bng sc ra d dy v than hot tnh. Ch nhng bnh nhn st gim tri gic cn phi c thng kh qun trc khi sc

ra trnh nguy cht phi dch v vo ng h hp. Bnh nhn hn m thcch loi trc cht hiu qu nht l thm phn mu.

o Bnh nhn ht phi d vt cn nhanh chng c gp d vt qua ng ni soi.o Bnh nhn trn kh trn mu mng phi: t dn lu kn xoang mng phi.

4.4.3.2-iu tr nhim toan h hp mn tnh:

Mc tiu:

o Ngn nga cc bnh l nhim trng, iu tr tch cc cc bnh l nhim trng nunh xy ra

oCi thin hot ng co bp ca ctim

o Ci thin cc ch s v huyt hc (nng huyt sc t nn duy tr ti thiu 10gm/dL)

o Liu php oxy thch hp (thoxy qua thng mi vi lu lng thp 3-5 lt/pht, thoxy vo ban m...)

o Chnh cc tc nhn dn ph qun thch hp, c th kt hp vi cc tc nhn kchthch h hp

o Ct t cc nguyn nhn lm cho bnh din tin nng thm (ngng thuc l)o iu tr nhim toan chuyn ho kt hp (thuc li tiu c ch carbonic anhydrase)

4.5-Nhim kim h hp:

4.5.1-Nguyn nhn:

Nhim kim h hp cp tnh:

o Giai on u ca cc bnh l phi do tc nghn hay gii hno Ph phi cp th nh-trung bnho Cc ri lon v tm lo Ngc cc loi thuc (salicylate, nicotine, aminophylline, nikethamide...)o St, say nngo Vn ng qu mc

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o Nhim trng huyto Ngc COo H huyt po Thmy vi ch tng thng kh qu mc...

Nhim kim h hp cp tnh hay mn tnh:

o Bnh nhn b thiu mu hay sng caoo Hot ng ca trung tm h hp b kch thch do:o Cc bnh l v thn kinh trung ng (chn thng, vim nhim, u bu...)o Suy gan

4.5.2-Chn on:

Cm gic nhp thb ngn li hoc kh th, hi hp, nh trng ngc

D cm u chiNgt hay ng kinh ton th

4.5.3-iu tr:

iu tr nguyn nhn v gim bt cc kch thch gy tng thng kh.

Tng thng kh do nguyn nhn tm l: c th thc hin nghim php th li: cho bnhnhn ht thvo mt ti giy trong vng mt vi pht.

Nhim kim h hp do cc sang thng h thng thn kinh trung ng hay do suy chcnng gan: tin lng d dt.

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