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I HC HU TRNG I HC Y DC HU

B MN GY M HI SC

GIO TRNH

GY M-HI SC C S

HU 2008

I HC HU TRNG I HC Y DC HU

B MN GY M HI SC

GIO TRNH

GY M-HI SC C S

Ch bin:

TS. H KH CNH

Tham gia bin son:

THC S. NGUYN VN MINH

THC S. TRN XUN THNH

BS. BI TH THNG

HU 2008

M u

Trng i hc Y Khoa Hu l mt trong nhng c s o to cn b Y Dc ca c nc,

l mt Trng o to a ngnh, a lnh vc v i hc v sau i hc trong h thng y hc

Nc nh. Nhim v trung tm ca Nh trng l ging dy, nghin cu khoa hc, iu tr,

chm sc v phc v bnh nhn.

Trong chng trnh o to Bc s a khoa, Hi ng Khoa hc Gio dc ca Nh trng

chn hc phn Gy m hi sc c s l mt phn chng trnh o to cho khi lp Y4 a

khoa chnh qui vi mc tiu trang b nhng kin thc c bn trong vic chn on, nh gi,

cp cu cng nh theo di, chm sc bnh nhn trong lnh vc ngoi khoa, c bit nhng

bnh nhn c iu tr can thip phu thut. Ngoi ra trang b mt s kin thc khi qut v cc

k thut v cm trong lnh vc Gy m hi sc nhm gp phn b sung kin thc trong cc

ni dung chng trnh ging dy thuc cc lnh vc c iu tr can thip ngoi khoa.

Tp gio trnh Gy m hi sc c s ca B mn Gy m hi sc Trng i hc Y Hu ra

i nhm p ng cc mc tiu trn, ng thi nhm p ng nhu cu hc tp ca sinh vin

cng nh xy dng b ti liu c bn lm c s ging dy cho i ng gio vin chuyn

ngnh gy m hi sc ca Nh trng.

Trong khun kh thi lng ca chng trnh o to v ln u thc hin, cn nhiu ni

dung cha th cp n, ngoi ra trong tng bi, tng chng cn c mt ny, mt khc

cha hon thin. Chng ti mong c gi lng th v xin tip thu b sung, sa cha ln

sau.

Thay mt nhm bin son

TS.BS. H Kh Cnh

Chng 1 1

Cc phng php gy m

Mc tiu hc tp:

1. Trnh by c khi qut cc k thut gy m.

2. Phn bit c k thut gy m ni kh qun v gy m tnh mch.

3. Nu ra c cc tai bin thng gp khi gy m ni kh qun.

I. i cng

Ngn ng trit hc Hy lp dng ch gy m (Anesthesia) m t tc dng gy ng ca cy

thc vt c tn Mandragora (cy khoai ma thuc h c). Trong cun t in "Bailey's An

Universal Etymological English Dictionary" (1721) nh ngha ch Anesthesia l gim cm

gic. Trong cun "Encyclopedia Britannica" (1771) ca Anh li nh ngha l "mt tri gic"

(privation of the senses). Hin nay ch gy m (Anesthesia) dng biu th mt tnh trng

gy ng m n c th lm mt cm gic au do phu thut c Oliver Wendell Homlmes

a ra t nm 1946. M ch "Anesthesiology" l biu th s thc hnh gy m, c

ngh s dng u tin vo thp nin th hai ca th k XX nhn mnh s pht trin v tnh

khoa hc c bn ca mt chuyn khoa. Mc d hin nay chuyn ngnh gy m hi sc mang

tnh khoa hc cn bn, nhng gy m vn cn mang tnh cht pha trn gia "khoa hc v

ngh thut". Hot ng v thc hnh ca chuyn ngnh gy m-hi sc pht trin su hn,

c bit n l mt chuyn khoa i hi s lm vic "c tnh cht tp th", gn kt vi nhiu

chuyn khoa khc nh: Ngoi khoa, Ni khoa, Nhi khoa, Sn khoa cng nh cc chuyn khoa

y hc c s nh: Sinh l hc, Dc l lm sng v K thut y sinh hc. ng dng nhng tin

b ca chuyn ngnh K thut y sinh hc mang li v thc y chuyn ngnh gy m-hi

sc pht trin nhanh chng.

Trong bi ny ch gii thiu nhng nt khi qut v cc phng tin gy m (h thng gy

m), mt s k thut gy m c bn trong c mt s k thut mang tnh lch s (v hin

nay t p dng), nhng l cc k thut cn bn l c s cho s pht trin cc k thut hin

i sau ny.

II. H thng gy m

1. H thng khng th li (h thng h hon ton)

H thng khng th li l h thng m c lu lng kh th vo cao, khi bnh nhn th ra,

kh th ra u b a hon ton ra ngoi h thng v khi bnh nhn th vo li chu k sau kh

th vo l hon ton mi. in hnh ca h thng ny l ng th hay mt n h Mask b

hong. H thng ny hin nay t s dng, n cn gi li c tnh cht lch s v s pht trin

ca ngnh gy m.

Hnh 1.1. Kiu th theo k thut h hon ton bng ng th

2. H thng th li mt phn (h thng na h, na kn)

V l thuyt h thng th li mt phn l h thng c lu lng kh mi i vo trong h thng

th cung cp cho bnh nhn t hn thng kh pht ca bnh nhn nhng ln hn t l cc

kh c hp thu (oxy, kh m) bi bnh nhn. Nh vy s chnh lch (hay kh tha) gia lu

lng kh mi v t l kh (oxy, kh m) c hp thu bi bnh nhn l tng ng vi th

tch kh c o thi ra ngoi h thng. Do kh b mt i c th bng mt phn ba th tch

Chng 1 2

ca qu trnh thng kh, th tch kh mt i ny c th do: o thi qua van gim p (h thng

na h), hp thu CO2 qua bnh vi soda hoc bnh nhn ti hp thu li mt phn (h thng

na kn).

2.1. H thng na h

Mc d v l thuyt h thng na h c xem nh h thng th li mt phn, nhng trong

thc hnh khi s dng h thng na h trnh bnh nhn th li kh CO2 nn i hi lu

lng kh mi th vo cao (thng gp 2,5-3ln thng kh pht ca bnh nhn (lu lng oxy

cn 200-250ml/kg/pht), khi bnh nhn th ra, mt phn kh th ra c o thi ra ngoi

h thng qua van gim p. Mt s loi h thng c dng cc van khng th li (non-

rebreathing valve). in hnh nh Van Ruben, bng Ambu, my th. Ngoi ra h thng Arye

's T-piece (ch T), h thng Mapleson, Bain, mt n (mask) th, cng c xem nh h thng

na h. i vi h thng Mapleson, h thng Mapleson A (cn gi l h thng Magill) c

s dng cho thng kh t nhin (bnh nhn t th). H thng Mapleson D c s dng cho

thng kh c kim sot.

u im ca h thng na h:

+ t cn tr s thng kh.

+ Khong cht ca h thng thp hn h thng th li (h thng kn)

+ H thng n gin, d ch to v r tin.

+ Lm sch kh m nhanh hn sau gy m.

+ Khng gy tng CO2 cho bnh nhn.

Hnh 1.2. Bng Ambu Hnh 1.3. Mt n th

Nhc im:

+ Mt nng lng do mang theo hi nc v nhit nn d gy h thn nhit.

+ Thi thuc m nhiu trong phng m gy nhim mi trng.

+ Bnh nhn lu ng hn so vi gy m kn v thuc m s dng nhiu hn.

+ C th gy nhc thn cho bnh nhn.

Hnh 1.4. H thng Mapleson A Hnh 1.5. H thng Mapleson B

Hnh 1.6. H thng Mapleson C Hnh 1.7. H thng Mapleson D (Bain)

Chng 1 3

Hnh 1.8. H thng Mapleson E Hnh 1.9. H thng Mapleson F

2.2. H thng na kn

L h thng c lu lng kh mi cung cp cho h thng thp hn thng kh pht ca bnh

nhn nhng cn c kh mi th vo c nng oxy, kh m vt qu nng tiu th ca

bnh nhn. Mt phn kh tha (oxy, kh m) c thot ra ngoi h thng m thng qua mt

van gim p phn cn li vn trong h thng v c ti hp thu bi bnh nhn hoc c

hp thu qua bu vi s a (hp thu CO2), v th khi gy m vi h thng m, my m theo

kiu ny nn c bnh vi s a hp thu kh CO2. H thng na kn c th p dng lu

lng kh th nh sau:

- Lu lng thp: 10-20ml/kg/pht (oxy hoc oxy + kh nn).

- Lu lng trung bnh: 20-40ml/kg/pht (oxy hoc oxy + kh nn).

- Lu lng cao: > 60ml/kg/pht (oxy hoc oxy + kh nn).

u im: An ton hn h thng kn (trnh ng c CO2). C th iu chnh nhanh nng

cc thuc m.

Nhc im: t tit kim c kh m so vi h thng kn. Vn c th gy nhim mi

trng v thuc m c th thi ra ngoi.

3. H thng th li hon ton (h thng kn, vng)

Khi gy m vi h thng th li hon ton (vng kn) ton b lu lng kh mi a vo h

thng tng ng lu lng (oxy, kh m) m bnh nhn hp thu. Hay ni cch khc lu

lng kh mi a vo h thng duy tr p lc ring phn ca cc kh m v oxy trong

ph nang. Lu lng kh mi ny tu thuc vo t l cc kh c hp thu v tiu th oxy ca

bnh nhn. Thng kh vi h thng th li hon ton th khng c bt k kh th ra no c

o thi qua van gim p. Vi h thng ny khi bnh nhn th ra tt c kh th ra u nm

trong h thng m. H thng ny c cc van nh hng (van th ra v van th vo). Trn

ng th ra c gn mt bnh vi s a hp thu kh CO2, cn kh m c gi li trong h

thng v bnh nhn s th li chu k sau.

- u im ca h thng kn: Khng lm nhim mi trng. Tit kim c kh m. t gy

nhc thn. n nh huyt ng trong qu trnh gy m nu p dng m dng thp. Khng

gy mt thn nhit. Khng gy chy n do hn hp kh m v oxy.

- Nhc im: C th gy u thn nu bnh vi s a hot ng km. Tng thn nhit nu gy

m nhit phng cao.

Hnh 1.10. H thng vng kn

Chng 1 4

4. Ch nh s dng cc h thng

- Mt n (mask) h: Dng cho tr em, phu thut nh thi gian ngn (ngy nay t dng).

- H thng na h: Khi mun bo m khng c ng CO2,

- H thng na kn: Dng v ma ng v khi s dng thuc m qu him.

- H thng kn: Dng cho thuc m d chy n v thuc m qu him.

III. Cc phng php gy m

1. nh ngha gy m

Gy m ton thn l phng php lm cho bnh mt tri gic v mt cm gic au tm thi c

hi phc bng dc cht.

Trong gy m c nhiu hnh thi v cm khc nhau ty thuc vo tng loi thuc s dng.

V d: Mt tri gic ri dn n mt cm gic au nh kh nitric oxide (N2O). Mt cm gic

au sau mi m nh ether. Ngc li m su mi mt cm gic au nh thiopental (v

thiopental khng c tc dng gim au).

2. Gy m ni kh qun

Gy m ni kh qun (NKQ) l phng php c thc hin bng cch t mt ng thng

lm bng cao su hay cht do i t ming hoc mi vo ti trong kh qun ca bnh nhn.

Qua a hn hp kh m, kh nn v oxy t h thng m hoc my m n phi bnh nhn

ri trao i qua mng ph nang-mao mch phi vo mu. K thut ny ngy nay c thc

hin khng ch s dng thuc m h hp m ngay c s dng thuc m tnh mch, c bit c

dng thuc gin c trong cc trng hp phu thut ln v thi gian di.

2.1. Dng c gy m ni kh qun

- ng ni kh qun: C hai loi ng ni kh qun loi c bng chn (cuff) v loi khng c

bng chn (Hnh 1.11). V nguyn liu lm bng cao su hoc cht do. Mi loi c c s khc

nhau thch hp cho tng bnh nhn v ng knh cng nh chiu di ca ng.

- n soi thanh qun: C hai phn: Phn cn: Trn, rng di t 15-16cm. Phn li n: C

nhiu loi khc nhau (tham kho thm chng k thut t ni kh qun)

- Mt s dng c khc:

+ Mt que kim loi lm nng (mandrin): Mt si dy kim loi ng knh 1-1,5mm, khi cn

lun trong ng ni kh qun hng chiu cong hay thng theo mun ca ngi gy m.

+ ng ni (ni gia h thng m v ng NKQ).

+ Ambu hoc bng mm.

+ Km Magill t ni kh qun qua mi.

- My ht: Chun b phng khi c tro ngc v ht m di.

+ ng ht cc c ht dch trong ng ni kh qun v dch hng, ming. ng thng d

dy.

+ Bm tim bm bng chn hoc mche chn khi dng ng ni kh qun khng c

cuff.

+ H thng cung cp oxy.

+ My theo di (monitoring): in tim, mch, huyt p, SpO2 ...

+ Dng c li (airway).

+ ng nghe tim phi.

2.2. Ch nh m ni kh qun

Trong cc trng hp phu thut ko di c dng thuc gin c, phu thut vng bng,

ngc, s no v cc t th cn tr h hp.

Chng 1 5

2.3. Cc bc t NKQ (gii thiu chi tit bi k thut t ni kh qun)

Hnh 1.11. Cc loi ng ni kh qun

Ghi ch. A: ng NKQ c l xo bn trong. B: NKQ t qua mi. C: NKQ bm cuff theo th tch

& NKQ khng c cuff. D: NKQ bm cuff theo p lc

Hnh 1.12. Cc dng c li (Airway)

2.4. iu kin rt ng ni kh qun

+ Bnh nhn phi hon ton t th tt, th m su u v tn s bnh thng. Da v nim mc

hng ho. Mch, huyt p n nh .

+ Bnh nhn phi thot m, thot ht tc dng ca thuc gin c. C ngha l gi bnh nhn

bit, bo bnh nhn m mt, l li, h mm v ho c.

2.5. Tai bin do gy m ni kh qun

Gy rng. t vo thc qun gy hi chng tro ngc c th a n ngng tim. V ph

nang do th vo p lc cao. Co tht thanh qun do m nng. t ni kh qun chn lc.

3. Gy m tnh mch

3.1. nh ngha

Gy m tnh mch l mt k thut gy m ton thn bng cch dng thuc m (thuc ng,

thuc an thn, thuc gim au) tim qua ng tnh mch hoc tim bp v bnh nhn t

th vi kh tri hoc vi oxy nhng khng pha trn vi kh m h hp.

3.2. Ch nh

- Phu thut nng, thi gian ngn trung bnh khong 1gi. Khi m tr em khi dng vi

ketamine.

3.3. Chng ch nh

Phu thut ln, thi gian di. Bnh nhn c d dy y. Khng c phng tin h hp nhn

to. Bnh nhn trong tnh trng thiu khi lng tun hon

3.4. ng dng trong lm sng

Trong lm sng thng ng dng gy m tnh mch cho cc trng hp phu thut n gin,

thi gian phu thut ngn (trung bnh khong 1 gi). K thut ny trc y c thc hin

rng ri ngay c trong cc trng hp cp cu. Tuy nhin do c nhiu bin chng v tun

Chng 1 6

hon v h hp nn ngy nay hn ch s dng v chng ch nh cc trng hp bnh nhn

c d dy y.

Tu theo mc v thi gian phu thut v thuc m s dng, k thut m tnh mch c

gii thiu tm tt nh sau:

- Gy m tnh mch vi thiopental

+ Chun b phng tin: Gm cc phng tin gy m ging nh gy m ton thn c t ni

kh qun.

+ Tin m: Thng tin m vi thuc gim au trung ng v atropine.

+ Khi m: Liu dng t 3-5mg/kg tim chm vo tnh mch (ch khng tim vo ng

mch v s gy co mch lm thiu mu nui dng dn n hoi t vng chi di ch tim),

sau 30-60 giy bnh nhn s hn m v ko di trung bnh khong 10 pht. Nu mun duy tr

m th phi tim nhc li 20-25% so vi liu u khi bnh nhn c du hiu tnh (theo di

mch, huyt p ng mch, tn s h hp), bng cch tim ngt qung hoc nh git lin tc.

Tuy nhin thiopental khng phi l thuc chn la duy tr m v n khng c tc dng

gim au v c thi gian o thi chm s c nguy c tch lu thuc. Tng liu s dng khng

qu 1g cho mt cuc gy m. Trong qu trnh gy m phi theo di cht ch mch, huyt p

ng mch, nhp tim v tn s h hp, nh gi tri gic bng cch xem ng t v tnh trng

kch thch do au duy tr m thch hp. Nu phu thut ch trong mt thi gian ngn

(15pht) c th bnh nhn t th kh tri, tuy nhin tt nht l cho th vi oxy.

Ngy nay m tnh mch n thun vi thiopental khng cn p dng do thiopental khng c

tc dng gim au nn ngi gy m thng kt hp cho thm thuc gim au h morphine,

v th phi theo di h hp tht cht ch, cng chnh v th m k thut ny ngy cng t p

dng do tnh cht an ton trong gy m.

Gy m tnh mch cn p dng c cho tt c cc thuc m tnh mch mi c khc nh

ketamine, propofol, midazolam, k thut ng dng cng tng t nh trn, ch khc nhau v

liu lng s dng v chng ch nh c th ca mi loi thuc s dng.

3.5. Tai bin v bin chng do gy m tnh mch

- Tai bin: Tim thuc ra ngoi mch mu gy hoi t da khi dng vi thiopental. Tim thuc

vo ng mch gy co mch, thiu mu nui dng vng chi di ch tim, nguy c ct ct

chi trong gy m vi thiopental. Gy hi chng tro ngc.

- Bin chng: Suy h hp cp do c ch h hp v tru tim mch do c ch c tim

(thiopental). Tng huyt p, tng p lc ni s (ketamine). D ng thuc, sc dng phn v

(thiopental).

Tm li k thut gy m ngy cng pht trin, v th trong gy m hin i c khuynh hng

phi hp cc loi thuc m tnh mch. Ngi ta thng phi hp cc loi thuc m nh:

Thiopental, propofol, etomidate, ketamine hoc thuc an thn nh midazolam (Hypnovel) vi

nhm morphine nh fentanyl, alfentanil, sufentanil... gy m tnh mch.

4. Gy m nh git

Cn c gi l m mt n h (mask), k thut ny ngy nay ch cn mang tnh cht lch s

v t c s dng. c im ca k thut ny l phi dng vi cc thuc m hi c bc

hi cao (ether, halothan) v ch ng dng m trong mt thi gian ngn. K thut c thc

hin nh sau:

- Mt n m c lm bng khung kim loi, qua lt chng 8 lp gc. Trc khi khi m

cn nh git thuc m cho t gc, a mt n (mask) st mi bnh nhn, cho ngi 3-4 nhp

th cho bnh nhn lm quen v khi s, sau p mt n che kn mm, mi bnh nhn v

tip tc nh git thuc m ln trn cc lp gc. S bc hi ca thuc m s lm gim nhit

ca mt n to nn ngng t hi nc lm tng p lc bc hi ca thuc m.

Chng 1 7

- su ca gy m ph thuc vo s thng kh ca bnh nhn, khi thng kh pht gim, p

lc bc hi tng v nu kh CO2 thot ra ht, trong th th vo ln sau thuc m s pha long

kh tri to ra mt hn hp kh th vo thiu oxy, v vy d phng thiu oxy ngi ta

thng cho thm mt vi oxy xung di mt n khi gy m. Trong qu trnh gy m cn

theo di mch, huyt p, nhp th ca bnh nhn cng nh tnh trng tri gic tng thm hay

gim s ln nh git thuc m. Thuc m s dng thng dng nh ether, halothan, klne.

5. Gy m phi hp

Ngy nay c khuynh hng gy m phi hp nhiu hn, kt hp nhiu cch gy m khc

nhau. C u im l m n nh, trnh c qu liu thuc m.

- Phi hp khi m bng thuc m ng tnh mch, duy tr m vi thuc m hi, kh m qua

ng ni kh qun cng vi thuc gim au h morphine v thuc gin c qua ng tnh

mch.

- Hoc khi m bng kh m, thuc m hi qua ng h hp, sau t ni kh qun ri duy

tr m vi thuc m hi, kh m qua ng ni kh qun cng vi thuc gim au h

morphine v thuc gin c qua ng tnh mch. Phng php ny cn c pht trin cao

hn bng k thut s dng cc thuc m hi, kh m gy m vi h thng m kn qua

ngi ta p dng k thut gy m vi lu lng cao, lu lng trung bnh, lu lng thp

hoc lu lng ti thiu. Vi phng php gy m phi hp t lm bin lon tun hon, h

hp, an ton, gim tai bin qu liu thuc m, t bin chng gy m, tit kim thuc m, trnh

c nhim mi trng v to iu kin tt cho phu thut.

6. Gy m bng phng php an thn, gim au (neuroleptanalgesia: NLA)

K thut gy m ny c pht trin vo thp nin 70-80 ca th k XX. Bng cch phi hp

mt thuc c ch thn kinh nhm butyrophenol (Droperidol) vi mt thuc gim au trung

ng mnh l fentanyl (bit dc Thalamonal gm 0,5mg fentanyl v 10mg droperidol trong

mt l 10ml). C nhiu k thut gy m c p dng . Cch tin hnh nh sau:

6.1. Khi m v duy tr m bng phng php NLA.

- Tin m: 2,5-5mg Droperidol + 0,1mg Fentanyl v 1/4-1/2mg Atropin. Tim bp 1gi trc

khi gy m.

- Khi m: Liu Droperidol ty theo huyt p ng mch: 10mg vi huyt p tm thu 160-

120mmHg, 5mg vi huyt p tm thu 120-100mmHg v 2,5mg vi huyt p tm thu 100-

80mmHg, sau tim tip fentany vi liu 10mcg/kg. Tim thuc gin c, t ni kh qun

v h hp iu khin.

- Duy tr m: Fentanyl liu 0,1mg cch 30 pht tim tnh mch mt ln, 30 pht trc khi kt

thc cuc m khng tim fentanyl na. Trong qu trnh m nu huyt p tng m khng phi

do thiu oxy hay tha CO2 th c th cho thm droperidol mi ln cho 2,5 mg. Sau khi m

xong cho h hp iu khin tip tc hoc dng Nalorphin 1,5-5 mcg/kg trung ha

fentanyl. Mt cch khc cng p dng nh k thut trn nhng sau khi khi m (c th khng

dng gin c hoc ch dng gin c kh cc (c thi gian tc dng ngn v o thi nhanh)

t ni kh qun, sau cho bnh nhn t th v khng dng thuc gin c. Phng php ny

ch dng cho bnh nhn khe mnh v m khng cn gin c.

6.2. Dng fentanyl liu cao trong phng php NLA

- Sau khi tin m 0,5mg atropin dng mt liu cao fentanyl ngay t u (25-50mcg/kg tim

tnh mch), sau tim thuc gin c t ni kh qun v h hp nhn to. Vi phng php

ny cho php thi gian phu thut t 3-4 gi m khng cn tim thuc lp li. Sau m

tip tc th my hoc trung ha bng nalorphine. Phng php ny c gi l k thut gy

m khng gy kch ng (Stress).

Chng 1 8

Cu hi nh gi 1. Khoanh trn ch ci biu th u im ca h thng m h:

A.Tit kim c thuc m

B. Khng gy thiu oxy

C. Khng gy thiu CO2

D. Khng gy tha CO2

E. D s dng

2. Khoanh trn ch ci biu th nhc im ca h thng m na h:

A. Gy tha CO2

B. Gy thiu O2

C. Bnh nhn d b ng c kh m nu khng kim sot nng cht ch

D. D gy thiu CO2

E. D gy m nng

3. u im ca h thng m na kn:

A. Khng gy thiu O2

B. Khng gy tha CO2

C. Khng gy thiu CO2

D. C th tit kim c kh m

E. Khng gy chy n khi dng kh m

4. u im ca h thng m kn:

A. Khng gy thiu oxy

B. Khng gy tha CO2

C. Khng gy chy n khi dng kh m

D. Khng gy thiu CO2

E. Khng gy ng c kh m

5. Ch nh ng nht gy m ni kh qun:

A. M bng di rn thi gian ngn

B. M ly thai v khung chu hp

C. M do chn thng chi di khng sc

D. M do chn thng bng

E. M do vim rut th cp

6. Gy m phi hp l k thut:

A. Gy m v gy t

B. Tin m v gy t

C. Dng kh m hi v thuc m tnh mch

D. T vng v gy m

E. Dng thuc m v gim au

7. Ch nh rt ni kh qun khi:

A. Khi bnh nhn tnh m

B. Khi bnh nhn t th c

C. Khi bnh nhn m mt c

D. Khi huyt p n nh

E. Tt c cc du hiu trn

8. Bin chng nguy him nht ca gy m ni kh qun:

A. Gp ng ni kh qun

B. Tt ng ni kh qun

C. Gy chn thng ming

D. Hi chng tro ngc

E. Suy h hp

9. Gy m nh git ngy nay t s dng v:

Chng 1 9

A. Khng c thuc m thch hp

B. Khng c h thng m thch hp

C. an ton thp

D. an ton thp v ch p dng c cho cc loi phu thut nh

E. Thy thuc gy m khng thch chn la k thut ny

10. Nhc im ln ca gy m nh git l:

A. an ton thp

B. Khng cho php gy m nhanh

C. Gy nhim mi trng

D. Chn a v b

E. Chn a v c

11. Chn phng php gy m phi da vo:

A. Tnh trng bnh nhn.

B. tnh cht cc phu thut

C. Cc trang thit b hin c

D. Kinh nghim ca ngi gy m.

E. Tt c cc yu t trn.

12. Tc dng chnh ca cc thuc gy m l:

A. Gy mt tri gic.

B. Gy mt cm gic au.

C. Tng trng lc c.

D. A, B ng

E. A, B, C ng

13. Trong phng php gy m phi hp th:

A. Ch dng thuc m qua ng h hp.

B. Ch dng thuc m qua ng tnh mch.

C. Dng thuc m qua ung h hp hoc tnh mch.

D. Bt buc phi c my th.

E. Tt c cc cu trn u ng.

14. Cc k thut gy m sau y c th ch nh trong m rut tha cp

A. Gy m tnh mch

B. Gy m ni kh qun

C. Gy m

D. Gy m phi hp

E. Cu B &D ng

Danh mc sch tham kho 1. B mn Gy m Hi sc (2002). Bi ging Gy m Hi sc tp 1, Trng i hc Y H

ni, NXB Y hc.

2. B mn Gy m Hi sc (2002). Bi ging Gy m Hi sc tp 2, Trng i hc Y H

ni, NXB Y hc.

3. B mn Gy m Hi sc (1997). Bi ging Gy m Hi sc, Trng i hc Y Dc

TPHCM.

4. Alan R. Aitken., David J. Rowbotham (2001). Textbook of Anaesthesia, Churchill

Livingstone, UK.

5. Dalens B. (2001). Trait d'anesthsie gnrale, Arnette.

6. Edward Morgan G. (2002). Clinical Anesthesioloy, McGraw-Hill, USA

7. Fancis Bonnet (1998). Le livre de linterne, Anesthsiologie, Flammarion Mdecine-

Sciences, France.

8. La collection de SFAR (2003). Elsevier.

Chng 1 10

9. Mark C. Rogers, Jone H. Tinker (1993). Principles and Practice of Anesthesiology, USA.

10. Miller R. D (2005). Miller 's Anesthesia, Vol 2, Esevier Churchill Livingstone, USA

11. Robert K. Stoelting, Ronald D. Miller (1989). Basics of Anesthesia, Churchill

Livingstone.

12. Rogers, Tinker, Covino, Longnecker (1992). Principles and Practice of Anesthesiology.

Volume I, II

13. Viars. P (1994). Anesthesie-Reanimation-Urgences, Tome I, II, III. Universite Paris VI -

Medecins du Monde.

14. Zetlaoui P (1999). Protocoles d'Anesthsie-Rnimation, Arnette.

Website: http://www. ykhoa.net

http://www.anaesthesiologists.org

http://www.anesthesianow.com

http://www.who.int/hinari

http://www.anesthetist.org

http://www.ebook.edu.vn

http://www.elsevier.com

Chng 2 11

Cc phng php gy t

Mc tiu hc tp:

1. Trnh by c khi qut cc k thut gy t.

2. M t v thc hin c k thut gy t ti ch (t tng lp v t b mt c th thc

hin tuyn c s).

3. Trnh by c cc bin chng thng gp ca gy t thn thn kinh v gy t vng.

I. i cng

1. S lc v cm gic au

- Cc kch thch gy au: C hc, nhit , cht gy au ni sinh, bnh l.

- C quan nhn cm: Do cc ngn tn cng ca dy thn kinh cm gic thu nhn. C quan

nhn cm gic au lp thng b, cc tng.

- Dn truyn cm gic au:

+ Cc si thn kinh A: C myeline, c ngng kch thch thp gm 3 loi si nh A , A , A c khu knh v tc dn truyn gim dn. Si A c khu knh 1-5mm, tc dn truyn 4-

30m/giy nm da, c, cc khp

+ Si C: Khng c myeline, ngng kch thch thp, khu knh rt nh 0,35-1,5mm, tc

dn truyn chm 0,5-2 m/s.

- Cc si dn truyn cm gic au: Si A dn truyn cm gic au cp, ngn, kiu chm

chc, phn nh c. Si C dn truyn cm gic au kinh nin, lan to, kiu rt bng km

theo phn ng tm l.

- Trn thc nghim kch thch cc si thn kinh bng in ngi ta nhn c cc kt qu

sau:

+ Nu kch thch cng thp s hot ho si A gy cm gic s m. Nu tng cng

th si A b kch thch gy cm gic au kiu chm chc, ngn, nh v, xut hin nhanh sau

0,2giy. Tip tc tng cng si C b kch thch gy cm gic au d di, rt bng lan to

v xut hin chm sau 2-3giy.

+ Cc xung ng au c dn i theo cc si thn kinh n cc t bo thn kinh th nht

nm trong cc hch thn kinh. Cc si hng tm i tip vo r sau tu sng tip ni vi t

bo trung gian dn truyn ln trung ng.

- Phn ng au: Ngng au khc nhau ty theo tng ngi, ngoi ra cn ty thuc vo tm

sinh l, tinh thn, tui v gii tnh. Tr em ngng au thp, nam gii ngng au cao hn n

gii.

- Cc phng php lm mt cm gic au

+ Loi b nguyn nhn au.

+ Phong b ng dn truyn xung ng thn kinh.

+ Tng ngng au.

Gy t l phng php phong b ng dn truyn xung ng thn kinh.

2. C ch tc dng ca thuc t

- Cc loi thuc t thng do mt cht kim kt hp vi mt acid (thng thng l HCl)

to ra mt mui. Cc mui ny vng bn v ho tan c trong nc, lan to qua c dch

gian bo ti si thn kinh.

Chng 2 12

B + HCl = BHCl

- Khi thuc t qua khu vc gian bo b pha long, m gim xung, thuc c phn ly

pH = 7,0 v to ra mt cht kim yu. Di dng kim, thuc t d tan trong m, thuc

khuch tn d dng qua cc cu trc xung quanh thn kinh, c th i xuyn qua lp t bo

thn kinh v khi vo bn trong mng thn kinh b ion ho tr li, ch phn thuc ion ho ny

c tc dng ngn chn ion Na+ i vo trong t bo lm cho in th hot ng b c ch v

mt s dn truyn xung ng thn kinh. Ch n khi m thuc t gim xung di mt

mc nht nh th si thn kinh mi c th b kch thch tr li.

- Ngng ca m thuc t c tc dng c ch in th hot ng ca si thn kinh gi l

m c ch ti thiu (vit tc Cm) v n thay i tu theo loi thuc t khc nhau, iu

cho php phn bit c mnh ca mi loi thuc t. Khng phi tt c cc t bo thn

kinh u c nhy cm ging nhau vi cc thuc t. Cc t bo thn kinh ca si C (khng

c myelin) c nhy cm cao hn t bo thn kinh c myelin.

- Tc c ch thn kinh ca mt thuc t khng hon ton ph thuc vo nng ca thuc

m ph thuc vo tnh tan trong m v pKa ca n, tc l ph thuc vo pH ca mi trng

m mc pH ny c 50% phn t thuc t dng khng ion ho ( dng ny thuc t mi d

dng i qua c mng t bo thn kinh) v 50% phn t thuc t dng ion ho. Cng

tng t nh vy thi gian tc dng ca thuc t ph thuc vo tnh tan trong m v mc

gn vi protein. Thuc gn vi protein cng mnh thi gian tc dng cng di.

- C mt hin tng hay gp m ngi ta gi l tnh quen thuc, nhn thuc, tc l tc

dng ca thuc km i sau khi tim lp li vi ln. C nhiu cch gii thch hin tng ny

nhng cch c cp nhiu nht l do acid ho dn v tr tim thuc v hin tng nhn

thuc c ghi nhn xy ra nhanh hn i vi thuc t c pKa thp hoc mi trng c

pH thp. V mi trng pH thp thuc t b phn ly cng nhiu, tc dng ca thuc t cng

km, nh trong trng hp gy t v tr ang b nhim trng.

3. Chuyn ha ca thuc t

Sau mt thi gian tc dng nht nh (tu loi thuc t), thuc t i vo mao mch v tr li

h thng tun hon, nng ca thuc thp hn nng trong si thn kinh. Thuc t chuyn

ho v o thi cho php phc hi in th hot ng v chc nng hot ng thn kinh tr

li.

- Nhm ester b thy phn bi enzyme pseudocholinesterase huyt tng v gan. Thuc

thuc nhm ny gm: cocaine, procaine, dibucain, tetracain. Thuc t thuc nhm ny c

nguy c gy d ng cao.

- Nhm amide c gan chuyn ha bi enzyme microsoma.

Thuc t thuc nhm ny c: lidocain, bupivacain, mepivacain, etidocain, prilocain,

ropivacain.

4. Cc loi thuc t thng dng

Cc loi thuc t c s dng trn lm sng bao gm: procaine, dibucain, tetracain lidocain,

bupivacain, mepivacain, etidocain, prilocain, ropivacain. Tn gc, bit dc, cch dng chnh,

dng sn xut, nhm thuc v nm s dng c tm tt bng 2.1.

II. Cc loi gy t

Ty theo v tr tim thuc v mc ch v cm tng vng phu thut m c th p dng cc

loi gy t nh sau:

1. T b mt

p dng cho nim mc v da mng. i vi nim mc c hai cch p dng:

- Bm bi (spray) vo vng nh m.

Chng 2 13

- Hoc tm bng thuc t ln vng nh m, thng hay p dng vi ct polype mi... Thuc

t hay dng lidocain nng 5%, 10%. Thuc t ch thm n su di 5mm. Ngoi ra c

th dng Klne (thuc ny va l thuc m qua ng h hp va c tc dng gy t b mt)

t b mt i vi cc p-xe nh v nht.

2. T tng lp

- Khi nh m vng no th gy t vng , t tng lp i t nng n su, va m va

gy t.

- K thut:

+ Gy t tng lp i t nng n su, bao gm bm thuc t trong da, di da, di cn c v

mng xng.

+ Trit li dng cn mc tim mt lng ln thuc t di cn, cn phng ln do tnh

n hi ri p thuc t xung su v lan ta ra xa lm cho vng t rng ra.

Cn ch :

- Mi kim bao gi cng i trc li dao.

- Nn tn trng thi gian thuc ngm v pht huy tc dng.

Bng 2.1. Cc loi thuc t

Tn gc v bit dc Nm s

dng Cch dng chnh

Dng

sn xut Nhm thuc

Cocain 1884 Ti ch, nim mc Bt kh Ester

Procain (Novocain) 1905

Ti ch, tu sng Dung

dch Ester

Dibucain (Nupercain) 1929

Tu sng Dung

dch Ester

Tetracain (Pontocain) 1930

Tu sng Dung

dch Ester

Lidocain (Xylocain)

1944

Ti ch, tu sng, nim mc,

ngoi mng cng, thn thn

kinh

Dung

dch,

dng m.

Amide

Mepivacain

(Carbocain) 1957

Ti ch, ngoi mng cng, thn

thn kinh

Dung

dch Amide

Prilocain (Citanest) 1960


thn kinh

Dung

dch Amide

Bupivacain (Marcain) 1963


thn kinh, tu sng

Dung

dch Amide

Etidocain (Duranest) 1972


thn kinh

Dung

dch Amide

Ropivacain 1990


thn kinh

Dung

dch Amide

3. Gy t thn thn kinh

Gy t thn thn kinh l a thuc t vo vng c thn thn kinh lm c ch xung ng thn

kinh ca on thn kinh v lm cho c vng n chi phi b mt cm gic. Cc loi gy t

nh gy t m ri thn kinh cnh tay, gy t dy thn kinh to, cng u thuc loi gy t

thn thn kinh.

Chng 2 14

Hnh 2.1. Mc gy t RTKCT ng qua nch

V tr kim gy t KT quanh mch mu 1. Xng n 2. M di n s c

1. nh phi 3. Tnh mch cnh ngoi

Hnh 2.2. Mc gy t RTKCT ng trn xng n

4. Gy t ngoi mng cng

4.1. nh ngha

Gy t ngoi mng cng l a thuc t vo khoang ngoi mng cng c ch dn truyn

cc r thn kinh xut pht t tu sng i qua khoang ngoi mng cng, qua l lin t sng v

ra ngoi, lm cho cc vng do cc r thn kinh ny chi phi b mt cm gic cng nh vn

ng. Cn c gi gy t gc thn kinh hoc gy t vng.

4.2. Mt s c im gii phu lin quan gy t ngoi mng cng v tu sng

- Ct sng: Ct sng cong hnh ch S ko di t l chm n hm cng. Gm 33 t sng

hp li vi nhau (7 t sng c, 12 t sng ngc, 5 t sng tht lng, 5 t sng cng, 4 t

sng ct) to thnh 4 on cong khc nhau: c cong ra trc, ngc cong ra sau, tht lng cong

ra trc, on cng li ra sau. Cc im cong nht ca ct sng cng l ch vn ng d nht

nn d chc kim khi gy t. Cu to mi t sng bao gm: Thn t sng, l t sng, mm

ngang, mm gai, cung t sng, mm khp trn, di. Gia 2 t sng k nhau to thnh khe

lin t, khe ny rng hay hp l tu theo tng on. Mm gai gn nh nm ngang on

tht lng nn thun li cho vic chc tu sng. Cc vng khc mm gai nm chch xung nn

kh chc.

- Cc dy chng v mng. T ngoi vo trong gm c:

+ Da, t chc di da.

+ Dy chng trn gai (thng hp v x ho ngi gi).

+ Dy chng lin gai.

+ Dy chng vng, dy chng ny thng cng, ko di t vng c n ct sng tht lng.

+ Mng cng v mng nhn st pha trong dy chng vng.

+ Mng nui p st tu sng.

- Cc khoang

+ Khoang ngoi mng cng: L khoang o, gii hn pha trc l mng cng, pha sau l dy

chng vng, cha nhiu t chc lin kt, m, mch mu.

+ Khoang di nhn: Bao quanh tu sng, gii hn bi mng nhn v mng nui. Thng vi

pha trn qua cc no tht. Trong khoang ny cha tu sng, r thn kinh, dch no tu.

- Dch no tu:

Chng 2 15

+ S lng khong 120-140ml tc khong 2ml/kg, tr s sinh l 4ml/kg, trong cc no

tht cha khong 25ml.

+ T trng thay i t 1003-1010, pH khong 7,39-7,50.

+ Thnh phn: Glucose t 40-80mg/dl, proteine t 15-45mg/dl, Na+ 140-150mEq/l, K

+

2.8mEq/l. p lc trung bnh 148mmH2O.

Hnh 2.3. Ct sng thng, nghing Hnh 2.4. S mt ct dc ct sng

- Tu sng: Tu sng cha dch no tu v cc r thn kinh (r vn ng trc, r cm gic

sau), tu sng thng dng li t sng L1-L2. Mi t tu c r thn kinh tng ng chi

phi vn ng v cm gic theo khu vc, qua c th p dng t tu sng cao hay thp

tu theo v tr phu thut. Dch no tu c to ra t m ri mng mch ca no tht IV.

Dch no tu theo l Luchka ra b mt no v qua l Magendic xung tu sng. Dch no tu

c hp thu bi cc nhung mao ca mng nhn.

4.3. Ch nh

Cc loi phu thut vng bng di rn, phu thut h tit niu, sinh dc, phu thut chi di

vi th trng bnh nhn thuc nhm ASA1 hoc ASA2. c bit bnh nhn c c a: D

ng thuc m, bnh nhn hen. Kh ph thng, suy h hp. Bnh mch vnh, i tho ng,

bnh nhn ln tui. Bnh nhn d dy y

4.4. Chng ch nh

Bnh nhn t chi nu gii thch r rng v y v u im ca k thut ny. Ri lon

ng chy mu. Nhim trng ti ch, nhim trng ton thn. Gim th tch tun hon cha

iu chnh. Suy h hp nu nh mc phong b trn t ngc XII. Hp van ng mch ch

hay hp van hai l kht. Suy tim nng mt b.

4.5. Bin chng v tai bin

- Tai bin: T ty sng ton b. Co git do nhim c thuc t. Lit thn kinh do lm thng

tn r thn kinh.

- Bin chng: H huyt p. Mch chm. Th yu hay ngng th. Bun nn hoc nn. Rt run

thng hay gp bnh nhn lo s. Nhc u do kch thch mng no. au lng. B i trong

giai on sau m.

5. Gy t ty sng

5.1. nh ngha

Chng 2 16

Gy t ty sng ngha l tim thuc t vo khoang di nhn hay khoang trong mng cng

gy c ch dn truyn cc r thn kinh ty sng, kt qu lm mt cm gic v vn ng cc

vng do cc r thn kinh chi phi.

5.2. Ch nh

- Phu thut bng di: Ngang rn tr xung v d nh ct rut tha, thot v bn...

- Cc phu thut sn ph khoa: Ct t cung, ct u nang bung trng, thng vi trng, m ly

thai...

- Cc phu thut chi di: Chnh hnh, mch mu, ct ct, ghp da...

- Cc phu thut tit niu: Ct ni soi u x tin lit tuyn qua niu o, si bng quang, si

niu qun, si thn.

- Cc phu thut tng sinh mn trc trng: Nang tuyn Bartholin, nt hu mn, tr...

5.3. Chng ch nh

- Chng ch nh tuyt i: Thiu khi lng tun hon cha b , sc. Ri lon ng mu

hoc ang dng thuc chng ng. Nhim trng ti ch chc gy t, nhim khun huyt. Bt

thng gii phu m khng th chc tu sng c. Bnh tim nng. Tng p lc ni s. D

ng thuc t. Cao huyt p nng hoc huyt p qu thp.

- Chng ch nh tng i: Bnh nhn t chi nu gii thch r rng v y v u im

ca k thut ny. au u v au ct sng. Vim xng khp.Ung th di cn vo xng.

Bnh mch vnh, nhi mu c tim. X mch no. Tr em qu nh di 5 tui.

5.4. K thut tin hnh

- Chun b bnh nhn

+ Tinh thn: Gy t tu sng l k thut i hi s hp tc tt gia bnh nhn vi ngi gy

m. Do vic gii thch r chi tit k thut cng nh cc vn c th xy ra trong cuc m

s lm bnh nhn yn tm.

+ Truyn dch trc gy t: Cn phi t ng tnh mch mt cch h thng trc khi tin

hnh gy t. Thng thng lng dch ny t 10-15ml/kg dung dch tinh th ng trng.

Truyn dch trc c 2 mc ch:

+ B li dch m bnh nhn cn thiu trc m do nhn n, ung hoc mt nc.

+ Chun b b khi lng tun hon do c ch giao cm gy gin mch sau khi gy t.

- Chun b phng tin, thuc

+ Cc phng tin cp cu: bng mmbu, mask th oxy, n ni kh qun, ng ni kh qun

cc s, canuyn Guedel, my theo di. My th (nu c iu kin)

+ Cc thuc cp cu: Atropine, ephdrine, dimedron, adrenalin, dopamine.

+ Cc thuc gy m: thuc m, gin c, gim au

+ Cc thuc gy t: lidocaine 1%, 5%, pthidine, bupivacaine 0.5%, fentanyl phi hp vi

thuc t tng tc dng gim au sau m...

+ Cc dch truyn: dung dch tinh th, dung dch keo.

- Dng c t tu sng:

+ Khay v trng gm: Khn l, bm tim cc c, kp st trng, cn iode 0.5%-1%, cn trng

hoc betadine, povidine...

+ Kim chc tu sng gm cc loi 25G, 27G, 29G, hin nay c kim 32G. Kim cng nh

th cng hn ch c tn thng t chc v mt dch no tu. Cc kim t 27 - 32G phi c

kim dn ng.

- T th bnh nhn

Chng 2 17

+ T th ngi: bnh nhn ngi cong lng, hai chn trn gh u, hay tay th lng. T

th ny c th d xc nh cc khe t sng hn nhng thng gy tt huyt p hoc cm gic

kh chu cho bnh nhn, thng dnh cho nhng ngi mp.

+ T th nm nghing cong lng tm: Hai u gi p st vo bng cm t vo ngc. Thng

dnh cho cc bnh nhn gi yu trnh tt huyt p, ngt, xu, kh chu...

Hnh 2.5. T th nm gy t tu sng. Hnh 2.6. Cch bm thuc

- Cch xc nh v tr chc: Thng chc vo khe gia 2 t sng do vy v tr chc s ph

thuc vo phu thut cao hay thp. Thng thng chc t khong lin t L2-L3 n khong

L4-L5 ng ni hai mo chu ca xng chu thng i qua L4-L5, sau dng ngn tay

chuyn dch ln trn s thy khe L2-L3 v L3-L4. Ngc li c th xc nh t trn xung bng

ly mc gc sn lng k xung s tng ng vi L1-L2 ri xc nh tr xung.

- St trng: Dng cn st trng ti vng chc kim 3 n 4 ln, sau lau kh v ph khn l

ln trn.

- Chc tu sng: m bo tuyt i nguyn tc v trng khi tin hnh k thut ny

+ Ngi chc ty sng: eo khu trang, ra tay, mc o, i gng v khun.

+ C hai ng chc: ng chc gia v ng chc bn, vi ng chc bn v tr chc

cch ng gia 1,5-2cm, hng kim vo ng gia, ln trn, ra trc.

+ Gy t ti ch vng chc bng lidocaine 0,5-1%.

+ Dng kim 18G dn ng, chc su t 1-2cm.

+ Dng kim tu sng lun qua kim dn ng 3-5cm (vt kim hng ln trn khi bnh nhn

nm, vt kim nm nghing khi bnh nhn ngi) rt nng kim nu thy dch no tu chy ra

tc l kim trong khoang tu sng (kim cng b th dch no tu chy ra cng chm).

Khi dng kim 22-24G chc tu sng th khng cn gy t ti ch v khng dng kim dn

ng (hin nay khng dng c kim loi ny).

5.5. Tai bin

Suy th do lit cc c lin sn. Ngng th do thuc t ln cao gy lit c c honh. H huyt

p hay try mch. Nn, bun. Mch chm. Ri lon nhp tim. Co git. B i. Nhc u. Lit

thn kinh hi phc chm hay khng phc hi.

6. Gy t qua khe xng cng

- Gy t qua khe xng cng cng l loi gy t ngoi mng cng, k thut ny c thc

hin bng cch chc kim qua khe xng cng vo nn cng ca khoang ngoi mng cng

Thuc t s lm c ch dn truyn cc r thn kinh ty sng nm trong khoang ny v t

lm mt cm gic v vn ng cc vng m n chi phi.

- Ch nh: Gy t ng cng n thun (20ml lidocaine 2%) m vng hu mn, phu thut

y chu, b phn sinh dc ngoi.

- Tai bin: Kim chc thng mng cng lm t ty sng ton b. Kim chc vo mch mu gy

nhim c thuc t. H huyt p (do tc dng gin mch qu nhanh). Mch chm (do tc dng

Chng 2 18

c ch dn truyn trong tim). Chc vo trc trng. Mu t trong ng cng chn p thn kinh

gy co git.

7. T trong xng

Bt u p dng nm 1974 do Fraiman xut v tin hnh.

- nh ngha: T trong xng l bm thuc t vo u xng xp. Thuc t s theo ng

tnh mch i t trong xng xp ra cc phn mm t su n nng (tn da) v lm c ch ton

b cc thn kinh nm trong phn mm . Nh vy, mun thuc t ngm c ti vng mun

m th pha trn vng phi c t mt garrot gi thuc li hoc lm thuc chm tr

v h thng tun hon chung.

- Phng tin dng c: Kim gy t trong xng di 5cm. Kim gy t trong da v di da.

Bm tim 20ml, 2ml. Dung dch st khun v phng tin st khun. Khn v khun. Hai

bng cao su rng 6-7cm, di 1,5-2cm hoc mt loi garrot lm bng p lc hai tng.

- Ni chc kim v t gar phi: Xng st da. Xa mch mu v thn kinh.

- V tr chn chc kim gy t:

+ Chi trn: Li cu xng cnh tay, mm khuu, mm trm tr, u cc xng t bn tay.

+ Chi di: Li cu xng i, mm chy, mt c ngoi v trong, u xng t bn chn.

Ba ni hay dng mm khuu, mm chy, mt ngoi xng gt.

- Ni t gar: t pha trn v tr chc kim, ni c nhiu c.

- Ch nh: Phu thut cch di gc chi 10cm. Thi gian m di mt gi

- Bin chng: Nhim c thuc t. Bin chng do t gar: au, bin lon thn kinh

8. Gy t tnh mch

c Abus nu ln nm 1886 n 1908, Bier (ngi c) p dng.

- nh ngha: Gy t tnh mch l bm thuc t vo tnh mch mt chi m trn c

t mt gar. Thuc t s theo ng tnh mch i khp phn mm di gar lm c ch cc

thn kinh chi phi vng .

- Ch nh: Phu thut bn tay, cng tay m thi gian d tnh di 90pht. Bnh nhn d dy

y, d ng, bnh nhn ASA3, ASA4. Phu thut ngoi tr.

- Chng ch nh tuyt i: Nguy c gar ng mch khng hiu qu: bo ph. Vim ng

mch, thiu mu cp chi phu thut. D ng tnh mch.

- Chng ch nh tng i: Vim t bo. Bloc nh-tht cp II, cp III khng c t my to

nhp. Bnh hng cu hnh lim.

- Cch tin hnh:

- St khun da.

- Lun kim vo tnh mch.

- t gar tm thi (gar th nht) trn t gar th hai (nu m di 45 pht th ch cn mt

gar).

- Dng bng Esmarch dn mu t ngn chi v gc chi.

- Bm gar th nht.

- Bm thuc t v th cm gic.

- Bm gar th hai, kim tra, x gar th nht. Tin hnh m.

- Cui cuc m tho gar th hai. Khi tho b gar phi tho b t t.

8.6. Tai bin

Nguy c ln nht l tt gar t ngt lm cho mt lng ln thuc t vo tun hon h thng

gy nhim c thuc t. Mc nng nh tu thuc vo lng thuc t vo tun hon h

Chng 2 19

thng v thi im tt gar. Biu hin nh l tai, nng th co git c th hn m, try tim

mch. Cn chun b sn cc thuc v phng tin hi sc trc khi tin hnh k thut gy t

ny.

Hnh 2.7. S cc bc thc hin gy t tnh mch

1. t 1 catheter tnh mch 2. Dn p mu bng bng Esmarch 3. Bm hi gar tng trn

4. Tim thuc t. 5. Bm gar tng di 6. X gar tng trn

Cu hi nh gi 1. Thuc t c chn thch hp nht cho gy t b mt l:

A. Xylocain 2%

B. Bupivacain 0,25%

C. Xylocin 5%

D. Procain 1%

E. Bupivacain 0,375%

2. Gy t b mt v t tng lp c th ging nhau v:

A. K thut gy t

B. V ch nh

C. Loi thuc t c th s dng

D. Chng ch nh

E. Bin chng do gy t

3. Gy t tu sng v gy t ngoi mng cng ging nhau v:

A. K thut gy t

B. V tr tc dng ca thuc t

C. Liu lng thuc t

D. C ch tc dng

E. Nng thuc t

4. Gy t tu sng v ngoi mng cng khc nhau v:

A. C ch tc dng

Chng 2 20

B. Ch nh v chng ch nh

C. Thuc t chn la

D. Liu lng v nng thuc

E. T r thn kinh, t thn thn kinh

5. Ch nh ng nht gy t tnh mch l:

A. M chi trn

B. M chi di

C. M cnh cng tay phc tp

D. M cnh cng tay

E. M chi trn thi gian ngn.

6. Thuc t c chn cho gy t tnh mh l:

A. Xylocain 1%

B. Bupivacain 0,25%

C. Xylocain 2%

D. Bupivacain 0,25%

E. Xylocain 0,5%

7. Ch nh ng nht khi dng thuc t phi hp vi adrenalin:

A. Gy t tng lp

B. Gy t b mt

C. Gy t tnh mch

D. Gy t ngn tay, chn

E. Gy t ngn tay, chn, dng vt

8. Chng ch nh phi hp thuc t vi adrenalin khi:

A. Gy t ngoi mng cng

B. Gy t tu sng

C. Gy t tnh mch

D. Gy t tng lp

E. Gy t phong b thn thn kinh

9. Bin chng tt huyt p hay gp trong gy t:

A. Gy t b mt

B. Gy t tng lp

C. Gy t tu sng

D. Gy t tnh mch

E. Phong b thn thn kinh

10. Bin chng nhc u hay gp trong gy t:

A. B mt

B. Tng lp

C. Tu sng

D. Ngoi mng cng

E. Tnh mch

11. Ch nh gy t tnh mch khi:

A. Phu thut chi trn

B. Phu thut chi di

C. Phu thut Cnh tay

D. Phu thut cng tay

E. Phu thut cng,bn tay, v 1/3 di cng chn tr xung

12. Gy t tu sng v ngoi mng cng c gi gy t vng v:

A. Gy t thn thn kinh

B. Gy t r thn kinh

C. Cng v tr gy t

Chng 2 21

D. Cng loi thuc t s dng

E. Ging nhau v bin chng

13. Gy t tu sng v ngoi mng cng c chng ch nh khi:

A. Phu thut vng chi di

B. Phu thut vng bng

C. Phu thut sn khoa

D. Phu thut thi gian lu

E. Bnh nhn khng ng k thut ny

14. Gy t tnh mch ch nh khi:

A. Chn thng chi

B. Chn thng h chi trn

C. Chn thng kn chi trn

D. Chn thng kn cng, bn tay

E. Chn thng cng bn chn

15. Gy t tnh mch ch nh khi thi gian phu thut l:

A. Di 2 gi

B. Di mt gi

C. Di na gi

D. Khong di 90 pht

E. Khng hn ch thi gian

16. Gy t qua khe xng cng ch nh thch hp nht cho phu thut:

A. Phu thut bng

B. Phu thut chi di

C. Phu thut bng cao

D. Phu thut vng bng di

E. Phu thut h tit niu

17. Tng sut xy ra nhim c thuc t c th gp theo cc loi gy t sau:

A. Tu sng-Ngoi mng cng- Tnh mch- ui nga

B. Ngoi mng cng-Tnh mch - ui nga-Tu sng

C. Tnh mch-ui nga-Ngoi mng cng- Tu sng

D. Tnh mch- ui nga- Tu sng-Ngoi mng cng

E. ui nga-tnh mch-Ngoi mng cng-Tu sng

18. Gy t m ri thn kinh c th gy bin chng hay gp:

A. Tt huyt p

B. au u

C. Trn kh ph mc

D. Lit chi trn

E. Ph mt

19. Gy t m ri thn kinh cnh tay c th gp bin chng:

A. Tt huyt p

B. Lit chi trn

C. Khi mu t vng c gy suy h hp

D. Ph chi trn

E. Ph mt

20. Gy t b mt c xp trong nhm:

A. Gy t vng

B. Gy t thn thn kinh

C. Gy t ti ch

D. Gy t tng lp

E. Khng xp vo cc loi trn

Chng 2 22


ni, NXB Y hc.

2. B mn Gy m Hi sc (2002). Bi ging Gy m Hi sc tp 2, Trng i hc Y H

ni, NXB Y hc.

3. B mn Gy m Hi sc (1997). Bi ging Gy m Hi sc, Trng i hc Y Dc

TPHCM.


Livingstone, UK.



Sciences, France.


8. Mark C. Rogers, Jone H. Tinker (1993). Principles and Practice of Anesthesiology, USA.


10. Robert K. Stoelting, Ronald D. Miller (1989). Basics of Anesthesia, Churchill

Livingstone.


Volume I, II


Medecins du Monde.

Website: http://www. ykhoa.net

http://www.anaesthesiologists.org

http://www.anesthesianow.com

http://www.who.int/hinari

http://www.anesthetist.org



Chng 3 23

Truyn mu

Mc tiu hc tp:

1. M t v phn bit c cc nhm mu ca h ABO.

2. Trnh by c cc nguyn tc truyn mu.

3. Trnh by c cc ch nh v chng ch nh khi truyn mu.

4. Nu cc tai bin v bin chng thng thng khi truyn mu v hng x tr khi xy ra tai

bin do truyn mu.

I. i cng

1. H thng nhm mu

Trong c th ngi, cc nhm mu thuc h ABO l nhm mu chnh, quyt nh cho s tai

bin trm trng v cht ngi do truyn mu. V trong mu lun lun c sn cht chng li

nhm mu m ngi khng c nn tai bin xy ra ngay tc khc v ngay ln u truyn

mu. Do , ch nh truyn mu khi tht cn thit v ng qui tc truyn mu.

T l nhm mu ngi Vit Nam: O (42,15%), B (30,12%), AB (6,57%), A (21,15%).

1.1. Khng nguyn

- Ngi c nhm mu A: trn hng cu c khng nguyn A.

- Ngi c nhm mu B: trn hng cu c khng nguyn B.

- Nhm AB: c khng nguyn AB.

- Ngi c nhm mu O: trn hng cu khng c khng nguyn A, B, nhng c khng

nguyn H. Ngoi ra nhm A cn c cc nhm ph A1, A2 v nhm AB c A1B v A2B. Ngi

c nhm A1 hay A1B s khng truyn c cho ngi c nhm mu A2 v A2B v trong huyt

tng A2, A2B c khng th chng A1.

1.2. Khng th

- Ngi c nhm A trong huyt tng c khng th .

- Ngi c nhm B trong huyt tng c khng th .

- Ngi c nhm AB trong huyt tng khng c khng th , .

- Ngi c nhm O trong huyt tng c khng th , .

Cn ch :

- Khng nguyn h ABO tng i bn vng nn nh nhm mu cho tr s sinh bng huyt

thanh mu c kh khn.

- Khng th h ABO thng hay thay i do nh nhm mu cho ngi gi bng hng cu

mu c kh khn .

2. S cn thit phi truyn mu

Cho n nay mu vn c xem l dung dch tt nht v khng th thiu c trong iu tr

khi bnh nhn b mt mu do bt k nguyn nhn no. Mu khng nhng cung cp huyt cu

t vn chuyn oxy m cn mang theo cc yu t ng mu (mu ton phn) rt cn hn

gn cc vt thng ang chy mu.

V vy khi truyn mu phi c ch nh cht ch ng nguyn tc v kp thi trnh xy ra

tai bin do truyn mu gy nn.

II. Ch nh v chng ch nh truyn mu

1. Ch nh

1.1. Mu ton phn

Chng 3 24

c ch nh rng ri, c bit truyn trong nhng trng hp mt mu nhiu trong thi

gian ngn nh:

- Xut huyt cp tnh.

- Thiu mu km theo suy gim lng mu.

Mu ton phn ti cn c cha tr thiu hoc suy gim yu t ng mu, thay th trong

phu thut tim mch hoc iu tr thiu mu tiu huyt tr s sinh.

1.2. Truyn hng cu khi

Hng cu khi l mu ton phn rt bt huyt tng sao cho dung tch hng cu cn 70%.

Truyn hng cu khi nhm nng cao huyt sc t (Hb) m c mc ch phc hi th tch

mu, p dng trong cc trng hp sau:

- V ngoi khoa:

+ Bnh nhn chun b m nhng thiu mu.

+ Cn khi phc lng huyt cu t trong cc trng hp sc mt mu c iu tr phc

hi bng huyt tng hoc cc dung dch khc nh cc dung dch keo...

- V ni khoa:

+ Bnh tim: Hng cu khi lm tng nhy (Vicosit) ca mu m t lm tng th tch huyt

tng.

+ Bnh khc: Thiu mu mn tnh do thiu st (v d thiu mu do giun mc), thiu mu

trong thi k thai nghn.

+ Thiu mu tr con: tr con cn t ln truyn nhng phi c tc dng phc hi hng cu v

trnh gy nghn tun hon.

1.3. Hng cu ra

Tc dng nh hng cu khi v c nhng im tt hn:

- Cha t bch cu, tiu cu nn truyn cho nhng ngi c truyn mu nhiu ln tt hn.

- Cha t huyt tng nn trnh c phn ng gy ra do cht m trong huyt tng (IgA).

- Gim c nguy c gy ra vim gan do virus.

1.4. Hng cu ngho bch cu

Tc dng nh hng cu khi nhng c bit dng truyn cho bnh nhn truyn mu nhiu ln

trnh c gy ra hin tng phn ng do khng th chng bch cu. Ngoi ra cn c

truyn cho bnh nhn chun b ghp thn, nhm gim bt hin tng min nhim do bch cu

to ra.

1.5. Huyt tng

Truyn huyt tng nhm mc ch tng th tch mu m khng cn tng lng huyt sc t.

- Huyt tng ti:

+ Cha tr cc tnh trng sc do mt nhiu mu.

+ Cha bng.

+ Mt nc do tiu chy.

+ Cc trng hp chy mu do thiu ht hay suy gim yu t ng mu.

- Huyt tng kh: Ch nh nh trn.

1.6. Truyn tiu cu

Khi b gim tiu cu. Truyn tiu cu phi thc hin ngay, khng c qu 12 gi k t

khi pha ch n khi s dng.

2. Chng ch nh truyn mu

2.1. Chng ch nh tuyt i

Chng 3 25

- Cc chng tc mch phi, ph phi cp (OAP).

- Suy tim cp.

2.2. Chng ch nh tng i

- Tnh trng vim cung phi.

- Tng huyt p, x cng ng mch. Nhng trng hp ny nu c ch nh phi rt cn

thn, phi truyn lng nh v tht chm.

- i vi ph n c thai v sau sinh hai tun cng phi thn trng v lc ny th tch tun

hon cn tng, d gy tnh trng qu ti tun hon.

3. Nguyn tc truyn mu

3.1. Nguyn tc chung

- Ch truyn mu khi no tht cn thit (sc do mt mu, thiu mu nng).

- Truyn mu cng nhm.

- Nu khng c cng nhm v nu khng truyn mu th nguy him n tnh mng bnh nhn

mi truyn nhm mu O.

- L mu truyn phi m bo k thut v ly mu, gi mu v cc quy tc truyn mu.

3.2. nh lut Landsteiner

"Khi truyn mu nu c phn ng khng nguyn v khng th th chnh do khng nguyn ca

ngi cho (hng cu cho) b ngng kt vi khng th ngi nhn (huyt tng ngi nhn)".

nh lut l c bn nhng ngy nay vn truyn mu cn nhiu phc tp nht l khi

truyn mt s lng ln v truyn nhiu ln, ngi ta nhn thy khng phi an ton 100%. V

vy truyn nhm O, AB phi cn thn.

A

O AB

B

Hnh 3.1. S truyn mu c in

III. Cc ngun mu

1. Loi mu ton phn d tr

L mu ly ra v b vo chai c cht chng ng ACD (Acide- Citrate- Dextrose) hoc CPD

(Citrate- Phosphat- Dextrose). D tr ngn hng mu.

- Cc thnh phn trong mu d tr c gi nguyn vn tuy nhin vn b mt i theo thi

gian ct gi.

- Loi mu ny phi ct gi nhit 4-60 (ACD bao gm 6,7mmol acid citrique: 13,4mmol

citrate de natrie: 13,9mmol Dextrose, nc ct va ).

- Dung dch ACD a vo nhiu c th dn n ri lon ng mu.

- Mu d tr lu khng nhng d b vn (kt ta) m cn d lm tc mch v gii phng

nhiu cht c.

1.1. S thay i t bo trong mu d tr

- Hng cu: Kh nng vn chuyn oxy trong mu d tr km hn mu ti (110mml mu d

tr bng 100ml mu ti). Nhit t 2-80C hnh dng hng cu t b bin i, nu 150C th

thay i khng hi phc.

Chng 3 26

- Bch cu: Cht mau, sau mt tun l ch cn 50%, bch cu ht cht trc. Tc dng thc

bo ca bch cu gim hoc mt sau 3-4 ngy.

- Tiu cu: Sau 24 gi gim v sau 7-10 ngy cht ht, kh nng co cc mu ch cn trong

vng 72 gi nhng vai tr ca thromboplastin cn ti ngy th 21.

1.2. S thay i cht in gii

K+ tng dn trong mu d tr, ngy th ba K

+ tch khi hng cu . V vy nn ch khi

truyn mu d tr cho ngi c bnh tim.

2. Mu ng lnh (Frozen blood , sang congel)

Ly mu, sau tch hng cu ra khi huyt tng, cho hng cu vo dung dch glycrol sau

ct gi nhit -700C n -80

0C, khi no dng si m ln nhit 37

0C, tch

glycrol ra khi hng cu. Vi phng php ny ngi ta c th ct gi mu t 6 thng n 3

nm, loi mu ny c th d tr vi khi lng ln. C th truyn mt th tch ln cho bt k

bnh nhn c nhm mu no m khng s nguy him do tai bin truyn nhm nhm mu v

cc khng th , cn li rt t v b ph hy trong thi gian d tr. Tuy nhin c nhc

im: Phi c phng tin p lnh, khi dng hm nng nng nhit ln 37oC, tch

glycrol ra hng cu pha li mu m t c s iu tr lm c.

3. Mu t thi

Ly mu trong 6 gi u khi bnh nhn cht nhng ngi b tai nn giao thng, cht ngt,

nhi mu c tim. Mun dng mu ny phi cy vi trng, lm cc xt nghim SGOT, SGPT,

NH4, sinh ha... Loi mu ny c u im: Truyn c mt s lng ln ca cng mt

ngi cho.

4. Truyn mu t thn v hon hi

- Mu ca cng mt bnh nhn c ly trc d tr (p dng m phin) sau truyn li

cho bnh nhn .

- Truyn mu hon hi thng p dng ly ngay trong lc m nhng ca v lch hoc ct

lch c chun b hoc trong cp cu nh v thai ngoi t cung, v tng c trong chn thng

bng kn. Khi ly mu phi dng 8 lp gc lc v cho vo chai c dung dch ACD. Trc

khi truyn phi kim tra c b v hng cu khng bng cch ly mt mu nghim quay ly

tm, th vi trng v sinh ha.

IV. Chn mu trc khi truyn

1. nh gi

- Xem chai mu c qu hn khng.

- Xem chai mu c b v hng cu, nhim khun khng.

- i chiu chai mu vi phiu xin mu c ph hp khng.

2. Th nghim ph hp qua 3 giai on

- Cho tng phn:

+ Hng cu cho ngi cho + huyt tng ngi nhn.

+ Hng cu ngi nhn + huyt tng ngi cho.

- Cho ton phn: mu ngi cho + mu ngi nhn.

Xt nghim ny cn soi di knh hin vi mi c gi tr (xt nghim ny thng do ngi

truyn mu lm trc khi truyn.)

3. Chn chai mu

Nguyn tc chung l hng cu ngi cho khng ngng kt bi khng th trong huyt tng

ca ngi nhn, c th l:

- Bo m hng cu sng bnh thng ca t bo mu ngi cho.

Chng 3 27

- Bo v hng cu sng ca t bo mu ngi nhn.

- Ngn chn nguy c gy min dch trong c th ngi nhn do tc dng ca t bo mu

ngi cho thuc v h: ABO. H Rhsus

- Ngi c nhm mu Rh dng chn chai mu Rh dng truyn.

- Ngi c nhm Rh m chn chai mu Rh m truyn.

V. Bin chng v tai bin truyn mu

Truyn mu l vic rt hu ch cu c nhiu ngi qua cn him ngho. Nhng cng do

truyn mu m c ngi b nhim bnh hoc lm bnh nng thm, thm ch dn n t vong.

V vy ngi truyn mu phi nm vng nhng tai bin truyn mu kp thi x l hoc

hn ch nhng mt cha tt ca truyn mu.

1. Tai bin truyn nhm nhm mu

1.1. Nguyn nhn

- Do nhm ln giy t h s (gp trong a s trng hp).

- Do k thut nh nhm mu v lm xt nghim ph hp khng tt.

1.2. Triu chng

- Phn ng trc tip: L phn ng gia hng cu ngi cho b v bi khng th c trong

huyt tng ngi nhn trong h ABO hoc Rhsus, xy ra rt nhanh sau khi truyn c 20-

50ml u tin.

+ i vi bnh nhn khng m: Thy kh th, tc ngc, mt hng, au tht lng d di l

du hiu c bit nht, mch nhanh, huyt p h. Sau na gi bnh nhn tiu (c huyt sc

t, c hng cu, tr ht), tip theo (sau 3 gi) l triu chng vim ng thn cp tnh, bnh

nhn tiu t ri v niu. Ur mu tng cao c th ln n 3-4g/l vo ngy th 7-8. Nu iu tr

tch cc qua c giai on ny th n giai on hi niu, bnh nhn i nhiu, s mt nhiu

mui v nc. Sau bnh nhn tr li bnh thng v khng li di chng g.

+ i vi bnh nhn m: ngoi cc triu chng nh trn thy: Mu en n ra vt m v

khng ng. Tt c v tr no c chc kim u c hin tng xut huyt.

- Phn ng gin tip: L phn ng gia huyt thanh ngi cho v hng cu ngi nhn do

truyn mu c khng th (, ( nhiu hoc mu c khng th chun cao (nhm mu O nguy

him). Triu chng thng b vng da nh, thiu mu tiu huyt nh.

1.3. Cch phng

- Phn loi mu v lm chng nghim ph hp t m.

- i chiu chai mu v phiu xin mu.

- Th ph hp trn lam knh ti ging mu ngi nhn v chai mu.

- Truyn 25-50ml mu u tin cn theo di cht ch, t m trng thi ca ngi c truyn

mu.

1.4. X tr

- Nu c du hiu phn ng tiu huyt th ngng truyn ngay.

- Chng sc ty theo tnh trng bnh nhn m c x tr thch ng.

2. Bin chng

2.1. Bin chng sm

- Cc phn ng d ng

+ Nguyn nhn: cha r rng.

+ Triu chng: Ni m ay, ph cng (ph Quinke), kh th nh hen suyn, st, au cc

khp.

Chng 3 28

+ Phng v x tr: Khng ly mu ngi hen suyn, ngi ang d ng. X tr bng cc

khng histamin tng hp hoc cc corticoide.

- Phn ng st

+ Nguyn nhn: c cht gy st trong dng c, trong dung dch pha truyn hoc nhit chai

mu cn lnh em truyn. Ngoi ra cn c cc nhm ph loi A ca h ABO hoc l cc

khng th chng bch cu ngi truyn mu nhiu ln.

+ Triu chng : St, sau c cn rt run d di nhc u, nn ma... nhit s gim dn

sau 30 pht n 1 gi.

+ Phng v x tr: m bo v trng chai mu v dng c truyn. X tr: Dng cc loi h st

v khng Histamin tng hp.

- Qu ti tun hon

Hay gp ngi bnh tim, ngi gi, tr s sinh, bnh phi cp tnh.

- Tc mch kh ph qun phi

Do khng kh trn vo gy tc mch phi, ph qun do kh.

- Truyn mu qu nhiu acide, potassium (K), Ammonium (NH4).

- Mu kh ng

V thiu calcium v yu t ng mu. Cn tim Calcium 10% c 2ml cho 250ml mu.

- Truyn mu qu lnh

Thng xy ra tr em do truyn nhanh v s lng nhiu, mu mi ly ra t lnh, c th

gy lnh mng tim, c th dn n ngng tim hoc lon nhp.

2.2. Bin chng mun

- Nhng bnh truyn nhim nh: Bnh giang mai, vim gan do virus, st rt. Sida.

- Nhim st do truyn mu qu nhiu: Nhng ngi truyn mu nhiu ln nht l trng hp

thiu mu mn tnh do a mt lng ln cht st vo c th, sau nhiu nm s gy mt

chng nhim sc: da sm, gan b tn thng, gan cng.

Cu hi nh gi 1. Khi c tai bin truyn mu do:

A. Mu ngi cho b ngng kt bi mu ngi nhn

B. Hng cu cho b ngng kt bi huyt tng ngi nhn

C. Mu cho b ngng kt bi huyt tng ngi nhn

D. Huyt tng cho ngng kt bi huyt tng nhn

E. Hng cu cho ngng kt hng cu nhn

2. Du hiu truyn nhm nhm mu khi ang m:

A. Tt huyt p

B. Tm ti

C. Chy mu nhiu

D. Mu en n ra vng m khng ng

E. Mu chy ra ng li

3. Du hiu sm gi truyn nhm nhm mu khi khng m:

A. Kh th

B. Run lnh

C. Tot m hi

D. Ku au bng

E. Chng mt

4. Ch nh truyn mu khi:

Chng 3 29

A. C mt mu

B. Mt th tch huyt tng

C. Cn thit

D. Mt mu c sc

E. Tt huyt p

5. Trng hp no sau y c th nhn c mu O khi khng c mu ng nhm:

A. Mt nhiu mu

B. Mt mu < 20% th tch mu

C. Mt ( 30% th tch mu

D. Bng la nng

E. Mt mu gy sc

6. Loi mu no sau y c xem l mu ti:

A. Mu d tr

B. Mu ng lnh

C. Mu d tr < 48 gi

D. Hng cu khi

E. Mu t thi

7. Hng cu khi c ch nh truyn khi:

A. Mt mu nng

B. Khi gim t bo mu

C. B ban u khi b mt mu

D. Khi b thiu mu

E. Khi khng c mu ton phn

8. Mu ton phn c ch nh truyn ng nht khi:

A. Mt mu ( 50% th tch mu

B. Mt mu ( 30% th tch mu

C. Mt mu ( 20% th tch mu

D. Khi mt mu nhiu

E. Khi b sc

9. Mu t thi c u im:

A. c cho s lng nhiu

B. Khi truyn s lng nhiu cng mt ngi cho

C. Khng s truyn nhm nhm mu

D. Khng cn th nhm cho

E. D tr lu hn

10. Nhm mu O c gi l nhm mu ph thng (nhm mu chung) khi:

A. Cho c khc nhm

B. Nhm mu O khng c khng nguyn trn b mt

C. Khng c khng th trong huyt tng

D. Khng c khng nguyn v khng th

E. Cc cu trn u ng.

11. Mu d tr ct gi nhit :

A. 4-10oC

B. 4-8oC

C. 4oC

D. 6oC

E. 0oC

12. Mu ng lnh c u im:

A. Ct gi trong thi gian di

B. Ct gi c t 6 thng n 3 nm

Chng 3 30

C. Ct gi c 3 nm

D. Ct gi c 6 thng

E. Ct gi c 1 nm

13. Mu ng lnh ct gi nhit :

A. 0oC

B. 4oC

C. -70oC

D. 70oC

E. 8oC

14. Truyn mu hon hi c ch nh khi:

A. Ly mu li trong m cc trng hp v tng trong bng

B. Ly mu li trong m cc trng hp v tng t trong phc mc

C. Ly mu trong m truyn li khi c phng tin lc mu

D. Cu A, B, C, ng

E. Cu A, B, C, sai

15. Truyn mu ton phn ti khi:

A. Mt mu nhiu

B. C ri lon ng mu

C. Khi mt mu c gy ri lon ng mu

D. Khi c sc

E. Khi gim th tch tun hon

16. Mu d tr ct gi trong thi gian khong:

A. 30 ngy

B. 28 ngy

C. 21-28 ngy

D. 21 ngy

E. 120 ngy


ni, NXB Y hc.


Livingstone, UK.



Sciences, France.


6. Mark C. Rogers, Jone H. Tinker (1993). Principles and Practice of Anesthesiology, Vol 1,

USA.


8. Robert K. Stoelting, Ronald D. Miller (1989). Basics of Anesthesia, Churchill Livingstone.


Volume I, II


Medecins du Monde.

Website:

http://www.ykhoa.net, http://www.anaesthesiologists.org, http://www.anesthesianow.com,

http://www.who.int/hinari, http://www.anesthetist.org, http://www.ebook.edu.vn


Chng 4 31

Cc dung dch thay th huyt tng

Mc tiu hc tp:

1. Trnh by v phn bit c cc loi dung dch thay th huyt tng.

2. Vn dng s dng c cc dung dch thay th huyt tng cho cc trng hp gim th

tch tun hon.

I. i cng

Ch nh c bn cc dung dch truyn tnh mch l nhm mc ch hi phc th tch tun

hon iu tr cc trng hp gim th tch mu hoc do gim tng i tun hon tr v

tim. C nhiu tin b ng k trong vic gii thch s chn la cc loi dung dch khc nhau

hi phc th tch tun hon: Trc ht l s hiu bit r sinh l v sinh l bnh v h tun

hon h thng v tun hon vng ca nhng trng hp gim th tch tun hon, th hai l

ngng chu ng c trong bi cnh ho long mu nhng trng hp gim th tch tun

hon c nguyn nhn khc nhau, th ba l nguy c lin quan ti cc dung dch c ngun gc

t sn phm ca mu.

Hin nay hai nhm dung dch truyn tnh mch c s dng ph bin l: Dung dch tinh th

v dung dch keo. Chn la s dng cc dung dch ny cn phi da vo tnh cht sinh ho,

tnh cht dc ng hc, dc lc hc v nhng tc dng ph ca dung dch cng nh hon

cnh khi s dng.

II. Nhng nt ch yu v sinh l chuyn ho nc v in gii ca c th

1. Cc khu vc cha nc trong c th

Nc chim 60% trng lng c th ngi trng thnh, c phn b ba khu vc: khu

vc trong t bo, khu vc khoang gian bo v khu vc trong khoang mch mu.

Nc trong t bo chim 70% tng s nc ca c th v chim 40% trng lng c th.

Nc khu vc ngoi t bo chim 28% tng s nc ca c th (20% trng lng c th),

c phn b khoang gian bo 21% v trong lng mch l 7%.

Phn cn li 2% thuc v th tch cc cht bi tit, dch ng tiu ho v dch no tu. Khu

vc trong v ngoi t bo c ngn cch bi mt mng sinh hc bn thm, mng ny ch

thm nc, cn cc cht phn t ln v cc ion khng thm qua c m ch c i qua bi

cc knh ion c th ca n, chnh v th to nn mt s khc nhau cc thnh phn ion ca hai

khu vc. Mng t bo ngn cch gia khoang gian bo v khoang mch mu cng d thm

nc v cc ion, nhng cc phn t ln (>35 A0) th khng thm qua c.

Nh vy hai khoang ny ging nhau v cc thnh phn ion, nhng protein th ch c

khoang mch mu v cng chnh l thnh phn ch yu to nn p lc keo gi v duy tr

nc trong lng mch. ngi bnh thng p lc keo c bo m bng 70% bi cc

albumin ca huyt tng.

2. Lu chuyn nc gia cc khu vc

2.1. Trao i nc gia khu vc trong v ngoi t bo

S trao i nc trong v ngoi t bo ph thuc vo nng cc ion Na+ v K

+, ion Na

+ l

ion ch yu ca dch ngoi bo, ngc li ion K+ l ion ch yu dch ni bo v cng l

nhng ion ch yu thit lp p lc thm thu ca c hai khu vc. Khi c s thay i p lc

thm thu ca mt khoang th s to ra s vn chuyn nc cn bng p lc thm thu.

2.2. Trao i nc gia khoang mch mu v khoang gian bo

Chng 4 32

Theo lut Starling cc yu t ch yu trong vn chuyn nc gia cc khu vc lng mch v

khong k l p lc thu tnh (c hng y nc vo khong k) v p lc keo (c hng rt

nc vo trong lng mch). Albumin gi vai tr chnh to p lc keo ca huyt tng ngoi

ra cng cn do fibrinogen v globulin. p lc keo bnh thng vo khong 21-25 mmHg, v

thng gim khi c tnh trng ho long mu.

Tm li chnh lch p lc thu tnh c khuynh hng y nc vo khong k, ngc li vi

chnh lch p l keo s gi nc trong lng mch mu. Kt qu dng sinh l t khoang mch

mu ti khoang gian bo chnh n c cn bng bi s p ng thch hp ca lu lng

bch huyt.

III. Dc l mt s dung dch truyn tnh mch

1. Cc dung dch tinh th

1.1. Dung dch tinh th ng trng

l cc dung dch mui sinh l (0,9%), dung dch Ringer lactate.

1.1.1. Dung dch Ringer lactate

- Thnh phn cu to:

+ Na+ 130mmol/l

+ K+ 4mmol/l

+ Ca++

1-3mmol/l

+ Cl- 108mmol/l

+ Lactate 28mmol/l.

+ C p lc thm thu 273-278mOsml/l

1.1.2. Dung dch NaCl 0,9%

- Thnh phn cu to:

+ Na+: 154mmol

+ Cl- 154mmol.

+ C p lc thm thu 308mOsml/l.

- Ion Na+ l mt cation ch yu ca dch ngoi bo, n chu trch nhim 90% p lc thm

thu ca khoang ny. Cung cp mui trong qu trnh mt mu l cn thit v gim mui dn

n mt tnh trng gim th tch ngoi bo.

- Dung dch tinh th ng trng khi truyn vo mu phn phi c trong lng mch v

khoang ngoi bo, chnh v vy dung dch ny lm gia tng th tch huyt tng km v ngn.

- Truyn 1000ml dung dch Ringer lactate ch gia tng th tch huyt tng t 200 - 250ml

trong vng 1 gi.

- Trong thc hnh ngi ta thch dng dung dch Ringer lactate hn so vi dung dch NaCl

0,9%, v dung dch NaCl 0,9% s lm tng Cl- m khng c thnh phn m.

- Dng dung dch Ringer lactate trong hi sc chng sc s lm gia tng lactate trong mu

nhng s gia tng ny ch thong qua v lactate s c chuyn i bi gan. Tuy nhin dung

dch Ringer lactate c p lc thm thu thp hn p lc thm thu ca huyt tng ngi

bnh thng, nn hin nay t s dng trong mt s trng hp nh sc chn thng nng km

chn thng s no.

Tm li:

Dung dch tinh th c u im:

- Thch hp cho tt c mi hon cnh.

- C th s dng s lng khng gii hn.

Chng 4 33

- Khng c tc dng trn s ng mu.

- Khng c nguy c d ng.

- D pha ch.

- Gi r.

Nhng cng c nhc im:

- Gia tng th tch huyt tng thp.

- Truyn nhiu d gy gy ph (ph k, ph no, ph phi).

1.2. Dung dch tinh th u trng

Hin nay cc nc u, M cho php s dng dung dch mui u trng hi sc

gim th tch tun hon trong mt s trng hp. Cc loi mui u trng c nng NaCl

1%, 3%, 5%, 7,5%, 10%. Dung dch NaCl 7,5% l dung dch c chn hi sc ban u

cc trng hp sc mt mu c kim sot s cm mu, dng hi sc bng, c bit dung

dch ny lm gim p lc ni s, gim ph no. Hin nay ngi ta cn kt hp dung dch ny

vi dung dch keo tng hp iu tr v c tn bit dc l Recueflow. Ngoi ra cng cn

c dung dch NaCl 20%. Tuy nhin s dng cc dung dch mui u trng phi ng ch

nh, trnh gy tng Na+ mu nguy him (Na+ > 160mmol/lt.

2. Dung dch keo

2.1. Dung dch keo tng hp

2.1.1. Gelatine

- Gelatine l mt thnh phn c ch bin t collagen ng vt, thy phn collagen to

thnh cc polypeptide ri c polyme ha to thnh cc gelatine. Trng lng phn t

trung bnh 20-26.000 daltons.

- Gelatine c th pha ch trong cc dung mi khc nhau: Trong Ringer lactate (plasmion),

trong Glucose 5% (Plasmagel dsod), trong Glucose 5%, mui Na+ v calcium (Plasmagel,

Haemacel).

- Trong cc dung dch ny nng gelatine c t 25-40g/l.

- V dc ng hc chuyn ha ca gelatine hin nay vn cha bit r, mt s gelatine c

thy phn huyt tng v mt s i ra ngoi mch mu vo t chc k, mt phn b

thoi ha v mt phn khc i vo li trong tun hon nh h mao mch bch huyt (h bch

mch).

- Tuy vy gelatine khng tch ly t chc, n c o thi di dng khng thay i trong

nc tiu.

- Gelatine lm tng th tch huyt tng t 80-100% th tch c truyn v thi gian tc

dng trung bnh trong 3 gi.

- V tc dng ph:

+ C phn ng d ng.

+ Lm thay i b mt ca hng cu v lm gim s n nh ca n trong dung dch keo, iu

ny gii thch mt s trng hp lm tng tc lng mu v lm sai lm khi nh nhm

mu.

Tm li gelatin c nhng c tnh chnh sau:

- Tng th tch huyt tng trung bnh v ngn.

- Thng c phn ng d ng.

- C th s dng s lng ln.

- Gi va phi.

- C th lm ri lon ng mu.

Chng 4 34

2.1.2. Dextran

- Dextran l mt cht ng a (polysaccharides) c ngun gc t dung mi nui cy vi

khun, c trng lng phn t vi ngn n 2 triu.

- Dextran dng trong lm sng c trng lng phn t 40.000 - 70.000 c pha ch trong

cc dung dch NaCl 0,9% hoc glucose 5%.

+ Dextran 70.000 c truyn thay th huyt tng khi sc cha xut hin.

+ Dextran 40.000 c truyn khi c sc v gip cho vi tun hon c ci thin lu thng tt

hn.

- Chuyn ha ca dextran rt phc tp, mt mt v c nhiu ng o thi, mt khc lin

quan n vai tr ca trng lng phn t. Mt phn dextran xuyn mch mu ra khong k

ri c chuyn ha nh h thng t bo li vng ni m v mt phn i vo h thng tun

hon nh h bch mch v o thi qua ng tiu ha.

- Dextran 40.000 tc dng gia tng th tch tun hon cao hn dextran 70.000 nhng thi gian

tc dng th dextran 70.000 ko di hn.

- Tc dng ph:

+ Phn ng d ng.

+ nh hng ti s cm mu gy ri lon ng mu

+ C th suy thn nu dng loi dextran 40.000 lp li nhiu ln.

2.1.3. Dung dch HEA, HES (HydroxyEthylAmidon, Starche)

HEA dn xut t ng, thnh phn c bn l mt polysaccharides, amylopectine, c thy

phn ha v n nh trong dung dch. Cc dung dch HEA c trng lng phn t trung bnh

t 200.000 v 450.000 daltons.

Hin nay c dung dch mi vi bit dc VOLUVEN c trng lng phn t 130.000 daltons

v t l thay th phn t l 0,45. Ngi ta cho rng vi trng lng phn t v t l thay th

phn t thp dung dch ny t gy bin chng ri lon ng mu hn.

Dc ng hc:

Sau khi truyn HEA xy ra 2 pha:

- Pha u o thi nhanh i vi nhng phn t < 50.000 daltons c lc qua cu thn.

- Pha sau o thi chm i vi phn t ln hn v c ct ngn bi amylaza huyt tng.

- HEA c trng lng phn t thp, thi gian bn o thi t 3-8 gi v t 2-5 ngy i vi

loi c phn t ln.

- HEA lm gin n th tch mu ty thuc nhiu yu t. Nhng yu t chnh l th tch mu,

protein mu, tnh thm mao mch, tc truyn v cui cng l phng php o th tch.

Khi truyn 500ml HEA th lm gia tng th tch huyt tng t 500-750ml (gia tng khong

100-150% th tch truyn).

- Tc dng ph ca dung dch HEA. Tc dng ph bao gm: Phn ng d ng. Lm thay i

ng mu, gy ri lon ng mu khi truyn s lng ln c bit vi dung dch HEA c

trng lng phn t cao v thay th phn t trn 0,5.

V vy ngi ta khuyn co ch s dng dung dch HEA vi s lng 33ml/kg trong 24 gi

2.2. Dung dch keo t nhin

Cc dung dch ny c ngun gc t mu, hin nay dung dch Albumin c xem nh dung

dch thay th huyt tng. C hai loi Albumin: Loi 4% v loi 20%. Dung dch 4% l dung

dch albumin ng trng, dung dch 20% l dung dch albumin u trng.

Cc dung dch ny thng c ch nh trong cc trng hp gim th tch tun hon nhng

hn ch s lng truyn nh ph n mang thai, cc trng hp bng hoc sc nhim khun

Chng 4 35

c ch nh truyn nhng vn cn nhiu tranh lun do c thng tn tnh thm mao mch nn

c th gy ra bt li v albumin c th thot nhanh ra dch k v c th gi nc khoang ny

nhiu hn, dn n gy ph k hn l gia tng th tch tun hon.

Bng 4.1. Hiu gi gia tng th tch huyt tng ca cc dung dch truyn tnh mch

Cc loi dung dch Gia tng th tch ban u

(% th tch truyn)

Thi gian gia tng

th tch (gi)

Dung dch tinh th

Ringer lactate

NaCl 0,9%

NaCl 7,5%

19

25

400-700

0,5

0,5

0,5

Dung dch keo t nhin

Albumin 4%

Albumin 20%

80

400

6-8

6-8

Dung dch keo tng hp

Dextran (Rheomacrodex)

Dextran (Hemodex)

140-180

4-6

12-24

Gelatin

Plasmion

Gelofusine

Hemaeccel

80-100

80-100

80-100

3-4

3-4

3-4

HEA (HES)

Lomol (1)

Elohes

Hesteril

150-170

100-140

100-140

6-8

10-18

4-8

(1): Hin nay khng dng

3. Dng kt hp

Dng kt hp NaCl 7,5 %- HEA c bit dc Hypher. Bc M v Chu u c dng kt

hp dung dch NaCl 7,5 %-Dextrans 6%/70 gi tn l Rescueflow. S kt hp ny c nhiu

hiu qu i vi huyt ng hc, ch truyn mt th tch nh nhng gia tng th tch huyt

tng ko di, dn n s quan tm trong mt s ch nh nh trong trng hp sc mt mu,

bi cnh hi sc ban u tin bnh vin, tuy nhin cc ch nh ny vn ang cn nghin cu.

4. Ch nh cc dung dch truyn tnh mch

Theo nguyn tc chung khi gim th tch tun hon nh ch nh tt vi dung dch tinh th.

Ngc li s dng rng ri dung dch tinh th c bit dung dch tinh th ng trng vi

mc ch duy tr hay gia tng th tch huyt tng s c nguy c gy ph k. Dung dch keo

cn c s dng phi hp khi b gim th tch tun hon nng, hay km theo thay i tnh

thm thnh mch nh trong cc trng hp nhim khun, ph no, chy tun hon ngoi c

th. Chn la dch truyn tnh mch c tm tt bng 4.3.

Tm li cho n nay cha c mt loi dung dch no c th ch nh tt cho tt c cc trng

hp gim th tch tun hon. V vy ty theo bi cnh lm sng v nguyn nhn gy gim th

tch tun hon cng nh iu kin thc t ca tng trng hp m c th p dng cc loi

dung dch khc nhau cho thch hp. Chn la ban u vn u tin dung dch tinh th (ng

trng hoc u trng) v tip n dung dch keo tng hp (kt hp hoc n thun). Cc

dung dch c ngun gc t mu v cc sn phm mu ch s dng khi b mt mu nng.

Chng 4 36

Bng 4.2. Nhng c tnh sinh ho ch yu ca dung dch keo tng hp

Ghi ch: N: nng ; DM: dung mi; PMp: Trng lng phn t theo cn nng; PMn: trng lng

phn t theo s phn t c hot tnh thm thu; KHRN: kh nng rt nc; : p lc keo ca dung

dch / p lc keo huyt tng; VI: qunh t c; TSM: t l thay th phn t; RA: ringer acetate.

Bng 4.3. Ch nh s dng ca mt s dung dch truyn tnh mch

Nguyn nhn gim th tch tun hon Cc dung dch tham kho ch nh

Chy mu Dung dch tinh th nu mt < 20% th tch mu

ca c th

Dung dch keo nu mt > 20% th tch mu hay

huyt p ng mch trung bnh < 80mmHg

Mt nc Dung dch tinh th

Dung dch keo nu sc ko di

Sc nhim khun Dung dch tinh th v dung dch keo

Sc phn v Dung dch tinh th

Gim th tch do gy m, gy t Dung dch tinh th

Sc do bng Dung dch tinh th

Dung dch keo sau 24 gi nu din tch bng >

40% v gim th tch tun hon ko di.

Chn thng s no Dung dch tinh th u v ng trng phi hp

dung dch keo

Bi cnh gim th tch tun hon do mt mu cp

thi gian tin bnh vin

Dung dch tinh th u trng

Dung dch keo

Gim th tch tun hon ph n mang thai Dung dch tinh th. Albumin

Dung dch N

%

DM PMp

kDa

PMn

KDa

KNRN

ml/Kg VI TSM C2/C6

Dextran

Rheomacrodex

Hemodex

10

6

NaCl

RA

40

60

25

39

30

20

3,5

2,0

5,4

3,5

-

-

-

-

Gelatin

Plasmion

Gelofusine

Haemaccel

3

4

3,5

RL

NaCl

NaCl

35

25

35

14

15

15

40

1,1

7

0,9-

1,2

2,2

1,8

HEA (HES)

Lomol (1)

Elohes

Hesteril

Heafusine

10

6

6

6-10

6-10

NaCl

NaCl

NaCl

NaCl

NaCl

250

200

240

130

200-

250

63

60

63

30

30

30

2,3

1,2

1

1,2

1

5,5

3

2,2

0,62

0,5

0,4

0,5

13,4

5,7

>8

5-6

Chng 4 37

Cu hi nh gi 1. Chn ni dung ng nht sau y:

A. Dung dch tinh th c nhiu u im

B. Dung dch tinh th c th gy d ng

C. Dung dch tinh th thay th huyt tng tt nht

D. Dung dch tinh th khng gy d ng

E. Dung dch tinh th n nh huyt p tt

2. Chn ni dung ng nht:

A. Dung dch gelatin c thi gian bn hu di

B. Dung dch gelatin c thi gian bn hu ngn

C. Dung dch gelatin c thi gian bn hu trung bnh

D. Dung dch gelatin gy d ng cao hn dung dch tinh th

E. Dung dch gelatin khng gy d ng

3. Dung dch Dextran 40.000 c u im:

A. S dng khng gii hn

B. Khng gy d ng

C. C th truyn lp li di ngy

D. Trnh kt dnh t bo, ci thin vi tun hon

E. L dung dch c nhiu u im nht trong cc loi dung dch

4. Nhc im ca dextran l:

A. Truyn nhiu gy ph

B. Truyn nhiu gy d ng

C. Truyn nhiu gy ri lon ng mu

D. Truyn nhiu gy li tiu

E. Truyn nhiu gy ph no, ph phi

5. Dung dch HEA, HES c u im:

A. Khng gy d ng

B. t gy d ng

C. Truyn nhiu khng gii hn

D. Khng gy tai bin do truyn nhiu

E. Thay th c mu

6. u im ca dung dch HEA, HES ni bt:

A. t tc dng ph

B. Thay th c mu

C. Gia tng th tch huyt tng cao

D. Gy li tiu

E. Khng gii hn s lng truyn.

7. Dung dch truyn tnh mch c thi gian bn hu di nht

A. Dung dch tinh th

B. Dung dch keo t nhin

C. Dung dch HEA,HES

D. Dung dch NaCl 0,9%

E. Dung dch Ringer lactate

8. Nhc im ln nht ca dung dch HEA l:

A. Gy d ng

B. Gy suy thn

C. Truyn nhiu gy ri lon ng mu

D. Gy suy gan

E. Gy ri lon p lc thm thu

9. Dung dch NaCl 0,9% c p lc thm thu:

Chng 4 38

A 290 mOsm/l

B. 308 mOsm/l

C. 295 mOsm/l

D. 270 mOsm/l

E. 278 mOsm/l

10. Dung dch Ringer lactate c p lc thm thu:

A. 300 mOsm/l

B. 308 mOsm/l

C. 273-278 mOsm/l

D. 295-308 mOsm/l

E. 270 mOsm/l

11. Chn dung dch truyn tnh mch thch hp trong iu tr cp cu sc phn v:

A. Dung dch ringer lactate

B. Dextran

C. HEA (HES)

D. Dung dch NaCl 0,9%

E. Cu A & D

12. Dung dch no sau y c thnh phn cc ion gn ging dch ngoi bo:

A. Dung dch Ringer

B. Dung dch Hartmann

C. Dung dch NaCl 0,9%

D. Dung dch Dextrose

E. Dung dch keo tng hp

13. u im ca dung dch tinh th l:

A. S dng thch hp cho mi hon cnh.

B. Giai tng th tch huyt tng tt.

C. Duy tr huyt p n nh.

D. A, B ng.

E. A, B, C ng.

14. Nhc im ca dung dch tinh th:

A. Gi thnh t.

B. Gia tng th tch huyt tng t.

C. Kh pha ch.

D. Gy d ng.

E. Gy ri lon ng mu.


ni, NXB Y hc.


Livingstone, UK.



Sciences, France.


6. Mark C. Rogers, Jone H. Tinker (1993). Principles and Practice of Anesthesiology, Vol 1,

USA.


8. Robert K. Stoelting, Ronald D. Miller (1989). Basics of Anesthesia, Churchill Livingstone.

Chng 4 39


Volume I, II


Medecins du Monde.

Website:

http://www.ykhoa.net,

http://www.anaesthesiologists.org,

http://www.anesthesianow.com,

http://www.who.int/hinari,

http://www.anesthetist.org,



Chng 5 40

Ri lon thng bng nc v in gii

Mc tiu hc tp:

1. Trnh by c nguyn nhn ca ri lon nc v in gii

2. Chn on c cc loi ri lon nc v in gii

3. Trnh by c cc bin php c bn x tr cc trng hp ri lon nc, in gii

I. i cng 1. Vi nt sinh l v chuyn ho nc

1.1. Phn b nc trong c th

Tu theo la tui, s lng nc trong c th c khc nhau. tr s sinh nc chim xp x

80% trng lng c th (TLCT). Ngi ln: 55-60%. nam: 60%, n: 55%. ngi gi,

t l nc thp hn ngi tr.

Nc trong c th c phn b thnh hai khoang:

- Khoang trong t bo (TTB) chim 40%.

- Khoang ngoi t bo (NTB) chim 20% trong :15% dch gian bo (GB), 5% dch trong

lng mch (TLM) tc l th tch tun hon.

V d: nam gii 70kg:

Hnh 5.1. S biu din s phn b nc trong c th ngi nng 70kg

1.2. Nc nhp

Trung bnh mi ngy lng nc nhp ngi ln khong 2500ml t ngun n ung v

nc oxy ho cc cht (khong 300 ml). C 100g m oxy ho cho 107g nc, 100g ng

oxy ho cho 37g nc, 100g protein oxy ho cho 45g nc.

1.3. Nc xut

Bnh thng nc thot ra ngoi c th qua cc ng nh da, h hp, thn, rut trung bnh

khong 2500ml mi ngy. Ngoi ra, cn c th do mt nc bt thng, xy ra khi:

- Khi chc nng c c nc tiu km, s lng nc o thi tng.

- Nc mt qua ng khng thy c nh m bng, m ngc, st.

- Vn ng, lao ng nng nht l mi trng nng.

- Nn, a chy.

- Trn dch mng phi, mng tim, mng bng...

1.4. Nhng yu t quyt nh s phn b v iu ho nc trong c th

Mc d c s thay i ln v lng nc vo ra nhng th tch v thnh phn khc nhau ca

cc khoang dch trong c th lun c duy tr n nh nh vo c ch iu ho nh sau:

- p lc thm thu huyt tng quyt nh s iu ho nc gia khu vc trong v ngoi t

bo.

- Cc knh ion chi phi s vn chuyn cc cht in gii qua mng t bo. Vai tr ca bm

K+-Na

+ trong c ch vn chuyn tch cc qua mng t bo. Cc cht in gii:

Nc ton th

P X 0,6 = 42 lt

Th tch ni bo

P X 0,4 = 28lt

Th tch ngoi bo

P X 0,2 = 14lt

Th tch gian bo

P X 0,15 = 11lt

Th tch trong mch mu

P X 0,05 = 3 lt

Chng 5 41

+ Khoang NTB thnh phn ch yu l Na+ (145 mEq/l)

+ Khoang TTB thnh phn ch yu l K+ (140 mEq/l)

Nhng ion ny l thnh phn ch yu to nn p lc thm thu cng nh c vai tr quan trng

trong iu ho v vn chuyn nc gia khoang trong t bo v khoang ngoi t bo.

- Cht hu c phn t nh: Ur, amino acide, glucose, nhng cht ny c th khuch tn qua

li mng t bo d dng nn t c vai tr trong iu ho v vn chuyn nc.

p lc thu tnh v p lc keo. Cht hu c c trng lng phn t ln ch yu l protein

(albumin) ng vai tr chnh trong s vn chuyn nc gia lng mch v khong k.

70% albumin

AL thu tnh mao mch AL keo huyt tng 30% globulin

1 9mmHg bi protein

9mmHg bi cc cation

AL thu tnh khong k AL keo khong k

90%

H thng bch huyt

(ng tr li tun hon

10% ca protein)

Hnh 5.2. S trao i nc gia lng mch v khong k

- Thn v tun hon l trung tm ca vic iu ho s vn chuyn nc ca khoang mch

mu. Tt c nhng thay i v huyt ng (gim huyt p ng mch, gin mch, gim th

tch tun hon lm thay i cung lng tim v dn n gim mc lc cu thn. Ngc li suy

thn c th gy nn nhng thay i ln v th tch dch, th tch tun hon ca c th. Nhng

thay i c tc ng bi:

+ Cc catecholamin v h giao cm ng vai tr chnh kim sot sc cn ca ng mch

n v ng mch i cu thn cng nh sc cn mch mu h thng.

+ H renine-angiotensine-aldosterone, hormon chng bi niu (ADH), yu t thi natri niu

ca tm nh (FAN) kim sot mc lc cu thn v trao i nc ng thn.

Hnh 5.3. S v c ch iu ho vn chuyn nc trong c th

17mmHg 28 mmHg

6mmHg 5mmHg

Chng 5 42

II. Ri lon thng bng nc Bnh thng c 4 ng xut nc ra khi c th: thn, da, rut, h hp. Khi lng nc b

mt qua cc ng ny tng do bt thng nh: nn, a chy, tot m hi nhiu, tng li tiu

hoc trong mt s hon cnh c bit nh bnh nhn th my, cc bnh l gy a niu (i

tho nht...) dn n ri lon thng bng nc trong c th.

V vy, chn on mt nc phi da vo:

- Nguyn nhn.

- Triu chng lm sng.

- Cn lm sng.

1. Mt nc trong t bo (mt nc nhiu hn mt Na+)

1.1. Bnh sinh

mt ngi bnh thng nu khng nhp nc, nc vn c to ra qua ng chuyn ho

cc cht. Lng nc cung cp cho c th theo ng ny khong 300ml/ngy. Nu vn

khng nhp nc th hu qu l c th b thiu nc. nh hng u tin n khoang ngoi t

bo to ra hin tng c c (u trng v phng din thm thu) v nc trong t bo vn

chuyn ra ngoi t bo, hu qu lc u mt nc ngoi t bo v sau dn n mt nc c hai

khoang.

Theo Mariotte: Nu khng nhp nc trong 24gi s gim 2% trng lng c th. Trng

hp nng (khng nhp km mt bt thng) c th mt n 15%. Khng nhp nc trong 36-

48gi, Na+ v Cl

- vn bnh thng nhng sau 48gi ng thn tng ti hp thu Na

+, Cl

- do 2

loi ion ny ngoi t bo tng. Khi mt nc, th tch nc tiu gim, Na+ v Cl

- trong nc

tiu khng tng, v sau gim do tng ti hp thu. Nguyn nhn do p lc thm thu ngoi t

bo tng, kch thch thu sau tuyn yn tit ra ADH lm tng ti hp thu mui v nc ng

thn. Mt khc, lng mu qua thn gim nn ur lc qua thn gim, do vy ur mu tng.

1.2. Nguyn nhn

- Mt qua thn: Bnh i tho nht, li niu thm thu (i ng, dng manitol)

- Mt ngoi thn: Qua da (st), h hp (th nhanh).

1.3. Triu chng lm sng

Kht, kh li v mi li, l ln, yu c, i t, c khi co git, hn m, khng c da nhn.

1.4. Cn lm sng

Tng Na+ v Cl

- mu, tng p lc thm thu (ALTT) huyt tng. Protid mu v Hct bnh

thng.

1.5. iu tr

Cung cp nc: Ung nc nguyn cht hoc truyn tnh mch dung dch nhc trng

(glucose 2,5%) khng cho NaCl lc u. i khi cn rt nhiu dch, nu thiu nc nng cn

cho t nht mt na lng dch thiu trong 12gi u.

- c tnh mc thiu nc trn lm sng:

+ Thiu di 1,5lt: kht va.

+ Thiu 1,5- 4lt: kht nhiu, kh ming v vng nch bn. Na+ mu tng, t trng v p lc

thm thu nc tiu tng. Hct , cng da, huyt p bnh thng.

+ Thiu trn 4 lt: kht khng chu ni, tng Na+ mu r, Hct tng nh, i t, th , nu khng

iu tr s hn m v cht.

2. Mt nc ngoi t bo (mt nc bng mt Na+)

2.1. Nguyn nhn

- Mt qua ng tiu ho: nn, a chy, ht dch d dy t trng, d ng tiu ho.

- Mt qua thn: suy thn mn, tiu nhiu do thm thu, dng thuc li tiu, suy tuyn thng

thn, bnh thn gy mt NaCl...

- Mt qua da: bng, tit m hi nhiu, say nng...

2.2. Triu chng lm sng

Chng 5 43

Da nhn, tt huyt p, mch nhanh, p lc tnh mch trung ng thp, i t. Khng kht,

khng kh nim mc.

2.3. Cn lm sng

C c mu: Hct tng, protit mu tng. Na+ v Cl

- mu v nc tiu bnh thng hoc gim

nh. Tng ur v creatinin mu.

2.4. iu tr

Cung cp nc v NaCl, khng bao gi b nc khng cha NaCl. Dng bng ng ung

hoc truyn tnh mch. Truyn tnh mch khi c nn nhiu.

3. nc ngoi t bo

3.1. Nguyn nhn

+ Thn: vim cu thn cp, vim thn cp v mn.

+ Tim: suy tim mu

+ Gan: x gan c trng

+ Ni tit: cng Aldosteron, cng Cortison

3.2. Lm sng

Tng cn, ph da v nim mc, nng gy ph phi, tng huyt p.

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