1. by death_nt88 source:diendanykh0a. c0m |20 l 0i A I A f T ' r?+ .1* ' I* I r *rr 1PDF created with pdfFactory Pro trial version www. gdffactory. com 2. by death_nt88 source:diendanykh0a. c0m |20 l 0Sau Chn don lm sng,nay tirp tuo Vi Bin lun cn lm sng. Theo trinh tu: 1) Sinh ha mu 2) Men tim 3) Kh mu dng mach 4) Cng thfrc mu 5) Pht mu ngoai bin - Ty d612) H hp ky. SU TH 1513.4? .BAA/ LTJ CI i thnure 0 l sn phm thoi ha quan trng nht ca protein duc thi qua thn.- tri s binh thung (bt):2.5 7.5 mmol/ l -> BUN (Blood Urea Nitrogen) =ure (mg) x 28/60; di don vi:mmol/ l x 6 =mg/ dl.I tng:bnh thn,n nhu dam,st,nhm trng,tc nghn dung tiu. . I gm:n t dam,bnh gan nng,suy kit. . BUN I l`a nito ca ure trong mu.I bt:4, ~ 23,. ? mg/ dl.-> Bun =mmol/ l x 6 x 28/60 =mmol/ l x 2,8 (mg/ dl).I tng:suy thn,suy tim,n nhiu dam,st,nhim trng. . I gim:n t dam,bnh gan nng. . Creatinin 0 l sn phm do thi ca thoi ha creatin phosphat e0, lugng tao thnh phu thuc khi lung e0, dugo loc qua cu thn & thi ra nuc tiu;cng l thnh phn dam n dinh nht khng phu thuc vo ch d n -> c gi tri xc dinh chc nng cu thn.I bt:nam 62 - 120, n' 53 ~ 100 (don vj:umol/ l).I tng:bnh thn,suy tim,tu dung,tng huyt p v cn,NMCT cp. . I gm:c thai,sn git. . I d@ thanh thi Creatinin (Cl - Cr) (ml/ pht) a [(140 - tu) X cn nng (kg)]/[creatinin/ mu (mg %) X 72 ],nu l n' x 0,85. Binh thung:100 ~ 120 ml/phU 1,73 m2 da.Didon vi:t ~ T" " "' '"'V'ACid Uric =urat - l sn phm chuyn ha ca base purn (Adenin,Guanin) ca ADN & ARN,thi ch yu qua nuc uu.I bt:nam 180 - 420, n 150 - 360 (don Vi:umol/ l).I tng: - nguyn pht:d0 sn xut tng,d0 bi xut gim (tu pht) -> lin quan cc men:bnh Lesh - Nyhan,Von Gierke. . 2 PDF created with pdfFactory Pro trial version wwwgdffactorycom 3. by death_nt88 source:diendanykhoacom 2010- th pht:d0 sn xut tng (u ty,bnh vy nn. .),d0 bi xut gim (suy thn,dng thuc,Xo Va dng mach. .). - bnh Gout (thng phong):tng acid uric/mu c th@ km nt tophi khp & si urat 0 thn. I gim:bnh Wilson,thuong tn t@ bo gan. .l) Dua vo Cl - Cr (C),phn d@ Suy thn man theo giai daan:D@ I -> C :60 - 41 -> Cre/ mu < 130 -> LS:binh thuong.D@ II -> C =40 - 21 -> Cre/ mu =130 - 299 -> LS:thiu mu nh.D@ IIIa -> C =20 - l 1 -> Cre/ mu =300 - 499 -> LS:triu chng tiu ha + thiu mu Va,D@ IIIb -> C :10 - 5 -> Cre/ mu :500 - 900 -> LS:thiu mu nng + hi chng ure mu cao.D@ IV -> C < 5 -> Cre/ mu > 900 -> LS:tiu t. 2) ure/ mu khng phn nh chnh xc chrc nng thn Vi:ure chi tng khi chc nng thn gim # 60%.2. su bi tit ure con ty thuc su' b tit nuc tiu:+ luong nuc tiu gim (d0 thiru nuc) + p luc nang Bownman tng (tc nghn duong tiu).-> 2 yru t@ trn lm tng ti hp thu ure -> tng ure/ mu.3. su bi tit ure phu thuc lutong dam hp thu:+ n nhiu dam,xut huyrt tiu ha + di ha dam tng (nhim trng,corticoid,tetracylin). _i3) creatinin/mu0 l cht bin duong ca creatn trong bp thit,pill).thuc khi luong bp thit & khng thay di o mi nguo.0 bt:O,8 - l,5 mga/ c (cho c 2 phi).I creatinin phn nh trung thuochc nng thn hon ure vi khng phu thuc cp yu t khc;chi tng khi chc nng thn dgim 50% & tng gp doi khi d@ loc cu thn gim xung con mt nfra -> do d tri s creatinin/mu gip ta uc don duoc chc nng thn con lai: cre 1 (mg%) -> thanh loc cu thn (ml/ pht) 120cre 2 -> 60cre 4 -> 30cre 8 -> 15cre 24 -> 50 di vi BN gy,suy kt:c th@ tri s@ Creatinin trong giri han bnh thung mc d d suy gim chc nng thn dng k@ (vico teo -> bin dung creatin km -> tao t creatinin/ mu). 4) sir tirang quan Bun - Creatinin/ mu:BUN/Creatinin mu (bt:10/ l)I BUN/Cre > 10: BUN tng nhiu so vi Cre -> cn nghi ngo cc yu t@ trurc thn hoc sau thn lm tng ti hp thu Ure:l.gim moi mu thn:chong,suy tim,mt nuc,mrt mu 2. to nghn sau thn:soi,u chn p 3. luong dam hp thu nhiu:n nhiu dam,XHTH,tng di ha dam.-> Trong truong hop Suy thn truc thn:BUN t tng > l00mg% & Cre t khi tng > 3 mg%.0 BUN/Crc < 10: BUN tng t so Vi Crc.l.do luong dam n vo t:suy dinh duong,xo gan 2. (inh trang hoai tr co,ly gii co Vn 3. cratinin tng gi tao do ung mt s@ thuc:Vit C,khng sinh. . - BUN/Cre # 10 :sn gia tng dng thoi c 2 ni s ny voi ty l duy tri 10/1 chng to c in thuong thuc th tai nhu ina thn.5) D@ thanh lgc cu thn (Clearance:Cl - Cr) - he s thanh thi mt cht l th tch huyrt tnong loc sach cht d trong 1 phlt.C nhiu cch tnh Cl - Cr:0 dua vo crc/mu & nuc tiu:liy nuc tiu 24 gif! , do th@ tch nuc tiu & luong crc bi tit Irong 24 gio -> C :( U x V ) / P Vi:u l CrC/NT (mga/ o),v l m6 tch nuc tiu (ml/ pht),P l nng d@ Crc/mu (mg%).0 -> kt qu thung nhiu do:khng gift dting nuc tiu 24 gi,con st nurc tiu trong bng quang.3 PDF created with pdfFactory Pro trial version wwwpdffactorycom 4. by death_nt88 source:diendanykhoacom 20100 Cng thc Corkroft - Gault:dua theo cn nng & tui (d nu trong bi post #2).Khng nn p dung cong thtc ny nru mp qu hoc ph nhiu,vi:chi dting khi ly zrrc cn nging tnrc khi ph (nic l cn nging chnh xc cna bnh nhn) v cng khng ding khi bnh nhn bo phi. I tnh GFR theo cong thrc MDRD (Modification of Diet in Renal Disease):GFR (ml/min per 1,73 n12) =1.86 X [(PCr) (m) - 1.154] X Kage) (ni) - 0.203] ( x 0.742: voi n).0 Ch y cc yNu t@ nh hung dn GFR:1. "su co gin tiu DM cu thn: + gin tiu DM vo lm tng dong mu dn thn -> tng loc & nguoc lai:co tiu DM vo lm gim dong mu dn thn -> gim loc. + Co tiu DM ra lm tng p luc thim thu cu thn -> tng loc & nguoc lai:gin tiu DM ra lm gim p luc thu thu cu thn ->gim loc.2. Ap sut DM tng gy tng p sut thy tinh mao mach cu thn -> tng loc.3. Ap sut keo ca protein huyrt turong gim gy gim mirc loc & nguoc lai:p sut keo ca protein huyt mong tng gy tng mirc loc.4. Ap sut thy tinh nang Bownman tng kh tc @ng thn,niu qun hoc ph thn -> gim loc. T1} {rng dung lm sng d nu c lin quan dn: l) Tniu mu a2) da niu - thiu niu - V@ niu3) h@i chfrng ure mu cao n r4) sinh 1y chc nng thn (lin quan gia cp p luc:loc,keo,thy tinh,thm thu)5) cch ly niroc tiu 24 gio. I Thiu mu: @ man: 1. BN ny c tnin mu khng? - hi:chong mt tai hoa mt?th nhanh?h@i h@p dnh trng nguc?(thiu mu gy thiu oxy cc mo)- khm:da nim,nuu rng,lui,long bn tay chn- CLS:dua vo Hb:trung binh 7 - 9, nng < 7, rt nng < 4; ring nh thi phn ra:nam > 9 -13, n' > 9 - 12, n mang thai > 9- 11 (don vi g/ dl). 2. TM man hay cp? - hoi:thori gian xut hin xanh xao- khm:m thi thiru mu n tim,kh nng cnin dung (nn Hb < 7 g/ dl nhung tinh to di lai duoc chng t BN thch ngni vri iniu mu t t,din ra nhiu ngy -> chiu dung duoc ),mach HA (thuong @n dinh khi TM man,manh nhanh HA thp/ tut khi TM cp mirc d@ trung binh hoc nng). 3. Dnh gi mc d@ TM? - hi:mt khi gng sfxc?-> nh,khi lm vic nh?-> TB,khng tu' lm V@ sinh c nhn dugo?-> nng- khm:da nim ming bch,di lai kh khn cn ngui gip d,nhip tim nhanh,tho nhanhNh-(D li Trung binh (Bo J) Nang (Do 3) Lqvxlg mu i 1091211@ rich mu 509t:th tch ntu mt Triu chmg Gim ttrovi mu co' quan ngoai Gim tui mu co quan nung Gim Iui mu co quan bin,tinh,hoi met.imng.Met zni,nim nhotp,trung Lrong khng con da xanlt,chong mt,do mo kh nng chiu duoc.Ht hoi,tiu it.hong,lo iru,li bi,vzjt Vi,th ilhanh.V niu ...l-'Iach 90-l001p 100-120lp `>120lp HATT > 90 mmHg 80 - 90 mniHg,< S0 mmHg.HA k_ Hct 2 3091 20 - 3091i p lixc loc,C -> p sut tai mao mach cu than,k -> p lixc keo ca mu trong mao mach cu than,n -> p lirc thy tnh ca nang Bownman.0 cch ly nuc tiu 24 gi:7h:BN tiu ra sau d tiu vo binh,binh trutc d d duoc rra sach.Dn BN hrng ly nuc tiuc khi di tam - dai tip.7h hom sau:tiu vo.V ,r _ ` -> d bo tn nuoc tiu trnh ln men Amoniac. , lm hu hai cc t bo,bin cht hay ngn cn su pht trin ca tap trng:cn cho vo trong binh phenol - 1 giot cho 30ml nuc tiu. Cl I ganCN BAI TIEKIT: 1) bilirubin2) phosphatase kim3) GGT ( Gamrna Glutamyl Transferase) 4) urobilino gen (nuc iiaa/24h). CN TNG HOP: l) albumin huyt thanh 2) Cilobnlin huyt thanh 3) yu t@ dng mu. HOAI T' T1?:BAO GAN1) transaminase 2) LDH =LD ( lactate dehydrogenase) 3) St (ferritin huyt thanh). KHAC:Cholesterol/mu. Bilirubin - Bilirubin l sn pnan cnayan ha ca Hem (nhm ngoai ca Hemoglobin):Bil ra doduoc tao thanh a lch & na thng vng n@i mo,n dugo chuyn tri gan tao thnh Bil lin hop.Bil lin hop theo duong mt xung ru@t.Bil ca do =Bil gin nap,Bil lin nap =Bil aai:aap.Bil ton pnn =Bil gin nap + Bil true aap.Dai don vi:umol/ l x 0,05s5 =mg%.Bil ton phn:- bt:< 17 umol/1(< lmg% ):0,8 -1,2 mg%. -Vngda khiBilTPr>2,5 mg%.I I Bil true tip ( lin hop):chim # 10% 5 PDF created with pdfFactory Pro trial version wwwgdffactorigcom 6. by death_nt88 source:diendanykhoa. com |2()10- bt:< 4,3 umo1/l(< 0,25 mg%)- Bil truc tip hinh thnh trong gan nho Glucur0ny1Transgerase - cn tao ha hoc:lin hop voi acid glucuronic- vi tr chuyn ha:sau gan- tnh tan:tan trong nnc- tnh dc:khng dc- phn ung dinh lnong:truc tip. o Bil gin : iap ( : a do):eniain # 90%- bt:< 12.7 umol/1(< 0,74 mg%)- Bil gin tip chua qua gan,khng thi qua than,mat (t)- cu tao ha hoe:khng lin hop- vi tr chuyn ho:trnrc gan- tnh tan:khng tan trong nnc,tan trong lipid,dung moi hfru co- tnh dc:dc- phn ang dinh inang;gin aap. -> tng Bil TP + Bii TD:vng da tiu naya:(mian mu : an huyt,sa:rt,sau : niyan mu khc loai. .). -> tng Bi1TP + Bil TT:tc mt trong gan ( vim gan,xo gan. ) tc mt ngo gan (do si,K,hach to). Phosphatase km 0 hoat dng a mi trnong km ( pH 8,5 - 9 ).Ngun gc:gan,xnong,rut,thn,nhau thai.I bt:20 - 45 U/ L. I rat nhay d@ pht hn tc mat.I tng nhe -> vna ( 2 lan ) :Vim gan,xo gan,di cn hoc thm nhim.Tng cao (> 3 ln ) :do tc mt ngoi gan.0 gim:nhnoc gip,thiu vitamin C. . Albumin I 1`a protein chim hon mt nna protein huyt tnong,dnocrtng hop boi gan,c vai tro quan trong trong chnh p & su duy tri dich trong long mach mu.Su gim Albumin huyt tnong khin dich trong mach thot ra m@ gy ph.- bt:35 - 50 g/ L -> 52 - 68% protein ton pnn.I:xo gan man tnh ( > 3 tun ),suy dinh dnng,mat albumin qua duong tiu (HCTH),mat albumin qua duong tiu ha (hi chung km hp thu).I tng:thnong khng tng,nu c do:mt nnc,nn nhiu,tiu chy nng.Globulin - ea tao knang : naan nni.Do na yang nai ma - gan - lch - hach tao nan.Gani;globulin al (anphal),a2 (anpha2),n (beta),y (gamma).I bt:24 - 38 g/ L. I:Vim gan tu rnin ( tng IgG ),Xo gan tc mat nguyn pht ( tang IgM ),Xo gan do rnou (tng IgA ).0 gim:thiru mu tan huyt,vng da nng.I t s@ AIG:binh thnong 60/40 # 1.5, khi < l -> bnh gan man tnh.Transaminase I l`a enzyrn chuyn nhm amin ( aminotransferase ).Ph@ bin l 2 loai:+ ALT ( alanine aminotransferase ) hay GPT ( glutamat - pyruvat transaminase ) + AST ( aspartate aminotransferase ) hay GOT ( glutamat - oxaloacetat transaminase ).I AST:c trong bo tnong,ty th@ co tim,gan - xnong - thn - no - tuy.ALT:c trong bo tnong t bo gan.- ALT & AsT trong mu map,nhnng khi c su hoai : a : a bo (Vim gan,Nnai mu co tim. .) -> ALT & AST /mu tng : a: cao.0 bt: + AST (GOT) 3000 U/ L) -> hoai : a t@ bo gan do Vim gan cp hoe man,Vim gan do thuc,d@c eht. . + tng vna( 100 - 300 U/ L ):vim gan do rnou (ch yu tang AST). + tng nhe ( 50 - 99 U/ L ):vim gan cp hoc man muc d@ nhe,e bnh 1y gan man khe.0 ti s@ De Ritis:AST/ ALT =GOT/ GPT =l - 1,3: < 1 :trong hoai : a t bo gan cp > 1,3: t@n IhIIOTIg gan man -> xo' gan,nghn mou,NMCT > 2: Vim gan do mou. GGTI GGT :Gamma Glutamyl Transferase -> rat nhay d@ dnh gi chne nng bi tieit cna gan.0 GGT c ch yu a:gan - thn,t hon a;tuyn tin lit - co tim - lch.v 0 GGT gip pht hin nhiu bnh nhu m@ gan:tng som & gi a mnc cao khi t@n thuong t bo vn eon.a W - N@ng aa GGT/mu cao 12 - 24 gio sau aang nhiu rnou,ya vn ean cao 2 - 3 tun sau khi mai aang rnou -> dting d km sot vic cai rnou.0 bt:nam 1 1 - 50, n 7 - 32, gi hoi cao han ngni lon.Chung:< 30 . Don vi:U/ L - 37oC.0 tng trong:suy thn,NMCT,Di tho duong,nghin rnou. . LDH 0 ` _LDH l 1 enzyrn n@i bo c trong hau ht cc t@ bo dang chuyn ha.Hm lnong cao a;tim - eo xnong - gan - thn - no - hng cu.0 _ LDH/mu :LDH ton phn.Trong Nh@i mu co tim,LDH tng rrt cao sau 24h dn 10 - 15 ngay,n@ng d@ tng ti l@ vi t@n thnong.I bt:230 - 460 U/ L - 37oC.a 0 @gg:NMCT,nh@i mu ph@i,bnh gan,suy thn cp. . St 0 Feritin =feric hydroxyd + apoferitin (protein).0 Feritin l protein du tr sat,dnoe sn xut a;gan - leh - ty xnong.N@ng d@ feritin lin quan dn lnong sat du tr a cc m@ 0 l00g huyrt sae t@ tnong duong 0,335 g sat.0 bt:nam 11 - 27, n 7 - 26 (don vi:umol/ l).Sau mn kinh # 7 - 27, ngni gi # 15 - 20. 0 gim trong:thiu mu thiu st,gim du tr. . I tng trong:qu tai' st,hoai t t@ bo gan,Thalassemia,nhim triing. . O I 0 biland li pid I biland lipid (b@ mo) g@m cc xt nghim:l) Cholesterol ton phn 2) Triglyeerid 3) I-lDL - cho v:4) LDL - cho.0 l nhm xt nghim dnh gi nguy eo Xo va dng maeh.Thnong dnoc chi dinh trong cc bnh:Tng huyt p,Di tho duong,H@i ehnng thn hn,Tang acid uric mu (Gout). . Cholesterol 0 Cholesterol l l thanh phn ca mt do gan t@ng hop,e trong h@ng eu - mng t@ bo - eo.7 PDF created with pdfFactory Pro trial version wwwpdffactoryeom 8. by death_nt88 source:diendanykhoaeom 2()l00 khong 70% cholesterol duoc ester ha (kt hop voi acid bo,30% dn dang tu do trong mu (huyt tnong).Tron g xt nghim,2 dang nay thnong dnoc do chung voi nhau goi l Cholesterol ton phn.Choles Ton phn :choles Tu do + Choles Ester. o Gan l co quan chnh tao Cholesterol & gan cng l co quan duy nhrt ester ha Cholesterol. 0 Cholesterol ehuyen ha thnh acid mt & mu@ mat (can cho su tiu ha mo),thnh cc hormon steroid (a v thnong than - bu@ng trng - tnh hon).Tng cholesterol huyt c the gy ra nhrng mang lang dong a DM vnh -> NMCT. 0 Cholesterol huyt tang ln theo tu@i a ca nam & n cho dn 60 tu@i.Trnoc 50 tu@i,choles a nam > n,sau 50 tu@i,choles a n > nam. 0 bt:3,9 - 5,2 mmol/ L. D@i don vi:mmol/ l x 387 =mg/ dl . 0 tgng:xo va DM,vng da trc mt,tiu duong,tng huyt p. .0 gim:cnong gip,h@i chnng Cushing. .o ya XVDM & nann inaen vnh,en ena y; + mong mu@n:< 200 mg/ dL ( < 5,2 mmol/ L ) + nguy eo vna:200 - 240 mgdL ( # 5 - 6 mmol/ L) + nguy eo' cao:> 240 mg/ dL ( > 6 mmol/ L ). Triglyeerid0 l ester cna glycerol vi 3 acid bo,duoc van chuyn trong mu dni dang lipoprotein. 0 a ngnoi,trong t@ ehnc mo du tr nhng acid bo thnong l:acid palmitic,acid oleic. o Triglyeerid e trong du : nae ya:& nna dng ya:Ma l glyeerid ea dng vt e nniaa acid bo no,yn du : nae ya:l glyeerid chna nhiu acid bo khng no. 0 Triglyeerid e 2 ngu@n gdc:ngoai sinh (thnc n) & ni sinh (do gan t@ng hop).Trong huyt tnong,TGngoai sinh dnoc vn chuyn boi chylomicron & TG ni sinh dnoc vn chuyn boi VLDL. 0 a ru@t non,TG bi thy phn boi lipase thnh g1yeero1& acid bo.Acid bo dnoe hap thu phn lon qua h@ baeh huyrt & cu@i cng toi dong mu dno dang hat mo (chylomicron). 0 TG gy ra huyt tnong duc nhn sa sau ba n mo (bin mat sau 6 gio,vi dnoc gan dna vo VLDL,LDL,HDL chuynaan ee ina,nht l ma ma). I bt:0,46 - 1,88 mmol/ l. D@i don vi:mmol/ l x 87,5 :mg/ dL -> bt:40 - 165 mg/ dL. 0 thay d@i sinh 1y:gim khi hoat d@ng th@ Inc manh.Tng trong:ht thu@c,u@ng rnou,tu@i 50 - 60, sau an. .0 tng trong:XVDM,nh@i mu co tim,tiu duong nang,thiru mu e tnh,xo gan,vim tuy,vim gan. .I giam trong:suy kit. HDL - cho0 HDL l lipoprotein : y trong cao ( High Density Lipoproteins ),dnoc t@ng hop a gan & ru@t dn dang hinh dia sau chuyn thnh hinh cu trong huyt tnong.choles huyt tnong dnoc van ehuyn trong HDL :# 25%. 0 HDL vn chuyn ngnoc cholesterol dn thna : a t@ bo ngoai bin v@ gan d@ gan oxy ha & do thai ra ngoi theo duong ru@t.Qu trinh nay gip cho t bo ngoai bin khi bi a dong lipid,chong lai hin tnong sinh xo va -> HDL dnoc goi la yu t@ chng xo va. 0 bt:>=0,9 mmol/ l.0 tang:gim nguy eo XVDM & bnh mach vnh. 0 gim:XVDM,bnh mach vnh,bo phi,ht thu@c l,tng Triglyeerid huyt,km tap luyn. LDL - choI LDL l lipoprotein : y trong thp ( Low Density Lipoproteins ),VLDL l lipoprotein : y trong rat thp (VeryLow Density Lipoproteins ) -> dnoc goi la nhng LP gy xo va. 0 Qu trinh tao LDL:lipid t@ng hop a gan dnoc dna vo mu trong thnh phn ena VLDL,dau tin l VLDL1. Trong mu: VLDL1 . > VLDL2 -> IDL -> LDL.Khoang 20% tiu pnan VLDL nian thnh LDL.LDL dnoc gan hay na:ea : a bo no khc cna eo ma nani b:nna cc ma : na dae niaa (ma : na LDL).Sau khi riaae nm n: , LDL tng trnong - dinh daang - enayan ha nna co che ni am bo qua trung gian thu th@o Nobel Y hoc 1935 (Goldstein & Brown):kni c na::naang : na ma LDL:knang e kh nng nm n:LDL lnu hnh,knang c kha nng ni am bo qua trung gian thu th@ dn cc h@ c ao va vo trong bo tnong -> hau qu l n@ng d@ LDL lnu hnh tng,lang dong dni lrp ni mae -> dn dn Xo va dng mach. 0 LDL (mmol/ l) =Choles - (TG/2,2) - HDL. o n: : LDL 7 mEq/ l. Khi e su phn hy mo:K roi t bo vo dich ngoai bo (dich k & huyt tnong). - 80 - 90% K ca co : na dnoc mai qua man.sa : nai qu nhiu K s an cian na K/ mu.Naa man : ia:< OOml naoe tiu/ ngy thi K s tch lai trong dich ieng mach -> K - naya:thanh tng.sa een lai thi qua duong phn & : na nai ( # 10 mEq/ ngay ).co : na knang du : ra K,thn thi : rang binh 40 mEq/ l/ngy ngay ea kni sn nhp K : nap Nhu ea K:3 - 4 g/ ngy.K ton co th:30 mEq/ l, cation ch yru ca khu vnc n@i bo,chi c 2% a khu vnc ngoai bo.dieu hoa K trong mu:than - pH/ mu - n@ng d@ lnsulin/ mu - Aldosteron.bt:3,5 - 5 mEq/ l. nguyn nhn gim:1) mat qua duong tiu ho:tiu chay - i mna - dng thu@c x@,do ru@t - do mt - do thng @ng dn tiu ru@t,ht da dy,kiim mu. 2) mat qua duong tiu:do dng loi tiu - khng , sinh (Carbenicilline,Amphotericine,Amioglycosides ) - corticoides lnong nhiu,loi tiu thm thu - toan huyt do nguyn nhn @ng than - cnong Aldosteron,h@i chnng Fanconi - h@i chung Bartter. 3) K+ cho vo khng dn:voi lnong K hang ngay < 10 - 20 mEq trong 1 - tnan dua dn Ha K/ mu. 4) K+ : a ngoai bo vo n@i bo:do km ha mi trnong ngoai bo hoac dng Glucose nu trnong + lnsulin.0 nguyn nhn tng: K/ rnu > 5,5 mEq/ l v nang > 6,5 mEq/ l -> cn tr' dn truyn than kinh (Acetylcholine) -> lit co,gim phn xa gn xnong,ph t@ bo,nhip cham,ngnng tim (rung that or v@ tm thu). 1) gim bi tirt qua duong than:suy than cp - suy than man,h@i chimg Addison - h@i chung gim Renin _ Aldosterone,loi tiu khong mat K,nann man : e nghn. 2) ti phn ph@i K : a dich n@i bo ra ngoai bo trong trnong hop:l.toan huyt,2. qu lieu Digitalis,thiru Insulin,gia tng nhanh chong thm thu dich ngoai bo (do dng nhiu Glucose nu unong,Manitol). 3) lnong K gia tng : a ngun ngoai sinh:ung - truyn K,truyn mu - truyn PNC K+ liu cao ( 1 triu PNC ehna 1,7 mEq K ). 4) K n@i sinh gia tng do hy hoai cc m@ ( tan huyrt,1y gii co vn,dai phu,XHTH,chan thnong do chen p).VTng kali gi:l.K phng thch : a cc mu mu bi dng e tng bach eu,tng tiu eu;2. dung huyt a cc mu mu;3. dat dy tht maeh qu lu. Trong Hn m do Di tho duong,tnroc diu tri K tng,sau diu tri K gim. Na+0 Na+ l cation chnh ca dich ngoai bao,c tc dung gi nnoe.Kh c thna Na+ tron g dich ngoai bo thi nnoe dnoe ti hp thu nhiu a than0 chnc nng Na+:dn truyen xung dng TK - co,tham gia hoat dng enzym,diu hoa thng bng acid - base( kt hop voi ion Cl- & ion HCO3- ). 0 nhng thay d@i ca Na+ thnong di d@i voi Cl-. I nguyn nhn gim: 1) mat mui: + suy thnong than (Addison)+ suy thn+ cia : na nai nniaa+ dng Loi : iaa. 2) do pha long: + ciiaa tri bng ADH or kch thch : ia:ADH+ h@i chnng bi tit ADH khng thch hop do carcinoma a ph@i,do stress,do cc bnh ly a no 9 PDF created with pdfFactory Pro trial version wwwpdffactoryeom 10. by death_nt88 source:diendanykhoacom 2010+ suy tim ' huyt,x0 gan,hi chng thn hu+ d0 dng nhiu nhng cht c nng d@ thm thu (Glucose u'u turong,Manitol. .)3) gim th tch dich ngoai bo: + i ma,tiu chy+ dng lgi tiu,lcy tiu thm thu+ Addison. 0 nguyn nhn tng: 1) tng Na+ huyt Vi p luc thm thu d0 mt nuc - mt mui,ch yru l mt nuc -> thung gp;hn m tng thm thu d0 tiu dung. 2) gia tng dich ngogi bo uu truong (d0 truyn Sorbitol uu truong).3) gim dich ngoai bo mt nuc nhuqc nuong,b khng dng hoc dng dung dich uu truong.4) ri loan chc nng dui di trong U no. 5) gi mui trong bnh 1y:suy tim,suy thn,x0 gan. I bt:135 - 145 mEq/ l. 0 Gim 145, nng > 160. Cl- I ` Cl- l anion chnh ca Dich ngogi bo,dng vai tr quan Irong trong duy tri thng bng nuc,thm d@ (cng vi Na+) & thng bng acid - base.0 Kt hp Vi H+ tao HCl dich Vi.Canh tranh vi HCO3- di V`1 Na+ (d duy tr`1 thng bng km toan).Phn ln C1- nhp kt hp vi Na+ tao thnh NaCl (mui bp).- C1-/ mu tng khi nhim toan,gim khi nhim km chuyn ho.' bt:98 - 106 mmol/ l. 0 gim d0: n nhat,mt nuc cp gy nhim km chuyn ho,nn ko di (hp mn vi),dng thuc lq tiu,tiu chy,vim dai trng,vim da dy rut. . 0 tng trong:n mn,toan chuyn ho,suy thn cp,shock phn v,hn m tng p luc thm thu. . Ca++ 0 khong 99% luong Ca ca co th Xuong - rng (Ch yu dui dang mui phosphat) 0 Ca - huyt thanh c 3 dang:phfrc hqp khuch tn duqc _ CaR,Ca ion ha _ Ca++,v Ca gn vi protein _ Ca - Prot.o Ca++ khurch tn dugo,nng d tng khi nhim toan & gim khi nhim km.0 bt:2,3 - 2,6 mm01/l(4,4 - 5,2 mEq/ l).I gim trong:thiu vitD,nhugc cn gip. . 0 tng trong:dng nhiiu vitD,cung cn gip,nhim dc gip. . 0 LS xurt hin ccrn tctanic khi Ca++/mu < 3,5 mEq/ l. 0 A Glucose & hen guan Glucose 0 l monosacarid c 6C,co cht chuyn ha chnh ca glucid.C ngun gc t thc n cha glucid ( tnh bt,sacarose, lact0se. .),dugo du' tr' dui dang glycogen gan - co - xnong.Glucose huyt =glycemie -> LS thung dng dung/huyt tuorng ( vi kt qu khng ty thu6c vo dung tch hng cu & gn vri tri s trong m gian bo). 0 cc yu t nh hung dn Glucose - huyt:+ lm tng:adrenalin,glucagon,honnon gip trang,honnon tng trung,glucorcorticod. .+ lm gim:insulin. .+ yu t gy bin thin sinh hQCI alcol,n nhiu glucid,thu6c (morphn,atr0pin. .),thuc m,lanh,kch thch thn kinh. . 1() PDF created with pdfFactory Pro trial version wwwpdffactorycom 11. by death_nt88 source:diendanykh0a. c0m |2010I Nhng yu : trn gip duy tri nong d@ glucose huyt on dinh & glucose khng ra nurc tiu.Kh glucose huyt vuot qu ngung thn( l,6 - 2 g/ L )( 160 ~ l80mg%) thi glucose xut bin nuc tiu. 0 Di don vi:mmolll X 18 =mg% =mg/ dl ;mg/ dl/1000 x 10 =mg/ dl /100 =g/ LI bt:3,9 - 6,4 mmol/ l ~ 80 - 120 mg%. I tri so binh thung trong duong huyt tuong:70 - 120mg% - cao hon tri s binh thurng trong mu ton phn 10 - 15%:60 - 1 l0mg%.(vi huyt taong khng con t bo mu nn luong duong trong mt don vi th tch lon). I duong mu ton phn durc dung trong trung hop khn cp:BN tu theo doi bng Glucometer. I tng:tiu duong,Basedow,suy gan,vim thn cp,sau tru yln Glucose,chn thuorng so no. .I gim:hn m ha duong huyt,dng Insulin qu liu,suy gan nng,xo gan,nghin rugu. .-> Buong huyt c th ly TM,mao mach,hoc do trong khong gian bo.LS dhg duong huyt/ mao mach,thumg dlroc thlircvhin lc BN hung d.BN Di tho duong thnong dugo xt nghim duong huyt vo 5h sng (d chnh liu Insulin bui chiu) & 5h chiu (d chnh liu Insulin bui sng).(huyt sn t Alc ket hop V glucose)I d0 phn ung Ketoamin (gia Glucose & nhm amin ca 2 chui beta ca phn t huyt sc t). o c 3 1061; HbAl - (a, b,c) gp thnh HbAl.HbAlc chim 4 - 6,5% :6ng s huyt sn t,70% HbAl. I r r H1r3A1c thung tng trong turong hop tng duong huyrt man tnh (phn ung Glycosylat ha khng do nguqc duqc & huyt sc t glycosylat ha tn tai theo doi song hong cu:trung binh 120 ngy). o l tiu ch tt gip dnh gi su n dinh duong mu trn BN DTD. o gi tri:5 - 765% ( 8%:khng duoc km sot tot. I Nru BN tng duong huyt dugo dieu tri tch cuc,duong huyt on dinh nhanh thi HbAlc gim srm nht sau 4 tun. I Theo UKPD:gim 1% HbAlc s gim 20% bin chung mun do DTD. - cc yu to nh hurng dn krt qu d0:l) mt mu cp/ man2) tn huyt3) suy thm man4) mt s bnh v huyt sc to. Ceton huyrt thanh & ntrc tiuI th ceton gm:acid beta hydroxybutyric,acid aceto - acetic,aceton.0 dng vin acetest d d0 ceton trong huyt thanh & nuvc tiu:nu vin thu6c di t' mu trng sang mu hoa c:(+).I c gi tri bn dinh lutong. chrc nng dong cm muTP (Prothrombin content)la ti l Prothrombin ( ~ TQ =Quick Time). kho st duong dong mu ngoai sinh (7) & duong chung (10, 2, l,5, Antithrombin). bt:80 - 100%. gimzygm mt sa;hoc mt yu to dong mu ( Prothrombin,Proconvertin,Proacelerin,yu to Stuart),gim nhiu brinogen,xut bin heparin. aPTT ( activative Partial Thromboplastn Time ) la thoi gian Thromboplastin thng phn ( ~ TCK =cephalin - kaolin time ).kho st duong dong mu ni sinh (12, ll,9, 8, Fletcher,Fitzgeraid) & duong chung ( 10, 5, 2, 1,Antithrombin).bt:30 - 45s.tng:ginn brinogen huyt,tiu fibrin,bnh ua chy mu. . 11 PDF created with pdfFactory Pro trial version wwwgdffactomcom 12. by death_nt88 source:diendanykhoa. com 2010Fibrinogen0 l 1 protein huyrt tuong duoc tong hop gan,bi phn ct boi thrombin thnh nhng sori brin cn cho su tao thnh cuc mu dong.Thiu hut Fibrinogen gy ra chay mu. 0 Fibrinogen huyt ch yu do gan tao ra.N ong dc} Fibri - huyt tnong thp c th do su dong mu ni mach ri rc do chn thuong nng hoc bin chung san khoa. 0 bt:0,2 - 0,4 g/ dL. 0 tng:nhim trng,tng bach cu,thip khop cp. .I gim:bnh gan nng (xo gan,ng@ dc phospho),lao ph6i,BCC,dong mu ni mach rai rc. .Odinh lu=0'ng hormon HORMON TUYEN GIAPgm:T3, T4 -> vn chuyin trong mu chu yu dui dang kt hop vi protein,dang tu d0 rt t. lm tng tc di) ly calci ra khi xuong ( curng gip ko di s lm mt calci xuong ) -> tng Ca/ mu.T3, T4 tng:cung gip,buu gip dc (bnh Graves - Basedow). .T3, T4 gim:suy thy trurc tuyrn yn,nhuqc gip. .T3 (Triodothyronin) 0 bt:+ T3 tu. ' do =FT3: 5,3 - 9,2 pmol/ l + T3 ton phn =T3: l,5 - 3,1 nmol/ l. 0 Buu e0 don thun:T3, T4 binh thnong. T4 (tetraiodothyronin) =thyroxin 0 l hormon chnh ca gip trang.I bt:+ T4 tu do:7y- 21 pmol/ l + T4 ton phn:50 - 130 nmol/ l.HORMON TUYEN YENTSH (Thyroid Stmulating Hormon ) 0 l`a hormon kch thch tuyn gip ( =kch : gip ),do tuyn yn trurc ch tit.I bt: y nghia xt nghim:kho st tinh trang vim.0 6 - 10h sau vim cp & hu hai mo,dat dinh trong vong 48 - 72h.- l xt nghim dng a theo doi cc pha vim cp ca vim khp dang thp & st thp khp.Bng thoi tin don nguy co bnh tim mach & dnh gi su. ' dp ung ca co th voi thu6c Statn.0 tng trong nhim vi trrtg,khng tng trong nhim virus.0 bt:< 10 mg/ L. 12 PDF created with pdfFactory Pro trial version wwwpdffactorycom 13. by death_nt88 source:diendanykhoa. com 2010o tng:nhim lIng,ky sinh trung,ihp khop cp,lupus d. .INR (Intemational Norrnalized Ratio :ty so binh thuon g ha quc t)o y nghia xt nghim;d dnh gi hiu qu st dung ca warfarin ya cc thu6c khng dong nng ( Sintrom. .) 0 T1`1y bnh,muc tiu INR khc nhau:van dong mach chu co hoc cn INR tn 2 - 3 trong khi van 2 l co hoc cn INR tn 2,5 - 3,5. 0 Nru INR khng dat toi ngung muc tiu thi s d bi cuc mu dong lm ket van,nu cao qu muc tiu thi d5 bi chay mu(nng nht l chay mu no). Amylase l enzym thuy phn tinh bt thnh maltose & glucose.Nguon gc:ch yu tuyrn tuy - tuyrn nuc bot,con c o gan - rut non - tinh hon - voi Fallope.Amylase huyt:bt 86 - 268 U/ L. tng:bnh tuy (vim tuy cp,vim tuy man).Ngoi ra:thng rut - tc rut,vim ti mt - nhim trung duong mt,vim rut thna,nhi mu mac treo,thai ngoi tu cung vo,vim tuyn mang tai,suy thn,K phoi. . 0 Vim tuy~cp m Amylase/ mu khng tng:l) vim tuy cp tr 2) bnh tng Triglyceride di kem 3) Vim tuy cp/Vim tuy man.- Do d xt nghim ny cn dnoc h tro h6i siu m hung (ihy dnoc tuy ph n hoai t dng thoi chn don phn bit Vl cc nguyn nhn gy tng Amylase mu khc) & choc do dich mang bung (dich mang phi) dni siu m - dinh lutong men tuy trong dich.(vim tuy cp:> 20.000 UI/ ml). Cholinesterase - l enzyme phn 1y Acetylcholin 6 tip din ihn kinh & oh n61 ihn kinh - co.0 c 2 loai: + Acetylcholinesterase:l choli tht,c trong hong cu & mo than kinh. + pseudocholinesterase:l choli huyrt thanh.I bt:5.300 - 12.900 U/ L - 37oC.0 gim:nhim doc thuc tru su (chrt phosphat hu co. .),vim gan,xo gan. .AFP :Alpha-Fetoproteino bt:10 - 20 ng/ ml. 0 K tc do tng nhanh gy tng AFP - gom nhnng bnh:1. K gan 2. K tinh hon 3. K buong trnng. 0 gi tri:+ Vim gan cp,3 thng cui thai ky:tng # 60 ng/ ml. + vim gan man:tng > 100 -> c kh nng K ha trong 5 nm lin tip.Tng > 200: kh nng K giai doan hin tai. + K nguyn pht:tng > 1.000.0 Luong Alpha-fetoprotein do bng cch Xt nghim mu. 0 Alpha-fctoprotcin (AFP) l mot chi diem ung thn thnong tng o tfr 60% dein 70% bnh nhn ung thn to bo gan (hepatocellular carcinoma:HCC). I Binh thnong,AFP o muc < 10 ng/ ml,nhnng thnong tng dn muc gii han (10 drn 100 ng) o nhnng bnh nhn vim gan man. 0 Tuy nhin,tt c nhng bnh nhn c tri so AFP tng cao dn nn dnoc tm sot HCC (bng siu m bung,CT scan hoc MRI) dc bit khi AFP tng hon so voi tri s cn bn o cc xt nghim d lm trnc dy. - Theo kinh nghim,khi ni s AFP tng ln dn dn thi chn don HCC hu nhn chc chn.13 PDF created with pdfFactory Pro trial version wwwpdffactorycom 14. by death_nt88 source:diendanykhoa. com 20100 Do chuyn bit cua AFP rt cao nru tri 55 vnot qua 400 ng/ ml. 0 Cc carcinom qui (teratocarcinoma) khng bit ho v carcinom t bo phi thai (embryonal cell carcinoma) ca tinh hon hay buong trung c th cho kt qu duong tnh gi,nn chung cn phai dnoc dua vo phn chain don phn bit tng AFP. - Thoi gian d tri e6 AFP tng gp d6i 12: t 60 dn 90 ngy. 0 Do d,nn km tra AFP mi 3 drn 4 thng d tm sot HCC o cc bnh nhn xo gan c nguy co cao (vim gan C,vimgan B,v binh mu nhim sit hemochromatosis). MEN TIM0 L nhm xt nghim khng th thiu doi voi cc trnong hop Nhi mu co tim.0 Cc men thnong lm:Troponin I,CK - MB. Troponin ITroponin:l protein soi co ca co vn.Gm 3 bn don vi:1)Tr0p0nin I:nc ch actomyosin ATPase2) Tropnonin T:gain phrc hop Troponin voi Tropomyosin 3) Troponin C:c 4 vi tr gn calci. TrapaninI Troponin tng cng cao,t surt cng cao0 Cn it nht hai ln do voi ln sau cung cch t nht 6 gio sau con dau ngnc de loai trn nhoi mu co tim0 Sau nhi mu co tim cp,troponin c th tng hon 10 ngay nn khng the dung d? : dnh gi dau ngnc sau nhi mu. I Troponin lc tnh nhay v dc hiu d chn don nhoi mu co tim chu phu0 Troponin khng dc hiu 100% cho nhi mu co tim cp Truzing hop duong tnh gi. '0 C the do gn ket khng dc hiu gia khng th trong thu6c thu' voi troponin trong mu c nguon gc khng t' tim (circulating troponin of non-cardiac origin)0 Suy thn:troponin l chi diem tim :6: o bnh nhn chay thn nhn tao nhnng khng hu ch o bnh nhn suy thn man khng duoc chay thn nhn tao0 Yu tf) dang thp (RF) cng c th lm ket qu doc troponin I duong tnh. 0 Troponin I:c d@ nhay - chuyn bit cao.Bc dim:+ ra eh:dnh du tim c d6 ehe ehn cho ehn don hon CK - MB.( Tuy CK - MB tng c d6 chuyn bit di voi CO' tim bi hoai tn > 95% nhnng doi khi chi s nay cu cao lin tuc -> khng dong hoc;nguyn nhn do phn nng cho gia CK - MB vri CK - BB ).+ gip chn don chnh xc NMCT o BN hu phu ( CK - MB c tng sau chn thnong co ). - bt:0,5 - 2 ng/ mL( < 0,1 - 0,2 ng/ mL ),> 2 ; ehn don ehe ehn. 0 Bong hoc:kho tng 3 - 12h,dinh 24 - 48h,v binh thnong 5 - 14 ngy.CK - MB0 CPK( Creatin Phosphat Kinase ),goi gon la CK( Creatin Kinase) :la enzym chuyn phosphat : n ATP sang Creatin.C nhiu o:tim - co xnong,t o no. 0 CK c 2 bn don vi l M (muscle:co) & B (brain:no),c 3 isoenzym l: 1) CK - BB ( CK1 ):c nhiu o no2) CK - MB ( CK2 );c nhiu 6:i_in3) CK .MM (CK3 );e6 nhiu 6 co. 0 CK - MB l isoenzym ca CK,duoc sn dung trong chn don NMCT vi c nhiu tim - dc hiu cho tn thnong co timkhi do 24 - 36h sau dau ngnc. CPK ( C reazne phosphoknase ) cling cnfuzrc goi l CK (Creatine knase) VCPK l mt enzyme duot tim thy ch yu ' tim,no v co' vn.CPK c 3 saenzymes c cn trc hoi kho nhau 14 PDF created with pdfFactory Pro trial version wwwpdffactorycom 15. by death_nt88 source:diendanykhoa. com |2()10- CPK-1 (een gei l CPK-BB,CK-BB) tp trung chu yen 6 no v phei I CPK-2 (con goi l CPK-MB,CK-MB) tim thy chu yu o tim 0 CPK-3 (con goi l CPK-MM,CK-MM) tim thy ch yu co vnD0 d0' CK tng khng c y' ngha chn don nh mu ca tim vi n khng dc hu cho tn thnong tai tim m c th d0 nhng tin thnong tai ca vn,no,phi. ..CK -MB co' tnh c hu cho nin thnong tai tim hon CK v duno xem l mt trong nhng chi dim ca haizt' tu" co tim CK-MB han 5% CK c y ngha dming tnh cho nhi mu e0 tim ` Nu CK-MB tng m CK binh thrtng cng c ngha l bnh nhn c nguy ca nh mu CU tim cao. CK-MB e thdwang tnh gi trung 8% trnong hop thuyn tc phi Bnh nhn chay thn nhn tao bt:CK - MB Nu BN dn tr d qu thoi gian dinh & thin gian ht ca CK ~ MB (qu 10 ngy):luc ny phi dna vo men LDH,Troponin.( =LD =Lactate Dehydrogenase )I LDH l enzym ni bo c trong hu het cc te bo dang chuyn ha,hrn lnong cao r:tim - co xnong - gan - thn - no - hng cn. I l men tng mun trong NMCT cp,nhay nhnng khng dc hien.N goi NMCT,LDH con tng trong:tn huyt,bnh bach eu,henh thn. .- LDH/ mu =LDH ton phn.Khi dien di,tch hie:dnoc 5 isoenzym:LDHl,LDH2, LDH3, LDH4, LDH5 -> nen thy LDH tng,lm them dng vi LDHl (c trong co tim) dc hiu hon & ti 56 LDHl/ LDH2 > l -> NMCT. I bt:230 - 460 U/ L - 37oC. 0 Dng hoc LDH:khri tng 12h,dinh 24 - 48h,ve binh thnong 10 - 14 ngay. 0 Troponin & CK - MB tiu tng trong trn`ong hop:1) vim co tim,vim mng ngoi tim 2) dung dp tim,phu thut tim 3) kh rung 1ien iiep. 0 Troponin I vnot tri hon CK - MB ve 2 mt:l) d@ nhay,dc} chuyn bit cao. 2) tng Sm 3 gie sau khei phtdau,dinh 24 - 48h,mi 5 - 14 ngy sau m6i : i6 ve binh : hneng v6i viee duy : ii se dnh du lu nh:nhn : he,Troponin bao gm uu dim (som) ca Myoglobin,CK ~ MB & nu dim (mun) ca LDH. I Troponin Inu tile hon CK - MB trong mt s hon cnh:+ en ehn don phn hie:NMCT kheng sr chnh ln vi Dau : h:ngnc kheng en dinh.( CDTNKOD kheng : he lm tng Troponin nhnng doi khi c CK - MB (tim) tng do giao thoa v'i su' tng CK - BB (no). + en pht hien NMCT ep 6 BN hen phu (rn CK - MB e6 : he tng d0 ve:me e6 hp).+ cn khng dinh NMCT cp nhng nguoi bi hy hoai co nhiu ( CK - MB cng tng ) nhn:vim da co,loan duong co,suy thnman;hoc or Bn Xut huyt no,Nhi mu no - c hy hoai mo no ( CK - BB tng & c sn tng giao thoa CK - MB);hoc BN dang K ph quan - ph6i,K tuyn tin lit,nhi mu rut. - Tuy nhin,khi en phn dinh NMCT v6i chen : hueng tim,phu tim,vim e6 tim,vim mng ngoi tim,see dien kht:rung : he:lin : iep:CK - MB & Troponin den tng (vi l du en : e bo e6 tim bi hy) nn uu : he c 2 nhn nhau. 0 Su' dung men tim cn cho trnong hop c 1 tiu chuin ri cn 1 tiu chun na: 6 + m6i me,gi,DTD -> d6 ECG c du NMCT -> deng men tim de ehn don xc dinh. 6 + dau ngee kieu NMCT nhnng ECG ehi c du hien block nhnh hay BN de:my tao nhip -> che rep ECG -> lm men tim. - Cc trnong hop:phinh vch : h: , Dau : h:ngnc kheng en dinh -> chi en ECG theo dei l dn.15 PDF created with pdfFactory Pro trial version wwwgdffactorigcom 16. by death_nt88 source:diendanykhoa. com i 2010kh mu dng mach0 chi dinh KMDM: 1) suy he hep mei ngnyen nhn::ei phei hay ngoai phei2) suy tun hoan,choang,nhiem trng mu (SEPSIS)3) suy thn & henh 1y eng thn4) benh ni tirt:di tho duong nhim toan ceton,bnh v thnong thn,suy gip5) hn m,ng@ dc6) bnh tiu ha:i,tiu chy,do ti mt or rut non,tuy tang7) cc ri loan dien giai:tng gim K mu,Chlor mu8) theo doi dieu tri:oxy liu php,tho my,nui n qua duong tinh mach,loc thn,truyen dich or truyn mu lnong lon,dieu tri loi tiu. .-> tm lai;suy h hp - suy thn - di tho duong - ri loan din gi - hn m ng@ dc,tho oxy - loc thn - truyn dich/mu lnong nhiu. .- i cc chi' se en quan tm de ehn don Rei loan kiem toan:pH,PaCO2, HCo3 std (=standard bicarbonate =HCO3 chun).0 cc tmong hop thnong gp:0 Toan h hrp trong bnh COPDToan h hfp Irong ARDS' ~ Toan chuyn ha trong sc nhim ming r ` Toan chuyn ha trung hn m nhim ceton /tiu ditong.Ri loan toan km hn hop: l) toan chuyn ha + toan h hp:ngung tim ngung me,phi`i phi cp nng,nhim dc.2) toan chuyn ha + kilm h hp:ng@ dc Salicylate,SEPSIS,suy gan nng. 3) toan chuyn ha + kilm chuyn ha:suy thzfin/i nhiu,nhm toan ceton/i nhiu.4) kiem ehuyen ha + toan he hp:COPD/6i nhieu,dung nhieu iei tiu. 5) kiem ehuyen ha + kiem he hep:suy gan nng/6i nhieu. 1. pH0 cho birt trang thi thng bng km toan (< 7,35: toan,> 7,45: km). 0 pH toan ciing voi PaO2 gim l du hiu thiu oxy r mo. I khi PaCO2 tng m pH binh thnong l tinh trang n dong CO2 man,con pH gim l cp. ' gi?F ,, ,7,3 - 7,5: ri loan toan km nhe -> chi cn diu tri nguyn nhn.7,1 - 7,3: toan mu nng mt bu.7,5 - 7,6: km mu nng mat bu.< 7,1 or > 7,6: nguy him tnh mang.< 6,9 or > 7,72 tn vong nhanh chong. 0 dna vo henh cnh d Xem xt muc di) nguy him.Vi tinh hung:_ I + pH =7,,2: cr th chua c triu chung boi sn chiu dung : e: ca BN COPD trong khi l trn`ong hop nguy him tnh mang doi voi BN suy h hp cp. + pH g 7; e6 : he c 6 BN bi deng kinh khi ln con nhung hiem khi en giai quye:vi pH s nhanh chng ve binh thnong sau khi dieu tri chm dnt con co git.15 PDF created with pdfFactory Pro trial version wwwpdffactorigcom 17. by death_nt88 source:diendanykhoa. com 20100 [H]+:l 1 trong 3 chi' S6 trong phnong trinh Henderson -> tnh [l-`I]+ d6 kiem tra krt qu kh mu ( vi may do thnong chi do pH & PaCO2 -> sau d tnh HCO3 ) dng thoi gip tnh nng d6 HCO3 cn thit d dieu chnh pH mu trong diu tri.Tnh [H]+ dna vo pH.Tnong quan: -> n6ng d6 [H]+ tng thi pH gim,n6ng d6 [H]+ gim thi pH tng:ti 16 nghich.(vi pH l log m ca n6ng d6 [H]+ ) -> pH tng hay gim 0,1 thi n6ng d6 [H]+ gim hay tng thm 20%.-> cn nho 2 cp:pH =4,0 -> [H]+ =40 ,pH =7,0 -> [H]+ =100. (don vi [H]+:nEq/ l)-> phnong trinh Henderson:[H]+ =24 X (PaCO2 /HCO3 ). 2. pCO2 binh thnong 35 - 45 mmHg (40 +/ - 5).l phn p carbon dioxide trong mu (ap sut phn cua kh CO2 d thng blng voi mu).trong mu:BM -> PaCO2, TM -> PvCO2. PaCO2 daee dien chnh h6i phei . > l thnh phn he hep cua thng hng kiem toan.i Y nghia:phn nh trirc tip muc d6 th6ng kh phe nang c ph hop voi t6c d6 chuyn ha ca co the khng -> dung trong LS d dnh gi th6ng kh ph nang.kheng dei theo tu6i.(e6 ihe) gim khi dei : aeng gia tng : heng kh (de lO reng,ien de cao > 2.500m).I PaCO2 anh hnong dn pH theo phnong trinh:CO2 + H2O H2CQ3 HCO3- + H+ i -> PaCO2 tng:s chuyn hnng phnong trinh qua phai:toan ho hp. -> PaCO2 gim:s chuyn hnong phnong trinh qua tri:kiem h6 hp.I gi tri:+ > 45 . > gim th6ng kh phe nang -> mnc th6ng kh : hep hon nhu een thai Co2 ca e6 : he.-> nguyn nhn:1.giiri : heng kh phe nang,2.he:xang gina : heng kh v : aei mu.+ < 35 -> tng th6ng kh ph nang -> muc th6ng kh cao hon nhu cu thi CO2 ca co the.-> nguyn nhn:1 . gim PaO2, 2.gim pH,3. he thn kinh bi kch thch,4. cho tho may qu dng.I chn don suy h6 hp nho PaCO2: suy h6 hp crp nu pH gim,man nu pH binh thnong. 3.Std ( HCO3 chun - standard bicarbonate) bt:21 - 26 mmol/ L. l n6ng d6 Bicarbonate trong mu d6ng mach (HCO3- khi PaCO2 =40mmHg,bo hoa voi oxy v or 37oC). men,l`a thnh phen ehnyen ha ca thng hng kiem toan.Doc KMDM qua 3 bnc d6 xc dinh toan kiem:Buoc l:Xem pH Buoc 2: Xem PaCO2 Buoc 3: Xem HCO3 std. o C6 3 : inh hu6ng: 1. pH < 7,350 l trnong hop Toan iriu. i 0 Tip theo xem PaCO2 d xc dinh l toan h6 hp or toan chuyn ha: > 45 -> toan h6 hp < 35 -> toan chuyn ha. 0 bnc 3: xem HCO3 std.C 2 nuong hop:1. PaCO2 > 45: toan b6 hp.-> xem HCO3 tng bao nhiu vei mei i0 mmHg tng ca PaCO2: 17 PDF created with pdfFactory Pro trial version wwwpdffactorycom 18. by death_nt88 source:diendanykh0a. c0m |20 l 0+ tng 1 - 1,2; toan h hp cp ( pH gim 0,07 )+ tng 3 - 4: toan h hp man ( pH gim 0,03 )+ tng 1,2 - 3: toan h hp cp trn nn man (pH 0,03 - 0,07) 2. PaCO2 < 35: toan chuyn ha. -> Xem PaCO2 gim bao nhiu vi mi 1 mEq gim ca HCO3:gim 1 - 1,2 JnmHg:toan chuyn ha c b (2 s l ca pH =PaCO2 hoc PaCO2 =(l,5 x HCO3) + 8, hoc PaCO2 =HCO3 + 15)2. pH > 7,45 I l trung hp km mu.- Tip theo xem PaCO2 d xc dinh l km h hp hay km chuyn ha:< 35; km na hp > 45: km chuyn ha.I buc 3: xem HCO3 std.`C 2 trumg hop:1. PaCO2 < 35: km h hp. -> Xem HCO3 gim bao nhiu vri mi 10 mmHg gim ca PaCO2:+ gim 2 - 235; kimrh hp cp ( pH tng 0,08 ) + gim 5: km h hp man (pH tng 0,03) 2. PaCO2 > 45: km chuyn ha. -> xem PaCO2 tng bao nhiu vri mi 1 mEq tng ca HCO3:tng 0,7 mmHg:km chuyn ha c b (2 s l ca pH =PaCO2 hoc PaCO2 =HCO3 + 15 )3. 7,35 < pH < 7,45c 3 kh nng: khng c ri loan:pH,PaCO2, HCO3 std du binh thung. c ri loan duqc b d:pH:binh thung PaCO2, HCO3: khng binh thurng. c ri loan kim toan hn hqp:pH:binh thung PaCO2, HCO3: khng binh thung. oogasoogxr-AP DUNG 5 QUY LUAT DQC KMDMLut 1 I Ri loan toan km chuyn ha nguyn pht nru:pH bt thung & pH,PCO2 thay di clug chiu.I Nhm toan chuyn ha:pH < 7,35 & PCO2 < 35. I Nhim km chuyn ha:pH > 7,45 & PCO2 > 45.Lut 2 Ri loan toan km h hp km theo nu: I PaCO2 d0 duqc > PaCO2 du don:toan h hp.- PaCO2 d0 dugo < PaCO2 du don:km h hp.13 PDF created with pdfFactory Pro trial version www. gdffactory. com 19. by death_nt88 source:diendanykh0a. c0m |20 l 0Lut 3 I Ri loan toan km h hp nguyn pht khi:PaCO2 bt thung & pH,PCO2 thay d nguqc chu.o toan h hp:1>co2>45 &pH 7,45. Lut 4 0 su' thay di pH mong dqi (tnh theo phnong trinh) quyt dinh:ri loan h hp cp/ man?C ri loan toan km d0 chuyn ha km theo?I Cc ri loan nguyn pht:o Toan chuyn ha -> thay di b mx:pCO2 =1,5 x HCo3 + ( 8 +/ - 2).o Kim chuyn ha -> TDBT:pCO2 =0,7 x HCO3 + ( 21 +/ - 2 ).o Toan h hp cp -> TDBT:A (dama) pH =0,08 x (pCO2 - 40).o Toan h hp man -> TDBT:/ pH =0,03 x (pCO2 - 40).o Km h hp cp -> TDBT:/ pH =0,08 x (40 - pCO2).o Kim h hp man -> TDBT:A pH =0,03 x (40 - pCO2).- gi m:< 0,003 -> man,> 0,008 -> cp (ri loan toan km d0 chuyn ha).B khi < 0,003 & b 1 phn khi 0,003 < A < 0,008. Lut 5. Ri loan toan lcm hn hqp:a pCO2 bt thung,pH binh thumg - pH bt thung,pCO2 binh thung. SO DA This image has been iesized.Click this bar to view the full image.'The original image is sized 645x359./PH thm IPaCO2 car. : PaCO2 BT PaCOg thpTom-i Ho Hip TOAh CH 'Z i lYzpHr PaCOgx 100 xzma-: Hcog-; ka 0:2,. 550.8 Y:0.8 Vzx-i-O 8 "(40.3 PaCDo>X PaCOcX PaCO tcan GH b tr,khi dc c b phi xem pH,nu pH trcng gii han BT I b tr hcn tcn.nu pH ngci gii han BT I tcan CH b tr khng hcn ton. is!This image has been resized.Click this ba:to view the full image.The original image is sized 634x343. 19 PDF created with pdfFactory Pro trial version wwwgdffactorycom 20. by death_nt88 source:diendanykh0a. c0m |20 l 0 /PH cao . gPaco;cas haie BT Paco?m , L Kir-. i cH KIEFJI HH x:naicHcoaiu-zuaizisa `i': pH= &PaCO; X100AGE/ vex*PaCOpX PQCUFX PaGOg 7,45: nhim km.I PaCO2 binh thung hoc cao:km chuyn ha nguyn pht.Dua vo quy lut 2 d bit ri loan toan km h hp kt hop?0 PaCO2 thp:km h hp l nguyn pht.Dua vo quy lut 4 d bit cp/ man & c ri loan toan kimchuyn ha kt hp?@ 3 I pH binh thung:7,35 - 7,45. - PaCO2 cao -> toan h hp & km chuyn ha hn hqp.I PaCO2 thp -> km h hp & toan chuyn ha hn hgp.0 PaCO2 binh thumg:c th l toan chuyn ha dng thi c km chuyn ha.Anion Gap (khong trng anion) I AG= Na+-(Cl-+HCO3-)=12+/ ~4mEq/ l. I AG cho birt toan chuyn ha l do tch tu acid hay d0 mt HCO3-:o AG tng -> tch tg acid hfru ca (acid lacc,keto acid) hoc suy thn khng thi acid duqc.Gp trong:l.suy thn cp 2. tiu durng 3. suy dinh dung 2o PDF created with pdfFactory Pro trial version wwwgdffactorycom 21. by death_nt88 source:diendanykhoacom 20104. chong (nhim trng,tim,gim th tch)5. ng@ dc thu6c,rugu. o AG binh thung -> toan chuyn ha mat HCO3- ,thun g km gim K+ mu.Gp trong:l.tip chy2. diu tri bng Diamox3. toan huyt 0ng thn. C N G T HITC MAU @ TE BAO MAU NGOAI VI=white blood cell =bach cu. o bt:4.000-10.000 bach cn/ mm3 . 0 l s lugng bach cu c trong mt don Vi mu. - Cng thc bach ciu:l ty l phn trm cc 10m bach cuhong mu.can tinh ra s lugng tuyt n61 ca m6i loai (vi c khi til phn trm giam nhung s luqng tuyt di lai binh thung nu tng s bach cu tng - hay ngugc lai).Bao gm:NEU:NEUTROPHIL =Da nhn trung tnhLYM:LYMPHOCYTE =Bach cu LymphoMONO:MONOCYTE =Mono b`aoEOS:EOSINOPHIL =Da nhn i toanBASO:BASOPHIL =Da nhn i km. 0 gi tri: > 10.000 -> tng tht su< 5.000 -> gim on th hi phuc< 4.000 -> gim ,kh nng hi phuc mp;c bnh 1y. 0 tng: - nhim trng,nhim dc,Vim- mt mu nhiu- sau n no,sau hoat dng (vi vy khng nn ly mu th lc ny). -> BC tng cao trong bnh Bach cu cp.0 gim:d0 thu6c,st rt,thnong hn,bnh d0 virus:vim phi khng din hinh,thy du,cm. . NEUTROPHIL :Da nhn trung tinh0 bt:60 - 66% ( 1.700 - 7.000 /mm3 ). I dc dim:+ l nhng t bo trung thnh trong mu tun hon v c mt chc nng quan trong lthirc bo,chng s tan cng v ph hy cc loai vi khun,virus ngay trong mu tun hon khi cc sinh vt ny vra xm nhp co th -> vi vy tng trong cc trurng hqp nhim trng cp. + trong trining hqp nhim trng qu nng nhu nhimrtrng huyt hoc bnh nhn suy kit,tr so sinh,lugng bach cu ny gim xung.Nu gim qu thp thi tinh trang bnh nhn rt nguy him vi src chng cu Vi khun gy bnh gim st nghim trong. + Bach cu cng gim trong nhng trurng hp nhim dc kim loai nng nhu chi,arsenic,khisuy ty,nhim mt 50 virus. .. 0 gi tri:tng:> 75% ( > 7.000 / mm3)gim:< 50% ( < 1.500/ mm3 ).0 tng:21 PDF created with pdfFactory Pro trial version wwwpdffactorycom 22. by death_nt88 source:diendanykh0a. c0m |20 l 0+ cc bnh nhim khun cp tnh:vim phi,vim ti mat. . + cc qu trinh sinh m:apxe,nhot. .+ Nhi mu co tim,Nhai mu phi+ cc bnh gy nghn mach+ bnh Hogdkin,banh bach cau+ sau ba an,vn dng manh ( tng t - tam thri ). I ~ gim:r r+ nhim trng ti cp+ cc bnh do virus trong thoi ky toan pht:cm,si,thuy du. . + 845t rt+ cc bnh c lch to gy cung lch,Hogdkin+ thiu 1312 c tnh ( bnh Biermer)+ nhim dc thu6c,ha cht+ sc phn v+ gim sn hay suy ty xnong+ Bach cu cp,Bach cu kinh th lympho.LYMPHOCYTE =Bach cu Lympho- bt:20 _ 25% ( 1000 - 4000 /mm3 i. o dc diam;+ l nhng ia bo c kh nng mian dich ca co tha,chng c iha trr thnh nhng ia bo "nh" sau khi dap xc vdi tc nhan gay banh ya ian tai lu di cho dan khi dap xc ian na vi cng tc nhn ay,khi ay chng s gay ia nhng phn ung mian dich manh m,nhanh v ko di hon so v6i ian dau. + Lympho bo tng trong ung thu mu,nhim khun mu,nhim lao,nhim virus nhu ho g,sori. .. Gim trong thnong hn nng,stpht ban. .. I gi tri: tng:> 30% ( > 4.000] mm3 ). gim:< 15% ( < 1000/mm3 ).' tng:.+ Bach cu cp th lympho+ Nhiam khuan man tnh:lao,ihap khdp. .+ cc bnh do virus:si,ho ga,Vim gan siu vi. .+ trong thri ky lui banh ca mt sa banh nhiam khuan cap tnh.I gim: + mt s bnh nhim trng cp tnh+ chung mat bach cu hat,sc phn V. . 22 PDF created with pdfFactory Pro trial version wwwgdffactorycom 23. by death_nt88 source:diendanykhoacom 2010+ bnh Hogdkin,nht l trong giai doan sau + Bach cu cp (tru th lympho) + cc bnh tur min,tao keo+ dian ni thu6c Uc cha mian dich,ha cht ni K. .O:MONOCYTE =Mono bo0 bt:2 - 2.5% ( 100 - 1000] mm3 ).' dc dim:+ l dang chua trung thnh ca dai thuc bo trong mu vi vy chua c kha nng thuc bo. + Dai thuc bo l nhng te bo c vai tro bqvbng cch thuc bo,kha nng ny cua no manh horn ca bach cu da nhn trung tnh.Chng s phn b dn cc m6 ca co th,tn tai tai d hang thng,hang nm cho dn khi duqc huy dng di lm cc chc nng bo v. + Vi Vy mono bo s tng trong cc bnh nhim khun mn tnh nhu lao,Vim Voi trng mn. ..0 tng: + bnh do virus:cm,quai bi,vim gan+ thi ky 1m banh cua mt sa banh nhiam khuan;vim ni tm mac bn cp (Osier),lao. .+ st ret+ bnh chat tao keo+ chung mt BC hat d0 nhim dc di ung+ mt s bnh c tnh:K duong tiu ho,bnh Hogdkin,u tuy,bach cu cp dong mono. -> Mono & Lym cng tng: + d0 virus:cum,quai bj,si+ thuong hn.EOSINOPHIL =Ba nhn i toan I bt:2-ll%(50-500/mm3).0 dc dim:+ kh nng thutc bo cua loai ny yu,nn khng dng vai tro quan trong trong cc bnh nhim khun th6ng thurng. + Each cn nay tng cao trong cc truong hop nhim ky sinh lrng,vi bach cn ny tan cong dugo ky sinh trung v giai phng ra nhiu cht d git ky sinh trung. + N goi ra bach cu nay con tng cao trong cc bnh 1y ngoi da nhu cham,mn do trn da. .. 0 gi tri: tng:> S00/ mm3gim:< 25/ mm3. I tng nhe & thong qua: + thi ky lui banh ca mai sa banh nhiam khuan,nht l sau khi dian ni khng sinh+ khi diu tri hng cu thiu mu bng cc tinh chat gan.a 23 aPDF created with pdfFactory Pro trial version wwwpdffactorycom 24. by death_nt88 source:diendanykhoacom 20100 tng cao & lin tuo:+ cc bnh giun sn+ cc trang thi di &ng;hen,chm,man nga,banh 1y huyt thanh,hai chung Loeffler + Leucemie ty th bach cu da nhn i toan,bnh Hogdkin+ bnh chat tao keo+ sau th thut ct b lch+ sau chiu tia X. 0 gim:+ suy ty bi ton thnong hon ton + nhim khun cp tnh,qu trinh sinh m cp tnh+ hi chng Cushing,trang thi sac dian ni bng Corticoide.BASOPHIL =Da nhn i km0 bt:O.5-l%(10-50/mm3).I dae dim:dng vai tro quan trong trong mt sd phn ung di ung.0 tng: + bnh Leucmie man tnh:cng tng - tin luong cng tt+ bnh tng hng cu Vaquez+ sau tim huyt thanh hay cc chat albumin+ trong vi (rang thi do thiu mu tan mu,BC da nhn i km tng 2 - 3%. I gim:_ + ty xuong bi tn thuong hon ton+ di ng. @ TE BAO MAU NGOAI VIRBC =Red Blood Cell:hang can. 24 PDF created with pdfFactory Pro trial version wwwgdffactorigcom 25. by death_nt88 source:diendanykhoacom 2010+ nam:4.000.000 - 5800000/ mm3 + n:3900000 - 5.400.000/ mm3. ' V dc diem:(wiki)+ l c trong mt don vi mu (thung l lt hay mm3). + c hinh dia 16m hai mat.Doi sng:120 ngy. + c chc nng chnh 1`a h hp,chuyn cho hemoglobin,qua d dua 02 t' phi dn cc m6.+ Hng cu dugo tao ra t1`I cc t bo mu gc trong ty xurorng,da sd bng cu bi hy lch. + Yru td ch yu diu hoa sn xut hng cu:mirc dc} xy ha ca co th.Khi gim luong xy chuyn ch ti cc m cng kch thch su tao hng cu. + khi co th bi thiu mu,ty xnong s tng sinh hng cu.Khi phn kin ty xnong bi hy hoai (chang han d0 Xa tri ung thu),cc phn ty con st lai cng s tng dung d b dp cho cn cn cung - cu. + Vitamin B l 2 v axit folic l cc chat dinh dung ht suo cn thit cho su:Imong thnh ca hdng cu.Thiu vitamin B l 2 v axit folic gy thiu ADN hoc tao ra cc ADN bt thnong,nh huorng dn su. ' trung thnh ca nhan v su:phn chia t bo. + cc ty bo di vo mu tun hon duoi dang hng cu bat thung voi l-p mng mong manh v thnong c dang trfing,to thay vi dang dia 16m hai mt:chng vn thuc hin duoc chc nng cho xy nhung voi hinh dang v lrp mng nhu Vy:doi sng 40 - 60 ngy. 0 gi tri:trung binh 3,5 triu - 4,5 triu t b`ao;< 3,5 triu -> thiu mu. ' tng:, ,, ,+ c dc mu (mt nuc,nn nhiu,di ngoi.. . ), da hng cu thuc (bnh Vaquez). + banh gay rai loan tun hon tim,phai i banh tim bam sinh,hep DM phi,COPD. .),ihiu oxy. . 0 gim:thiu mu,suy tuy,thp khop cp,gi,mang thai. . :Hb :Hemoglobin :huyt sc td.bt:+ nam:14 - 16 g/ dl,trung binh 15 g/ dl + n:12,5 - l4,5 g/ dl,trung binh 14 g/ dl.0 dao dim: + l sir kt hop ca heme v globin. + chua bn don vi con,mi don vi kem theo mt nhm heme.M51 nhm heme cha mt phn tu' st - dam nhim cho vic gn kt vri oxy. + Nng d@ hemoglobin trongbo taong ca bng cu c th ln dn 34 g/ dL t bo.B6 la nng dc} ti da khng lm ri loan chrc nng tao hemoglobin trong hng cu. + ngui khe manh binh thnong,ndng d hemoglobin trong hngncu lufin gan muc ti da ny.Tuy nhin,khi chic nng tao hemoglobin bi suy yu,nng d ny tut gim dang k,c th lm th tch hng cu gim theo. + do trong luong so td ca hng cu. 0 gi tri:chain don thin mu + Nam Hb < 13 g/ dl + N Hb < 12 g/ dl+ Phu n mang thai & nguoi gia Hb < l l g/ dl.0 lin quan truyn mu (Vin Huyt hoc TW):25 PDF created with pdfFactory Pro trial version wwwpdffactorigcom 26. by death_nt88 source:diendanykhoacom 2010+ Trn 10 g/ dl;thiru mu nhe,kh6ng can truyn mu. + T1} 8-10 g/ dl:thiu mu Vixa,can nhac nhu cau truyn mu.+ T1} 6-8 g/ dl:thiu mu nng,can truyn mu. + Dui 6 g/ l: can truyn mu cap ctru. -> < 7g:can duyan mu/XHTH.:Hematocrit :dung tch h6ng cau. 0 bt:trung binh 40% + nam:42% + n:38%.I dc dim: + l ti ia phan trm gia khai h6ng cau & mu ton phan. + do th tch ca h6ng cau+ trong m6t S6 truong hop do truyn dich Hct gim.Vi Vay,theo trinh tu lu'u tam:Hb (vi kh6ng ty thu6c:th tch nuc co th mirc d6 thiu nuc ca BN -> Hct -> RBC. + HCT/3 :HGB. + c gi tri trong Vi6c dnh gi v theo d6i cc tinh trang mat mu cap:thiru mu do Xuat huyt tiu ha,gin V6 tinh mach thuc quan... d0 hin turong b trix ca co th mu duoc huy d6ng t cc co quan du tr mu nhu lch,h tinh mach sau. .. nn gi tri huyt sc t thay di cham hon so Voi luong mu d mat. +`can duoc duy tri an dinh d mutc t6i thiau 25% hoc d mirc 30% d nhtmg bnh nhan mac banh tim hoc ph6i bng duyan khai hng cau. 0 gi tri:+ > 55%:nguy co tai bin mach mu no (stroke)+ gim:l co so( quyrt dinh truyn mu:< 20% (25%) di voi nguoi trung thnh< 30% (28%) dai v6i ngubi gia. 0 tng:' nuc trong t bo,bnh tng h6ng cau,shock. . 0 gim:thiu mu,xuat huyt cap. . :Mean corpuscular volume :th tch trung binh m6t h6ng cau 0 bt:80 -100 i1 ( fi :femtolit,1 fi =10 (m)-15 lit).I c6ng thrc:MCV =HCT/RBC X 10I gi tri:< 80: nh> 100: to> 140: kh6ng la.25 PDF created with pdfFactory Pro trial version wwwpdffactorycom 27. by death_nt88 source:diendanykhoacom 2()l0 :Mean corpuscular hemoglobin :sd litong hemoglobin trung binh trong m6t h6ng cau0 bt:27 - 32 pg (pg:picogram,1 pg =10 (m)-12 gram ).0 c6ng thrc: MCH =HGB/RBC 0 gi tri: < 27: nhuoc sc> 32: uu sc.=Mean corpuscular hemoglobin concentration =ndng d hemoglobin trung binh trong m6t h6ng cau. 0 bt:32 - 36 g/ dL.0 c6ng thc: MCHC =HGB / HCT x 100 0 gi tri: < 32: gim sc 32 - 36: dang sc> 36: tng sc. TM LAI- Thiu mu h6ng cau nh,nhu-qc sc l d0 bat thnong chat llrng t6ng hrp huyt sc t6 gay loan sn h6ng cau.- Thiu mu h6ng cau to l d0 bat thnong cung cap cc chat d6 san xuat tai tao h6ng cau. - Thiu mu h6ng cau binh thumg binh sc:n6n thiu mu kh6ng h6i phnc l do bat thumg (r ty xnong.Nu thiu mu c h6iph1_1c c th d0 mat mu chy mu (r ngoai vi. @ TE Bao MAU NGOAI VIRDW =Red (cell) Distribution width =phan ba hinh thi kch thrrdc h6ng cau (khong phan ba h6ng cau).0 bt:12 - 15%.0 dc dim:+ do d6 thay d6i ca kch thu6c v hinh dang h6ng cau -> gi tri cng cao kch thu6c ca h6ng cau thay d6i cng nhiu. + l ty ia % d6 iach (so) S0 vdi kch thurc trung binh ca h6ng cau.0 y nghia:(botruong) -> Chi s6 ny cng ln th6 hin rang cc h6ng cau c kch thu6c chnh nhau cng lon gin tip cho thay c c h6ng cau non V`a h6ng cau trung thanh o mu n goai vi hoc c th ton h6ng cau trung thnh nhung kch thu6c lai to nh khc nhau (cc loai thiu mu h6ng cau to,nh).0 gi tri:dua vo 2 chi s6 RDW (khong phan b6 HC) & MCV (th tch TB l HC) d6 phan bit gia: + Thiau mu thiu sat,Thiau mu d0 thiu acid folic,Thiau mu bat sn my.(khi LS hudng dan nhng banh ny). > Nhin vo RDW.Nau > 15% do TMTS hoc do TM thiu acid folic.Xem tiap MCV:nau MCV < 80 -> TMTs,> 100 -> TM thiau acid folic. -> RDW binh thuong (12 - 15%) & MCV > 100: TM bat sa`n tuy. * M6t cht phan bit: Bat san l hin turong kh6ng hinh thnh day d m6t co quan.Gim san l co quan d hinh thnh nhung chi c hinh dang V cau trc mong tu nhung kh6ng hon chinh.TM bat sn tuy l trung hop tuy xuong mat kh nng sn sinh cc t6 bo mu,nguyn nhan thuong do bnh tu mi6n (kh6ng r6 NN).TM gim san tuy l truong hop TM dang sc dng bo,gap trong Suy than man.27 PDF created with pdfFactory Pro trial version wwwpdffactorycom 28. by death_nt88 source:diendanykh0a. c0m |20 l 0+ B Thalassemia,Bnh V6 gan,Thi6u mu do tan mu mi6n dich & B6nh suy ty x1r0'ng. (khi LS hung dn nhng b6nh ny) -> Nhin Vo RDW.N6u gi tri binh thung & MCV > 100: b6nh Suy ty Xuong. -> RDW > 15% :c th6 TM do 'tan mu MD,b6nh V6 gan hoc B Thalassremia.Xem MCV:n6n MCV < 80 -> B Thalassemia (d RDW cao hoc binh thnong),nu MCV > 100 -> TM do tan mu MD,nu MCV binh thuorng (80 - 100) -> b6nh V gan.% =% Reticulocyte =HC 1116i =HC mang. bt:0,2 - 2%.I dc dim: + HC lu6i (HCL):l HC tr Vita trung thnh tit Nguyn HC di toan trong qu trinh sinh HC,la dang chuyn ti6p gianon trong ty Xuong & HC tr116ng thnh 6 ngoai Vi.H6ng cau 1u6il`a giai doan bi6t ha v trurng thnh cu6i cng ca h6ng cau trong ty Xuong trurc khi Vo dong mu tuan hon. + Nguyn bo h6ng cau tch luy dan hemoglobin cho dn khi d d6 thnh HCL,HCL mat nhan ( mang lu6i cc cau trc ua ki6m ) v di Vo mu thnh h6ng cau. + Tn goi h6ng can 1116i l do khi dude nhu6m (bng m6t sa phnong php nhat dinh) va quan st d116i knh hian Vi,ngnbi ta thay m6t cau trc dang lu6i trong bo tuong ca loai t bo ny. + doi s6ng:24 48 gid. + xc dinh`ti 16 70 HC 1116i ( % reticulocyyte ) cho php dnh gi ! rang thi & kh nng sinh HC ca ty Xuong -> phn nh mc d6 sn xuat h6ng cau mau hay cham,cho bit ty Xuong d dp {rng ra Sao tru6c S1_1 thiu mu. + N 6u reticulocyte count ( tnh ra tit % reticulocyte ) thap,s cho ta thay ty Xuong b6nh,kh6ng sn xuat d cc h6ng cau;nguorc lai,khi tri s6 ny cao,ta bit dang c su that thot h6ng cau qu mc (nhu chay mu dirng tiu ha,chy mu dung sinh duc. ..),hoc dang c hi6n tuorng tan huyt,hy hoai h6ng cau bat thnong trong co th (Vi truyn sai mu,Vi dng thu6c. ..)I r tng:H6ng cau 1116i tng c V6 S6 litong lan ty 16 phan trm khi c sir tng sn xuat h6ng cau chang han trong h6i chfrng thiu mu huyt tn hay trong b6nh thiu mu h6ng cau hinh lim.I gim:Suy tuy,ha tri li6u,thiu mu c tnh. . :platelet =Ti6u cau.I bt:150.000 - 400,000/ cm3. I dc dim:+ Ti6u cau c d6i s6ng 8-12 ngay.D6i m6i Sau 4 ngay. + l nhng manh V6 hinh da mng,kh6ng nhan,t1`1 t6 bo chat ca nhng t6 bo megakaryocyte duorc tim may trong ty Xuong. + Binh thung ti6u can tr6i tn d0 theo dong mu.khi mach man bi dnt,nhng Sqi cciagen 6 d116i l6p bian ma bi b6c 1d ya ti6u can S6 kt dnh tu lai ch6 mach dirt (do thnh mach rnt di6n am kh6ng day , tiu cau na).Tip d,nhng tiu cau dang l1`1u th6ng S dn kt tu Vo d V ko theo su' kt tu ca l6p tiu cau th1'1 3, th1'1 4.. . cho dn khi hinh thanh nt tiu cau (con goi dinh cam mu Hayem) bit kn ch6 t6n thnong. + Suy gim ti6u cau V6 mat S6 luqng hoc chat luqng s gay ra b6nh sinh chy mu. I gi tri:V r + TC < 100.000: hay c xuat huyt + TC < 20.000: xuat huy6t nng -> t1"1 vong. + > 500000/ mm3: tng.I tng:% PDF created with pdfFactory Pro trial version wwwgdffactorigcom 29. by death_nt88 source:diendanykhoacom 2010+ h6i ch1'1ng tng sinh ty,thi6u mu thi6u sat,sau cat lch,tng do phn 11ng sau m6t s6 b6nh 1y:ung thu di cn ty Xuong,u than,u gan... + Tng ti6u cau gi tao:do may d6m nham thnh TC h6i:- manh h6ng cau V6 hoc h6ng cau kch thu6c qu nh (MCV < 65 fl). - man mu ian bni ban.- may n6i dat kh6ng t6t gay hi6n tuong nhi6u nn cc xung di6n nh s ducyc may ghi nhan l cc ti6u cau.I gim: + gim sn iruat (suy ty Xuong,b6nh mu c tnh lan t,ung thu di cn ty xuong,xuat huy6t gim ti6u cau mi6n dich/ ITF),tng tiu thu (xuat huyt gim liu cau,r6i loan d6ng mu tiu thu). + Da S6 cc tr116ng hop tng sir dung ti6u cau dan d6n hoat ha ti6u cau,m6t S6 c lin quan d6n huy6t tat.V6i nhi6m Vu tao ra Vn cuc rnu (Clot),TC tch tu pha trn mng thnh m6t kh6i c1'1ng bao quanh Vnh d6ng mach,gay ra chrig huyt kh6i (Thrombus),huy6t kh6i tch tu lau ngay s day lam bit dung knh ca d6ng mach V lm tt nghn hon ton.Bao gm: .thiu mu gim tiu cau do hy tiu cauff TP.h6i chng tn huy6t - tng ur huy6t/ HUS.ti6u hemoglobin c1_1c di6m V6 dm/ PNH.d6ng mu n6i mach lan ta/ DIC.gim ti6uvcau`do heparin/ HIT, + Gim tiu cau gia tao c th gap do:n ` r N r n ` r r- tiu cau tng kt dinh:lay mu qu lau lm hoat ha tiu cau,lay mau Vo 6ng thy tinh lm tiu cau kt dnh do thnh 6ng lmhoat ha va kat dnh tiu can. - ti6u cau tap trung xung quanh bach cau. ..So b0 TIEN TRIBN TE BAO MAUA This image has been resized.Click this bar to View the full image.The original image is sized 571x702. 29 PDF created with pdfFactory Pro trial version wwwpdffactorigcom 30. by death_nt88 source:diendanykhoacom 2010T aAo Gc ~ Nguynbotin nguyn HC Nguyn un?bo Nguyn bo lympho Nguyn bo mom nhn kh6ng : aQ (W (O) Tln l bo hal 1g T bo nhan khng i6 Tuy" b Tuy" o khinUaikirn uaadd lmng llnh@CODCc giai : oanc T bo nhn kh6ng i5 v ngangalang ui Cc t bo da H6ng cu-Iui0 C 0 Q lai *- i i i BC mmo TiucuHNG cAu sc uakimBCuaacidBCTI' Lympho ' 6.0 'a0 e I a o Q} ~' t=Mean platelet Volume =The tch trung binh tiu cu. * bt:5-8 tl. PCT =Plateletcrit =Th tch kh6i nu cn. * bt:l,6 - 3,6%. PDW =Platelet distribution width =Di phn b6 kch thurc TC. *btz ll-l5%.3) PDF created with pdfFactory Pro trial version www. gdffactory. com 31. by death_nt88 source:diendanykhoacom 2010-> Cc chi s6 v tiu cn:PL~T (s6 luQng),lVlPV (th tch trung binh),PCT (th tch kh6i),PDW (phn b6 kch thuoc);(yahoo) + khi cao hon binh thnong:d bi d6ng mu (tc mach)+ khi thp horn binh thnong;d chy mu. @ NHM MAU 0 phn loai nhm mu dua vo su hin din ca Khng nguyn trn mng te bo hng cu.I cc KN nhm mu ABO l mucopolysaccharide.0 dua Vo su c mt hay kh6ng q mt ca cc KN A & B trn mng HC,Landsteiner phn thnh 4 nhm mu:A,B,AB,O: + A:c KN A trn mng HC,Khng th Anti - B trong huyt thanh.+ B:c KN B trn mng HC,KT Anti - A trong huyt thanh.+ AB:c KN A & B trn mng HC,kh6ng c Anti - A & Anti - B trong huyit thanh. + O:kh6ng c KN A & B trn mng HC,c KT Anti - A & Anti - B trong huyt thanh. a_ ,Anti-A and Anti-B A antigen B antnqen A grid 8 antigens I ti l nhm mu o nguoi VN:0 (48%) -> B (28%) -> A (20%) -> AB (4%).0 h Rhesus: + quy uc:hong cu c cha yu to Rh -> Rh+,nguqc lai -> Rh-.VD:Nhm mu A+ -> nhm mu A & Rh+.+ yu t Rh l l h th6ng gm 13 khng nguyn trong d quan trong nhrt l yu t D.+ cc khng th h Rh kh6ng c sn trong mu,chi Xut hin khi c su tip xc Vi KN -> Vi Vy,khng the h Rh dugo goi l KTnnn dich. M6t cht phn bit: - ngun gc:kh6ng qua qu trinh min dich r6 rng - khng th;IgM- diu kin hoat d6ng:4 - 200C (0 - 37oC)- dc dim: l) kh6ng qua nhau thai2) gy ngung h6i & hy dit HC 3) tiu huyt trm trong trong long mach. ma}PDF created with pdfFactory Pro trial version wwwpdffactorycom 32. by death_nt88 source:diendanykh0a. com |20 l 0- ngun gc:c qu trinh min dich r6 rng- khng th:IgG - diu kin hoat d6ng:370C- dc dim: l) qua nhau thai2) kh6ng gy ngung kt o nhit d@ lanh & phng th nghim3) chi bm ln b6 inat HC. + Trong cc khng th ca h Rh,anti D l KT quan trong nhat.Anti D l 1 ioai IgG. + nhng phn nng d0 yu tdthnong xy ra trong 2 nuong hop:l) ngnoi c mu Rh- nhn nhiu ln lin tnc mu Rh+2) me c nhm mu Rh- nhiu lan mang thai c mu Rh+. + gi tri: - Nu truyn mu ca ngnoi c Rh+ cho ngnoi c Rh- thi s xy ra ngung kt vi mu ca ngno Rh- s sn sinh ra m6t loai khng th dao bit oh6ng Rh+. - Khng th chong Rh+ kh6ng c sn trong huyt tnong nhn alpha v beta ca mu ma chi dnoc hinh thnh nhng ngnoi Rh- sau khi nhn dnoc nhiu ln 1 lnong mu Rh+.Khng th pht trin chm,khong 2 - 3 thng sau khi nhn mu Rh+ moi phn nng.Khi d dnoc tao ra thi tnh min dich s duoc t6n tai nhiu nm. - Do d,nu 1 ngnoi Rh- chua h tip xc voi mu Rh+ thi vic truyn mu s kh6ng gy 1 phn nng tnc thoi no.Tuy nhin nru ln sau ho lai dnoc truyn mu Rh+ c th xy ra tai biin nghim trong nhn o h th6ng ABO.I Nhm mu Bombay (Oh): + L nhm mu kh6ng c khng nguyn H trn HC,nhnng c khng th chong H trong huyt thanh gy tan mu voi hiu gi cao.Vi Vy,huyt thanh ny c th lm ngnng kt Vi cc hong cu ca tt c cc nhm mu Irong h ABO,tr hong cu ca ngnoi c c1`1ng nhm mu Bombay. + phn bit voi nhm mu O nguy him:l nhm mu O c nong di) anti A & anti B cao,do vna c Anti A,Anti B tn nhin,vna c Anti A & Anti B min dich. I y nghia ca xc dinh nhm mu:+ l co st quyt dinh cho truyn mu.Nguyn tic truyn mu:` 1) kh6ng d cho KN & KT tnong nng gap nhau trong mu ngnoi nhn -> phi truyn mu cng nhm. 2) khi c mu cng nhm,c th cho truyn khc nhm theo nguyn tc:KN trn mng HC ngnoi cho kh6ng bi ngung kt boi KT tnong nng trong huyt tnong ngnoi nhn. + Tn dy c th gii thch dnoc ve tnh cht ca nhm mu: - nhm mu 0: kh6ng c KN trn mng HC nn kh6ng bi KT trong huyt tnong ngnoi nhan lm ngnng krt.D0 d nhm o c th truyn cho c 3 nhm. - nhm mu AB:kh6ng c KT trong huyt tnong nn kh6ng th ngnng kt bait ky HC nguoi cho no.Do d nhm AB c th nhn mu ca c 3 nhm. - nhm mu A:c KT Anti B trong huyt thanh nn c th bi ngnng krt boi KN trn HC nguoi cho.Do do nhm A chi c th nhan tn nhm mu O l nhm mu kh6ng c KN trn HC.Nhm mu B:gii thch tnong tn. - Mi nhm mu dn c th nhn mu cng nhm (t6t nhat):vi bo dm KN & KT tnong nng kh6ng gp nhau trong mu nguoi nhn. + Cu hi dt ra:KT trong huyt tnong ngnr cho c gy ngung kt HC ngnoi nhn kh6ng? -> Trong thnc t,kh nng ny kh6ng Xy ra vi KT dnoc truyn vo Voi lnong rt nh nn bi pha long ngay trong mu ngnoi nhn,kh6ng d ngung kt HC.Ngo ra KT con bi trung ha boi nhnng KN c trong cc t bo & cc dich co th. + tai bin: M32 PDF created with pdfFactory Pro trial version wwwgdffactorigcom 33. by death_nt88 source:diendanykh0a. com |20 l 0- E ngnoi c mu nhm A thi chi c th tip nhn dnoc mu tn ngnoi nhm A V nhm O/ Rhesus m tnh.Nu nhn mu tn nhnng nhm khc thi s gy ra cc phn nng di nng,c th gy tu' vong Vi cc yu td A,B,AB,O,Rh l nhng antigen (khng nguyn) s lm cho co th tao ra cc khng th (antibody) chng lai cc nhm mu khc v huy hoai cc nhm mu khc ny gy ra nhng kch xc rzit nguy him. - VD2: Nu thai nhi thua hnrng Rhesus duong tnh (=khng nguyn D) ca ngni cha,thi c th gap nguy him.D0 sn trao doi mu gina ngnoi me v thai nhi qua l nhau (placenta),ngnoi me sn xurt cc khng th chong lai khng nguyn D (=anti-D antibody).Cc khng th ny xuyn qua l nhau v c th ph hy cc h6ng huyt cau ca thai nhi,do d thai nhi bi thiu mu va c khi cht trong bung me. Cng thnc mu c 17 chi sd,theo trinh tn doc ca my:l) WBC =white blood cell =bach cu2) NEU:NEUTROPHIL =Da nhn trung tnh3) LYM:LYMPHOCYTE =Bach cu Lympho4) MONO:MONOCYTE =Mono bo5) EOS:EOSINOPHIL =Da nhn i toano) BASO:BASOPHTL z Da nhn km7) RBC z Red Blood Cell z h6ng caus) HGB z Hb z Hemoglobin z huyt so t69) HCT =Hematocrit =dung tch bng cu10) MCV =Mean corpuscular volume =th tch trung binh mot hong cu11) MCH =Mean corpuscular hemoglobin =s6 lnong hemoglobin trung binh trong mot hong cu12) MCHC =Mean corpuscular hemoglobin concentration 2 nong d6 hemoglobin trung binh trong m6t hong cu13) RDW =Red (cell) Distribution width =phn bd hinh thi kch thnoc hdng cu (khong phn b5 hong cu)14) PLT z platelet z Tiu cau15) MPV =Mean platelet volume =Th tch trung binh tiu cu16) PCT z Plateletcrit z Th tch kh6i tiu cau17) PDW =Platelet distribution width =Di phn bd kch thnoc TC.`L Ngoi ra,c th d nghi lm thm b@ 3 xt nghim chnc nng d6ng cm mu: 1) TP (Prothrombin content) =ti l Prothrombin ( ~ TQ =Quick Time )2) aPTT ( activative Partial Thromboplastin Time ) =thoi gian Thromboplastin tung phn ( ~ TCK =cephalin - kaolin time). 3) Fibrinogen._ ` `,D phn bit cc cp bnh:Schoenlein Henoch & Suy nhnoc tiu cu,Hemophilia & Willebrand cn lm thm TS (Saignement time) _=thoi gian mu chy.r r ` `,D dnh gi trang thi & kh nng sinh HC ca ty imong,nht l trong Suy ty,xem mnc d sn xut h6ng cu mau hay chm & ty xnong d dap nng ra sao trnrc sn thiu mu -> cn lm H6ng cu lnoi.Xt nghim ny con girp cung c cho buong chn dontn huyt cng nhn phn bit cc nguyn nhn thiu mu:TM c tnh (kh6ng sn Xut du h6ng cu) hay TM h6ng cu hinh lim =Thalassemia (HC bi huy:TM tn huyt). :Voi case bnh c nuong diu tri tiuyn mu (XHTH,BCC,TM nang);xc dinh nhm mu l diu bt buoo.Chi dinh uuyn khi:Hb < 7 g/ dl (huyt hoe) hoc Hct < 20 % voi ngnoi tr,< 25% voi ngnoi gi (liu ho).33 PDF created with pdfFactory Pro trial version wwwgdffactorigcom 34. by death_nt88 source:diendanykhoa. com |20l0L Trongtrnong hop cn truyn mu,cn cn nhc lna chon:truyn loai no?truyn bao nhiu?toc dc} truyn?nhnng phn nng phu no co th xy ra - hnong xn tr? Nhng trnong hop thnong gp: 1)XHTH: + truyn loai no?-> mt mu toan phn + yru to dong rnu + HC + huyt tnong,vi vy tot nht cho truyn mu ton phn tnoi - con yu to dong mu & TC,tuy nhin mu thnong tr' sn o nhit do 4 - 60 nn 2 thnh phn vna nu kh6ng c dong thoi mu ton phn d tai bin,vi Vy thnc t ty trnong hop:truyn HC lng kem dung dich N aC1 9 o/ oo (t nguy him hon). * Quan dim hin nay V mu ton phan:` ` ` l.trong muton phn d c du cc thnh phn nhnng nhng thnh phn ny Voi diu kin bo qun:+ hong cu lng,mu ton phn dn tr' o 4 oC trong vong 35 ngy. + Tiu cu dm dc bo qun o 220C - 24OC v lc nhe lin tuc V chi bo qun trong vong 5 ngy. + Huyt tnong dong lanh,kt ta lanh dn tr o:-18 oC trong 1_2 thng;- 40 oC trong 2 nm;-65 oC trong 7 nm.a. . thnong kh6ng con d khi truyn.Voi trnong hop thiu yu~t dong mu (Hemophilia,Rosentha1.. ): do trong co th ngnoi chi cr 30% nhm yu to tham gia vo qu trinh dong mu,vi Vy Vn con > 50% tr. ' sn cho qu trinh dong cm mu;khi truyn HC lng vn d. 2. truyn mu ton phn s dua mot so thnh phn kh6ng mong muon Vo co th:huyt tnong thna s gy tinh nang qu ti tuan hon,hoc bach cu l loai t bo gy phn nng kh6ng mong mun. .3. truyn tnan ton phnoo nguy co nhnrnhiu main bnh:vim gan siu vi B,C,HIV,HTLV,Giang mai,s6t rt. . * Quan dim`hin nay V truyn mu:thiu gi truyn d.+ thiu hut hong cu -> truyn hong cu lng- bnh na chy mu -> truyn kt ta lanh giu yu t6 VIH (hoao huyt tnong tnoi dong lanh nu kh6ng c krt ta lanh)- thiu hut tiu cu ->`truyn tiu cudc.. . ` ` r * Trong trnong hop cn kh6i phuc kh6i lnong tun hon:truyn HC lng bvn canh b dich.- nu 2 duong truyn dong thoi:dung dich duy nht dnoc truyn voi ch phm mu l NaCl 9 o/ oo. - c cc loai:dich tinh th,dich keo.- dich tinh th:Nnoc muoi dang trnong 0,9% (NaCl 9 0/00) l dich truyn tot nhit,ngoi ra c th dng dung dich Ringer Lactat. - dich keo:dung dich Albunlin 5%nv 25%,plasma,10% Dextran-40 v 6% Dextran-70 -> c khuynh hnong o lai trong mu gi dang nhnng Protein huyrt tnong d duy tri hoc lm tng p lnc keo,p lnc thm thu ca mu.n+ truyn bao nhiu?-> 1 don Vi HC lng (250ml) nng nngd Hb ln thm 1 g/ dl hoc tng Hct ln thm 3%.Tuy gi tri cu th so Voi muc tiu (nng Hb > 10 g/ d1& Hct > 30%) quyt dinh s don Vi tmyn.VD:BN Hb 7 g/ dl,Hct 21% -> cn truyn 3 don Vi HC lng. + t6t;d6 truyn?-> HC lang 1000ml/3 W.4 gio -> # XL giot/plllt.cong thnc tnh:T (gifr) z V /( s6 giot x 3) -> p dung cho inoi phm mu & dich truyn.VD:chon phm mu 450ml d truyn,gi dinh tc doc XL g/ p = > T =450 /(40x3) =3,75h:thoa diu kn. + phn nng phu c th xy ra?-> XHTH la trnong hop mt mu cp,thnc to sau truyn lnong Hb & Hct dnoc nng lnrkhng lun tnong nng theo ti l:1 don Vi HCL - 1 g/ dl Hb - 3% Hct.Trnong hop cp cnu co th truyn > 6 don Vi d dm bo huyt dong cho BN.Khi truyn mu ton phn khc nhm > 6 don Vi,Luong khng th truyn vo co th d cao c th gy phn nng truyn mu.Hnong xn tr:lm phn nng cho trnoc cho moi don Vi mu & han ch truyn mu ton phn khc nhm. + cch lm phn nng cho:r I r ` - phn nng cho chnh (khoa Xt nghim):HC ngnoi cho + huyt thanh ngnoi nhn -> ngung kt?- nu c kh6ng truyn (Vi tnong ky). M34 PDF created with pdfFactory Pro trial version wwwpdffactorycom 35. by death_nt88 source:diendanykhoa. com |20l0- phn nng cho phu (bnh phong):HC ngnoi nhn (chch mu mao mach nhn thn duong) + huyt thanh ngnoi cho (tn bich mu) -> ngnng kt?- nu kh6ng dnoc miyn. F Vi nt v truyn dich - truyn mu/XHTH: X' tr theo cc mila da'XHTH mc d@ trung binh:Tr lai kh6i lnong tudn hon mdt bdng dung dich dng tnmng,iru tin dd mn,c th dting LR.-1-Khng duot' dting cc dung dich m4 nuong vi tng d nht ca mu --1-> lm chm tdc d tudn hon -> toan mu dxy ra sda. Khng dting cc thu6c vn mgch.ot-X' trXHTH mc aja 111 - IV: Tr lai th tch kh6i [Ilang tudn hon:bdng dich dng imong v mu.Tmyn dn khi M,HA dn dinh (st-HA z 90mmHg),nt thiu oxy no,Hct > 20%,Hdng cn > 2 mau. *2/3 dich daing trimng. *I/3 mu. VD:Mdt1200ml =2/3 dich (800ml) + I/3 mu (2 don vi). Nru b/ n cn chy mu,tip tuc truyn dich mrc s ra gian bo --1-> ph ir nwc.LLc d khng dting dd dting turong nu m phi dting dd cao phn ni' ka mtc vo: *Huyt tnong. *Albumna*Dextrana*GelatnexLIEU PHAP DICHCc laai dich truyn: Theo Tlachrc y td thd gii 200],dung dich tinh thd v dung dich keo diwa ch dinh trong moi trining hop chy mu cdp dd kh6i phuc th tch mu tnroc khi truyn mu,bi vi: Khng th c mu ngay d truyn.-1-Vdn cn mt lnong 02 dn tln tai o" m td bo mc d Hb gim-1-Co ch huy ng hng loat phn ng dp Ling bti trr dd duy tri cung cdp 02 dn m6.: -Khi co' ch b m} duvc si?dung,truyn dich thay th s lm tng cung lnong tim d0 d6 vdn dm bo cung cdp 02 mc d1) ndng d Hb gim-Y-Truyn dich thay th lm pha long mu v cc thnh phdn mu -at-> gim d nhot ca mu -> ci thin lim lnong mao mzch v cung litong tim -> tng cnong cung cp 02 toi m.35 PDF created with pdfFactory Pro trial version wwwpdffactorycom 36. by death_nt88 source:diendanykhoacom |20 10Loai dich Ndi khuyfch tn Th' tch Protein Bn hylN-'lu i Trong long : nach 30-35 ngy Huyt (no'ngGelatnAlbuminDextran 40NaCl 03% Ngoi t' boLactate R l! Glucose 5% h'axDich keo (Plasma,Albumin,HAES,Gclatiz,Dcstran.. .):gh?dp [irc keo huyt tirang v ' [du trong lng mach (thi gian nim doi sng [ 3 -g ). b. Dich tnh th (NaCl 0,9%,Ringer lactate):TI/2 trung binh l 20-30 pht,cn bdng v khuych tn khdp ton b khoang Iigo td bo. M6t sd' dim d dimo nhdt tr: -1- _ i,_ *Dich tnh th diroc truyn dti ! irong c tdc dung bn g dich keo trong tlc kh6i phuc th tch tun hon. *Bit dli th tch {ndn hon bdng dich tinh th:cdn ! wang gdp 3-4 ! dn so voi dich keo. *Hdn ht cc b/ n thin dich ngoi td bo > thiu dich trong lng mzch (th tch tudn hon). *Truyiz nhanh v tzhtt dich tinh th ) thnong km ph td chdc. Vn chuyn xy ti td chc phu thu6c rdt ; thiu vo cung litong tim v Hb mu,khi Hb gim thi co' the?b: ) trr bdng tng hm ! trong tim.Vn chuyn xy ti t chdc gim nu thiu mu bnh nhn khng th tng diroc hm [trong rim.-1-Hb-t- hoc thi khng truyn mdn.Hb hoc thi triiyrlz mu.Tuy nhin cn phn thuc vo thi gian thiu mu (thiu mu tr tr bnh nhn c th chiu dung dnac). Khi huyt (ng dn dinh,xem xt truyn India-1- *Bnh nhn khc. ' git?Hct*Bnh nhn c bnh h thng cn hii tdt:gil} Hct*Bnh nhn tim mqch hoc bnh phi c tru chng:gi' Hct Tmyn mu thch hap:truyn ; min tmg phn-1- 35 PDF created with pdfFactory Pro trial version wwwpdffactorycom 37. by death_nt88 source:diendanykh0a. c0m |20 l 0*Bnh nhn bi mdt mu cdp:b th tch l ch y514, cn h5ng cdu vn chuyh xy d0 d` khng truyn h5ng edu d5 lm tng th tch. *H5ng edu ldng:c thin kh nng vn chuyh xy. -Chinh:duy t11` Hb 7- I0 g/ zll+Kh51` laong:I - 2 don vi. Mu ton ph5n: -1-*Chi nh: -Truyn dich khng dp #ng-Mt kh5lug71g mu ln (d5 111 m} ln)+0 n01' khng lm duot h5ng cdu ldng. *Kh5i laang:2 r 4 don vi,khng nn truyn kh5i lung ln mu ton phdn di;m? . Truyn mu kh5 [itang ln l truyn mt luzmg mu du' tr* mong duong laang mu d mdt hoc ln hon th tch mu ca bnh nhn trong thi gian < 24 gi. *Tmyeln mt kh5 luvng ln mu ton phdn d1; m} c th gy mt S5 biln chng sau:I.Nhm toan2. Tng kali mu3. Nhm dc ctrate v ha calci4. Ha than nhit5. Gmfibrnogen va` cc yru r5 dng mu (dc bit V va` VIII),plasma dng lanh r0 < -200C,cc yyu r5 dng mau vn 13511 tai.6. Gim tiu cdu (tiu cdu gim ri nhanh,sau 48 gi' khng cn tu cdu). 7. QIC (pisgemnated Intravyascalar Coagulaton):DIC l sa hoat hoa' ca h th5ng dng mu v h th5ng tiu F brn him tiu tha nhiu yu t5 dng mu v tiu cu. 8. V1' ngung kt:d0 cc nhm mu phu s tao nn cc vi ngung kyt ddn dh DIC. 9. Gim 2, 3 dphosphoglycerate (2, 3 DPG).M 2,3DPG gip cho sir giai phng 02 ca Hb.Cng thc tnh th tch mu mt . imu Jil-Lam;v3g: :rw" , nvvT! " &lan;nni-'Tff I. ." 4.IIHTIL!;jjIi: :jjjjn'(`fj3l. g. .-. ... _.. ... ... ... ;.. ;,. .;: ... ;;. ..; ;:. ... km2.-. ... ... .;. ... ... ,_. ... ... .;. ..i-', mir' . . .-- . b my. : . JJLI1_b': ;`"7 ; Laal ung -gliBnh nhn khng r5i loan dng mu: :- a*I/3 th tch mu mdt dtrrc thay th bng dung dich tinh th (Lactale,ntrc mu5i sinh 1y). *2/3 dung dich keo (Dextran,Albumin. ..)B/ n c r5 loan dng mu hay Hemophe B4-*1/3 mu mdl =dung dich tinh th theo 13)?l I :3*I/3 mu mdl?= dung dich keo 133 l 1:1*1/3 mu mdt =huyt taong 133 l 1:/ B/ n c gim tiu cdu:b1) th tch + truyn tiu cdu-! n a a*Tiit edu < 200/z;truyn 1-2 kit tiu cdu (1 kit =7 khi,v c th lm tng s5 [wang tiu edu tk 35-50 G/ l)*Tiu cdu 20-500/1; truyn 1 kit tiu edu.B/ n Hqmoghil A:b th tch + yu r5 VIII-1- *Tmyn yu t5 VIII. ' theo cng thc. 437)}PDF created with pdfFactory Pro trial version www. gdffactory. com 38. by death_nt88 source:diendanykhoacom |20 10; M (th tch. ) hfhin rin =5 97o T`L(i. `T(1n1) 2) XH gim tiu cu:I `-?thiu TC truyn 'ISC dnh dc.` I- TC dm dc l kh6i TC dugo diu ch t nhiu don vi mu ton phn (thung 4 - 12d0n vi) hoc t tch TC true tip ca 1 ngui cho. - 4 chi tiu ca 1 pool kh6i TC diu ch' re:4 don vi mu ton phn (250m1/dv):1) th tch:130 +1- 20ml2) sa luqng TC:>=130.000/ cm33) s lnong BC cn lai: cn truyn 5 doh vi TC.` r , + tc d6 truyn?-> 1 darn Vi truyn trong # 1/2 - 1 gif),gi dinh truyn vi tc dc} C gigt/pht.T (gif! ) =V /(s giot x 3) =150 /(100 x 3) =1/2 giai;tha diu kin.(thuc : LS thy x kha truyn tc d@ ti da). + phn {mg ghu c th Xy ra: - hiu qu km d0 nguyn nhn MD - kh6ng MD dn tri TC gim st di sng,c trung hqp chi tn tai vi pht trong co th ngui nhn -> tc dung phng chy mu kh6ng dat.Thung d0 bt dng min dich h HLA. HLA :Human Leucocyte Antigen.Trong truyn mu:cc BC & TC mang khng nguyn HLA.Do d,truyn cc huyrt phdm c chra cc : bo ny q th gy di min dich.I ` I , - x tr:chi dinh truyn kh6i TC my.TC my l kh6i TC tch t' 1 ngui cho bng my tch t bo.1 kh6i TC my ~ 4 don vi TC thung. - tham kho thm. ' dnh gi hin qu sau truyn dua vo CCI ( Corrected Count Increment ):I _ CCI= P1-P0/BSAxn P1 =s luqng TC sau truyn ( G/ l ;G =10(m) 9 ) (trong 1 gi).Binh thung TC =150 - 400 G/ l.P0 =S5 luqng TC truc truyn ( G/ l) 33 PDF created with pdfFactory Pro trial version wvvw. gdffact0ry. com 39. by death_nt88 source:diendanykh0a. com 20l0BSA =din tch da co th tha nhnn:s luqng TC dugo truyn ( 10(m) 11 ) -> Khi CCI >=5.000: truyn c kt qu. 33 XH d0 thiu vit K,bnh gan man ! x0 gan,K ganu! :-> thiu yu t d6ng mu truyn Huyt tnong tuoi d6ng lanh (nu kh6ng c kt ta lanh). - qu trinh:huyt tnong tuoi dlIQC tch ra tit mu tuoi ton phn ngay trong 6 - 8 gi du sau khi lry mu,sau d durc d6ng lanh & bo qun nhit di) -300C drn -200C. - Huyt mong tuoi c nng d@ yu t V,VIII mc binh thung trong khi huyt turong bo qun c nbng di) yu td V,VIH gim thp. - 3 chi tiu ca mt pool huyt mong (diu ch t' 2 don y;mu ton phan logi 250ml/ dv): 1) tn tch:250 +1- 20m] 2) yu t VIH:>= `0,7 UI 3) protein ton phn:>=50g. - thnh phn H"I`T:albumin,immunoglobulnucc yu t d6ng mu.[oc b cc yu t d6ng niuc huyt thanh. diu tri & di:phng cc r6i loan d6ng mu dp thiu huit l hoc nhiu yu t d6ng mu, . r 1) thiu hut yu t d6ng mu:VIII,IX,XI (Hemophilia) & thuc t lm sng kh6ng c dung dich c dc cc yu t ny. 2) thiu hut ang thents learn 1