HUYT HC - TRUYN MU

TI LIU SU TM TNG HP - DCH

TI LIU SU TM TNG HP DCH
Gii thiu Information Mc lc


Bin son ebook : L nh Sng
I HC Y KHOA H NI
Trang web : www.ykhoaviet.tk
Email : Lesangmd@gmail.com, bachkhoayhoc@gmail.com
in thoi : 0973.910.357

THNG TIN

THNG BO V VIC XUT BN BCH KHOA Y HC 2010 :
Theo yu cu v nguyn vng ca nhiu bn c, khc vi Bch Khoa Y Hc cc
phin bn trc, bn cnh vic cp nht cc bi vit mi v cc chuyn khoa
mi,cng nh thay i cch thc trnh by, Bch Khoa Y Hc 2010 c chia ra
lm nhiu cun nh, mi cun bao gm mt ch ca Y Hc, nh th s gip
bn c tit kim c thi gian tra cu thng tin khi cn. Tc gi xin chn thnh
cm n tt c nhng kin ng gp ph bnh ca qu{ c gi trong thi gian
qua. Tt c cc cun sch ca b sch Bch Khoa Y Hc 2010 bn c c th tm
thy v ti v t trang web www.ykhoaviet.tk c L nh Sng xy dng v
pht trin.
NG H :
Tc gi xin chn thnh cm n mi s ng h v mt ti chnh gip cho Bch
Khoa Y Hc c pht trin tt hn v ngy cng hu ch hn.
Mi tm lng ng h cho vic xy dng mt website dnh cho vic ph bin ti
liu hc tp v ging dy Y Khoa ca cc c nhn v Doanh nghip xin gi v :
Tn ngn hng : NGN HNG U T V PHT TRIN VIT NAM
Tn ti khon ngn hng : L nh Sng
S ti khon : 5111-00000-84877

CNH BO :
TI LIU NY CH MANG TNH CHT THAM KHO nhm mc ch nng cao hiu bit v Y
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on v t iu tr bnh, nht l vi nhng ngi khng thuc nghnh Y . Tc gi
ebook ny khng chu bt c trch nhim g lin quan n vic s dng thng tin
trong cun sch p dng vo thc tin ca bn c. y l ti liu su tm t
nhiu tc gi khc nhau, nhiu cun sch khc nhau, cha c kim chng , v
th mi thng tin trong cun sch ny u ch mang tnh cht tng i . Cun
sch ny c phn pht min ph vi mc ch s dng phi thng mi, bt c
hnh vi no lin quan n vic mua bn, trao i, chnh sa, in n cun sch ny
vo bt c thi im no u l bt hp l . Ni dung cun ebook ny c th
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GII THIU

B sch ny c L Sng su tm , bin dch v tng hp vi mc ch cung cp
mt ngun ti liu tham kho hu ch cho cc bn sinh vin y khoa, v tt c
nhng ai c nhu cu tm hiu, nghin cu, tra cu , tham kho thng tin y hc.
Vi tiu ch l b sch m , c xy dng da trn ngun ti liu ca cng ng ,
khng mang mc ch v li, khng gn vi mc ch thng mi ha di bt kz
hnh thc no , nn trc khi s dng b sch ny bn phi ng vi nhng
iu kin sau . Nu khng ng , bn khng nn tip tc s dng sch :
B sch ny c cung cp n tay bn , hon ton da trn tinh thn t nguyn
ca bn. Khng c bt kz s thng lng, mua chuc, mi gi hay lin kt no
gia bn v tc gi b sch ny.
Mc ch ca b sch phc v cng tc hc tp cho cc bn sinh vin Y khoa l
chnh, ngoi ra nu bn l nhng i tng ang lm vic trong nghnh Y cng c
th s dng b sch nh l ti liu tham kho thm .
Mi thng tin trong b sch u ch c tnh chnh xc tng i, thng tin cha
c kim chng bi bt c c quan Php lut, Nh xut bn hay bt c c quan
c trch nhim lin quan no . V vy, hy lun cn trng trc khi bn chp nhn
mt thng tin no c cung cp trong b sch ny.
Tt c cc thng tin trong b sch ny c su tm, tuyn chn, phin dch v
sp xp theo trnh t nht nh . Mi bi vit d ngn hay di, d hay d d cng
u l cng sc ca chnh tc gi bi vit . L nh Sng ch l ngi su tm v
phin dch, ni mt cch khc, ngi gip chuyn ti nhng thng tin m cc tc
gi bi vit cung cp, n tay cc bn .

B sch ny l ti liu su tm v dch bi mt sinh vin Y khoa ch khng phi l
mt gio s tin s hay mt chuyn gia Y hc dy dn kinh nghim,do c th
c rt nhiu li v khim khuyt khng lng trc , ch quan hay khch quan,
cc ti liu b tr c th cha hp l , nn bn cnh vic thn trng trc khi thu
nhn thng tin , bn cng cn c k phn mc lc b sch v phn hng dn s
dng b sch s dng b sch ny mt cch thun tin nht.
Tc gi b sch in t ny khng chu bt c trch nhim no lin quan n vic
s dng sai mc ch , gy hu qu khng tt v sc khe, vt cht, uy tn ca
bn v bnh nhn ca bn .
Khng c chuyn mn , khng phi l nhn vin y t , bn khng c php t s
dng nhng thng tin c trong b sch ny chn on v iu tr. T trc ti
ny, cc thy thuc IU TR BNH NHN ch khng phi l IU TR BNH. Mi
ngi bnh l mt thc th c lp hon ton khc nhau, do vic b nguyn xi
tt c mi thng tin trong b sch ny vo thc tin s l mt sai lm ln . Tc gi
s khng chu bt c trch nhim g do s bt cn ny gy ra.
V l b sch cng ng, to ra v mc ch cng ng, do cng ng , b sch ny
c pht trin c hay khng mt phn rt ln, khng ch da vo sc lc, s
kin tr ca ngi to ra b sch ny , th nhng ng gp, xy dng, gp , b
sung, hiu chnh ca ngi c chnh l ng lc to ln b sch ny c pht
trin. V mt mc tiu tr thnh mt b sch tham kho y khoa tng hp ph hp
vi nhu cu v tnh hnh thc tin trong lnh vc y t ni ring v trong cuc sng
ni chung . Tc gi b sch mong mi bn c nhng li ng gp chn thnh
mang tnh xy dng, nhng ti liu qu m bn mun san s cho cng ng , v
mt tng lai tt p hn. l tt c nim mong mi m khi bt u xy dng
b sch ny , ti vn kin tr theo ui .
Ni dung b sch ny, c th ch ng trong mt thi im nht nh trong qu
kh v hin ti hoc trong tng lai gn. Trong thi i cch mng khoa hc cng
ngh tin nhanh nh v bo nh hin nay, khng ai bit trc c liu nhng
kin thc m bn c c c th p dng vo tng lai hay khng . tr li cu
hi ny, ch c chnh bn thn bn , phi lun lun khng ngng-T MNH-cp
nht thng tin mi nht trong mi lnh vc ca i sng, trong c lnh vc y
khoa. Khng ai c th, tt nhin b sch ny khng th, lm iu thay bn.
Nghim cm s dng b sch ny di bt kz mc ch xu no, khng c
php thng mi ha sn phm ny di bt c danh ngha no. Tc gi b sch
ny khng phi l tc gi bi vit ca b sch , nhng mt rt nhiu cng sc,
thi gian, v tin bc to ra n, v li ch chung ca cng ng. Bn phi chu
hon ton trch nhim vi bt kz vic s dng sai mc ch v khng tun th ni
dung b sch ny nu ra.
Mi l thuyt u ch l mu xm, mt cun sch hay vn cun sch cng ch l l
thuyt, ch c thc t cuc sng mi l cun sch hon ho nht, bn khng
phi l c gi m l din vin chnh. V Bch Khoa Y Hc cng ch l mt ht thc
nh, vic s dng n xo nu hay nhn ging l hon ton ty thuc vo bn
c. V ngi to ra ht thc ny s vui mng v c truyn thm ng lc
tip tc c gng nu bit rng chnh nh bn m bit bao ngi khng cn phi
xp hng ch cu tr.
Mi ng gp lin quan n b sch xin gi v cho tc gi theo a ch trn. Rt
mong nhn c phn hi t cc bn c gi cc phin bn sau c tt hn.
Knh chc bn c, gia quyn v ton th ngi Vit Nam lun c sng trong
khe mnh, cuc sng ngy cng m no hnh phc.
Lng, Ngh An. Thng 8/2010



ABOUT

ebook editor: Le Dinh Sang
Hanoi Medical University
Website: www.ykhoaviet.tk
Email: Lesangmd@gmail.com, bachkhoayhoc@gmail.com
Tel: 0973.910.357
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MC LC


CHNG 1. SINH L V SINH L BNH
A. GII PHU - SINH L TO MU
1. MU V CC THNH PHN MU
2. SINH L MU
3. HUYT TNG
4. HNG CU ( RED BLOOD CELLS)
5. BCH CU ( WHITE BLOOD CELLS)
6. TIU CU(PLATELETS)
7. NHM MU V AN TON TRUYN MU
8. SINH L CM MU V NG MU
9. CHNG NG MU
10. RI LON LM SNG MU
11. RI LON C CH CM MU
B. SINH L BNH MU - TO MU
12. RI LON KHI LNG MU TUN HON
13. RI LON TO HNG CU
14. SINH L BNH CA THIU MU
15. C CH THCH NGHI KHI THIU MU
16. THAY I BNH L CA BCH CU
17. THAY I BNH L CA TIU CU
CHNG 2. TRIU CHNG HC
18. HI CHNG THIU MU
19. HI CHNG TAN MU
20. HI CHNG XUT HUYT
21. HI CHNG HEMOGLOBIN
22. HI CHNG LCH TO
23. HI CHNG HCH TO
24. HI CHNG XUT HUYT
25. S LC MU V H LYMPHO
CHNG 3. BNH L HUYT HC
26. HI CHNG DIC
27. XUT HUYT GIM TIU CU T MIN
28. BNH THIU MEN G6PD
29. ULYMPHO C TNH
30. THIU MU
31. THIU MU DO DINH DNG
32. U LYMPHO KHNG HODGKIN
33. THIU MU THIU ST
34. THIU MU HUYT TN T MIN
35. BNH SUY TY XNG
36. CHY MU DO IU TR TAN HUYT KHI
37. BNH BCH CU TY MN
38. BNH BCH CU LYMPHO MN
39. U LYMPHO C TNH
40. XUT HUYT GIM TIU CU MIN DCH
41. XUT HUYT GIM TIU CU MIN DCH
42. SUY TY XNG
43. BCH CU CP(LEUKEMIA)
44. BNH BETA THALASSEMIA
45. BNH A CHY MU(HEMOPHILIA)
46. VIM THNH MCH D NG
CHNG 4. CN LM SNG HUYT HC
47. XT NGHIM HUYT HC
48. CNG THC CH CU
49. MIN DCH - DI TRUYN
50. T BO T CHC HC
51. NG MU
52. MIN DCH SNG LC
53. CH PHM MU
54. QU LIU THUC CHNG NG
55. CC PHN NG TRUYN MU
CHNG 5. ATLAS HUYT HC
CHNG 6. THUC CHNG NG MU
56. C CH CA S HNH THNH HUYT KHI
57. SINH L BNH CA S HNH THNH HUYT KHI
58. CC THUC CHNG NG
CHNG 7. BO CO KHOA HC
59. C U NH GI H THNG NG CM MU BNH NHN A U TU XNG
60. C U NGHIN CU MT S C IM MU V TU XNG BNH NHN
GIM BA DNG MU NGOI VI
61. NH GI TNH HNH NGI HIN MU TNH NGUYN CA VIN HUYT HC -
TRUYN MU TRUNG NG NM 2005
62. GP PHN CHNH L K THUT XT NGHIM SC BN HNG CU
63. NGHIN CU SNG LC KHNG TH BT H HNG CU BNH NHN B BNH MU
TI VIN HUYT HC - TRUYN MU TW (2004-2005)
64. TM HIU MT S YU T NH HNG TI S XUT HIN NHNG PHN NG LM
SNG KHNG MONG MUN NGI HIN MU TNH NGUYN
65. NG DNG PHNG PHP MIN DCH TRONG CHN ON PHN LOI MT S TH
BNH CA L X MI CP
66. M HNH CUNG CP MU TP TRUNG T NGN HNG MU KHU VC N CC BNH
VIN
67. THC HIN CHIN LC QUC GIA PHNG CHNG HIV/AIDS TRONG CNG TC AN
TON TRUYN MU NC TA N NM 2010 V TM NHN 2020.







CHNG 1. SINH L V SINH L BNH



A. GII PHU - SINH L TO MU

1.1. C quan to mu:
C quan to mu bao gm: ty xng, t chc lymph (lch, hch, tuyn c) v
t chc vng m. V tr to mu thay i theo tui:
* Trc khi : to mu qua 3 giai on:
+ Giai on bo thai (khong 2 thng u): ch yu to mu t ni mc huyt
qun trong nhng o Pander. Cc hng cu non nguyn thy u thuc dng
megaloblast (i hng cu).
+ Giai on gan lch (t thng th 3): cc hng cu non ch yu c to ra t
gan, lch v u thuc dng normoblaste (ging nh hng cu non ngi
trng thnh).
- Sinh mu gan:
T tun th 4 sinh mu gan, bt u t t bo trung m vn nng cha bit
ho. Cc t bo mu c to ra trong cc b gan, cc khoang lin kt xung
quanh v trong cc huyt qun. Gan sinh ch yu l hng cu (HC), bch cu ht
(BC) v c th c mu tiu cu (TC), cha sinh lymph v mn. Cao im sinh
mu gan l vo thng th 4 ca thai kz, sau gim dn.
- Sinh mu lch:
T tun th 10 ca thai, lch bt u sinh mu v sinh ch yu l hng cu ri
bch cu ht, n tun th 23 sinh lymph. n thng th 5 ch sinh lymph.
T thng th 5 tr i lch, gan ht chc nng to hng cu, t y cho n
trng thnh ty l c quan duy nht sinh hng cu, bch cu ht v mu tiu cu
(tr trng hp bnh l to mu ngoi ty) v d: bnh lch to sinh ty.
+ Giai on ty: t thng th 5 gan lch ht chc nng to hng cu, v t y
cho n trng thnh ty xng l c quan duy nht to hng cu (tr trng
hp bnh l to mu ngoi ty).
* Sau khi : v tr to mu nm trong 3 t chc :
+ Ty xng (ty ) to hng cu, bch cu ht v tiu cu, nhng cng tham gia
to nhng t bo lymph gc ty.
+ T chc lymph nh: tuyn c, hch, lch, mng Payer tham gia to v
trng thnh cc t bo lymph.
+ T chc vng ( lch, ty xng l chnh) to cc t bo mn.
Tuy nhin, trong i sng, tm quan trng ca cc t chc to mu cng thay
i: tr em ty xng v t chc lymph rt pht trin v hot ng mnh,
tui trng thnh ty to mu (ty ) gim th tch, tuyn c teo i.
1.2. Cu trc ca c quan to mu:
1.2.1. Ty xng:
Ty xng sinh ra hng cu, bch cu ht v tiu cu. tr mi sinh, ty
chim hu ht ty xng ca ton b h thng xng ca c th. Nhng dn dn
ty thu hp li chuyn phn ln thnh ty vng (ty m). T tui 18 ty hot
ng khu tr li cc xng sng, sn, xng s, xng chu v u trn cc
xng i, xng cnh tay.
Ty hot ng trong nhng khong trng ca t chc xng xp, t chc thnh
nhng o to mu c bao quanh bi cc xoang mch v gii hn bi cc t
bo lin vng ni mc. Cc o to mu c to thnh t hai loi t bo chnh:
+ Cc t bo to mu: chim hn 95%. Cc t bo non ngoi vi, cc t bo
trng thnh hn nm gia.
+ Cc t bo m, bao gm: cc t bo lin vng ni mc, nguyn bo si, t bo
m, i thc bo.
T chc ty c nui dng bi nhng ng mch nh pht sinh ra t cc ng
mch nui ca xng. T cc ng mch nh y to ra mt h thng mao qun
vo cc xoang mch m thnh l cc t bo ni mc ta ln mt mng nn.
1.2.2. C quan lympho:
C quan lymph nm ri rc khp c th, chim khong 1% trng lng c th,
hp thnh nhng khu khc nhau khng cng mt chc nng sinh l{. V phng
din chc phn c th chia thnh 3 khu: khu ty, c quan lymph trung ng v
c quan lymph ngoi vi.
+ Lymph ty xng: ty xng sinh ra cc lymph nguyn thu.
+ C quan lymph trung ng: tuyn c c nhiu tiu thy, c chia ra vng v
v ty, gia c mt trc gm cc t chc lin kt v huyt qun, cc t bo t-
ng t nh lymphocyte nh gi l thymocyte. Cc thymocyte c bit nhiu
vng v. Tuyn c thoi bin dn t lc sinh ra ti lc gi nhng vn lun tn ti
mt s mi chc phn.
+ C quan lymph ngoi vi: gm cc hch lymph, lch, cc t chc lymph ng
tiu ho, hng... cu to ca cc hch lymph cng c mt vng v v ty. Cc t
bo lymph c sinh sn ch yu cc nang lymph vi trung tm mm gia.
1.3. Qu trnh to mu:
C nhiu l thuyt v ngun gc t bo mu, nhng c hai thuyt sinh mu chnh
c cp nhiu hn c l:
+ Thuyt nhiu ngun: mt s tc gi cho rng: ngun gc t bo mu l do
t hai, ba hoc nhiu loi t bo khc nhau sinh ra.
+ Thuyt mt ngun: thuyt ny c nhiu ngi tha nhn.
Thuyt ny cho rng cc t bo mu u c sinh ra t t bo gc vn nng, ty
theo s kch thch c hiu m t bo gc vn nng ny s bit ho to thnh
nhng t bo c chc nng cn thit. Qu trnh to mu ny c th hin theo
s sau:



Ch thch: NHC: nguyn hng cu; MTC: mu tiu cu; LT: lymph-T; LB:lymph-B

1.4. Chc nng sinh l{ ca mu:
Mu l mt cht dch lu thng khp c th c cc chc nng rt quan trng v
phc tp, bao gm:
+ H hp: chuyn ch oxy v kh carbonic (oxy t phi ti cc t chc v carbonic
t t chc ti phi).
+ Dinh dng: vn chuyn cc cht dinh dng c bn: cht m, cht bo, -
ng, vitamin... t rut ti t chc, t bo.
+ o thi: vn chuyn cc cht cn b ca chuyn ho ti cc t chc ti cc c
quan bi tit (thn, phi, tuyn m hi...).
+ iu ho hot ng cc c quan thng qua vn chuyn cc hormon v cc
yu t iu ho th dch khc.
+ iu ho thn nhit.
+ Bo v c th: thng qua chc nng ca bch cu, khng th v cc cht khc.
Khi lng mu trong c th ch chim 7-9% tng trng lng c th, ngi
trng thnh c khong 75ml mu trong mi kg trng lng c th.
1.5. Hnh thi v chc nng ca cc t bo mu:
1.5.1. Hng cu:
Hng cu c sinh ra ty xng v pht trin qua nhiu giai on: t tin
nguyn HC nguyn HC i kim nguyn HC a sc nguyn HC i toan HC
mng li v cui cng l hng cu trng thnh hot ng mu ngoi vi.
+Hng cu trng thnh l t bo khng nhn, hnh a lm hai mt, ng knh
khong 7 m. Nhum giemsa thy hng cu mu hng, gia nht hn. Hng cu
cha huyt sc t l thnh phn chc nng chnh trong hng cu.
+ Huyt sc t l mt protein mu, gm hai thnh phn chnh l:
- Heme (c cha st)
- Globine gm 4 chui polypeptid ging nhau tng i mt:
Huyt sc t A : 2 chui a v 2 chui b.
Huyt sc t A2 : 2 chui a v 2 chui d.
Huyt sc t F : 2 chui a v 2 chui g.
ngi trng thnh : HST A chim 95 - 99%.
HST A2 chim 1,5 - 3%.
HST F chim 1 - 2%.
Chc nng ch yu ca hng cu l vn chuyn oxy v kh carbonic. i sng
trung bnh hng cu khong 120 ngy. Hng cu gi c tiu hy ti h thng
lin vng ni mc ca c th m ch yu ti lch v ty xng. Sau khi b tiu hy,
cc thnh phn ca hng cu nh st c gi li v v ty xng to hng cu
mi, heme c thoi bin thnh bilirubin gin tip ri v gan chuyn thnh
bilirubin trc tip.
Mt s yu t c tc dng kch thch to hng cu nh: erythropoietin, androgen,
kch t sinh trng ca tuyn yn v mt s yu t khc: acid folic, vitamin B12,
B6, st, protein cn thit to hng cu v huyt sc t.
1.5.2. Bch cu ht:
Dng bch cu ht c sinh ra t ty xng v pht trin qua nhiu giai on:
t nguyn ty bo (myeloblaste) tin ty bo (promyelocyte) ty bo
(myelocyte) hu ty bo (metamyelocyte) C a (segment) v cui cng l
bch cu a nhn (l loi t bo trng thnh m nhim chc nng bo v c
th). Bch cu ht trng thnh c i sng khong 5-7 ngy. Bch cu gi c
tiu hy ti h lin vng ca lch. Nhn ca bch cu ht trng thnh c nhiu
mi, bo tng c cc ht c hiu v c chia ra lm 3 loi:
+ Bch cu a nhn trung tnh (N): bo tng c cha cc ht bi mu hng (khi
nhum giemsa). Chc nng ch yu l thc bo vi khun v cc vt l, bo v c
th (gi l tiu thc bo).
+ Bch cu a nhn toan tnh (E): bo tng c cha cc ht to, trn u, bt mu
da cam, nhn thng ch c hai mi. Chc nng ca chng hin nay cha bit y
, nhng s tng bch cu i toan c lin quan mt thit ti d ng v nhim k
sinh trng.
+ Bch cu a nhn kim tnh (): bo tng c cha cc ht bt mu en sm,
th, to khng u nhau, chng ln c nhn. Chc nng ca chng cng cha r
rng.
1.5.3. Bch cu lymph:
Bch cu lymph c to ra t t chc lymph (hch, lch, tuyn c) v mt
phn t ty xng. i sng ca cc lymphocyte rt khc nhau: c loi i sng
ngn ch 1 - 3 ngy, c loi i sng di vi thng, vi nm, c khi c i ngi.
Bch cu lymph gi b tiu hy lch v cc t chc vng m.
V hnh thi chia ra:
+ Bch cu lymph nh: ng knh ch khong 8-9 micromet, bo tng rt t ch
l mt vin nh quanh nhn.
+ Bch cu lymph to: bo tng rng hn.
Chc nng ch yu ca bch cu lymph l tham gia vo p ng min dch ca
c th. Ngi ta chia: lymph T m nhim chc nng min dch t bo, lymph B
m nhim chc nng min dch dch th tc l sn xut ra cc khng th lu
hnh.
1.5.4. Bch cu mn:
Bch cu mn l nhng t bo to, bo tng rng, bt mu xanh khi, khng
ht, c th c khng bo (vacuol). Nhn cun khc, cu trc cht nhn nh mi
tc un. Bch cu mn c sn sinh ra t ty xng cng ngun gc vi bch
cu ht. Chc nng quan trng nht ca chng l thc bo vi khun v vt l (do
vy cn gi l i thc bo) v chnh thng qua bch cu mn tham gia
truyn t thng tin min dch.
1.5.5. Tng bo (plasmocyte):
Tng bo chim t l rt thp mu ngoi vi (0,5-1%). Tng bo c sinh ra
t lymph khi c kch thch khng nguyn v m nhim chc nng sn xut
khng th lu hnh.
1.5.6. Tiu cu:
Tiu cu l nhng mnh bo tng ca mu tiu cu, ng knh khong 2-3
micromet, khng phi l mt t bo hon chnh. Tiu cu c th hnh tam gic, t
gic, hnh trm, hnh phy... c cha cc ht ta. nh thng trn tiu bn
nhum giemsa tiu cu ng thnh tng m to nh khc nhau m khng ng
ri rc.
i sng tiu cu khong 7-10 ngy. Tiu cu gi cng b phn hy ti lch v h
thng lin vng ni mc. Chc phn ch yu ca tiu cu l tham gia vo qu trnh
cm mu - ng mu ca c th.
1.6. H nhm mu ngi:
1.6.1. H thng ABO:
H ABO l h nhm khng nguyn hng cu quan trng nht c Landsteiner
pht hin nm 1940. Theo h thng khng nguyn ny, mi ngi u mang mt
trong bn loi nhm mu c bn sau: A, B, AB v O.
+ Khng nguyn h ABO: khng nguyn H l nn tng ca h ABO, t khng
nguyn H mi bin i dn thnh khng nguyn A v B. Tt c cc khng nguyn
ca h AO u ging nhau v cu to:
- Mt chui peptid ging nhau.
- Cc sarcarit gn quanh peptid.
S khc nhau gia cc khng nguyn A, B, H l do s thay i ca cc thnh phn
sarcarit.
S cu to yu t A, B, H trn hng cu.



Ghi ch: glu: glucose ; gal: galactose ; gnac: N-acetylglucosamine
galnac: N-acetylgalactosamine ; fuc: fucose
+ Khng th h ABO: l cc khng th t nhin, bn cht l cc IgM nn
khng qua c mng nhau thai, hot ng mnh c nhit 4
o
C v 37
o
C. Gi
l khng th t nhin v chng hnh thnh v tn ti mt cch t nhin ngoi tt
c cc c ch gy min dch bit. Tt c mi c nhn u c trong huyt thanh
ca mnh nhng khng th tng ng vi khng nguyn m hng cu ca h
khng c.
- Nhm mu A: HC c khng nguyn A, huyt thanh c khng th anti B.
- Nhm mu B: HC c khng nguyn B, huyt thanh c khng th anti A.
- Nhm mu AB: HC c khng nguyn A v B, huyt thanh khng c anti A v anti
B.
- Nhm mu O: HC khng c khng nguyn A v B, huyt thanh c c anti A v anti
B.
Cho n nay ngi ta thy nhm A c 2 loi khng nguyn hi khc nhau : A
1
v
A
2
cho nn nhm A cng chia ra lm 2 nhm ph : A
1
v A
2
v nhm A cng chia
ra 2 nhm ph : A
1
B v A
2
B.
Vit Nam:
Nhm A chim 19,8%
Nhm B chim 26,6%
Nhm AB chim 4,2%
Nhm O chim 47,3%
Ngoi cc khng th t nhin k trn cn c cc khng th min dch sinh ra do
truyn mu, sinh ... Bn cht cc khng th min dch ny l IgG, c kh nng
qua c mng nhau thai nn c th gy nn nhng tai bin sinh sn.
1.6.2. H thng Rhesus:
Ngi ta thy trong HC ngi c khng nguyn tng t HC ca kh Macacus
Rhesus. y l h khng nguyn ch c trn HC (h ABO c trn tt c cc t bo
ca ngi - h nhm m).
Nhm Rhesus (Rh) c xc nh bi khng nguyn D l chnh v cn c khng
nguyn C, c, E, e.
Hng cu c khng nguyn D: nhm mu Rh (+).
Hng cu khng c khng nguyn D: nhm mu Rh (-).
Vit Nam nhm Rh (-) rt him, khc vi ngi u, M.
Khc vi h ABO, ngi Rh (-) bnh thng khng c khng th t nhin chng Rh,
cc khng th ny ch c sinh ra khi truyn mu khc nhm, sau cha ...
1.6.3. Cc h nhm mu khc :
Cn c nhiu h nhm mu khc nh :
+ Kell(K), MNSs, Duffy, Kidd: cc khng th min dch ca cc h nhm mu ny l
nguyn nhn gy huyt tn ngi truyn mu nhiu ln v tr s sinh.
+ H Lewis, h P: cc khng th thng gy huyt tn sau truyn mu nhiu
ln, khng gy huyt tn tr s sinh. Cc anti P gp trong i huyt sc t do
lnh.
1.6.4. H thng khng nguyn C ngi - HLA:
L h khng nguyn m khng nhng c trn bch cu m c trn tt c cc t
bo tr HC. Gen chi phi h khng nguyn ny nm NST s 6.S lng cc
khng nguyn h HLA rt ln v c chia lm 4 nhm :
HLA - A c 17 khng nguyn.
HLA - B c 31 khng nguyn.
HLA - C c 8 khng nguyn.
HLA - D c 20 khng nguyn, trong HLA - DR c 10 khng nguyn.
Khng c cc khng th t nhin chng HLA, ch c cc khng th min dch xut
hin sau truyn mu, thai nghn, sau ghp.
1.6.5. H thng khng nguyn tiu cu:
Tiu cu c cc h khng nguyn nh ca hng cu v bch cu v cn c cc
khng nguyn ring nh PLA1, KO4... khng c khng th t nhin, khng th
min dch hnh thnh sau truyn mu, sinh ...

1. MU V CC THNH PHN MU

Mu ton phn:
L mu c ly ra t ngi hin mu thch hp, mu v khun, an ton sinh hc,
c cht chn ng v bo qun. Mu ton phn l ngun nguyn liu sn xut
cc ch phm mu. Bo qun 2-6 C, nu dng cht chng ng CPD-A1
c 35 ngy. Do c coi l ngun nguyn liu, vic s dng mu ton phn
trn lm sng rt hn ch. Mu ton phn c xem xt dng cho cc trng hp
ng thi c thiu ht hng cu v th tch mu, v d mt mu do chn thng.
Khi hng cu:
L phn cn li ca mu ton phn sau khi loi b phn huyt tng m khng
s l g thm. Sn phm c hematocrit t 0,6-0,75, vn cn nhiu bch cu v
tiu cu. Bo qun 2-6 C, nu dng cht chng ng CPD-A1, c 35
ngy. Khi hng cu c dng thay th trong mt mu v dng iu tr trong
thiu mu.
Khi hng cu loi b lp bch-tiu cu: c ch t mu ton phn bng ch
tch phn huyt tng v lp bch tiu cu khi khi hng cu. Sn phm c
hematocrit t 0,6-0,75, s lng bch cu v tiu cu thp. Bo qun 2-6
C, nu dng cht chng ng CPD-A1 c 35 ngy. Khi hng cu loi b lp
bch-tiu cu c dng thay th trong mt mu v dng iu tr trong thiu
mu.
Khi hng cu c thm dung dch nui dng: c ch t mu ton phn bng
cch tch phn huyt tng khi khi hng cu, sau thm vo mt dung dch
nui dng thch hp. Sn phm c hematocrit khng vt qu 0,7 s lng
bch cu v tiu cu cn nhiu. Bo qun 2-6 C, nu dng cht chng ng
CPD-A1 c 35 ngy. Thnh phn ny c dng thay th trong mt mu v
dng iu tr trong thiu mu.
Khi hng cu loi bch cu: c ch t mu ton phn bng cch tch phn
huyt tng khi khi hng cu, loi b lp bch-tiu cu, sau lc loi b bch
cu khi khi hng cu. Sn phm c hematocrit t 0,6 n 0,75, s lng bch
cu v tiu cu cn rt t. Bo qun 2-6 C, nu dng cht chng ng CPD-A1
c 35 ngy. Nu trong qu trnh lc bch cu c p dng h thng m th
ch c php bo qun trong vng 24h 2-6 C. Khi hng cu ny c dng
thay th trong mt mu v dng iu tr trong thiu mu. c bit p dng cho
bnh nhn c nguy c nhm trnh xy ra phn ng khng ho hp vi khng
nguyn bch cu ng loi.
Khi tiu cu:
c ch t mu ton phn, phn ny c chc phn ln lng tiu cu c trong
ti mu v c tc dng iu tr. Khi tiu cu c iu ch bng 2 phng php:
t huyt tng giu tiu cu v t lp bch-tiu cu. Sn phm c s lng bch
cu v hng cu cn rt t. Bo qun trong ti nha c chc nng trao i kh,
trn my lc v 20-24 C. Hn s dng 5 ngy, nu sn xut trn h thng h
ch dng c trong 24 h. Khi tiu cu c ch nh dng cho cc trng hp
xut huyt gim tiu cu mc nng.
Tiu cu my:
c ch bng cch trc tip tch ra thnh phn tiu cu t ngi hin mu s
dng thit b tch t bo t ng. Sn phm c s lng tiu cu rt cao thng
gp 5-10 ln lng tiu cu c trong khi tiu cu. Bo qun trong ti nha c
chc nng trao i kh, trn my lc v 20-24 C. Hn s dng 5 ngy. Tiu
cu my c ch nh dng cho cc trng hp xut huyt gim tiu cu mc
nng.
Huyt tng ti ng lnh: c th tch t mu ton phn hoc trc tip tch
bng my t ngi hin huyt tng. Sn phm ny c cha cc yu t ng
mu, albumin v globulin min dch. Bo qun 180Cn 250C: 3 thng, 250C:
24 thng, 800C: 25 nm. Huyt tng ti ng lnh c dng trong iu tr
cc ri lon ng mu, trong iu tr xut huyt gim tiu cu. L ngun nguyn
liu chnh sn xut ta lnh yu t 8.
Ta lnh yu t 8:
L thnh phn huyt tng c cha phn on globilin kt ta c lm t huyt
tng ti ng lnh. Vi th tch khong 10-20 ml, thnh phn ny cha yu t
ng mu vi nng cao. Sn phm c cha t l ln yu t 8, yu t Von
Willebrand, fibrinogen, yu t 13 v fibronectin. Bo qun 180Cn 250C: 3
thng, 250C: 24 thng. Dng trong iu tr cc trng hp thiu ht yu t 8
(bnh a chy mu A, bnh Von Willebrand), ng mu ri rc lng mch, thiu
ht fibrrinogen.
Huyt tng loi ta 8:
L thnh phn iu ch t huyt tng bng cch ly i phn ta lnh yu t 8.
So vi huyt tng ti ng lnh, sn phm ny cha cng mc albumin, cc
globulin min dch, cc cht ng mu, ngoi tr c gim r yu t 5, yu t 8 v
fibrinogen. Bo qun 180Cn 250C: 3 thng, 250C: 24 thng, 800C: 25 nm.
Huyt tng loi ta 8 ch c dng cho cc trng hp xut huyt gim tiu
cu.


2. SINH L MU

1. KHI LNG.
Mu l t chc lng, lu thng trong h tun hon. Trong 1 kg th trng, c 75 -
80ml mu. Tr s sinh c 100ml mu /kg cn nng, sau khi lng mu gim
dn. T 2 -3 tui tr i khi lng mu li tng dn ln, ri gim dn cho n tui
trng thnh th hng nh. Mt ngi trng thnh, bnh thng mu chim 7 -
9% trng lng c th. Mt ngi nng 50kg c khong 4 lt mu. Ngi ta c th
xc nh khi lng mu chnh xc bng nhiu phng php khc nhau: phng
php tim cc cht c mu vo mu, cht ny t b lc ra khi thn, phn hu
nhanh v khng c hi hoc dng cc cht ng v phng x nh du hng cu.
Khi lng mu tng ln sau khi n, ung, khi mang thai, khi truyn dch... Khi
lng mu gim khi c th ra nhiu m hi, nn ma, a chy, chn thng c
chy mu bn trong hoc bn ngoi c th ... Nu khi lng mu tng ln trong
c th, dch t mu s vo khong gian bo ca da v cc m, sau nc c
bi xut dn theo nc tiu. Nu khi lng mu gim trong c th, dch t
khong gian bo vo mu lm cho khi lng mu tng ln. Trong nhiu trng
hp mt mu cp din (mt mu cc tng ln, cc xng ln, mt mu ng
ng mch ...) khi lng mu b gim t ngt, c th khng c kh nng t b
tr; nu khng cp cu kp thi, c th s khng sng c.
2. THNH PHN.
Mu gm hai thnh phn: th hu hnh (huyt cu) v huyt tng. Cc th hu
hnh ca mu l hng cu, bch cu v tiu cu, chim 43 - 45% tng s mu, ch
s ny c gi l hematocrit. Hng cu l thnh phn chim ch yu trong th
hu hnh. Huyt tng chim 55 - 57% tng s mu. Huyt tng cha nc,
protein, cc cht in gii, cc hp cht hu c v v c, cc hocmon, cc
vitamin, cc cht trung gian ho hc, cc sn phm chuyn ho ... Huyt tng
cha ton b cc cht cn thit cho c th v ton b cc cht cn c thi ra
ngoi. Huyt tng b ly mt fibrinogen th c gi l huyt thanh.
3. CHC NNG SINH L CA MU.
Mu c rt nhiu chc nng , di y l nhng chc nng c bn ca mu:
3.1. Chc nng dinh dng.
Mu mang trong mnh ton b cc cht dinh dng nui c th. Cc cht dinh
dng c a t ngoi vo qua ng tiu ho. Ngoi ra bch cu cn vo
lng ng tiu ho nhn cc cht dinh dng theo kiu "m bo" v "thc bo", ri
li vo lng mch mang thm mt phn cc cht dinh dng cho mu.
3.2. Chc nng bo v.
Mu c kh nng bo v c th khi b nhim trng nh c ch thc bo, m bo
v c ch min dch dch th, min dch t bo. Mu cng c kh nng tham gia
vo c ch t cm mu, trnh mt mu cho c th khi b tn thng mch mu
c chy mu.
3.3. Chc nng h hp.
Mu mang 0xy t phi ti t bo v m, ng thi mu mang cacbonic t t bo
v m ti phi.
3.4. Chc nng o thi.
Mu mang cc cht sau chuyn ho, cht c, cht l ti cc c quan o thi
(thn, b my tiu ho, phi, da ) thi ra ngoi.
3.5. Chc nng iu ho thn nhit.
Mu mang nhit phn "li" ca c th ra ngoi thi vo mi trng hoc gi
nhit cho c th nh c ch co mch da.
3.6. Chc nng iu ho cc chc phn c th.
Bng s iu ho tnh hng nh ni mi, mu tham gia vo iu ho ton b
cc chc phn c th bng c ch thn kinh v thn kinh - th dch.
4. C TNH CA MU.
Mu c tnh hng nh. Tnh hng nh ca mu c nh gi qua cc ch s sinh
l, sinh ho ca mu. Cc ch s ny, trong iu kin sinh l{ bnh thng l rt t
thay i hoc ch thay i trong mt phm vi rt hp. V vy chng c coi nh
l mt hng s. Kim tra cc ch s sinh l, sinh ho ca mu l mt vic lm v
cng quan trng v rt cn thit nh gi nhng ri lon chc nng ca c th.
3. HUYT TNG

Huyt tng l phn lng ca mu, chim 55-56% th tch mu ton phn.
Huyt tng l dch trong, hi vng, sau khi n c mu sa, v hi mn v c
mi c bit ca cc acid bo.
Huyt tng cha 92% l nc, cn li l cc cht hu c v cc cht v c. Huyt
tng b ly mt fibrinogen th gi l huyt thanh.
Mt s ch s vt l ca mu:
nht ca huyt tng: 2,0-2,5
nht ca mu ton phn: 4,7 (i vi nam); 4,4 (i vi n)
T trng ca huyt tng: 1,028
T trng ca huyt cu: 1,097
T trng ca mu ton phn: 1,057
p sut thm thu ca mu: 7,6 atm
pH ca mu: 7,36.
1. PROTEIN HUYT TNG.
Protein huyt tng l nhng phn t ln, c trng lng phn t cao, v d
trng lng phn t ca albumin: 69000, ca fibrinogen: 340000 v.v...
Protein ton phn: 68-72 g/l. y l phn ch yu ca nhng cht cha nit. ng
cc phng php hin i, ngi ta c th tch protein huyt tng ra thnh
hng trm thnh phn nh khc nhau. Thng thng protein huyt tng c cc
thnh phn c bn sau y:
Albumin: 42g/l
Globulin: 24g/l
T l albumin/globulin: 1,7.
a
1
globulin: 3,5g/l
a
2
globulin: 5g/l
b globulin: 8g/l
g globulin: 7,5g/l
Fibrinogen: 4g/l.
Protein huyt tng c cc chc nng chnh sau:
- Chc nng to p sut keo ca mu:
Cc phn t protein u mang in. Trong mi trng huyt tng c pH=7,36;
chng mang in m v dng proteinat. Do c nhng du in tch khc nhau
mt ngoi, nn c kh nng gi nc nhiu hay t quanh phn t. V vy protein
huyt tng gi c nc trong lng mch. Lc gi nc to nn p sut
keo. Thnh phn quan trng nht ca protein huyt tng l albumin. Cc protein
ni chung hay albumin ni ring u do gan sn xut v a vo mu. Khi gim
chc nng gan, protein huyt tng gim, nc khng c gi li trong mch
m vo khong gian bo, gy ra hin tng ph (ph do thiu protein huyt
tng). Trong nhiu trng hp iu tr, mun gi nc trong lng mch
duy tr huyt p v khi lng mu lu hnh ngi ta thng truyn dch c cha
cc hp cht hu c c phn t lng cao (c p lc keo cao).
- Chc nng vn chuyn.
Cc protein thng l cc cht ti cho nhiu cht hu c v v c v d nh
lipoprotein, Thyroxin binding prealbumin, Thyroxin binding globulin...
- Chc nng bo v.
Mt trong nhng thnh phn quan trng ca protein huyt tng l cc globulin
min dch: IgG, IgA, IgM, IgD, IgE (do cc t bo lympho B sn xut). Cc globulin
min dch c tc dng chng li cc khng nguyn l xm nhp vo c th. Thng
qua h thng min dch, cc globulin min dch bo v cho c th.
- Chc nng cm mu. Cc yu t gy ng mu ca huyt tng, ch yu l cc
protein do gan sn xut.
- Cung cp protein cho ton b c th.
2. CC CHT HU C KHNG PHI PROTEIN.
Nhm ny rt a dng v thng c chia lm hai loi: nhng cht c v khng
cha nit.
Nhng cht hu c khng phi protein, c cha nit:
Ur: 300mg/l
Acid amin t do: 500mg/l
Acid uric: 45mg/l
Creatin, creatinin: 30mg/l
Bilirubin: 5mg/l
Amoniac: 2mg/l
Cc cht hu c khng phi protein, khng cha nit:
Glucose: 1g/l
Lipid: 5g/l
Cholesterol: 2g/l
Phospholipid: 1,5g/l
Acid lactic: 0,1g/l
a s cc lipid huyt tng u gn vi protein to nn lipoprotein, trong lipid
gn vi a
1
globulin (25%), vi b globulin (70%).
Ngoi nhng cht c bn trn, trong huyt tng cn c nhng cht c hm
lng rt thp nhng li c vai tr v cng to ln i vi cc chc phn c th
nh: cc cht trung gian ho hc, cc cht trung gian chuyn ho, cc hormon,
cc vitamin v cc enzym.
3. CC CHT V C.
Cc cht v c thng dng ion v c chia thnh hai loi anion v cation. Cc
cht v c gi vai tr ch yu trong iu ho p sut thm thu, iu ho
pH mu v tham gia vo cc chc nng ca t bo.
- p sut thm thu.
n v o p sut thm thu l OsMol, tng ng vi 22,4 atm. Thng dng
l mOsMol. mOsMol l p sut thm thu ca 1/1000 Mol trong 1 lt nc. Bnh
thng p sut thm thu ca mu l 300-310 mOsMol. p sut thm thu ch
yu do Na
+
v Cl
-
quyt nh (95%), ngoi ra cn c mt s cht khc nh: HCO
3
-
,
K
+
, Ca
++
, HPO
4
--
, glucose, protein, ur, acid uric, cholesterol, SO
4
--
...
p sut thm thu gi nc v tr cn bng. Thay i p sut thm thu lm
thay i hm lng nc trong t bo v gy ra ri lon chc nng t bo.
Trong thc hnh vic xc nh p sut thm thu t nng Mol l phc tp, cho
nn ngi ta thng o h bng im tnh ra mOsMol. Mt nng 5,35
mOsMol lm h bng im 0,01
0
; p sut thm thu l 5,35 mOsMol.
- Cn bng ion.
Cc ion (anion v cation) trong huyt tng l cn bng in tch. o nng ion
bng Equivalent (Eq). Eq l ng lng mt ion bng trng lng Mol chia cho
ho tr (Eq=1000 mEq).
Cn bng ion c vai tr quan trng i vi chc nng t bo, vi cn bng acid
base mu... Nng ca cc ion trong huyt tng l:
Cl
-
: 3650 mg/l, 103 mEq/l
HCO
-
: 1650 mg/l, 27 mEq/l
Protein: 70000 mg/l, 15-18 mEq/l
HPO
4
--
: 5-106 mg/l, 3 mEq/l
SO
4
--
: 45 mg/l, 1 mEq/l
Acid hu c: 45 mg/l, 5 mEq/l
-------------------------------------------------------------------
+ 155 mEq/l
Na
+
: 3300 mg/l, 142 mEq/l
K
+
: 180-190 mg/l, 5 mEq/l
Ca
++
: 100 mg/l, 5 mEq/l
Mg
++
: 18-20 mg/l, 1,5 mEq/l
Cc thnh phn khc 1,5 mEq/l
----------------------------------------------------------------------
+ 155 mEq/l
S cn bng ca cc ion trong huyt tng c thc hin nh cc c ch:
khuch tn, tnh in, cn bng Donnan, vn chuyn tch cc ca t bo, c ch
siu lc, ti hp thu v bi tit tch cc ca thn ...
HUYT TNG
Huyt tng l phn lng ca mu, chim 55-56% th tch mu ton phn. Huyt
tng l dch trong, hi vng, sau khi n c mu sa, v hi mn v c mi c
bit ca cc acid bo.
Huyt tng cha 92% l nc, cn li l cc cht hu c v cc cht v c. Huyt
tng b ly mt fibrinogen th gi l huyt thanh.
Mt s ch s vt l ca mu:
nht ca huyt tng: 2,0-2,5
nht ca mu ton phn: 4,7 (i vi nam); 4,4 (i vi n)
T trng ca huyt tng: 1,028
T trng ca huyt cu: 1,097
T trng ca mu ton phn: 1,057
p sut thm thu ca mu: 7,6 atm
pH ca mu: 7,36.
1. PROTEIN HUYT TNG.
Protein huyt tng l nhng phn t ln, c trng lng phn t cao, v d
trng lng phn t ca albumin: 69000, ca fibrinogen: 340000 v.v...
Protein ton phn: 68-72 g/l. y l phn ch yu ca nhng cht cha nit. ng
cc phng php hin i, ngi ta c th tch protein huyt tng ra thnh
hng trm thnh phn nh khc nhau. Thng thng protein huyt tng c cc
thnh phn c bn sau y:
Albumin: 42g/l
Globulin: 24g/l
T l albumin/globulin: 1,7.
a
1
globulin: 3,5g/l
a
2
globulin: 5g/l
b globulin: 8g/l
g globulin: 7,5g/l
Fibrinogen: 4g/l.
Protein huyt tng c cc chc nng chnh sau:
- Chc nng to p sut keo ca mu:
Cc phn t protein u mang in. Trong mi trng huyt tng c pH=7,36;
chng mang in m v dng proteinat. Do c nhng du in tch khc nhau
mt ngoi, nn c kh nng gi nc nhiu hay t quanh phn t. V vy protein
huyt tng gi c nc trong lng mch. Lc gi nc to nn p sut
keo. Thnh phn quan trng nht ca protein huyt tng l albumin. Cc protein
ni chung hay albumin ni ring u do gan sn xut v a vo mu. Khi gim
chc nng gan, protein huyt tng gim, nc khng c gi li trong mch
m vo khong gian bo, gy ra hin tng ph (ph do thiu protein huyt
tng). Trong nhiu trng hp iu tr, mun gi nc trong lng mch
duy tr huyt p v khi lng mu lu hnh ngi ta thng truyn dch c cha
cc hp cht hu c c phn t lng cao (c p lc keo cao).
- Chc nng vn chuyn.
Cc protein thng l cc cht ti cho nhiu cht hu c v v c v d nh
lipoprotein, Thyroxin binding prealbumin, Thyroxin binding globulin...
- Chc nng bo v.
Mt trong nhng thnh phn quan trng ca protein huyt tng l cc globulin
min dch: IgG, IgA, IgM, IgD, IgE (do cc t bo lympho B sn xut). Cc globulin
min dch c tc dng chng li cc khng nguyn l xm nhp vo c th. Thng
qua h thng min dch, cc globulin min dch bo v cho c th.
- Chc nng cm mu. Cc yu t gy ng mu ca huyt tng, ch yu l cc
protein do gan sn xut.
- Cung cp protein cho ton b c th.
2. CC CHT HU C KHNG PHI PROTEIN.
Nhm ny rt a dng v thng c chia lm hai loi: nhng cht c v khng
cha nit.
Nhng cht hu c khng phi protein, c cha nit:
Ur: 300mg/l
Acid amin t do: 500mg/l
Acid uric: 45mg/l
Creatin, creatinin: 30mg/l
Bilirubin: 5mg/l
Amoniac: 2mg/l
Cc cht hu c khng phi protein, khng cha nit:
Glucose: 1g/l
Lipid: 5g/l
Cholesterol: 2g/l
Phospholipid: 1,5g/l
Acid lactic: 0,1g/l
a s cc lipid huyt tng u gn vi protein to nn lipoprotein, trong lipid
gn vi a
1
globulin (25%), vi b globulin (70%).
Ngoi nhng cht c bn trn, trong huyt tng cn c nhng cht c hm
lng rt thp nhng li c vai tr v cng to ln i vi cc chc phn c th
nh: cc cht trung gian ho hc, cc cht trung gian chuyn ho, cc hormon,
cc vitamin v cc enzym.
3. CC CHT V C.
Cc cht v c thng dng ion v c chia thnh hai loi anion v cation. Cc
cht v c gi vai tr ch yu trong iu ho p sut thm thu, iu ho
pH mu v tham gia vo cc chc nng ca t bo.
- p sut thm thu.
n v o p sut thm thu l OsMol, tng ng vi 22,4 atm. Thng dng
l mOsMol. mOsMol l p sut thm thu ca 1/1000 Mol trong 1 lt nc. Bnh
thng p sut thm thu ca mu l 300-310 mOsMol. p sut thm thu ch
yu do Na
+
v Cl
-
quyt nh (95%), ngoi ra cn c mt s cht khc nh: HCO
3
-
,
K
+
, Ca
++
, HPO
4
--
, glucose, protein, ur, acid uric, cholesterol, SO
4
--
...
p sut thm thu gi nc v tr cn bng. Thay i p sut thm thu lm
thay i hm lng nc trong t bo v gy ra ri lon chc nng t bo.
Trong thc hnh vic xc nh p sut thm thu t nng Mol l phc tp, cho
nn ngi ta thng o h bng im tnh ra mOsMol. Mt nng 5,35
mOsMol lm h bng im 0,01
0
; p sut thm thu l 5,35 mOsMol.
- Cn bng ion.
Cc ion (anion v cation) trong huyt tng l cn bng in tch. o nng ion
bng Equivalent (Eq). Eq l ng lng mt ion bng trng lng Mol chia cho
ho tr (Eq=1000 mEq).
Cn bng ion c vai tr quan trng i vi chc nng t bo, vi cn bng acid
base mu... Nng ca cc ion trong huyt tng l:
Cl
-
: 3650 mg/l, 103 mEq/l
HCO
-
: 1650 mg/l, 27 mEq/l
Protein: 70000 mg/l, 15-18 mEq/l
HPO
4
--
: 5-106 mg/l, 3 mEq/l
SO
4
--
: 45 mg/l, 1 mEq/l
Acid hu c: 45 mg/l, 5 mEq/l
-------------------------------------------------------------------
+ 155 mEq/l
Na
+
: 3300 mg/l, 142 mEq/l
K
+
: 180-190 mg/l, 5 mEq/l
Ca
++
: 100 mg/l, 5 mEq/l
Mg
++
: 18-20 mg/l, 1,5 mEq/l
Cc thnh phn khc 1,5 mEq/l
----------------------------------------------------------------------
+ 155 mEq/l
S cn bng ca cc ion trong huyt tng c thc hin nh cc c ch:
khuch tn, tnh in, cn bng Donnan, vn chuyn tch cc ca t bo, c ch
siu lc, ti hp thu v bi tit tch cc ca thn ...

4. HNG CU ( RED BLOOD CELLS)

I. CU TO
1. HNH DNG V KCH THC.
Hng cu trng thnh, lu thng trong mu l t bo khng c nhn. iu
kin t nhin, n c hnh a lm hai mt, ng knh khong 7,2mm, b dy
ngoi vi l 2,2mm, trung tm l 1mm
Th tch mt hng cu l 83mm
3
(83femtolit). Nh c tnh n hi tt m hng
cu d dng thay i hnh dng khi i qua cc mao mch. Din tch b mt hng
cu ln (do c hai mt lm), v vy khi hng cu bin dng mng hng cu khng
b cng v v ra. Nu tnh din tch ton b mng hng cu trong c th cng li,
c th ln n 3000m
2
.
2. THNH PHN.
T l thnh phn ca hng cu
% Cc thnh phn
67,00 Nc
28,00 Hemoglobin
0,30 Lipid cc loi (lecitin, cholesterol)
2,00 Nhng cht khc c cha nit (enzym,
protein, glutation)
0,02 Ur
1,20 Cc cht v c (K
+
)
Hng cu c mt cu trc c bit vi nhiu thnh phn khc nhau. N gm mt
nn do protein v lipid to nn. a s lipid u kt hp vi protein to thnh
lipoprotein. Trong nn cn c glucose, clorua, phosphat... Nn v mng chim 2 -
5% trng lng hng cu. Gia cc mt ca nn c hemoglobin. Hai thnh phn
quan trng nht ca hng cu c nghin cu nhiu l mng hng cu v
hemoglobin. Mng hng cu mang nhiu khng nguyn nhm mu. Hemoglobin
l thnh phn quan trng trong s vn chuyn kh ca mu.
3. S LNG.
Ngi trng thnh, mu ngoi vi c 3,8 x 10
12
hng cu/lt (i vi n); 4,2
x10
12
hng cu/lt (i vi nam). Tr mi sinh, ngy u s lng hng cu rt
cao (5,0 x10
12
hng cu/lt). Sau , do hin tng tan mu, s lng hng cu
gim dn. Tr em di 15 tui c s lng hng cu thp hn ngi trng
thnh 0,1 - 0,2 x 10
12
hng cu/lt. S lng hng cu n nh tui trng
thnh.
S lng hng cu tng ln sau ba n, khi lao ng th lc, sng trn ni cao
700 - 1000m, khi ra nhiu m hi, i nhiu, a chy, bng mt huyt tng, trong
bnh a hng cu, bnh tim bm sinh.... S lng hng cu gim lc ng, khi ung
nhiu nc, cui kz hnh kinh, sau , i lu ngy, ni c phn p oxy cao, cc
loi bnh thiu mu, suy tu, nhim c, chy mu trong, chy mu do vt
thng...
4. QU TRNH SINH HNG CU
4.1. Ngun gc v cc giai on pht trin ca hng cu
Nhng tun u ca thai nhi hng cu c nhn c l thai gia sn xut. T
thng th hai tr i gan, lch, sau l hch bch huyt cng sn xut ra hng
cu c nhn. T thng th 5 ca kz pht trin thai, tu xng bt u sn xut
hng cu v t tr i, tu xng l ni duy nht sinh ra hng cu. Sau tui 20
cc tu xng di b m ho, cn tu xng xp nh xng sng, xng sn,
xng c, xng chu sn xut hng cu. V vy tui gi d b thiu mu hn.
T bo tu xng l t bo gc vn nng c kh nng duy tr ngun cung cp t
bo gc v pht trin thnh t bo gc bit ho to ra cc dng khc nhau ca
t bo mu (theo thuyt mt ngun gc). T bo gc bit ho sinh ra hng cu
c gi l n v to cm ca dng hng cu: C.F.U.E (Colony forming unit
erythrocyt). Sau cc t bo dng hng cu tri qua cc giai on sau y.
Tin nguyn hng cu (proerythoblast)
Nguyn hng cu a kim( normoblast a kim) Nguyn hng cu a sc
(normoblast a sc) Nguyn hng cu (normoblast) Hng cu li
(reficulocyt) Hng cu trng thnh (erythrocyt)
Nhn ca nguyn hng cu mt i khi nng hemoglobin trong bo tng cao >
34%. Hng cu chnh thc khng c nhn xuyn mch ri b tu xng vo h
tun hon chung. Hng cu li cng c kh nng vo mu nh hng cu trng
thnh nhng t l rt thp ch chim 1% tng s lng hng cu mu ngoi vi,
khong 1-2 ngy sau hng cu li tr thnh hng cu trng thnh. Hng cu
sng trong mu khong 120 ngy (ngi da trng), gn 120 ngy (ngi Vit).
H thng enzym ni bo hng cu lun lun tng hp ATP t glucose duy tr
tnh n hi ca mng t bo, duy tr vn chuyn ion qua mng, gi cho st lun
lun c ho tr 2, ng thi ngn cn s oxy ho protein trong hng cu. Trong
qu trnh sng, h thng enzym gim dn, hng cu gi ci, mng hng cu km
bn v d v.
Mt phn hng cu t hu trong mu, cn i b phn hng cu b hu trong t
chc vng - ni m ca lch, gan, tu xng. Hemoglobin c gii phng ra b
thc bo ngay bi cc i thc bo lch, gan, tu xng. i thc bo gii phng
st vo mu v n c vn chuyn di dng ferritin. Phn porphyrin ca hem
trong i thc bo c chuyn thnh sc t bilirubin gii phng vo mu, ri qua
gan bi tit theo mt.
4.2.Cc nguyn liu cn thit cho qu trnh sinh hng cu
to thnh hng cu, trong c th c hai qu trnh song song: s to thnh t
bo hng cu v s tng hp hemoglobin. y l nhng qu trnh rt phc tp,
i hi nhiu nguyn liu nh protein, cholin, thymidin, acid nicotinic, thiamin,
pyridoxin, acid folic, vitamin B12, Fe
++
, nhiu enzym v cht xc tc cho qu trnh
tng hp ny.
Vitamin B12 v acid folic rt cn cho qu trnh tng hp thymidintriphosphat,
mt trong nhng thnh phn quan trng ca DNA. Thiu vitamin B12 v acid folic
s lm gim DNA, t bo s khng phn chia v khng trng thnh c.Lc ny
cc nguyn hng cu trong tu xng c kch thc ln hn bnh thng, c
gi l nguyn bo khng l. T bo to ra l v lng DNA khng nhng lng
RNA li tng dn ln hn bnh thng, t bo tng tng hp hemoglobin hn v
cc bo quan cng nhiu hn. Cc hng cu trng thnh s c hnh bu dc
khng u, mng mng hn v i sng s ngn hn (ch bng 1/3 - 1/2 thi gian
ca hng cu bnh thng).
Vitamin 12 qua ng tiu ho kt hp vi yu t ni (t bo vin tuyn d dy
bi tit). Phc hp ny gn vo receptor mng t bo nim mc hi trng v
vitamin 12 c hp thu theo c ch m bo. Vitamin B12 vo mu, d tr
gan. Nhu cu vitamin B12 l 1 - 3 mg/24h. Trong khi s d tr vitamin B12 ca
gan c th gp 1000 ln nhu cu ca c th trong mt ngy.
Thnh phn th hai khng km phn quan trng l st. St c hp thu theo
ng tiu ho vo mu. Trong mu, st c kt hp vi mt globulin l
apotransferrin to thnh transferrin vn chuyn trong huyt tng (v st lin
kt vi globulin rt lng lo). St c vn chuyn ti cc m c bit: t chc
vng - ni m v gan. Ti y, st c gii phng ra v c t bo hp thu.
Trong bo tng, st kt hp vi mt protein l apoferritin to thnh ferritin
l dng d tr st. Mt lng nh st c d tr dng hemosiderin trong t
bo. c tnh duy nht ca transferrin l n gn rt mnh vi receptor mng t
bo nguyn hng cu. Trong t bo, transferrin gii phng st vo ty lp th. Ti
y din ra qu trnh tng hp hem. Mi ngy mt ngi trng thnh cn 1mg
st. Ph n cn st nhiu gp i so vi nam gii v b mt mu qua mu kinh
nguyt. St b thi hng ngy qua phn v m hi.
St c hp thu rut nh apoferritin do gan sn xut, bi tit theo mt vo t
trng. Apoferritin gn vi st t do hoc vi st ca hemoglobin, myoglobin
to thnh transferrin.Transferrin gn vo receptor t bo nim mc rut, ri vo
mu. St c hp thu rt chm v rt t, mc d st c n vo theo thc n l
kh nhiu. Khi apoferritin trong c th bo ho st th transferrin khng gii
phng st cho cc m v cng khng nhn st t rut, hp thu st b ngng li.
Khi c th tha st, gan gim sn xut apoferritin lm cho apoferritin trong mu
v mt gim v cng lm gim hp thu st. Trong trng hp n qu nhiu st,
st vo mu nhiu dn n lng ng hemosiderin trong cc t bo vng - ni m,
gy c hi cho t bo ny.
4.3. S iu ho qu trnh sinh hng cu
S lng hng cu mu ngoi vi c iu ho hng nh nhm cung cp
oxy cho t bo hot ng. S tng trng v sinh sn ca cc t bo gc c
kim sot bi cc protein kch thch tng trng, v d nh interleukin 3.
Cc t bo gc bit ho n lt mnh li chu s kch thch tng trng ca cc
cht gy bit ho, m cc cht ny li c rt nhiu c quan nh thn, gan... sn
xut khi chng b thiu oxy.
Bnh nhn b thiu mu do mt mu, b gim chc nng tu xng khi b chiu x,
nhng ngi sng vng ni cao c nng oxy trong khng kh thp hn bnh
thng, bnh nhn b suy tim, cc bnh v phi c gim trao i kh phi... u
gy ra thiu oxy cc m lm cho qu trnh oxy ho cc m b gim i.
Khi cc m b thiu oxy chng sn xut ra erythropoietin. Erythropoietin l mt
glucoprotein c TLPT l 34000. nh thng 80-90% erythropoietin l do thn sn
xut, cn li l do gan sn xut. Mt s m khc cng sn xut erythropoietin,
nhng khng ng k. V vy chng ta c th gp bnh nhn thiu mu do suy
thn mn tnh. Khi thn v gan thiu oxy, erythropoietin s c sn xut sau vi
pht hoc sau vi gi.
Erythropoietin do thn sn xut dng cha hot ng gi l erythogenin. Nh
kt hp vi mt globulin (do gan sn xut) erythogenin chuyn thnh
erythropoietin hot ng. Erythropoietin c tc dng: kch thch qu trnh chuyn
C.P.U.E thnh tin nguyn hng cu v kch thch chuyn nhanh cc hng cu non
thnh hng cu trng thnh.
5. SC BN HNG CU
Mng hng cu l mt mng bn thm. Nc c th qua mng hng cu khi p
xut thm thu bn trong v bn ngoi hng cu khc nhau. Ngi ta xc nh
sc bn hng cu bng dung dch mui NaCl nhc trng c nng khc nhau
t 0,02% mt ( phng php Hamberger).
Hng cu trong dung dch mui NaCl nhc trng b trng to ln v v ra do
nc t dung dch mui vo trong hng cu.Khi hng cu v, hemoglobin gii
phng vo dung dch v lm cho n c mu hng. Mt s hng cu bt u v
trong dung dch mui NaCl nhc trng 0,44%. Nng mui NaCl 0,44% c
gi l sc bn ti thiu ca hng cu. Ton b hng cu v ht trong dung dch
NaCl nhc trng 0,34%. Nng mui NaCl 0,34% c gi l sc bn ti a
ca hng cu.
Sc bn ca hng cu gim trong bnh vng da hu huyt, tng ln sau ct lch.
6. TC LNG HNG CU
Mu c chng ng, t trong ng nghim, hng cu lng xung di, huyt
tng ni ln trn. iu xy ra l do t trng ca hng cu (1,097) cao hn t
trng ca huyt tng (1,028). Khi c qu trnh vim din ra trong c th lm hm
lng cc protein mu thay i, cn bng in tch protein huyt tng thay i,
in tch mng hng cu cng b bin i theo, hng cu d dnh li vi nhau hn
v lm cho n lng nhanh hn.
Nh vy tc lng mu cng cao th qu trnh vim ang din ra trong c th
cng mnh. Ch s tc lng hng cu l chiu cao ct huyt tng tnh bng
mm trong 1h, 2h v 24h.
7. HEMOGLOBIN
7.1. Cu trc ca Hemoglobin.
Hemoglobin (Hb) l 1 protein mu, phc tp thuc nhm chromoproteid mu ,
c nhm ngoi l hem. Hb l thnh phn ch yu ca hng cu, chim 28% v
tng ng vi 14,6g trong 100 ml mu. TLPT ca Hb l 64.458.
Hb gm 2 phn: hem v globin. Mi phn t Hb c 4 hem v 1 globin. N c
to thnh t 4 di n v. Mi di n v l 1 hem kt hp vi globin.
Globin c cu trc l cc chui polypeptid. ngi ln, 4 chui polypeptid ging
nhau tng i mt: 2 chui a v 2 chui b. Cc di n v lin kt vi nhau bng
lin kt yu: lin kt ion, lin kt hydro, to nn cu trc bc 4 ca phn t Hb
(hnh 3.2). chui polypeptid ca mi di n v c 1 hc cha hem. Trung tm
ca phn t Hb c 1 hc rng gi l hc trung tm (hnh 3.3). Hc trung tm tip
nhn phn t 2,3 diphosphoglycerat (2,3 DPG) v s kt hp ca hc trung tm
vi 2,3 DPG c vai tr iu ho i lc ca Hb vi 0xy.
Thnh phn th 2 ca Hb l hem. Sc t hem thuc loi porphyrin l nhng cht
c kh nng kt hp vi nguyn t kim loi. Hem ngi l porotophyrin IX kt
hp vi Fe
++
. Hem c 4 nhn pyrol lin kt vi nhau bng cu ni menten (-
CH=). Vng porphyrin c gn cc gc metyl (-CH
3
) v tr 1, 3, 5, 8; cc gc vinyl (-
CH=CH
2
) v tr 2,4; cc gc propionyl (-CH
2
- CH
2
- C00H) v tr 6,7. Fe
++
gn vi
nh pha trong ca nhn pyrol bng hai lin kt ng ho tr v hai lin kt phi
tr v vi globin qua gc histidin (hnh 3.4).
Porphyrin l ph bin trong th gii sinh vt. Porphyrin kt hp vi Mg
++
to
thnh cht dip lc ca thc vt.
Hem c th kt hp vi nhiu cht khc nhau. Nu hem kt hp vi globin th to
thnh Hb. Nu hem kt hp vi albumin, NH
3
, pyridin, nicotin... to nn cht gi
l hemochromogen. Hem phn ng vi NaCl trong mi trng acid to ra
chloruahem (hemin). Phn ng ny c s dng trong php y.
7.2 Cc loi hemoglobin ngi.
Hemogobin khc nhau phn cu to globin. Hb ca thai nhi l HbF. Globin ca
HbF gm hai chui a v hai chui g. Hb ca ngi ln l HbA. Globin ca HbA gm
hai chui a v hai chui b (v tr th 3 ca chui b l glutamin c thay bng
threonin chui g). Hb ca bnh nhn mc bnh thiu mu c hng cu hnh
li lim l HbS (HbB) v tr th 6 ca chui b l valin c thay bng glutamin.
Loi hng cu ny rt d v khi qua mao mch nh. HbC v HbD l cc Hb bnh
thng gp mt s chng tc ngi Chu Phi.
C nhiu phng php nh lng Hb, k c cc phng php khng chy mu.
nh thng ngi Vit c Hb l 14,6g (i vi nam) v 13,3g (i vi n) trong
100ml mu. m s lng hng cu v nh lng Hb l nhng xt nghim quan
trng trong nh gi s thiu mu, thiu mu ng sc (gi tr hng cu =1), thiu
mu u sc (gi tr hng cu >1) v thiu mu nhc sc (gi tr hng cu <1).
7.3. Chc nng ca hemoglobin.
- Hemoglobin kt hp vi oxy to thnh oxyhemoglobin (Hb0
2
). Kh nng kt hp
lng lo v thun nghch to iu kin cho vic Hb nhn oxy phi ri vn chuyn
n m gii phng oxy cho t bo. Oxy kt hp vi Hb phn Fe
++
ca hem.
Mi Hb c 4 hem, mi hem c 1Fe
++ .
Nh vy v mt l thuyt mt phn t Hb c
th kt hp bo ho vi 4 phn t oxy. Thc t trong c th iu ny rt kh xy
ra v khng bao gi c s bo ho 100% Hb0
2
. S kt hp gia oxy vi Fe
++
xy ra
nh sau: Khi mt phn t oxy gn ti Fe
++
(do oxy khuych tn t ph nang vo
mu, t mu vo trong hng cu) th cng mt lc xy ra hai mi lin kt: Fe
++
-0
2
-
v Fe
++
-N
+
- (nit ca nhm imidazol). Lc ny oxy mang in tch m v nhn in
t ca nit. Fe
++
lc ny tr thnh mt acid yu. V mt l{ do no m khng c
mi lin kt Fe
++
-N
+
-, lc ny oxy khng lin kt vi Fe
++
m li nhn in t ca
Fe
++
, Hb chuyn thnh methemoglobin, lm cho Hb mt kh nng vn chuyn
oxy. Imidazol nh hng trn b mt hem l nguyn nhn to ra mi lin kt
Fe
++
-N
+
- .
S kt hp v phn ly Hb0
2
chu nh hng ca p0
2
,

pC0
2
, pH, nhit mu.
- Hemoglobin kt hp vi carbonic to thnh carbohemoglobin (HbC0
2
). y cng
l mt phn ng thun nghch. S kt hp xy ra m, s phn ly xy ra phi.
Carbonic kt hp vi Hb nhm amin ca globin nn gi l phn ng cc
carbamin. Carbonic c vn chuyn dng HbC0
2
khng nhiu, ch chim 6,5%
tng s C0
2
vn chuyn trong mu.
- Hemoglobin kt hp vi carbonmonocid to thnh Carboxyhemoglobin (HbC0).
HbC0 rt bn vng v khng cn kh nng vn chuyn oxy v i lc ca Hb vi C0
rt cao, gp 210 ln i lc ca Hb vi 0
2
, thm tr C0 cn y c 0
2
ra khi Hb0
2
.
Khi ng c C0, cn cho th 0
2
phn p cao ti to li oxyhemoglobin
- Hemoglobin c tnh cht m. H m hemoglobin l mt trong cc h m
quan trng ca mu, l h m HHb/KHb v h m HHbC0
2
/KHb0
2
.
Kh nng m ca Hb l ng k v hm lng Hb trong mu kh cao v chim
khong 35% dung tch m ca mu.
- Trong qu trnh chuyn ho Hb, c th to ra sc t mt. Sc t mt khng c
chc nng sinh l{ nhng n l cht ch th mu i vi cc nh lm sng, n cho ta
bit mt c mt u, qua nh gi chc nng gan mt.
II. CHC NNG
1. Chc nng vn chuyn kh oxy v carbonic.
Hng cu vn chuyn kh oxy t phi n m v vn chuyn kh carbonic t m
n phi nh chc nng ca hemoglobin.
Mt khc C0
2
m sau khi khuych tn vo trong hng cu th ti y din ra
qu trnh C0
2
+ H
2
0 H
2
C0
3
nh men xc tc carboanhydrase (men ny c nhiu
trong hng cu). Sau H
2
C0
3
phn ly H
+
+ HC0
3
-
. Nh hiu ng Hamburger m
HC0
3
-
c khuych tn rt nhiu t trong hng cu chuyn sang huyt tng
to ra dng vn chuyn C0
2
quan trng nht ca mu (C0
2
c vn chuyn di
dng HC0
3
-
). Nh vy hng cu ng vai tr quan trng bc nht trong s vn
chuyn C0
2
dng HC0
3
-
ca huyt tng.
2. Chc nng iu ho cn bng acid - base ca mu.
Chc nng ny do h m hemoglobinat m nhim. ng thi vi h m ca
Hb, hng cu cn to ra HC0
3
-
trong qa trnh vn chuyn C0
2
, nn n to ra
h m bicarbonat HC0
3
/H
2
C0
3
,

h m quan trng nht ca mu.
3. Chc nng to nht ca mu.
Hng cu l thnh phn ch yu to nht ca mu, nh nht m tc
tun hon, nht l tun hon mao mch, hng nh. Tc tun hon hng nh
l iu kin thun li cho s trao i vt cht gia t bo v mu. Khi nht ca
mu thay i s gy ra thay i tc tun hon v lm ri lon trao i vt cht
ca t bo.

5. BCH CU ( WHITE BLOOD CELLS)

1. HNH DNG V S LNG.
Bch cu l cc t bo c nhn, hnh dng v kch thc rt khc nhau tuz tng
loi. Bch cu khng phi ch lu thng trong mu, m n cn c mt nhiu
ni trong c th: bch huyt, dch no tu, hch bch huyt, cc t chc lin
kt...
Thnh phn bch cu rt phc tp, gm nhiu cht hu c v v c. o tng
ca bch cu cha nhiu st, calci, lipid (cholesterol, triglycerid v acid bo). Cc
lipid ny lin quan ti vai tr chng nhim trng ca bch cu. Bch cu cha
nhiu lipid c xem nh tin lng tt chng nhim trng (Boyd,1973). trong
bch cu cn c nhiu acid ascorbic, ht glycogen. Ht glycogen nhiu ln trong
qu trnh tiu ho v mc bnh i tho ng. Bch cu c mt h thng enzym
rt phong ph (oxydase, peroxydase, catalase, lipase, amylase) v mt s cht
dit khun.
Trn mng t bo bch cu c rt nhiu th th lin quan ti chc nng ca bch
cu. Da vo cc th th ny, nh cc k thut hin i, ta c th phn loi c
bch cu v theo di cc giai on pht trin ca bch cu.
Trn b mt lympho bo c h thng khng nguyn ph hp t chc. Mc d mt
s khng nguyn c mt trn t bo ca nhiu m, nhng chng li b pht hin
d dng trn lympho bo. Do tt c khng nguyn ph hp t chc ch yu
ca ngi c k hiu l HLA (humanlymphocyt antigen). Tt c HLA hp thnh
h thng khng nguyn ph hp t chc ca ngi, cn gi l h thng HLA, chia
thnh 5 nhm. Nhm HLA-A, nhm HLA-B, nhm HLA-C, nhm HLA-D v nhm
HLA-DR. Di cc nhm ny c rt nhiu phn nhm c t tn. H thng
khng nguyn HLA di truyn v rt c { ngha trong p ng min dch thi ghp.
Trong 1lt mu ngoi vi c 7,0 x 10
9
bch cu (i vi nam) 6,2 x10
9
bch cu (i
vi n), nhn chung vo khong 5,0 x 10
9
n 9,0 x 10
9
bch cu (i vi ngi
trng thnh). Tr s sinh c s lng bch cu rt cao: 20,0 x10
9
bch cu/1lt
mu ngoi vi. Lc mt tui cn 10,0 x 10
9

bch cu/1lit mu. T 12 tui tr i s
lng bch cu tr v n nh bng ngi trng thnh.
S lng bch cu tng ln khi n ung, khi lao ng th lc, thng cui ca thi
kz mang thai, sau khi . c bit s lng bch cu tng ln khi nhim khun,
bnh bch cu. Mt s hormon v mt s tinh cht m cng lm tng s lng
bch cu nh: hormon tuyn gip, adrenalin, estrogen, tinh cht gan, tinh cht
lch, tu xng. S lng bch cu gim khi b lnh, khi b i, khi gi yu, suy
nhc tu, nhim virus, nhim c, nhim trng qu nng, hoc iu tr bng cc
hormon corticoid, insulin ko di...
2. PHN LOI BCH CU.
V mt i th, vi k thut kinh in, da vo hnh dng, kch thc t bo, hnh
dng nhn, s bt mu ca ht trong bo tng. Ngy nay nh k thut hin i
cn pht hin c cc th th b mt t bo bch cu v.v...; ngi ta c th
phn loi bch cu thnh bch cu ht (bch cu a nhn) v bch cu khng ht
(bch cu n nhn). ch cu a nhn c chia lm 3 loi: trung tnh, a acid
v base. Bch cu n nhn c chia lm 2 loi: monocyt v lymphocyt. ngi
bnh thng, t l cc bch cu trong mu ngoi vi nh sau:
Bch cu ht a acid (E): 2,3%
Bch cu ht a base (): 0,4%
Bch cu monocyt (M) : 5,3%
Bch cu ht trung tnh (N): 62,0%
Bch cu lymphocyt (L): 30,0%
Cc nh lm sng thng gi t l % cc loi bch cu mu ngoi vi l cng thc
bch cu ph thng. Cng thc thay i khi n ung, khi lao ng, khi c kinh
nguyt, khi c thai trn 4 thng, khi . Tr s sinh c ti 70% l bch cu a
nhn, t thng th 3 tr i ch cn 35% l cc bch cu a nhn (lc ny ch yu
l lympho bo). Cng thc bch cu dn n nh n sau tui dy th mi bng
ngi trng thnh.
Ngy nay nh k thut cao chng ta c th phn loi bch cu mt cch chi tit
hn vi mc ch tm hiu chc nng ca tng loi bch cu phc v cho nghin
cu khoa hc, chn on v iu tr. Tuy vy vic xc nh cng thc bch cu
ph thng v s lng bch cu vn c coi l xt nghim thng quy ca bnh
vin v n vn cn gi tr thc tin. ng thi vi xc nh gi tr tng i (l t l
% ca tng bch cu), cc nh lm sng cn xc nh gi tr tuyt i (s lng
tng loi bch cu c trong 1lt mu). Ch s ny rt cn cho s tin lng bnh.
Bch cu a nhn trung tnh (N) tng >70% trong cc trng hp nhim khun
cp, qu trnh lm m, vim tnh mch, nghn mch, nhi mu c tim, nhi mu
phi. N cn tng trong co git ng kinh, a protein vo trong c th, chy
mu phc mc nh. ng thi vi N tng cn c bch cu a (stab) tng.
- Bch cu a nhn trung tnh gim <60% trong cc trng hp nhim trng ti
cp, nhim virus kz ton pht, st rt, cng lch, nhim c, suy nhc tu.
- Bch cu a nhn a acid (E) tng nh v thong qua gp trong hi phc sau
nhim trng, kh c protein. E tng lin tc trong cc bnh giun sn, d ng,
bnh cht to keo.Bch cu a nhn a acid gim trong sc, trong hi chng
Cushing, trong giai on iu tr bng corticoid.
- Bch cu a nhn a base () tng trong mt s trng hp vim mn tnh ko
di, vim hi phc. cn thay i trong mt s trng hp nhim c.
- Bch cu n nhn monocyt (M) tng trong nhim trng, bnh bch cu, nhim
virus. M gim trong mt s trng hp nhim c.
- Bch cu n nhn lymphocyt (L) tng do tng sinh trong nhim khun mn tnh,
nhim virus, giai on lui bnh ca nhim trng.
3- I SNG CA BCH CU.
Nh phn loi phn trn, bch cu c chia ra thnh 3 dng: dng bch cu
ht, dng monocyt v dng lymphocyt. Ba dng bch cu ny c sinh ra t t
bo gc vn nng trong tu xng.
Dng bch cu ht: t bo gc pht trin qua nhiu giai on tr thnh myeoblat
promyelocyt myelocyt metamyelocyt bch cu a nhn trng thnh. T
myelocyt, bch cu chia thnh ba loi bch cu a nhn (bch cu ht) khc nhau:
bch cu ht trung tnh, bch cu ht a acid, bch cu ht a base.
Dng lymphocyt: t bo gc vn nng pht trin qua nhiu giai on bit ho
v c "x l" cc m c bit ri thnh lympho trng thnh d tr trong
cc m bch huyt lu thng mu cc m m bch huyt v.v... chu kz xy ra
lin tc.
Dng monocyt: t bo gc vn nng pht trin qua nhiu giai on bit ho thnh
monocyt.
Cha bit chnh xc thi gian sng ca bch cu trong mu l bao lu v bch cu
c mt khp mi ni. ch cu vo cc c quan ri t cc c quan quay tr li
mu. Thi gian bch cu c mt trong mu chng qua l thi gian vn chuyn
bch cu t ni sn xut n ni s dng. V vy thi gian sng ca bch cu
trong mu l rt ngn.
Nu ngng sn xut bch cu t ngt (bng cch chiu tia g) trong 3 n 6 ngy
u mu ngoi vi khng cn bch cu a nhn trung tnh. Thi gian bch cu sng
trong mu khang 4-5 ngy. Thi gian bch cu sng c trong v ngoi mch
khong 8-12 ngy. Thi gian bch cu tn ti trong tu xng khong 4-8 gi. Kh
c th xc nh chnh xc thi gian sng ca bch cu monocyt v n lun lun
qua li gia cc m. Thi gian lu thng ca monocyt trong mu khong 10-20
gi. Thi gian sng ca monocyt trong cc vim di hn bch cu a nhn trung
tnh. Lympho bo vo h tun hon lin tc qua ng ngc. S lng lympho bo
trong ng ngc vo h tun hon chung trong 24 gi thng l gp nhiu ln s
lng lympho bo mu mt thi im. iu chng t thi gian lympho bo
sng trong mu l rt ngn (24h). Bch cu lympho t c quan bch huyt vo
mu, t mu ti m, t m li vo c quan bch huyt, ri li vo mu... chu kz
c th din ra lin tc.
Bch cu b tiu dit khp mi ni trong c th khi b gi ci, nhng ch yu l
trong lng ng tiu ho, phi v lch. Bch cu (c bit l cc i thc bo, bch
cu ht trung tnh) b tiu dit cc vim, cc vng v cc din ca c th d b
vi khun t nhp nh da, phi, nim mc.
4. C TNH CA BCH CU.
Bch cu c nhng c tnh chung sau y:
4.1. Xuyn mch.
Bch cu M v N c kh nng thay i hnh dng, xuyn qua vch gia cc t bo
ti nhng ni cn thit.
4.2. Chuyn ng theo kiu a mip.
Bch cu M v N c kh nng chuyn ng bng chn gi (theo kiu amip) vi tc
: 40mm/min.
4.3. Ho ng ng v nhit ng ng
C mt s cht do m vim sn xut, do vi khun to ra hoc nhng cht ho hc
a t ngoi vo c th thu ht bch cu ti (ho ng ng dng tnh) hoc xua
ui bch cu ra xa hn (ho ng ng m tnh). Tng t, vi nhit cng nh
vy, bch cu cng c nhit ng ng dng tnh v m tnh. Cc c tnh ny ch
yu l ca bch cu M v N.
4.4. Thc bo.
Bch cu M v N c kh nng thc bo, m bo. Nhng iu kin thun li cho
thc bo l:
+ B mt ca vt rng v x x.
+ Khng c v bc. Cc cht t nhin trong c th c v bc l protein, cc cht
ny y t bo thc bo ra xa nn kh thc bo. Cc m cht, cc vt l khng c
v bc v thng tch in rt mnh nn chng d b thc bo.
+ Qu trnh opsonin ho. Cc khng th (c sn xut trong qu trnh min dch)
gn vo mng t bo vi khun lm cho vi khun d b thc bo.
S thc bo c thc hin nh sau:
Bch cu tip cn vt l, phng chn gi bao vy vt l, to thnh mt ti kn
cha vt l. Ti ny xm nhp vo trong t bo, tch khi mng t bo to ra mt
ti thc bo tri t do trong bo tng. Ti thc bo tip cn lysosom v cc ht
khc trong bo tng v xut hin hin tng ho mng. Cc enzym tiu ho v
cc tc nhn git vi khun c trt vo ti thc bo x l vt l. Ti thc bo
tr thnh ti tiu ho. Sau khi tiu ho, cc sn phm cn thit cho t bo c
gi li, cc sn phm khng cn thit s c o thi ra khi t bo bng qu
trnh xut bo.
Tnh thc bo ca bch cu khng phi l v hn. Mt bch cu ht trung tnh c
th thc bo 5-25 vi khun th cht. i thc bo c kh nng thc bo mnh hn
nhiu. N c th thc bo ti 100 vi khun. Khi nghin cu chc nng thc bo
ca bch cu, ngi ta thng s dng "ch s thc bo" nh gi chc nng
ny.
Bch cu c mt khp ni trong c th cho nn vi khun t nhp bng bt kz
ng no cng b tiu dit. c bit bch cu trn gi nhng ni quan trng ca
c th m vi khun d xm nhp vo nh: da, nim mc, cc hc t nhin, phi,
ng tiu ho, gan, lch. Tuy vy c mt s vi khun b bch cu "nut" nhng
khng "git" c nh mycobacteria, salmonella, listera ... Nhng vi khun ny
n nu ri nhn ln trong i thc bo. Bch cu N v i thc bo cn cha
nhng cht git vi khun. Mt s vi khun khng b tiu ho bi cc enzym ca
lysosom v chng c v bc bo v, hoc c cc yu t ngn chn tc dng ca cc
enzym tiu ho nhng li b cht bi cc cht git vi khun. Cc cht git vi khun
l cc cht oxy ho mnh nh superoxid (0
2-
), hydrogenperoxid (H
2
0
2
), ion
hydroxyl (0H
-
). Ngoi ra enzym mieloperoxydase ca lysosom cng c kh nng
git vi khun v n lm tan mng lipid ca vi khun.
5. QU TRNH VIM.
Khi vim, c tnh ca m b thay i nh sau:
- Gin mch ti ch lm cho lu lng mu tng ln.
- Tng tnh thm mao mch gy ph n.
- ng dch k v dch bch huyt do fibrinogen v cc yu t gy ng mu thot
vo.
- Tp trung nhiu bch cu N v i thc bo.
- Cc t bo ca m trng phng ln.
M b thng tn do bt kz mt nguyn nhn no (vi khun, chn thng, ho
cht, nhit v.v...) s gii phng histamin, bradykinin, serotonin, prostaglandin, cc
yu t gy ng mu. Lympho bo T hot ho gii phng ra lymphokin. Mt s
cht trn hot ho i thc bo v cng vi mt s sn phm khc do t bo
tn thng v vi khun to ra gy ho ng dng tnh vi bch cu N v i
thc bo. Bch cu bm mch, xuyn mch v di chuyn ti vim.
S ng dch k v bch huyt to ra mt bc tng bo v ngn cch gia vng
vim v vng lnh. S tp trung ca bch cu (i thc bo ti trc: sau vi
pht, bch cu N ti sau: sau vi gi) l mt hng ro th hai. ng thi vi s
tp trung ca bch cu, t bo vim sn xut ra cc globulin, cc sn phm phn
hu bch cu vo mu, theo mu ti tc ng ln tu xng lm tng sn xut
bch cu (sau mt, hai ngy). Do qu trnh tng sn xut bch cu cho nn trong
mu s c nhiu bch cu non hn bnh thng (bch cu a).
vim hnh thnh mt ci hc cha xc vi khun, bch cu N, i thc bo, t
chc hoi t gi l m. M nhiu s b v thot ra ngoi hoc vo cc xoang, cc
tng rng ca c th. Nu hng ro bo v km, vi khun s lan rng vo cc c
quan, c khi vo c mu. mu cng c i thc bo v bch cu N sn sng tiu
dit chng. Trong nhiu trng hp c th khng t bo v c mnh cc triu
chng nhim khun tng ln dn v cn phi c iu tr kp thi.
6. BCH CU A NHN A ACID .
Bch cu E c kh nng thc bo v ho ng ng rt yu nn khng quan trng
trong nhim trng thng thng. nhng ngi nhim k sinh trng (KST), s
lng bch cu E tng cao v chng ti cc nhim k sinh trng. Bch cu E gii
phng ra cc cht git KST: men thu phn t cc ht ca bo tng, oxy
nguyn t, cc peptid v.v... Bch cu E cng tp trung nhiu cc c phn ng
d ng (tiu ph qun, da v.v...). Trong qu trnh tham gia vo phn ng d ng,
dng bo v bch cu gii phng ra cc cht gy ha ng ng dng tnh
vi bch cu E. Bch cu E c tc dng kh c l cc cht gy vim do dng bo
v bch cu B gii phng ra. Bch cu E cng c th c tc dng thc bo
chng qu trnh lan rng ca vim.
7- BCH CU A NHN A BASE.
Bch cu a nhn a base c th gii phng heparin, histamin, mt t bradykinin
v serotonin. Ti vim cc cht trn cng c dng bo gii phng ra trong
qu trnh vim. Dng bo v bch cu ng vai tr quan trng trong phn ng
d ng v khng th IgE gy phn ng d ng c kh nng gn vo mng dng bo
v bch cu B. Khi gp khng nguyn c hiu phn ng vi khng th lm cho cc
t bo ny b v ra v gii phng heparin, histamin, bradykinin, serotonin, enzym
thu phn lysosom v nhiu cht khc. Cc cht trn gy ra d ng.
8. BCH CU LYMPHO.
Bch cu lympho c chia thnh hai loi: lympho bo B v lympho bo T. Chng
u c chung ngun gc trong bo thai l cc t bo gc vn nng. Cc t bo ny
s bit ho hoc c "x l{" thnh cc lympho bo trng thnh. Mt s t
bo lympho di tr tuyn c v c "x l" y nn gi l lympho bo T
(Thymus). Mt s t bo lympho khc c "x l" gan (na u thi kz bo
thai) v tu xng (na sau thi kz bo thai). Dng t bo lympho ny c pht
hin ln u tin loi chim v chng c "x l" bursa fabricicus (cu trc
ny khng c ng vt c v) nn c gi l lympho bo B (ly t ch bursa).
Sau khi c "x l{" cc lympho bo lu thng trong mu ri d tr m bch
huyt, ri li vo mu v.v... chu kz tip din nhiu ln. Chc nng chnh ca
lympho bo l: lympho bo B chu trch nhim v min dch dch th. Lympho bo
T chu trch nhim v min dch t bo. Hai chc nng ca hai loi t bo ny c
mi lin quan cht ch vi nhau.
8.1. Chc nng ca lympho bo B.
Trc khi tip xc vi khng nguyn c hiu, cc clon lympho B ng yn trong
m bch huyt. Khi khng nguyn xm nhp vo, cc i thc bo thc bo khng
nguyn v gii thiu (trnh) khng nguyn cho cc lympho bo B v lympho bo T.
Cc lympho bo T h tr c hot ho cng gp phn hat ho lympho bo B.
Cc lympho bo c hiu vi khng nguyn c hot ho, ngay lp tc tr
thnh cc nguyn bo lympho. Mt s nguyn bo bit ho tip thnh nguyn
tng bo l tin thn ca tng bo plasmocyt. Trong cc t bo ny c mng
ni bo tng c ht tng sinh. T bo phn chia rt nhanh: 9 ln phn chia trong
khong 10 gi v trong 4 ngy u mt nguyn tng bo sinh ra ti 500 t bo.
Cc tng bo sinh khng th globulin vi tc rt nhanh v mnh. Mi tng
bo sn xut khong 2000 khng th/1giy. Cc khng th vo h tun hon. S
sn xut khng th ko di vi ngy hoc vi tun cho n khi tng bo b cht.
Trong qu trnh thc hin chc nng min dch, mt s nguyn bo lympho sinh
ra mt lng kh ln t bo lympho B mi ging nh t bo lympho B gc ca
clon v c b sung thm vo s t bo lympho gc ca clon. Cc t bo ny
cng lu thng trong mu v cng c tr trong m bch huyt. Khi gp li cng
mt khng nguyn chng s c hot ho mt ln na, l cc t bo nh. S
p ng khng th ca cc t bo lympho B ny din ra nhanh v mnh hn rt
nhiu so vi nhng t bo lymphpo gc ca clon c hiu. iu ny gii thch ti
sao p ng min dch nguyn pht (tip xc khng nguyn c hiu ln u) li
chm v yu hn so vi p ng min dch th pht (tip xc vi cng mt khng
nguyn ln th 2).
8.2. Chc nng ca lympho bo T.
Khi tip xc vi khng nguyn c hiu do i thc bo gii thiu, cc t bo
lympho T ca m bch hyt tng sinh v a nhiu t bo lympho T hot ho vo
bch huyt ri vo mu. Chng i khp c th qua mao mch vo dch k ri tr
li bch huyt vo mu mt ln na. Chu kz c tip din nh vy hng thng
hoc hng nm.
T bo nh ca lympho bo T cng c hnh thnh nh t bo nh ca lympho
bo . p ng min dch t bo th pht l to ra lympho bo T hot ha mnh
hn, nhanh hn p ng min dch t bo nguyn pht. Trn b mt ca mt
lympho bo T c hng trm ngn v tr receptor.Cc khng nguyn gn vo
receptor c hiu trn b mt t bo lympho T cng ging nh gn vi khng th
c hiu do lympho bo B sn xut ra.
Cc lympho bo T c chia thnh lympho bo T h tr, lympho bo T gy c v
lympho bo T trn p. T bo lympho T h tr chim 3/4 tng s t bo lympho T
v c chc nng iu ho h thng min dch. S iu ho ny thng qua
lymphokin m quan trng nht l interleukin. Nu thiu lymphokin ca lympho
bo T th h thng min dch s b t lit. Interleukin 2, 3, 4, 5, 6 c tc dng kch
thch to cm bch cu ht, bch cu M v lm tng chc nng thc bo ca cc
t bo ny. Interleukin 2, 4, 5 kch thch tng sinh, tng trng t bo lympho T
gy c t bo v lympho bo T trn p. Cc interleukin, c bit l interleukin 4,
5, 6 kch thch rt mnh t bo lympho v lm tng cng chc nng min dch
dch th. Ngoi ra, interleukin 2 cn c vai tr iu ho ngc dng tnh i vi
t bo lympho T h tr lm cho p ng min dch mnh ln gp bi.
Lympho bo T gy c t bo c kh nng tn cng trc tip cc t bo, c kh
nng git cht vi khun, i khi git c chnh bn thn c th mnh. Do c
ngi gi n l t bo git t nhin (Native Kill cell, thng vit tt l NK). Cc
receptor trn b mt t bo git c kh nng gn cht vo vi khun hoc t bo c
cha cc khng nguyn c hiu. T bo git gii phng perforin (bn cht l mt
protein) to ra nhiu l trn mng t bo b tn cng. Qua l ny, cc cht gy
c t bo c bm t t bo git sang t bo b tn cng, lm cho t bo b
git tan ra. T bo git c th git lin tip nhiu t bo khc m vn c kh nng
tn ti hng thng. T bo git c tc dng c bit ln cc t bo c cha virus,
v tnh khng nguyn ca virus trong t bo rt hp dn t bo git. T bo git
cng c vai tr quan trng trong s ph hu t bo ung th, nht l t bo cc m
ghp.
Lympho bo T trn p c kh nng trn p t bo lympho T h tr v t bo
lympho T gy c t bo. Chc nng ny l iu ho hot ng ca t bo, duy
tr s p ng min dch khng qu mc, v p ng min dch qu mc s gy
tc hi cho c th. V vy t bo lympho T trn p v t bo lympho T h tr c
gi l t bo lympho iu ho. C ch iu ho ca t bo lympho T trn p i
vi t bo lympho T h tr l c ch iu ho ngc m tnh. Lympho bo T trn
p cng c kh nng c ch tc dng ca h thng min dch tn cng vo t bo
cc m c th (hin tng dung np min dch).

6. TIU CU(PLATELETS)

Trong tu xng c nhng t bo nhn khng l (40-100mm). Cc t bo ny
c bit ho t t bo gc vn nng.
T bo c nhn rt to, nhiu thuz, a dng vi nhim sc th phn b khng u.
o tng nhiu, mu nht, c nhiu ht rt nh mu xanh l. T bo nhn khng
l cho gi tc di chuyn. Cc gi tc ny b teo li, tch ra, t on thnh tiu
cu lu thng trong mu. Nh vy, tiu cu (thrombocyt) l mt phn bo tng
ca t bo nhn khng l, l mt t bo khng hon chnh, khng c nhn, rt a
dng, bo tng tm nht c ht mu xanh, rt kh m v d v khi ly ra khi c
th
Tiu cu c kch thc 2-4mm, th tch 7-8mm
3
. nh thng c 150-300 x
10
9
tiu cu trong 1 lt mu ngoi vi.
Tiu cu c cu trc mng glycoprotein, lp ny ngn cn tiu cu dnh vo ni
mc nhng li d dnh vo ni thnh mch tn thng c cht collagen l ra.
Mng tiu cu cng rt d dnh vo cc vt l. Khi bm vo vt l, chng li c th
t bm vo nhau thnh tng m. Tiu cu cha actomyosin, thromstbohenin
nn tiu cu c kh nng co rt. Tiu cu co rt mnh s b v ra v gii phng
serotonin gy co mch, cc phospholipid v cc yu t gy ng mu tham gia vo
qu trnh gy ng mu.
- Yu t 1 l yu t c kh nng chuyn prothrombin thnh thrombin. V bn cht
yu t 1 gn ging yu t V ca huyt tng.
- Yu t 2 l yu t c tc dng y nhanh fibrinogen thnh fibrin khi c mt ca
thrombin.
- Yu t 3 l mt phospholipid c hot tnh ca thromboplastin.
- Yu t 4 l yu t c hot tnh ca antiheparin to iu kin thun li cho giai
on u ca qu trnh ng mu.
- Yu t 5 l serotonin c kh nng gy co mch v c kh nng lm mu ng ti
ch.
- Yu t 6 l mt protein c tc dng lm dy thnh mch v lm gim tnh thm
thnh mch.
- Yu t 7 l antifibrinolysin, cht c tc dng ngn cn phn ng lm tan cc mu.
- Yu t 8 retractozym l mt yu t c tc dng lm co cc mu ng.
- Yu t 9 l mt cht lm n nh fibrin.
Vi c im chc nng trn y, tiu cu tham gia vo qu trnh cm mu,
c xem nh l mt hng ro bo v s mt mu. Tiu cu cng c kh nng
gn ln vi khun to iu kin thun li cho qu trnh thc bo c d dng.
Ngoi ra tiu cu cn c tc dng khc na nh lm h huyt p, chc nng min
dch v chc nng sn xut cc enzym hu protein.
S sn xut tiu cu c iu ho bng s lng tiu cu nh c ch do cc yu
t trong huyt tng kim sot. Tiu cu b tiu dit lch. i sng tiu cu
cha c nghin cu y , ngi ta cho rng n sng trong mu khong 9-
11 ngy.
S lng tiu cu tng ln khi lao ng, khi n ung, khi b chy mu, bnh a
sinh mn tnh th tu bo, bnh Hodgkin, bnh Vaquez. S lng tiu cu gim
trong nhim c, nhim x, xut huyt di da, nim mc, suy tu, bnh Biermer,
bnh Werlhoff.


7. NHM MU V AN TON TRUYN MU

1. NHM MU.
S hiu bit v khng nguyn nhm mu l v cng cn thit cho cng tc truyn
mu. Truyn mu c p dng t lu trong cp cu v iu tr. Khi truyn
mu gp nhiu tai bin rt nguy him, mc d truyn mu ln u.
Ngy nay chng ta hiu rng nguyn nhn tai bin l do s c mt cu khng
th t nhin trong c th. Cc khng th ny chng li cc khng nguyn vi tnh
min dch cao c trn b mt hng cu.
Trn b mt hng cu ngi c nhiu khng nguyn khc nhau ngi ta tm
c khong 30 khng nguyn thng gp v hng trm khng nguyn khc
nhng u l khng nguyn c tnh min dch yu, thng ch dng nghin
cu gen. Cc khng nguyn xp thnh h thng cc nhm mu AB0, Rh, Lewis,
MNS
s
, P, Kell, Lutheran, Duffy, Kidd... Trong s ny c hai h thng nhm mu AB0
v Rh ng vai tr c bit quan trng trong truyn ma.
1.1. H thng nhm mu AB0.
Nm 1901, Landsteiner pht hin ra hin tng: huyt thanh ca ngi ny lm
ngng kt hng cu ca ngi kia v ngc li. Sau ngui ta tm c
khng nguyn A v khng nguyn B, khng th a( chng A) v khng th b ( chng
B).
Khng nguyn A v B c mt trn mng hng cu; khng th a v b c mt trong
huyt tng. Khng th a s lm ngng kt hng cu mang khng nguyn A,
khng th b s lm ngng kt hng cu mang khng nguyn B.
Do c th c trng thi dung np vi khng nguyn bn thn, nn trong huyt
tng khng bao gi c khng th chng li khng nguyn c trn b mt hng
cu ca chnh c th . T h thng nhm mu AO c chia lm 4 nhm:
nhm A, nhm B, nhm AB v nhm O. K hiu nhm mu biu th s c mt ca
khng nguyn trn b mt hng cu.
C th nhm mu A c khng nguyn A trn b mt hng cu v c khng th b
(chng B) trong huyt tng .
C th nhm mu B c khng nguyn B trn b mt hng cu v c khng th a
(chng A) trong huyt tng
C th nhm mu AB c khng nguyn A v B trn b mt hng cu v khng c
khng th a v b trong huyt tng.
C th nhm mu 0 khng c khng nguyn Av B trn b mt hng cu, trong
huyt tng c c khng th a v b.
Ngi ta cng bit rng cc khng th a v b l nhng khng th xut hin t
nhin trong huyt thanh. S phn b cc khng nguyn, khng th thuc h thng
nhm mu A0 nh sau:
Genotypes Nhm
mu
Khng
nguyn
Khng
th
T L %
Ngi da
trng
Ngi Vit
00
0A hocAA
0B hoc BB
AB
0
A
B
AB
-
A
B
A v B
a v b
b
a
-
47
41
9
3
43
21,5
29,5
6


Nhm A c chia thnh hai phn nhm A
1
v A
2
. V vy s lng nhm mu
tr thnh 6 nhm: A
1
, A
2
, B, A
1
B, A
2
B v 0. Mt s ngi c khng nguyn A
1
, c
khng th chng A
2
. Mt s ngi c khng nguyn A
2
, c khng th chng A
1
.
Cc khng th ny yu nn t gy nguy him, nhng trong thc t c th gy tai
bin nghim trng khi truyn nhm mu A
2
nhm tng l nhm mu 0 v nhm
mu A
2
B nhm tng l nhm B cho bnh nhn nhm mu B.
Cc khng nguyn thuc h ABO do mt locus kim sot vi 3 alen A0 trong A
v B l tri. Vic pht hin ra cu trc khng nguyn nhm mu thuc h A0
lm thay i quan nim trc y cho rng: khng nguyn A l sn phm trc
tip ca gen A, khng nguyn B l sn phm trc tip ca gen . Ngi ta cho
rng tham gia hnh thnh khng nguyn nhm mu trong h AB0 c cc h gen Hh
v h thng gen AB0. Cc h thng gen ny di truyn c lp. Ngi c nhm
mu 0 ch c gen H m khng c gen A v B nn khng c enzym bin cht H
thnh khng nguyn A hoc , do ch c cht H chim ton b b mt hng
cu. Ngi c nhm mu A c c gen H v gen A nn c enzym bin cht H thnh
khng nguyn A do trn b mt hng cu c c cht H v c khng nguyn A.
Vi s gii thch tng t, ngi c nhm mu B, trn b mt hng cu c c cht
H v khng nguyn . Ngi c nhm mu AB, trn b mt hng cu c c cht H,
khng nguyn A v khng nguyn B.
i b phn ngi l c gen H. Mt s t ngi khng c gen H (c th ng hp
t hh), khng c cht H trn b mt hng cu. Ngi khng c gen H, d c gen A
hoc gen th cng khng c khng nguyn A hoc khng nguyn B, v cc khng
nguyn ny ch xut hin t cht H. Khi th mu bng k thut ngng kt, ngi
khng c gen H u c ghi nhn l nhm mu O, nhng h (c th ng hp
t hh) c th to ra khng th chng H khi truyn mu ca ngi nhm mu O
tht s (c cht H) v th c th gy tai bin. Ngi c nhm mu ny c gi l
nhm mu O Bombay.
a s ngi (80%), khng nguyn nhm mu cn c mt trong cc dch tit: nc
bt, dch v...
Ngay sau khi ra i, khng th c nng rt thp. T thng th 2 tr i, khng
th tng dn ln v cao nht t 8 -10 tui, sau gim dn tr v bnh thng
tui trng thnh ri gim dn theo tui tc. Khng th l g globulin, hu ht l
IgM, sau l IgG. Ging cc khng th min dch khc IgM v IgG cng do cc
lympho bo sn xut.
1.2. H thng nhm mu Rh.
Nm 1940 Landsteiner v Wiener nhn thy: nu ly hng cu kh Macacus
Rhesus gy min dch cho th th huyt thanh min dch th ngoi vic gy ngng
kt hng cu kh cn gy ngng kt hng cu ngi. Lc u xp nhng ngi c
hng cu b ngng kt bi huyt thanh ny vo nhm Rh
+
nhng ngi c hng
cu khng b ngng kt vo nhm Rh
-
. Nhng sau ny thy h thng khng
nguyn Rh khng n gin nh vy. Trong h thng Rh c nhiu khng nguyn,
phn ln chng c tnh phn ng cho v sinh min dch yu. Do khng th
khng gy ngng kt mnh nh h thng AB0.
Khng nguyn h Rh phn b tha tht trn b mt hng cu. C 3 loi khng
nguyn chnh: khng nguyn D (Rh
0
), khng nguyn C (Rh'), khng nguyn E (Rh'').
Ch c khng nguyn D c tnh khng nguyn mnh v c tnh sinh min dch cao.
V vy khi c khng nguyn D th c gi l Rh
+
. Nhng nhm mu khc thuc h
Rh u c tnh khng nguyn rt yu, t c ch { nh Rh
1
, Rh
2
, Rh
z
, Rh
y
, rh. T l
Rh
+
ca ngi da trng l 85%, ngi M da en l 95%, ngi Phi da en l
100%, ngi Vit l 99,92%. Ni mt cch khc l t l Rh
-
ca ngi Vit l 0,08%
gn nh khng ng k.
Khng nguyn h thng nhm mu Rh l di truyn, cn khng th chng Rh ch
xut hin c th Rh
-
khi c min dch bng hng cu c khng nguyn D (Rh
+

). Khng th ny thng l IgG. Nu mt ngi Rh
-
, cha h c truyn mu Rh
+

bao gi th vic truyn mu Rh
+
cho h s khng bao gi xy ra phn ng tc th
no. Tuy nhin sau khi truyn mu Rh
+
t 2-4 tun sau, lng khng th chng Rh
tng i cao gy ngng kt hng cu Rh
+
ca ngi cho vn tn ti
trong mu ngi nhn. Phn ng ny chm v rt nh. Sau 2-4 thng truyn mu
Rh
+
, nng khng th chng Rh trong mu ngi Rh
-
mi t ti a. Nu truyn
mu Rh
+
cho nhng ngi ny ln th 2, c th gy ra tai bin truyn mu nng,
chng km g tai bin nh h AB0. Sau vi ln truyn mu Rh
+
cho ngi Rh
-
,
ngi Rh
-
tr nn rt mn cm vi khng nguyn Rh, tai bin khi truyn mu l
cc kz nguy him. l l do ti sao ta phi cn lu { ti ngi c truyn
mu nhiu ln. Cn phi xc nh nhm mu h Rh cho h, s rng h l ngi Rh
-
.
Trng hp th hai l ngi m Rh
-
, b Rh
+
. a tr c di truyn Rh
+
t b.
Hng cu Rh
++
ca thai sang mu m. Ngi m s c qu trnh to khng th
chng Rh, cc khng th ny qua nhau thai lm ngng kt hng cu thai. Nu
ngi m c thai ln u th c th ngi m cha sn xut khng th gy
nguy him cho thai nhi. Khong 30% s thai th hai Rh
+
c triu chng tng
nguyn hng cu bo thai, vng da hu huyt v t l mc bnh tng dn ln v
triu chng bnh cng nng hn cho nhng thai sau.
Nhiu ngi b Rh
+
d hp t, do c khong 25% s con ci l Rh
-
. V vy sau
khi a con trc b vng da hu huyt, tng nguyn hng cu, khng nht
thit a tr sau cng b bnh ny. Nhng a tr mc bnh tng nguyn hng
cu bo thai thy cc m sinh mu u tng sinh hng cu; gan, lch to ra v sn
xut hng cu kz bo thai. Hng cu ny xut hin nhiu trong mu. Tr thng
cht do thiu mu nng. Nu sng st tr thng thiu tr tu, tn thng v no
vn ng do lng ng bilirubin trong cc neuron. Cng c th khng th chng
Rh cn tn cng mt s t bo khc ca c th.
Trng hp th hai m ta cn lu { trn y chnh l ngi ph n c tin s sy
thai, non, con c tng nguyn hng cu bo thai, vng da hu huyt. Nhng
ngi ny nu cn truyn mu, phi xt nghim nhm mu Rh. Ngi ta s rng
ngi m ny mu Rh
-
v trong mu c khng th chng Rh. Nu truyn mu
Rh
+
cho h th s c tai bin rt nguy him xy ra.
ca thai v sn phm phn hu hng cu Rh 1.3. Cc h thng nhm mu khc.
Trong cc h thng nhm mu cn li th h Kell chim v tr hng u. Khng
nguyn Kell rt nguy him. Nm 1947 ngi ta pht hin tai nn do khng
nguyn ny gy ra, t v sau tai nn do khng nguyn ny vn c theo di.
Khng nguyn F
y
a thuc h Duffy cng c quan tm. 1950 ln u tin Mollison
pht hin khng th chng F
y
a trong huyt tng bnh nhn b tan mu c
truyn mu nhiu ln. Trong vng 20 nm ngi ta miu t nhiu trng
hp tng t. Nm 1951 c mt tai bin cht ngi do F
y
a.
Khng nguyn S thuc h MNS
s
c th gy ra min dch sau truyn mu v xut
hin tai nn tan mu.
Nhng khng th lnh c hiu t nhin nh khng th chng Le
a
, Le
b
(thuc h
Lewis), M, N, P ch gy ra phn ng mt nhit nht nh v khng nguy him.
2. TRUYN MU.
Trong thc hnh truyn mu, ngoi nhng qui nh v nhng xt nghim pht
hin cc virut ly theo ng mu, v k thut bo qun... chng ta cn phi thc
hin ng qui tc v nhm mu, qui tc c bn l: khng khng nguyn v
khng th tng ng gp nhau trong mu ngi nhn. i vi h thng nhm
mu ABO, tho mn qui tc trn l phi truyn cng nhm.
Da vo khng th bit ca huyt thanh mu (antiA, anti, antiA) ngi ta
xc nh chnh xc khng nguyn A v B trn b mt hng cu. ng thi vi vic
xc nh nhm mu thuc h ABO, cn phi lm cc phn ng cho: trn hng
cu ngi cho vi huyt thanh mu ngi nhn v ngc li trn hng cu ngi
nhn vi huyt thanh mu ngi cho. Cc phn ng trn khng c hin tng
ngng kt hng cu th mu mi c truyn.
C mt s tc gi ngh rng, m bo an ton tuyt i, tt nht l truyn
mu t thn. i tng c ly mu lc kho mnh v c bo qun trong
ngn hng, khi cn th ly chnh mu ca h truyn cho h. Hin nay cha c iu
kin k thut bo qun mu c lu (c bit l cc nc ang pht trin)
cho nn iu ny cha thc hin c. khc phc tai bin truyn mu v tnh
trng ly nhim bnh qua truyn mu, cc nh khoa hc nghin cu sn xut
ra mu nhn to lm dch truyn thay th mu. Song phm vi ng dng mu
nhn to cha c rng ri v gi thnh cn qu t.
Trong trng hp cn truyn mu m li khng c mu cng nhm, ngi ta c
th truyn theo mt qui tc ti thiu: khng xy ra ngng kt hng cu ca
ngi cho trong mu ca ngi nhn. Nu xy ra tai bin ny th ch cn
truyn nhm 2ml mu c th gy cht ngi do tc mch, ri lon trao i kh
ca mu, tan mu, suy thn cp... Nh vy c th truyn mu khc nhm, nhng
bt buc phi theo s sau

Nhm O truyn c cho nhm A,B v AB. Nhm A v B truyn c cho nhm
AB. Nhm AB khng truyn c cho nhm O, A v . Trong trng hp truyn
mu khc nhm nh vy, ch c truyn khong 250ml mu (mt n v mu),
vi tc rt chm. Tai bin do truyn mu rt kh xy ra v khng th trong mu
ngi cho ngay lp tc b pha long trong mu ca ngi nhn do nng
khng th rt thp. Cc khng th ny sau s b cc enzym phn gii. Tuy vy,
ngy nay nh s hin mu nhn o c ph cp nn s truyn mu theo qui
tc ti thiu t c ng dng.
i vi h thng Rh, khng th chng Rh ch hnh thnh ngi Rh
-
khi c
min dch bng hng cu Rh
+
. T l Rh
-
ca ngi Vit li rt thp, cho nn thc t
ngi ta ch { hai trng hp cn xt nghim nhm mu h Rh l ngi
c truyn mu nhiu ln v ngi ph n c tin s xy thai, non, con c
hi chng vng da hu huyt. Vic xt nghim nm mu h Rh cng da trn
khng th ca huyt thanh mu tm khng nguyn. Nu ngi cn c truyn
mu l Rh
+
th truyn mu Rh
+
hoc Rh
-
u c. Nu ngi cn c truyn
mu l mu Rh
--
. th nht thit phi c truyn mu l Rh

8. SINH L CM MU V NG MU

1. CM MU.
Cm mu l mt qu trnh sinh l, sinh ha tng hp nhm chm dt hoc ngn
cn s mt mu ca c th khi mch mu b tn thng hoc b t. Cm mu
c thc hin nh cc c ch: co mch, s hnh thnh nt tiu cu, ng mu,
co cc mu, tan cc mu ng v s pht trin m x trong cc mu ng
ng kn vt thng.
nh gi khi qut chc nng cm mu, cc nh lm sng thng s dng hai
xt ngim: xc nh thi gian chy mu (s b nh gi cc yu t ca thnh mch
v tiu cu), xc inh thi gian ng mu (s b nh gi cc yu t gy ng
mu ca huyt tng). Thi gian mu chy theo phng php ca Duke l 3 pht.
Thi gian mu ng theo phng php ca Milian l 7 pht.
1.1. Co mch.
Ngay sau khi mch b tn thng, mch mu b co li do tnh n hi ca thnh
mch. Co mch cn c thc hin nh c ch thn kinh v thn kinh-th dch.
Nhng kch thch gy au t ni tn thng, nhng cht trung gian ho hc c
gii phng khi au gy phn x co c trn thnh mch. ng thi lc ny ti ni
tn thng, tiu cu b v ra, gii phng serotonin gy co mch ti ch.
1.2. S hnh thnh nt tiu cu.
Ti ni tn thng, t bo ni mc hoc thnh mch tn thng l si
collagen, tiu cu bm vo nhng ni ny v b hot ho. Khi tiu cu b hot ho,
cc protein trong n c rt mnh v gii phng ra cc yu t lm hot ho cc tiu
cu bn cnh, lm cho chng dnh vo nhau to nn nt tiu cu bt kn ch tn
thng (nu l cc tn thng nh). Hng ngy c th ta phi chu hng trm vt
rch rt nh ni mao mch do sang chn. Nh c chc nng ny m c th trnh
c s chy mu mao mch.
1.3. S hnh thnh cc mu ng.
Tiu cu gii phng ra cc yu t gy co mch v gy ng mu, to ra cc mu
ng b sung cho nt tiu cu bt kn ch tn thng (nu l cc tn thng
ln hn). ng mu pht trin nhanh trong vng 1-2 pht. Nhng cht hot ho
gy ng mu c gii phng do t chc v mch mu b tn thng, nhng
cht do tiu cu gii phng v nhng cht gy ng mu ca huyt tng c
hot ho, pht ng mt qu trnh ng mu. Nu vt thng khng qu
nng, sau 3-6 pht cc mu ng hnh thnh bt kn vt thng. Sau 20 pht n
1 gi, cc mu ng co li lm cho cc mu vng chc hn.
Sau khi cc mu ng hnh thnh, vi gi sau cc nguyn bo si xm nhp, bin
cc mu ng thnh m x trong 1-2 tun l, nu l cc mu ng nh v vt
thng nh. Nu l vt thng ln, tn thng rng, mu mt nhiu, c th
khng t bo v c, cn phi c s can thip kp thi.
2. NG MU.
Trong mu v trong cc m c cha khong 50 cht c nh hng ti qu trnh
ng mu. Cc cht kch thch qu trnh gy ng mu gi l cc cht gy ng
mu. Cc cht li c ch qu trnh gy ng mu gi l cc cht chng ng mu.
Mu c ng hay khng ng l ph thuc vo s cn bng gia cc cht gy
ng mu v cc cht chng ng mu. nh thng mu trong c th khng
ng l do cht chng ng mu chim u th. Khi mu, mch mu b tn
thng, khi mu ly ra ngoi c th, cc cht gy ng mu c hot ho v tr
nn u th, ng mu c thc hin.
2.1. nh ngha.
ng mu l mt qu trnh chuyn mu th lng sang th c, m thc cht l
chuyn fibrinogen dng ha tan thnh fibrin dng khng ho tan.
2.2. C ch ng mu (cc giai on ca qu trnh ng mu).
ng mu c din ra theo mt c ch rt phc tp. y l mt qu trnh hot
ho v hot ng ca cc enzym vi mc ch l to ra fibrin. Thng thng
ngi ta chia qu trnh ng mu ra lm ba giai on:
Giai on hnh thnh phc hp prothrombinase.
Giai on hnh thnh thrombin.
Giai on hnh thnh fibrin.
2.2.1. S hnh thnh phc hp prothrombinase.
Khi ng cho c ch ng mu l s hnh thnh phc hp prothrombinase. y
l mt c ch rt phc tp (c l l phc tp nht ) v ko di nht ca qu trnh
ng mu. Qu trnh c xy ra khi c chn thng thnh mch v m, khi c
chn thng mu, khi c s tip xc ca mu vi t bo ni mc tn thng hoc
vi si collagen ca mch mu, vi cc m khc ngoi ni mc hoc vi bt kz vt
l no.
S hnh thnh phc hp prothrombinase theo hai c ch ngoi sinh v ni sinh.
C ch ngoi sinh xut hin nu c chn thng thnh mch hoc cc m k cn.
C ch ni sinh xut hin nu c chn thng mu hoc mu ly ra ngoi c th
t lng mch. Trong c hai c ch ni sinh v ngoi sinh c mt lot protein huyt
tng (c bit l a
2
-globulin) ng vai tr rt quan trng, l cc yu t gy
ng mu ca huyt tng. Hu ht cc yu t ny l cc enzym dng khng
hot ng. Khi chuyn thnh hot ng, chng gy ra cc phn ng ho sinh lin
tip nhau ca qu trnh ng mu. Cc yu t ny c k hiu bng ch s Lam
phn bit vi cc yu t ca tiu cu c k hiu bng ch s rp.
Yu t I: fibrinogen
Yu t II: prothrombin
Yu t III: thromboplastin ca m
Yu t IV: ion Ca
++

Yu t V: proaccelerin
Yu t VII: proconvertin
Yu t VIII: globulin A chng a chy mu (antihemophilic globin-AHG).
Yu t IX: globulin B chng a chy mu (plasma thromboplastin component-
PTC).
Yu t X: Stuart-Prower
Yu t XI: globulin C chng a chy mu (plasma thromboplastin antecedent-
PTA).
Yu t XII: Hageman
Yu t XIII: n nh fibrin (fibrin stabilizing factor-FSF).
- S hnh thnh phc hp prothrombinase theo c ch ngoi sinh.
M b tn thng gii phng yu t III, phospholipid t mng t bo m. Yu t X
c hot ho (X
a
) nh yu t III, yu t VII
a
(yu t VII c hot ho nh yu t
III), ion Ca
++
v phospholipid. S hnh thnh phc hp prothrombinase t yu t
X
a
c s tham gia ca yu t V
a
(yu t V c hot ho nh thrombin), ion Ca
++
v phospholipid. Yu t V
a
lm tng hot tnh ca yu t X
a
. Phospholipid ng vai
tr l cht nn cn ion Ca
++
lm cu ni gia cc yu t. Thrombin trong trng
hp ny c tc dng iu ho.
- S hnh thnhphc hp prothrombinase theo c ch ni sinh.
Mu b chn thng, mu tip xc vi collagen hoc b mt vt l th lm hot
ho yu t XII v gii phng phospholipid tiu cu. Yu t XII
a
chuyn yu t XI
thnh yu t XI
a
(c s tham gia ca yu t Fletcher v Fitzgerald). Yu t XI
a

chuyn yu IX thnh yu t IX
a
(c s tham gia ca yu t tiu cu). Yu t X c
hot ho c s tham gia ca yu t VIII
a
(yu t VIII c hot nh thrombin), yu
t IX
a
, ion Ca
++
v phospholipid. S hnh thnh phc hp prothrombinase t yu
t X
a
c s tham gia ca phospholipid, yu t V
a

(yu t V c hot ho nh
thrombin) v ion Ca
++
. S hnh thnh phc hp prothrombinase theo c ch ni
sinh chm hn rt nhiu (1-6 pht) so vi c ch ngoi sinh (15 giy).
Prothrombinase c hnh thnh t c ch ni sinh hoc ngoi sinh hoc ng
thi c hai c ch ni sinh v ngoi sinh. iu ny chng t hot tnh ca
prothrombinase l ph thuc vo s hot ho ca cc yu t tham gia vo qu
trnh ny.
2.2.2.S hnh thnh thrombin
Prothrombin l a
2
-globulin, do gan sn xut, c trng lng phn t 68700, nng
trong mu bnh thng l 15mg/100ml mu. Khi phc hp prothrombinase
hnh thnh n s chuyn prothrombin thnh thrombin. Giai on ny cng cn s
c mt ca ion Ca
++
. S hnh thnh thrombin t prothrombin l rt nhanh, c
tnh bng vi giy.
2.2.3. S hnh thnh fibrin.
Fibrinogen l mt protein do gan sn xut, trng lng phn t 340000, nng
trong mu bnh thng l 100-700mg/100ml mu. nh thng fibrinogen rt kh
vo dch k. Khi thnh mch tng tnh thm (m b vim) th fibrinogen vo dch
k v b ng li do cc yu t gy ng mu cng vo dch k.
Thrombin sau khi c hnh thnh chuyn fibrinogen thnh fibrin n phn.
Cc fibrin n phn t trng hp thnh fibrin dng si. Mt mng li fibrin
hnh thnh v c n nh nh yu t XIII. Giai on ny cng c s tham gia
ca ion Ca
++
. Cc t bo mu c gi li trn li fibrin v to nn cc mu
ng. Chnh mng li ny dnh vo v tr tn thng ca thnh mch ngn
cn s chy mu.
Bn cht ca mu ng l hnh thnh li fibrin t fibrinogen nh thrombin.
Chnh v vy cc nh ngoi khoa s dng thrombin (dng tm, gc hoc bt...)
cm mu khi phu thut, c bit l cm mu cc xng xp.
2.3. S co cc mu ng.
Sau khi cc mu ng hnh thnh, n bt co li v r ra huyt thanh (huyt
tng b ly mt fibrinogen th c gi l huyt thanh).
Tiu cu c vai tr quan trng cho s co cc mu ng. Tiu cu c tc dng gn
cc si fibrin li vi nhau v n nh vng chc fibrin. Tiu cu bm trn li
fibrin, khi n co rt n lm cho li fibrin co theo, ng thi vi s gii phng yu
t 8 ca tiu cu lm cho cc mu ng co cng mnh hn. Co cc mu ng cn
c s tham gia ca thrombin, ion Ca
++
. Cc mu ng lc ny rt bn vng, gi
cho cc mp ca thnh mch tn thng khp li gn nhau to iu kin thun
li cho lin vt thng.
2.4. S tan cc mu ng.
Trong huyt tng c pasminogen (profibrinolysin). Cc m tn thng, ni mc
tn thng v vi khun gii phng ra cht hot ho plasminogen. Khong mt
ngy sau khi cc mu ng, cht ny chuyn plasminogen thnh plasmin.
Plasmin l mt enzym lm tiu fibrin v c fibrinogen lm tan cc mu. V l do
ny m c th gy ra chy mu th pht rt nguy him, cn phi c phng.
Ti vim, nu vi khun lm tiu fibrin i th c th s lm cho vi khun lan rng
v hng ro fibrin bo v b ph v. Song cng nh c ch ny m trong c th
c hin tng t tiu fibrin lm khai thng nhiu mch mu nh b tc nghn.

9. CHNG NG MU

1. Cc yu t trn b mt ni mc.
- S trn nhn ca ni mc ngn cn s hot ho do tip xc b mt ca h
thng gy ng mu.
- Lp glycocalyx (bn cht l mucopolysaccarid) hp ph trn b mt ni mc, c
tc dng y tiu cu v cc yu t gy ng mu cho nn ngn cn c s hot
ho h thng gy ng mu.
- Thrombomodulin l mt protein ca ni mc c kh nng gn vi thrombin lm
bt hot thrombin. Ngoi ra phc hp thrombomodulin-thrombin cn c tc dng
hot ho protein C ca huyt tng, m protein C hot ho s ngn cn tc dng
ca yu t V
a
v yu t VIII
a
.
2. Cc yu t trong huyt tng.
- Antithrombin.
Sau khi cc mu ng c hnh thnh i b phn thrombin c hp ph trn
b mt si fibrin (fibrin c gi l antithrombin I). Phn cn li ca thrombin
c kt hp vi antithrombin III lm cho thrombin mt hot tnh sau 12-20 pht.
Tc dng trn y lm gii hn cc mu ng trnh cho s ng mu lan rng.
Ngoi ra cn c antithrombin IV c tc dng phn hu thrombin, antithrombin V
hn ch tc dng ca thrombin trn fibrinogen.
- Heparin.
Heparin (cn c gi l antithrombin II) l mt cht c hiu qu chng ng rt
mnh v n c nhiu c ch rt phc tp va ngn cn s hnh thnh thrombin
va gy bt hot thrombin. Heparin l mt polysaccarid kt hp tch in m kh
mnh, bn thn n hu nh khng c tc dng chng ng mu. Nhng khi n
kt hp antithrombin III to nn phc hp heparin-antithrombin III th li c tc
dng chng thrombin v cng mnh, mnh hn hng trm, hng nghn ln
antithrombin III. Do ch cn s c mt ca heparin th thrombin b bt hot
ngay v ng mu khng xy ra. Phc hp heparin-antithrombin III cn lm bt
hot cc yu t IX, X, XI v XII cho nn cng chng c s ng mu.
Heparin do rt nhiu t bo ca c th sn xut, c bit l dng bo khu tr
cc m lin kt quanh mao mch c th. Chng tp trung vi mt cao quanh
mao mch gan v phi. nh thng dng bo bi tit mt lng nh heparin v
heparin ny c khuch tn vo h tun hon cng vi mt lng nh heparin
ca bch cu ht a base thng xuyn chng c cc mu ng hnh thnh
mao mch (c bit l mao tnh mch). V vy heparin c dng lm thuc
bo v chng ng mu trong lm sng.
- a
2
-macroglobulin.
a
2
-macroglobulin c trng lng phn t 360.000, n c kh nng kt hp vi cc
yu t gy ng mu v lm bt hot chng, nhng tc dng chng ng mu ca
n yu hn rt nhiu ln so vi heparin.
- Coumarin.
Coumarin l cht a t ngoi vo c th lm gim s tng hp ca cc yu t
II, VII, IX v X, do ngn cn c s ng mu trong c th. Coumarin l cht
cnh tranh vi vitamin K, m vitamin K l cht rt cn thit cho qu trnh tng hp
cc yu t II, VII, IX v X. Vitamin K l loi vitamin tan trong du dng iu tr
thi gian ng mu ko di do thiu vitamin K.
3. Chng ng mu ngoi c th.
- ng hoc bnh cha mu c trng silicon, ngn cn s hot ha do tip xc b
mt ca yu t XII v tiu cu, v vy mu khng ng.
- Heparin c s dng trong v ngoi c th u cho hiu qu chng ng mu
rt cao.
- Cc cht lm gim ion Ca
++
nh kalioxalat, amonioxalat, natricitrat do to ra
calcioxalat, calcicitrat nn c tc dng chng ng mu rt tt.
- Mui trung tnh nh natriclorua vi nng cao cng lm bt hot thrombin
nn chng c ng mu.
- Bo qun mu nhit thp (4
0
C-6
0
C) lm ngng hot ng cc enzym gy
ng mu nn mu cng khng ng.

10. RI LON LM SNG MU

1. Thiu mu.
Thiu mu l gim Hb trong mu di mc bnh thng. Theo W.H.O ngi b
thiu mu l ngi c hm lng Hb mu gim:
< 13gHb trong 100ml mu (i vi nam)
< 12g Hb trong 100ml mu (i vi n)
< 14g Hb trong 100ml mu (i vi tr s sinh)
Thiu mu l do mt mu, do mu b hu nhanh hn trong c th hoc do tu
xng gim sn xut.
- Thiu mu do mt mu cp tnh hoc mn tnh.
- Thiu mu do suy nhc tu v b nhim x, nhim c (cht c ho hc cng
nghip, chin tranh).
- Thiu mu do thiu acid folic, thiu vitamin B12 hoc thiu yu t ni v ct b
d dy vim teo d dy, vim lot d dy- t trng.
-Thiu mu do thiu st, do thiu dng.
- Thiu mu do thiu cc yu t kch thch tng sinh, tng trng hng cu
erythropoietin (suy thn, gan mn tnh).
- Thiu mu do tan mu, do i sng hng cu qu ngn. Mt s bnh ca hng
cu do mng hng cu km bn d v nh bnh thiu mu c hng cu hnh li
lim, bnh thiu mu c hng cu hnh cu (kch thc hng cu rt nh, hnh
cu).
2. a hng cu.
- a hng cu th pht do sng vng ni cao, do suy tim, do bnh ng h
hp... y l a hng cu do thiu oxy cc m.
- a hng cu tht s do tu xng tng sn xut hng cu (c km theo tng
bch cu v tiu cu). Hu qu l qu ti chc nng tun hon, nht mu tng,
ri lon tun hon mao mch.

11. RI LON C CH CM MU

Cm mu l mt c ch rt phc tp, cho nn nhng ri lon ca c ch cm
mu tht s l nhng hi chng gy nhiu tr ngi cho vic chn on, iu tr
ca cc thy thuc. Chng ta c th gp ri lon c ch cm mu do nhng
nguyn nhn sau.
- Ri lon chc nng gan s dn n ri lon c ch cm mu, v gan l c quan
hu nh sn xut ton b cc yu t gy ng mu v chng ng mu.
- Thiu ht vitamin K dn n gim cc yu t II, VII, IX v X v vy gy ri lon c
ch cm mu.
- Bnh a chy mu (hemophilia) do thiu cc yu t VIII (hemophilia A), yu t IX
(hemopilia B), yu t XI (hemophilia C). y l nhng bnh di truyn.
- Suy v nhc tu lm gim tiu cu gy ri lon c ch cm mu.
- Huyt khi.
Cc mu ng hnh thnh bt thng trong lng mch gy nghn mch
(thrombus) hoc cc mu ng hnh thnh bt thng u trong h tun
hon ri bong ra tri t do trong lng mch ti ch mch nh hn th dng li v
gy tc mch ti (emboli). Ri lon c ch ng mu gy huyt khi l mt
bnh l nng nht l hyt khi ti ng mch vnh, ng mch no, ng mch
thn, ng mch phi sau l ng mch chi v cc c quan khc.
Nguyn nhn ca huyt khi l b mt lp t bo ni m b x x do x va ng
mch, do nhim trng (thp tim, nhim trng mu), do chn thng... pht
ng qu trnh ng mu. Hin nay ngi ta thng dng catheter a cc
cht hot ho plasminogen ca m vo vng huyt khi iu tr.
- ng mu ri rc trong lng mch mu nh c xut hin do rt nhiu nguyn
nhn khc nhau. Khi m b cht hoc tn thng n gii phng thromboplastin
vo mu v to ra nhiu cc mu ng lm tc phn ln cc mch mu nh ngoi
vi. ng mu ri rc cn gp trong shock nhim khun. Vi khun hoc c t ca
vi khun, nht l ni c t (endotoxin) s hot ho qu trnh ng mu gy tc,
nghn mch v y tnh trng shock nng thm.
- Nhim trng hoc nhim c gy hu fibrin lm chy mu. Cng c nhiu trng
hp bnh thng c ch cm mu rt cn bng nhng khi c s can thip phu
thut vo c th th ri lon c ch cm mu mi xut hin, gy chy mu ko
di.
- Cu trc thnh mch b bin i, thnh mch km bn rt d gy chy mu.

B. SINH L BNH MU - TO MU

HONG DUNG


I CNG

C th ngi ta l mt b my hon chnh c h thn kinh bit ho cao, li c
mt t chc c bit l mu m bo s sinh tn ca c th. Nhim v ca t
chc mu nhiu v phc tp, c th xp thnh ba chc nng chnh:
1. Mu gi vai tr vn chuyn oxy v o thi kh cacbonic nh huyt cu t ca
hng cu. Ngoi ra cn lun chuyn cc ni tit t, cc cht nui dng t bo v
chuyn cc cht cn b, sn phm chuyn hoa, cht c n cc b phn bi tit
o thi ra ngoi.
2. Mu c nhim v bo m s hng nh ni mi nh cc thnh phn ca mu :
protein, cht in gii, pH mu nn c s trao i u n gia mu v t chc
t bo sng v pht trin.
3. Mu c nhim v bo v c th chng bnh tt nh cc chc phn thc bo,
min dch, chng c ca cc bch cu v vai tr ca tiu cu trong duy tr cn
bng ng mu.
Nh vy mu chy qua tt c cc c quan b phn, cung cp oxy v cht dinh
dng, iu ha chc nng sinh l{ ca ton b c th, lin kt cc b phn nn
tham ra vo mi trng thi bnh l{ cng nh tham gia u tranh chng mi s tn
cng ca bnh tt. Cng v vy trong tt c cc trng thi bnh l{ u c bin i
v mu v chc nng to mu, nn cc xt nghim mu c coi l thng qui, l
vic trc tin phi lm gip cho chun on, theo di lm sng. V bnh l
ca mu cng nh hng n cc chc phn khc ca ton b c th.
Sinh l bnh ca h thng mu v to mu gm nhiu phn :
Ri lon khi lng mu tun hon.
Ri lon to hng cu.
Ri lon to bch cu.
Ri lon to tiu cu v cn bng ng mu.
Ri lon cc thnh phn protit huyt tng.
Cc ri lon ny c th pht sinh ring r, hnh thnh nhng qu trnh bnh l
ring, hoc c th nh hng ln nhau m ngi ta gi chung l bnh l ca c
quan to mu.
12.
RI LON KHI LNG MU TUN HON

Mu nm trong h tim mch nhng lun c s trao i gia mu v t chc cho
nn trong iu kin bnh l khi lng mu tun hon cng nh s tng quan
gia hng cu v huyt tng, thng c nhng bin i gy mt cn bng gia
sc cha v khi lng dch, ta gi chung l ri lon huyt ng hc.
ngi khe mnh khi lng mu ph thuc vo 3 yu t:
Tng lng mu ca c th bng 6- 8% cn bng ton thn, trong khi lng
hng cu phi mc bnh thng thay i t 36- 48%(hematocrit )
H tim mch k c cc kho d tr mu ( lch v gan ). l sc cha lun lun
c iu chnh duy tr khi lng mu tun hon ( bnh thng khi lng
mu tun hon chim 3/4, d tr 1/4, ca tng lng mu )
S phn b mu iu ha gia cc khu vc ( tiu tun hon, tun hon no, tun
hon gnh, di da thn, gan ).

I. THAY I BNH L CA KHI LNG MU

1. Thay i theo tui: tr con khi lng mu nhiu hn ngi ln.
Ngi ln 76,6 ml/cn
Tr con 77,1 ml/cn
Tr s sinh 84,7 ml/ cn ( Mollison )
2. Thay i thoe t th v hot ng :
T th ng l gim, th nm lm tng khi lng mu.
Nm ngh khng hot ng trong 2- 3 tun lin, khi lng huyt tng gim r
rt.
3. Thay i do thai nghn :
T thng th 3, khi lng mu tng, thng th 9 tng cao nht, ch yu l tng
huyt tng nn ph n c thai khi lng hng cu gim.

II. THAY I SINH L CA KHI LNG MU

A- TNG KHI LNG MU

c chia thnh nhiu loi :
Tng song song c huyt tng c t bo mu v hin tng nht thi sau khi
truyn mt khi lng ln mu hoc sau khi lao ng nng.
Tng khi lng mu nhng gim t bo, ch tiu hematocrit gim c th pht
sinh khi b bnh thn do thiu nng chc phn lc; trong giai on c ph n ( do
dch gian bo vo dng mu ) hoc sau khi tim cc dung dch sinh l v dch thay
th mu. Truyn nhanh cho ng vt mi khi lng ln dung dch sinh l c th
dn ti t vong do ri lon nghim trng tun hon vi mu tiu tun hon v
ph phi cp. Trong mt s th thiu mu, suy mn v cc trng thi gim s
lng hng cu m khng c bin i tng lng mu th khi lng mu bnh
thng nhng hematocrit vn gim
Tng khi lng mu, tng t bo : c th gp cc bnh nhn tim, cc dn sng
trn ni cao, c tnh cht thch nghi b p. Tng sn xut hng cu c th l do
bnh c tnh ca h to mu( bnh nguyn hng cu c tnh ). Khi lng mu
tng gp i hoc hn na do khi lng hng cu, hematocrit tng. Trong thc
nghim trn ng vt xc nh rng tng khi lng mu n 100% cng
khng gy ra bin i bnh l{ ng ch {. Khi tng n 150% v hn na mi pht
sinh ri lon tun hon nghim trng do lm cng v lm gim trng lc cc
mch mu, tnh thm thnh cc mao mch tng cng dn n mt huyt tng
vo trong t chc v cc khong thanh mc, mu ng li tr ngi hot ng ca
tim.

B- GIM KHI LNG MU

Cng chia nhiu loi :
Gim song song huyt tng v t bo pht sinh nht thi do mt mu cp hoc
sc khi mt khi lng ng k mu b bnh l khng tham gia vo vng tun
hon, ch tiu hematocrit khng thay i.
Gim t bo mu, ch yu gim hng cu xut hin sau khi mt mu cp khi khi
lng mu c khi phc bng bin php huy ng dch gian bo vo dng mu,
ch tiu hematocrit gim
Gim huyt tng hng cu vn bnh thng nhng b co li ( mu c ), ch tiu
hematocrit tng ti 55- 60% v hn na, pht sinh trong trng hp mt nc, i
lng nhiu ln, nn dai dng, nhim nng, mt nhiu m hi, bng rng

III. SINH L CA BNH MT MU

Mt mu l mt hin tng sinh l ph bin trong lm sng ni, ngoi khoa, c
bit trong ngoi khoa thi chin. Trong thc t, mt mu thng gp nht l phi
hp vi chn thng, v trong cc vt thng huyt qun. Kh nh gi ng
mc l chy mu trong mng phi, bng, gian bo, c xng C xng c rt
nhiu mch mu nht l ngi tr v n nang : gy xng i n thun mt 1
lt mu; gy xng nhiu mnh c nhiu c b hy hoi c th mt ti 2 lt
mu.Trong phu thut, mt mu cng c vai tr quan trng : th thut thn
xng i, ng inh, ghp xng mt ti 1,5- 2 lt mu. Chy mu ni khoa
gp trong thng d dy, hang lao, bong rau thai sm cng gy mt nhiu mu.

A- DIN BIN SAU KHI MT MU

Khi mt mu c th pht sinh nhiu ri lon, mc nng nh ph thuc vo ba
yu t :
1. Khi lng mt mu :
Mt mu t, di 10% tng lng mu thng khng gy hu qu g nghim trng
( ngi cho mu )
Mt mu t 20% tng lng mu tr nn hu qu thng phi lu {. Thng k
trong chin tranh Triu tin trn 186 thng binh c 152 trng hp mt mu
trn 20% u b sc ( 81,7% ). Ni chung c vi ngi khe mnh, mt 1 ln t
1/4 n 1/3 khi lng mu rt ng lo ngi cho i sng v huyt p ng
mch gim thp gy thiu oxy nghim trng nhng nu mt t t trong nhiu
ngy mt khi lng mu nh vy li khng nguy him do cc c ch thch ng b
p ca c th pht huy tc dng.
2. Tc mu chy : tc mu chy nhanh hay chm, gy mt mu nhiu hay t
ph thuc vo v tr mt mu tnh mch hay ng mch, huyt qun ln hay nh :
Chy mu ng mch, nht l cc ng mch ln mu chy thnh tia mnh nn
thng nguy him hn mt mu tnh mch ( chy t t, nh git ). Chy mu
nhiu trong mt thi gian ngn gy ra gim huyt p t ngt tc ng nn cc
th cm p lc ca thnh mch ng thi tnh trng mt mu, thiu oxy nui
dng h thn kinh v cc c quan quan trng ca c th ( tim, gan, thn, tuyn
thng thn ) cng l nhng nguyn nhn gy sc v t vong trong cc trng
hp mt mu nng
Chy mu cc tnh mch nh v nh thng khng nguy him nhng tn thng
c tnh mch ln nht l cc tnh mch gn tim cng quan trng v gy ri lon t
ngt sc cha ca tim, tim p rng c th gy phn x ngng tim v cht mc d
c khi lng mu mt khng ln lm ( 300- 500 ml)
3. Tnh phn ng ca c th :
Tr s sinh v tr con di 2 tui rt mn cm vi mt mu do kh nng b p
ca h tim mch v h thn kinh cha pht huy c y .
Tnh trng mn cm vi mt mu tng khi c th suy nhc, b chn thng nng,
mt mi, i, lnh, trong trng thai gy m su c khi lng mu mt ch 10-
15% cng gy nhng hu qu nguy him.
B- C CH THCH NGHI P KHI MT MU
Khi mt mu c th s ng vin mt chui phn ng sinh vt phc tp nhm bo
v c th mt mc nht nh :
1. Phn ng cm mu:
Tn thng huyt qun gy phn x co mch ti ch, v cc tiu cu t li thnh
mt nt sinh hc bt kn vt thng, ng thi c hin tng tng cng cc yu
t ng mu, tng to thromboplastin t chc, tng to fibrinogen gan v cc yu
t khc. Kt qu l tnh ng mu tng, c th gp 3- 5 ln bnh thng, hin
tng ny xut hin ngay sau khi mt mu v ko di 5- 8h sau, cho nn mu c
th ngng chy nhng nu khng pht hin c tn thng mch mu v c
bin php phng nga th khi vn chuyn thng binh c khi ch nhng ng tc
khng nh nhng, thay i t th c th gy chy mu th pht, sc c th
dn ti t vong nu khng x l kp thi
2. Phn ng nng huyt p ( phn x tim mch ):
Do mt mu, lng mu lu thng gim, huyt p ng mch gim kch thch
phn x cc th cm huyt qun vng xoang dng mch cnh v quai ng mch
ch gy tng co bp tim, mch nhanh v mnh hn, tc mu chy cng tng
cng. ng thi c hin tng tng tit adrenalin gy co mch ngoi vi v gin
cc mch no, mch vnh. Kt qu l tim tng cng hot ng, co mch ngoi vi
v mu d tr c phng ra vng tn hon nn huyt p ng mch c
nng ln tm thi iu ha hin tng mt cn bng huyt ng lc, ng thi
cng phn phi li mu bo m cung cp cho no v tim l cc c quan quan
trng duy tr s sng.
3. Phn x tng h hp : pht sinh do kch thch phn x trung tm h hp khi
nng O
2
/ mu gim v nng CO
2
/ mu tng. H hp tng cng, th nhanh
v su; qu trnh trao i hi kh v s phn ly HbO
2
, cng tng t chc d
dng s dng oxy.
4. Phn ng b p khi lng mu :
Lu lng mu gim gy tng tit ADH v aldosteron c tc dng tng ti hp thu
nc v mui ti lin bo cc ng thn do lm gim bi tit nc tiu ( thiu
niu hoc v niu ). ng thi c hin tng huy ng dch gian bo vo dng
mu, c thc hin thun li v lc ny p lc mu gim thp. Trn thc t, khi
mt 1 lt mu, khi lng mu c khi phc sau 8- 24h, c khi ti 2- 3 ngy sau
mi khi phc hon ton. V mi ch khi phc phn dch nn mu long, khi
lng hng cu v huyt cu t gim, hematocrit cng gim, ( l hin tng
thiu mu sau khi mt mu )
5. Phn ng tng to cc t bo mu :
Phn ng ny xut hin mun nht 4- 5 ngy sau, pht sinh do tnh trng thiu
oxy mu kch thch ty xng tng to cc t bo mu c tnh cht thch ng b
p, phn ng ca ty xng v tc ti to t bo mu ph thuc vo tnh
trng ton thn, mc mt mu v s cung cp cc nguyn liu to mu ( protit,
st ) C th tr, khe mnh, mt mu khng nhiu lm, dinh dng y
thng hi phc nhanh hn. ch cu v tiu cu i sng ngn, ti to nhanh
nn ch 8- 10 ngy s lng mu ngoi vi c th c khi phc, hng cu
th phi ti 30- 50 ngy sau, chm nht l hut cu t phi sau 2 thng mi tr li
mc bnh thng.
Nh vy, nu mt mu khng nhiu lm v iu tr gii quyt kp thi, hp l th
cc phn ng b p ca c th c th n nh c tnh trng ton thn. Nhng
nu mt mu nng hoc bnh nhn vo cc iu kin hon ton khng thun
li, c th dn ti sc mt mu v cc bin c nguy hi cho i sng.
Tn thng huyt qun
Mt mu

Gim khi lng mu tun hon

Gim huyt p Gim Oxy- mu
Tim co bp yu Thiu Oxy

Kch thch th Hng phn h
cm huyt qun TKT

Tng cc phn c ch h TKT
ng b p

Hi phc Ri lon cc chc Sc MM
phn v c ch b t vong
S v bnh sinh ca mt mu

c) Sc mt mu ( sc chy mu ) :
Sc mt mu l hin tng th pht xy ra sau khi mt mu nng din bin sau
mt thi gian h huyt p ng mch, s oxy ha khng y dn ti suy sp
h TKT v ri lon nghim trng ton b chc nng c th, biu hin r nht l
h tn hon. Mt mu cng nhanh, mnh ( chy mu cc ng mch, tnh mch
ln ) cng nhiu ( 25- 30% v hn na ) th sc mt mu pht sinh cng c tnh
cht ph bin v din bin cng nng.
1. Cc giai on din bin ca sc mt mu : ( hnh 1 ).
Sc mt mu thng din bin theo 3 giai on ( La porte, 1965 ).
a) Giai on 1 ( ngay sau khi mt mu )
Giai on ny ph thuc vo mc mt mu v trng thi tng c th. Bnh
nhn thng trng thi vt v, kch thch nhng nu mt mu nhiu li mt l
mt ti nht, chn tay lnh, c th ngt do thiu oxy t ngt no.
Huyt p ng mch gim do gim khi lng mu tun hon, mt mu cng
nhiu huyt p gim cng r, mt qu nhiu c th gy try tim mch dn ti t
vong do cc phn ng b p khng kp thi pht huy tc dng.
Mch nhanh v mnh pht sinh theo c ch phn x, nhng nu mt mu nhiu
khi lng mu gim nhiu tim c th p yu v lon nhp,c s chun on
mc ca sc.
- H hp cng tng cng, th nhanh v su. Nhp v tn s h hp c th b ri
lon ngay khi mt mu nghim trng.
b) Giai on 2 ( cn gi l giai on tim )
Giai on ny ph thuc vo kh bng thch ng ca c th. C hai kh nng :
Nu c ch thch ng b p ca c th pht huy tc dng th tnh trng bnh
nhn c xu hng hi phc dn: huyt p ng mch c nng ln, mch vn
nhanh v mnh hn, thng khng qu 120 p/ pht; h hp cng u v su
hn, sc mt nht nht v chn tay lnh, tnh to.
Nu cc im din bin xu dn i, huyt p khng tng m tip tc gim; mch
yu, rt nhanh v lon nhp; h hp ri lon v th nhanh- nng l c ch b p
bt lc v sc c th nhanh chng chuyn sang giai on nhc.
c) Giai on sc nhc :
L giai on suy sp h TKT v ton b chc nng c th, l giai on mt b c
th khi pht do mt yu t thun li: gy m su, chn thng, au n, lnh,
thay i t th, vn chuyn
2. Bnh sinh ca sc mt mu :
Mt xch ch yu ca bnh sinh mt mu l gim khi lng mu tun hon v
thiu Oxy mu gy ri lon nghim trng h TKT. Cc t bo no b thiu oxy
nng t hng phn nhanh chng chuyn sang trng thi c ch su sc gy ri
lon iu ha cc chc phn v c ch cc c ch thch ng b p ca c th.
Quan trng nht l ri lon h hp do hnh no v cc trung tm h hp b tn
thng v ri lon hot ng tim do huyt p ng mch gim v thiu oxy c
tim. Tnh trng ny cng lm suy sp s cung cp oxy cho t chc gy ri lon
chuyn ha nng n. Cht trong mt mu pht sinh do lit trung tm h hp v
ngng tim.
Do tc dng ca catecholamin, h thng ng mch b co tht, tun hon no v
vnh gin ra l c ch bo v cho trung tm sng nh tun hon gan, thn li b
co nhiu cho nn tnh trng ny ko di cng gy nhng tn thng nghim trng
trong gan, thn, rut, thng thn cng l nguyn nhn lm cho sc kh hi
phc.
H thng tnh mch xp, khng c mu, tun hon tr v tim gim nh hng
ti hot ng tim dn n ngng tim. H thng mao mch b gin nghim trng
co ri lon cc c tht tiu mao mch. Mu trong h mao mch, ch yu khu
vc ni tng, cng gy gim huyt p ng mch to thnh vng xoy c bnh l
lm cho sc nng thm.
Nguyn tc ch yu ca vic iu tr mt mu l khi phc tun hon, tr li khi
lng mu mt, gi cn bng huyt p.
Trong khi x l{, m bo cm mu tt v nn cho bnh nhn nm u dc.
iu tr sm, truyn mu ngay trong hai giai on u phc hi th cn bng
huyt ng lc, phng sc v ngn nga nhng hu qu do thiu oxy gy ra. iu
tr trong giai on ny l mt thun li khng nn b qua v tc dng iu tr
tng i d dng rt c hiu lc, khi chun sang giai on sc nhc iu tr
kh khn hn. Sau khi ti lp c th cn bng, tnh trng cn khng chc chn
trong mt thi gian, cn tip tc hi sc v theo di ngn nga sc th pht, kh
hoc khng cu cha c.
3. Try tun hon ( try tim mch )
Khc vi sc, l trng thi gim huyt p t ngt, c th dn ti t vong trong
mt thi gian ngn. Nguyn nhn do chy mu nhiu, nhanh v khng cm c
gy thiu oxy cp ( apoploxie ) cc c quan b phn quan trng. Thiu oxy cp c
th gy gin mch do thiu oxy nui dng cc t bo thnh mch, cc mao mch
b gin, nht l cc mao mch ni tng lm ton b khi lng mu trong
gy gim huyt p trm trng. Tnh trng ny lm gim khi lng mu v tim, h
thng tnh mch xp nn mc d kh nng tim cha b tn tht, tun hon mu
cng khng thc hin c. Thiu oxy cp no nn bnh nhn bt tnh ngay v
cc chc nng thch ng bo v b c ch, cc trung khu quan trng nh tun
hon, h hp b tn thng ng thi thiu oxy cp tuyn thng thn u l
nhng nguyn nhn dn n t vong sm trong mt mu cp v nghim trng.

13. RI LON TO HNG CU

I CNG
Cc t bo mu c sn sinh t c quan to mu. Khi cn bo thai, t tun l
th ba, cc t bo mu u tin c hnh thnh t t chc trung dip, ni to
thnh mu l nhng t bo ni mc ca huyt qun. Sau cc t chc gan, lch
cng tham gia vo to mu, t thng th t thm ty xng to mu nhng khi
ra i th cc t chc trn chm dt nhim v, ch c ty xng tr thnh c
quan to mu quan trng nht ngi.
Nh vy ngi cc c quan to mu gm :
Ty xng, c quan to mu chnh l ni sn sinh 3 dng t bo mu : hng cu,
bch cu ht, tiu cu.
Lch, cc hch bch huyt ch yu to dng bch cu lympho.
H vng ni m ( SRE ) ch yu to dng bch cu mono. V h vng ni m ri
rc nhiu nitrong c th ( ty xng, gan, lch, hch ) nn ngi ta thng
phn bit bch cu mono mu, ngun gc ty xng v cc t bo t chc lin
kt, cc i thc bo xut hin nhiu khi b vim nhim cc b.
V ngun gc cc t bo mu t trc ti nay c rt nhiu l thuyt gii thch
khc nhau. Ni chung u thng nht l cc t bo mu u bt ngun t t bo
gc a nng, gi l hemohistioblaste ( huyt nguyn t chc bo ). T t bo ny
s cho cc t bo gc chung cho cc t bo mu, nguyn bo hay hemocytoblas,
ri ty theo nhu cu c th bit ha thnh cc t bo m ca tng dng t bo :
proErythroblas hay tin nguyn hng cu, t bo m ca dng hng cu;
Myelobalsthay nguyn ty bo l t bo m ca dng bch cu ht;
Megacaryoblast l t bo m ca dng tiu cu;Lymphoblast hay nguyn lympho
bo l t bo m ca dng bch cu lympho; Monoblast hay nguyn mono bo, t
bo m dng bch cu mono
Hng cu c sn sinh ty xng, t t bo tin nguyn hng cu, qua cc giai
on :
ProErythroblast

Erythroblast

Hng cu li
( rticulocyt)

Hng cu

Cc ProErythroblas v Erythroblas kim l nhng hng cu non, t bo ln, nhn
to v trn trn, li nhim sc thanh, nguyn sinh cht bt mu xanh thm kim
tnh do cha nhiu ARN, cc Erythroblast a sc l t bo hng cu non giai on
bt u c tng hp hemoglobin nn nguyn sinh cht va bt mu xanh kim
va bt mu hng do huyt sc t. Cc nguyn hng cu ni chung ( Erythroblast )
l nhng hng cu non c nhn ch trong ty xng to mu, bnh thng
khng mu ngoi vi.
Hng cu li l nhng hng cu gn trng thnh mt nhn v nu mang
nhum bng phng php nhum sng vi cht mu xanh sng Cresyl s thy
b mt t bo c nhng ht nh xp thnh mng li. nh thng hng cu li
c tung ra mu ngoi vi thay th cho cc hng cu gi b hy, nn c t l
0,5- 1.5% v nh vy hng cu li l ch tiu theo di s tng sinh ca dng hng
cu.
ngi bnh thng, s lng hng cu ngoi vi c gi mc tng i hng
nh t 4- 4,5 triu trong 1mm
3
mu do c s cn bng gia hai qu trnh sn xut
v tiu hy hng cu. ( hnh 1 ). Nh phng php nh du hng cu bng cht
ng v phng x Cr51 ngi ta xc nh hng cu sng c trung bnh t
110-120 ngy, t khi ra khi ty xng. Cc hng cu gi b hy nn hng ngy c
s hy huyt sinh l khong 0,83% khi lng hng cu trong cc h vng ni m,
ch yu l lch, v ty xng li sn xut tung ra mu ngoi vi cng ngn y hng
cu thay th. Khi cn bng ny b ri lon s pht sinh 1 trng thi bnh l m
ngi ta thng gi l thiu mu.

A. QU TRNH SN XUT HNG CU

1. Chc nng sn xut cc t bo mu ca ty xng :
Ty xng gm ty vng hay ty m thn cc xng di v ty hay ty to
mu ch yu cc t chc xp ca xng dt v u cc xng di.
Ty to mu gm hai phn:
Phn m l cc mao mch v giy h rticulin to thnh t chc xp lm nn
m cho cc t bo.
Phn nhu m gm cc t bo gc cha bit ha v cc t bo m, t bo trung
gian ca cc dng hng cu, bch cu ht v tiu cu. Ngoi ra cn mt s t bo
lin vng to lympho v t bo mno.
Tt c hp thnh mt t chc thng nht, lin quan, tip xc vi nhau m
ng chc phn to mu theo c ch iu ha nhp nhng ca thn kinh v ni
tit.
Tng s lng ty xng ngi ln l 2600g, tc 4,6% so vi cn nng c th,
trong 1 na l ty to mu. Thm d chc nng ty xng bng phng
php chc d ( ponction ) xng c hoc mo xng chu, u trn xng
chy. Cht ty c dn vo lam knh, nhum ri m t l % cc t bo ty, gi l
ty ( mylogramme ). Khi qut 1 cng thc ty gm:
Cc t bo dng bch cu 60%
Cc t bo dng hng cu 20- 25%
Tiu cu, bch cu lympho, mono, t bo lin vng 5- 10%
nh gi chc nng ca ty xng qua 1 ty , ngi ta thng da vo cc yu
t :
1. T l cc t bo non, trung gian ca tng dng t bo mu tng, chng t dng
t bo c tng sinh theo yu cu ca c th. V d: cc t bo Erythroblast
kim, a sc, toantng cao trong cc trng hp thiu mu.
2. T l cc phn bo ca tng dng t bo mu: Cc t bo mu c nhn ln
bng cch phn chia t bo. Kh nng phn chia c thc hin cc t bo non,
v ch yu cc t bo gn trng thnh c lng axit nhn cao: Erythroblast a
sc, toan vi dng hng cu; Ty bo, Hu ty bo vi dng bch cu ht
3. T l BC/ HC, tc l t l gia cc t bo bch cu v hng cu. nh thng t
l ny bng t 2-3, v bch cu i sng ngn nn sn xut phi c tng cng.
T l ny gim khi cc t bo hng cu c tng sinh trong thiu mu, ngc li
t l ny tng ln trong cc trng hp nhim khn, c tng sinh dng bch cu
ht.
4. T l cc t bo non so vi cc t bo gn trng thnh trong ty xng tng
cng, v d t l cc Erythroblast kim tng cao so vi cc Erythrob-last a sc,
toan c th do tnh trng thiu st c ch s tng hp hemoglobin...
5. S xut hin cc t bo non cc dng mu ngoi vi. nh thng cc t bo
non, nguyn bo v cc t bo trung gian ch c trong c quan to mu. S xut
hin bt thng cc t bo ny mu ngoi vi ni ln kh nng bit ha t bo
ca ty xng b gim st hoc c ch nn c hin tng tng cng qu mc
cc nguyn bo; c trong ty xng v trn ra ngoi mu ngoi vi.
Cc t bo non cc dng c phn chia, chuyn qua cc giai on trung gian, ri
trng thnh v c a vo mu ngoi vi thay th cho cc t bo gi hoc v l
do bnh l b hy. Thiu Erythropoietin trong bnh vim thn mn, hin tng
cng lch c tc dng c ch nn qu trnh trng thnh hng cu a ra
mu ngoi vi thay th cc hng cu gi, bnh l gim st v gy thiu mu. Trong
bnh thng hn, c t vi khun c ch qu trnh trng thnh dng bch cu
ht nn mu ngoi vi c hin tng gim bch cu ht

B- QU TRNH TIU HY HNG CU

Hy hng cu sinh l l s ph hy cc hng cu gi cui giai on sng. Hng
cu v v gii phng ra huyt cu t t do. nh thng, huyt cu t t do c
gii phng khi c hy hng cu s kt hp vi 1 globulin alpha trong mau l
haptoglobulin, v nh vy hut cu t hay st ( Fe ) c gi li trong c th
s dng cho tng hp cc hng cu mi; ch khi huyt hy qu mc trong bnh l
lm cho lng huyt cu t t do tng qu cao trong mu vt kh nng kt hp
ca haptoglobulin th mi c huyt cu t niu ( Hb t do tng qu 150mg%
).
Huyt cu t (hemoglobin) gm globin v hemedo porphyrin v Fe
2+
to thnh.
Thoi bin hemoglobin bt u ph hy vng porphyrin, heme tch khi globin
oxy ha thnh hematin. Phn c st s gii phng Fe di dng hemosiderin (
Fe
3+
) c d tr trong lch v gan s dng trong tng hp cc hng cu mi.
Phn khng c st c to thnh sc t mt, bilirubin kt hp ( ha hp ), xung
rut thnh Urobilin v Stercobilin cui cng bi tit qua nc tiu v phn. Do
khi c hy hoi nhiu hng cu trong bnh l, bilirubin t do tng cao trong mu
gy vng da, ng thi tng Urobilin nc tiu v tng Stercobilin phn cng l
nhng ch tiu phn on mc ca hy hut.
Cc hng cu b hy c phn mnh v sau b thc bo bi cc t bo vng
ni m ty xng, gan, ch yu l lch. Lch l c quan chnh tiu hy hng cu,
c nhiu nhim v lin quan ti h thng mu :
D tr mu trong cc xoang ca ty ( pulpes rouges ) ca lch.
To cc bch cu lympho v l ni sn xut cc globulin min dch.
C tc dng c ch ty xng, i lp vi kh nng sn xut t bo mu v c kh
nng a ra mu ngoi vi nhng t bo trng thnh ca ty xng.
C chc nng hy cc hng cu gi v hng cu bnh l bng cch tng hot tnh
thc bo ca cc t bo ni m lch. Trong trng hp bnh l, chc phn ny
tng cng, c th hy c cc hng cu bnh thng v c cc bch cu v tiu
cu bnh thng, v c ch bnh sinh, c tc gi cho rng do lch sn sinh ra
nhng cht c nhng men tiu hy ( lisolecithin, lysin ) hoc nhng khng th c
nh vo b mt cc hng cu, lm o ln cn bng l ha ca hng cu do
hng cu d b v, d b nh hng bi cc tn thng c gii ( tr tun hon,
tn thng thnh mch ) hoc cc tn cng bnh l khc.
14.
SINH L BNH CA THIU MU

Thiu mu l mt hin tng bnh l ph bin pht sinh khi c ri lon s cn
bng gia hai qu trnh sn xut v tiu hy hng cu, hoc do hng cu b tiu
hy qu mc ( mt mu, hy hng cu do cc nguyn nhn bnh l ), hoc do qu
trnh sn xut hng cu b gim st, c ch ( thiu nguyn liu, nhim khun,
nhim c nng ). Biu hin ca thiu mu l gim s lng hng cu, huyt cu
t ngoi vi, ng thi c nhng ri lon v cht lng hng cu.
1. Thay i ca hng cu v chc nng to hng cu trong thiu mu.
Khi thiu mu, hng cu khng nhng thay i v s lng m c cht lng cng
c nhng bn i, v ty xng p ng li kh mnh b p trong cc
trng hp thiu mu va phi, c x tr iu tr hp l.
A- THAY I V S LNG HNG CU
Khi thiu mu, s lng hng cu ngoi vi gim di mc bnh thng. Gim
nhiu hay t mt phn ni ln mc nng hay nh ca thiu mu. Trong cc
trng hp nng, s lng hng cu c th gim di 2.000.000 trong 1mm
3
.
Huyt sc t cng gim song song vi hng cu, trng hp nng c th gim
di 50% so vi mc bnh thng.
B- THAY I V CHT LNG HNG CU
Cht lng hng cu b bin c th do cc yu t bnh l{ tc ng trc tip
tn hng cu, hoc do qu trnh sn xut b ri lon, c biu hin bng cc ch
tiu :
1. Thay i ch s nhim sc ca hng cu:
Ch s nhim sc l m huyt sc t trong hng cu, th hin gi tr chc nng
ca hng cu nn c in gi l gi tr hng cu c tnh theo cng thc n
gin:
hemoglobin%
CSNS = = 1
2 s u HC.2
Gii hn bnh thng ca ch s nhim sc l 0,9- 1,1. Trong bnh l, ty theo s
thay i ca ch s nhim sc c th phn bit
Thiu mu ng sc khi hng cu v huyt sc t gim tng ng, cc trng
hp thiu mu c hy hng cu va phi, t hoc khng b thiu st do Fe c
gi li s dng cho ti to hng cu.
Thiu mu nhc sc khi CSNS gim di 0,9 do hut sc t gim nhiu hn so
vi hng cu, gp cc bnh nhn suy nhc thiu protit, thiu st. suy dinh
dng, hoc kh nng tiu ha hp thu km, kh nng tng hp protit b ri
lon
Thiu mu u sc khi CSNS trn 1,1. y khng phi l tha d huyt cu t, s
lng tuyt i Hb trong 1 n v th tch mu vn gim, tuy s lng Hb trong
tng hng cu c tng cao hn bnh thng, do th tch ca hng cu tng. nh
thng mi hng cu ch cha mt lng Hb nht nh, t l bo ha Hb ca
hng cu l 33- 34%, nn khi th tch hng cu tng thi lng Hb trong tng hng
cu cng tng. Thiu mu u sc gp trong bnh thiu mu c tnh Addison-
Biermer, c hng cu bnh l mgelo t l cao trong mu ngoi vi,s lng HC
gim thng di 1- 2 triu/ 1mm
3
. V d mt trng hp thiu mu vi s lng
HC 1 800 000 trong 1mm
3
, Hb 45%, c ch s nhim sc ( 45/18,2= 1,5 ) l thiu
mu u sc.
y ch l mt cch tnh ton n gin, v chuyn khoa cn phi da vo nhiu
yu t chnh xc hn nh xc nh th tch ca hng cu, bo ha Hb ca hng
cu, lng Hb trong tng HC
2. C kh khng u hay hin tng a c ( anisocytose ). C th phn bit : trong
mu thy xut hin mt s hng cu to hn bnh thng, ng knh 8- 10
micromt l nhng hng cu gn trng thnh, hng cu li va c tng sinh
thay th l biu hin tt thiu mu ang c phn ng tng sinh hi phc. Nu
trong mu c nhiu hng cu nh, ng knh 5- 6 hoc 3- 5 micromt, l biu
hin khng tt v l nhng HC gi ci, nhng mnh v ca HC, hoc nhng HC
b teo i di tc dng ca yu t bnh l, nhng HC sn xut trong iu kin xu,
thiu nguyn liu c cc HC khng l Mgalo, ng knh trn 10micromt, gp
trong bnh thiu mu u sc Biermer.
Do ng knh hng cu bng micromt qua knh hin vi v v thnh ng biu
din Prices- jones c gi tr nht nh trong chun on thiu mu lm sng:
ng biu din chuyn sang tri do trong mu c nhiu hng cu nh, c th
gp trong cc trng hp thiu mu do nhim c, bnh vng da tan mu
ng biu din chuyn sang phi l c nhiu hng cu ln, c th gp trong
thiu mu c hng cu Mgalo
3. Bin i v hnh dng hay hin tng a dng ( poikilocytose ) do mng hng
cu km bn vng nn khi dn trn lam knh hng cu mo m khng u, to
thnh cc hnh dng khc nhau: hnh qu du, bn nguyt, qu l, qu chy hoc
do cc bnh l di truyn gy bin i cu trc v hnh dng hng cu, nh hng
cu hnh bia trong bnh huyt cu t F, hnh lim trong bnh huyt cu t bnh l
S.
4. Bin i v mu sc hay hin tng lon sc ( anisochromie ) biu hin bng s
bt mu khc nhau ca cc hng cu:
Hng cu nhn l nhng hng cu khng bt mu gia do thiu huyt cu t,
nhc sc.
Hng cu a sc l nhng hng cu trng thnh nhng do qu trnh chuyn
ha vi vng nn vn cn tnh cht i kim trong nguyn sinh cht nh t bo
non, gp trong cc trng hp mt mu tan mu cp tnh v qu mc
5. Xut hin nhng hng cu bt thng trong mu ngoi vi.
Trong cc Erythroblast kim, a sc, toan gp trong thiu mu nng gy phn ng
mnh vi ty xng; hoc trong cc bnh nguyn hng cu c tnh.
Xut hin cc hng cu mang d tt nh th Joly, vng Cabo trong cc trng hp
thiu mu nng v c ri lon chc nng ty xng.
Xut hin cc hng cu c ht i kim trong thiu mu do nhim c c bit
nhim c ch.

C- THAY I CHC NNG TO HNG CU CA TY XNG.

Khi thiu mu chc nng ca ty xng b bin i theo hai hng :
1. Tng sinh bnh thng: Ty xng thng phn ng rt nhanh v nhy trong
tt c cc trng hp thiu mu thng thng. Ta gi l thiu mu c hi phc
biu hin :
Tng hng cu li 10- 20% c khi ti 50% v hn na
Bin i v cht lng hng cu t hoc khng r rt.
Bch cu ht v tiu cu cng c du hiu tng sinh nh.
2. Chc nng b ri lon hoc b c ch:
Phn ng ca ty xng yu t hoc khng xut hin, ta gi l thiu mu kh
hoc khng hi phc, hay suy ty v nh hn l nhc ty, vi nhng biu hin :
Hng cu li gim thp hoc khng xut hin.
Nhiu bin i v cht lng hang cu.
Bch cu v tiu cu gim song song vi thiu mu.

NGUYN NHN V BNH SINH CA THIU MU

Ty theo nguyn nhn v bnh sinh, c th chia thiu mu thnh ba bnh chnh:
thiu mu do tan mu; do mt mu; v do chc nng to hng cu ca ty xng
b ri lon.

A- THIU MU DO MT MU

Tt c cc trng hp mt mu ni hay ngoi khoa, cp tnh hay trng din u
dn ti trng thi thiu mu vi cc mc khc nhau.
1. Thiu mu do mt mu cp din thng do nguyn nhn ngoi khoa ( vt
thng, t mch mu, gy xng,phu thut) hc bin chng ni khoa ( nn
ra mu, khc ra mu, chy mu d dy, i ra mu, chy mu cam, chy mu di
da, ni tng quan trng). Ngoi nguy c trc mt ( sc, try tim mch ), thiu
mau pht sinh sau vi cc c im sau y:
Gim hng cu v hut cu t nghim trng, mu long do dch gian bo vo
dng mu b p khi lng tun hon.
Thiu mu nhc sc, ch s nhim sc gim r rt, v mt hng cu, hut cu t
thng dn ti thiu st do st trong c th ch yu dng kt hp vi huyt cu
t ( chim ti 2/3 tng s lng st trong c th, c 1lt mu cha khong 500mg
st
Tng hng cu li, ty giu t bo v c du hiu tng sn dng hng cu. Hi
phc cng nhanh nu mc thiu mu khng nng ( di 20% tng lng) v
trng thi ton thn tt. Cc bin i v cht lng hng cu cng t hoc khng
xut hin.
2. Thiu mu do mt mu trng din:
Pht sinh trong cc bnh l mn tnh c chy mu. t mt, ko di ( lot d dy,
tr, giun mc, dong kinh ph n). Thiu mu din bin thng ko di , mc
gim hng cu, huyt cu t khng nhiu lm, thng l thiu mu nhc sc,
cng c khi ng sc. Trong mu thy tng hng cu li, nhng t l khng cao
v tc hi phc cng chm hn, bin i v cht lng hng cu cng nhiu v
r hn ph thuc vo cc bnh chnh ca bnh nhn. Bnh cng din bin lu di
cng nh hng ti th trng ton thn nht l tim v h thn kinh ( gim tr nh,
d b chong vng, ngt lm, tim c ting thi chc phn ) Gii quyt thiu mu
trong nhng trng hp ny phi song song vi iu tr bnh chnh.

B- THIU MU DO TAN MU ( DO HY HNG CU )

L loi thiu mu do hng cu b ph hy qu mc, nguyn nhn v bnh sinh rt
phc tp c th phn thnh ba yu t chnh.
1. Tan mu nguyn nhn do yu t hng cu: hay do bn thn hng cu km bn
vng, d v v b thc bo bi cc t bo h vng ni m, do ngi ta xp vo
loi tan mu trong t bo loi thiu mu ny c th gp trong cc bnh:
Bnh huyt cu t pht sinh do ri lon tng hp huyt cu t, cc b bin d
to thnh cc huyt cu t bnh l{ F,S lm thay i cu trc v hnh th hng
cu, hng cu chuyn thnh cc dng hnh bia, hnh lim nn d v, kt dnh
vi nhau gy thiu mu tan mu c tnh cht di truyn, gia nh.
Bnh vng da tan mu do hng cu hinh trn ( spherocyte ) do thiu men enolaza
l men chuyn lysophotphattidyl- ethalonamin do kh nng dung gii ng
ca hng cu lm hng cu d b hy.
Bnh vng da tan mu bm sinh do hng cu b thiu men pyruvatkinaza hoc
men diaphoraza.
Bnh thiu mu tan mu do dng mt s thuc ( premaquine, sulfamid,
acetalinit, l u fve ) do hng cu thiu men G.6.P.D. ( gluco- 6 photphat
dehydrogenaza).
Trong cc bnh ny sc bn ca hng cu vi cc nng dung dch NaCl nhc
trng gim, i sng hng cu ngn li ch cn 40- 80 ngy hay t hn na.
2. Tan mu nguyn nhn do yu t t chc:
Do cng hot h thng li ni m ch yu l cng lch thng gp trong
bnh thiu mu tan mu c km gim tiu cu, hoc trong cc hi chng gan-
lch to. Nguyn nhn c th do tng chc phn thc bo ca lch i vi hng
cu, v tng tc dng c ch ca lch i vi ty xng. C tc gi cho rng khi
cng lch c hin tng xung huyt ng hng cu do hng cu km bn
vng v d v. C th do t chc lch tit ra cc men tiu hy ( lysin lysolecithin...
) hoc sn sinh cc ngng kt t khng y c nh vo b mt hng cu lm
o ln cn bng l ha ca hng cu lm hng cu d v do nh hng ca tn
thng c gii cng nh ca cc tn cng bnh l khc.
Loi thiu mu do hai nguyn nhn trn c xp chung vo loi thiu mu tan
mu trong t bo v hng cu b hy v thc bo trong cc t chc vng ni m.
3. Tan mu nguyn nhn do yu t dch th:
Cn gi l thiu mu do tan mu mc phi, chim mt v tr ch yu trong bnh l
thiu mu Vit Nam. Nguyn nhn v bnh sinh loi thiu mu ny rt phc
tp, thng do cc yu t bn ngoi hoc yu t min dch tc ng trc tip trn
hng cu lm cho hng cu b tiu hy ngay trong huyt qun, thng l cc
huyt qun thn nn du hiu lm sng ph bin ca loi thiu mu ny l c
huyt cu t niu.
a) Cc tai nn truyn mu thng hay gp :
Truyn nhm nhm ABO: trong mu c sn cc khng th t nhin khng A,
khng , cng nh c sn cc khng nguyn A, B... nn tan mu c th xy ra ngay
tc khc hoc do khng th mu truyn vo hy hng cu ca ngi bnh, hoc
do khng th ca ngi nhn hy hng cu ca ngi cho mu a vo. Nhm
mu O nguy him l do c tng cng khng A min dch rt mnh nn c
th lm tan v hng cu A ca ngi nhn, gy tai nn truyn mu nghim trng
lm sng.
Truyn khc nhm Rh: V nhm mu RH(-) Vit Nam rt him nn tai nn ny t
gp hn v khng th khng Rh ch xut hin sau mt qu trnh min dch ngha l
sau khi mu Rh (+) tip xc vi mu Rh (-) gy kch thch h min dch th khng
th khng Rh mi xut hin vi hiu gi tng dn. Do tai nn ny ch xy ra
cc bnh nhn c truyn my nhiu ln, hay ph n sinh nhiu ln.
Thng gp nht l khc nhm Rh gia m v con, gy vng da tan mu tr s
sinh do yu t Rh. Ngi m c nhm mu Rh (-) b min dch bi mu con mang
Rh (+) ca ngi b truyn cho, mu m s xut hin cc khng th khng Rh, c
th gy hy hng cu a tr khi sinh ra, hc khi xy thai, thai cht lu trong
nhng thng cui, ch yu nhng a con sau. Vit Nam v t l ngi c
nhm mu Rh (-) rt t nn tai nn ny rt him gp, Chu Phi, Chu u t l
ngi mu Rh ( -) ti gn 15% nn c chng 6 a tr b bnh trn 10 000 dn (
Bevan 1961).
Min dch hy hng cu cn c th gp khi ngi m c nhm mu O v cc con
thuc nhm mu A hoc B (5-6/1000).
Ngoi ra cn phi k cc tai nn hy huyt do truyn mu nhiu ln, do cc khng
nguyn hng cu khc: h Lewis, h Kell, h Duffy
b) Cc bnh thiu mu tan mu t nhim: do cc qu trnh bnh l thng thng (
nhim khn, nhim c, bng) gy hy hoi v bin cht hng cu. Cc hng cu
b bin cht ny c th tr thnh khng nguyn kch thch h min dch ca c
th to ra cc t khng th khng hng cu, c th gy hy hng cu ca chnh
bn thn mnh, bnh l{ ny i khi cng gy nhiu bin c cho bnh nhn v ngy
cng gp nhiu lm sng. Cc t khng th khng hng cu c chia thnh
nhiu loi:
- Cc khng th gy ngng kt hng cu hay ngng kt t (agglutinin ) hot ng
nhit 4
o
C, 22
o
C, v 37
o
C, pht hin nh nghim php Coombs trc tip v
gin tip
- Cc khng th gy tan mu hay tiu huyt t ( hemolysin), c th phi hp hoc
khng phi hp vi ngng kt t, hot ng cc mi trng nng 37
o
C, lnh
4
o
C, hoc axt v hot ng c nh c b th. Cho nn theo ri s tng v gim
b th trong mu c th gp phn xc nh nguyn nhn ca tan mu.
Cc khng th ny tc dng trn khng nguyn hng cu, lm hng cu b ngng
kt v tan v trong huyt qun v chn b cho h vng ni m thc bo hng cu
d dng.
c) Cc hin tng tan mu do cc yu t bn ngoi tc ng trc tip trn hng
cu:
- Nhim c cc cht ha hc trong k ngh nh phenyl hydrazinanilin, ch,
benzon, phenol, hoc n phi nm c.
- Nhim k sinh khn: st rt gy tan mu trong chu trnh plasmodium sinh sn
trong hng cu
- Nhim khn, cc vi khn lin cu hy huyt B, t cu vng, vi khn ym kh, vi
khn gram (-), vi khn lm m,trong cc bnh cm, st hch, vim no
- Cc cht c trong cc qu trnh bnh l c tnh: bnh Ho gkin, bnh bch cu,
bnh ung th cc loi
Cc bnh l{ ny gy tan mu theo hai c ch:
- Tc ng trc tip ln hng cu b tn thng hoc oxy ha hemoglo-bin thnh
methemoglobin, sulfhemoglobin nn hng cu d v, mt khc cn gy nhim
c ty xng nh hng n s sn xut hng cu.
- thng qua c ch min dch, kch thch c th to ra cc t khng th khng
hng cu.
c im ca thiu mu tan mu:
1. Thiu mu c tnh cht ng sc nu tan mu va phi, chuyn thnh nhc
sc khi tan mu nghim trng. S lng hng cu gim nhanh, d di ngay trong
giai on u.
2. Cht lng hng cu thay i r ri: hng cu a dng, mo m khng u, c
hin tng a c, nhiu tiu hng cu v vi hng cu, do mng hng cu b tn
thng, hng cu b bin cht thoi ha. C nhiu dng hng cu bt thng do
chuyn ha vi vng khi hng cu b hy qu mc( nguyn hng cu, th Joli,
vng Cabo, ht i kim). c bit trong tan mu trong t bo th sc bn hng
cu v i sng hng cu u gim.
3. Thiu mu c hi phc, hng cu li tng rt mnh 10- 20- 30 % v hn na.
Tc v tnh trng hi phc ph thuc vo mc tan mu v tnh cht ca
nguyn nhn gy tan mu. Nu c tnh trng nhim c ty xng th phn ng
tng sinh yu t v hi phc chm, kh khn hn.
4. C cc du hiu ca tan mu : tng hemoglobin t do, tng bilirurbin t do
trong mu, tng sc huyt thnh tng sc t mt trong phn v nc tiu.
5. Din bn ca thiu mu ph thuc vo nguyn nhn: tan mu trong huyt
qun th din bin thng rm r, cp tnh, cc du hiu tan mu biu hin r rt,
c huyt cu t niu v gan lch to, mm, au. Tan mu trong t bo th phn ng
lng l hn, din bin mn tnh, ko di v ch c hut sc t niu khi kch pht,
cc biu hin tan mu kn o, gan lch to, rn chc v khng au.
C- THIU MU DO RI LON CHC NNG TO HNG CU

Chc nng to hng cu ca ty xng c th b ri lon do thiu nguyn liu to
hng cu ( protit, st, sinh t 12, axitfolic ) hoc do ty xng b c ch do cc
nguyn nhn bnh l khc nhau.
1. Thiu mu do thiu nguyn liu to hng cu :
Thiu mu do thiu protit hay thiu dinh dng:
Nguyn nhn ca thiu protit thng do cung cp khng y : i, thiu n,
nht l nhng c th ang pht trin nh tr ang ln, ph n c thai hoc do
hon cnh chin trng tip t vn chuyn lng thc kho khn, lc rng, lc
bin, t y lu ngy.
Trong bnh l thiu protit go trong cc trng hp : bnh nhn n khng c
hp th km ( bnh d dy, rut) tng hp cht protit gim, ri lon ( bnh gan,
ri lon chuyn ho ), tnng cng thoi bin protit, mt protit ( st, nhim
khun, bng, bnh thn v cc bnh khc.
c im ca loi thiu mu ny l:
Thiu mu nhc sc, s lng hng cu v huyt sc t gim ph thuc vo mc
ca thiu mu, thiu protit. Da v nim mc nht nht, bnh nhn c th teo
c, mt mi v ph n nh. Ty ti sinh nhanh v mnh khi thiu mu va phi.
Prott mu ton phn gim, albumin gim ganma, globulin tng, cc t bo bch
cu v tiu cu ngoi vi u gim khi thiu protit nghim trng, ko di, c th
dn ti suy ty.
Cung cp y nguyn liu, bi dng n ung hp l, dung cc rhuc kch thch
to mu kp thi, c th gii quyt tt.
Thiu mu do thiu St :
St l nguyn liu tng hp huyt cu t cn thit cho s trng thnh hng
cu. Qu trnh chuyn ha st c th tm tt theo s sau :
St hu c, v c t thc n ti d dy, nh HCl in t ha thnh st c ha tr:
Fe
3+
, Fe
2+
sau c hp th qua mng rut vo mu. mu, mun vn chuyn
c st phi c kt hp vi 1 glubulin bta, vn chuyn st l transferrin( hay
siderophill ) a ti d tr ti gan di dng Ferritin v c s dng theo
yu cu c th.
Thiu st c th do nhiu nguyn nhn:
- Mt mu, chy mu ra ngoi c th.
- Cung cp thiu m nhu cu cao: tr n sa b, c th pht trin, ph n c
kinh nguyt, c thai, cho con b
- Ri lon hp th st: bnh l d dy rut, ct on d dy.
- Ri lon chuyn ha st: thiu nng bung trng, thiu nng tu{n gip, bnh l
gan
c im thiu mu thiu st:
- Thiu mu c tnh cht nhc sc, s lng hng cu, huyt cu t gim r rt,
ch s nhim sc gim, c nhiu hng cu nh v hng cu hnh nhn. Trong ty
xng t l Nguyn hng cu kim tng, t l Nguyn hng cu a sc v Nguyn
hng cu gim hn.
- St huyt thanh gim hn.
- Thiu mu c ti sinh nhng tc v tnh trng ti sinh ph thuc vo s cung
cp nguyn liu v trng thi ton thn ca bnh nhn.
-Thiu mu do thiu sinh t B12 v axit folic:
- Axit folic c chuyn thnh axit folililic cn thit cho s hnh thnh cc nhn
purin v pyrimidin l nhng cht c bn cu to axit nhn
- Sinh t B12 c tc dng trong khu kt hp cc nhn purin hoc py- rimdin vi
riboza hoc desoxyriboza v axit photphoric to thnh AND v ARN.
S hp t B12 li cn c cht nhy ca d dy( gastromuco- protin = GMP )
bo v B12 trnh b hy hoi bi cc men tiu ho. Sinh t B12 t thc n, ( trc
kia gi l yu t ngoi ) vo d dy kt hp vi GMP ( trc gi l yu t ni) to
thnh phc hp sinh t B
12
( cn gi l yu t chng thiu mu ), c d tr
gan, c tc dng kch thch ty xng to hng cu v trng thnh theo nhu cu
ca c th.
Thiu mu do thiu sinh t B
12
c th nguyn phat hoc th pht, thng gp l
thiu mu do thiu B
12
th pht.
a) Bnh thiu mu do B12 nguyn pht, cn gi l thiu mu ac tnh Bic- men (
bnh Addison- Biermer ). Nguyn nhn do thiu cht GMP d dt nn khng hp
thu c sinh t B12. S dng phng php khng th huznh quang c th pht
hin c cc khng th khng d dy hay khng th khng muco- protein, nn
bnh ny c gii thch bng c ch t min dch, nguyn nhn chnh cn cha
sng t.
c im loi thiu mu ny:
Thiu mu c tnh cht u sc, ch s nhim sc tng trn 1,2. S lng hng cu
gim rt thp thng di 2 triu /1mm
3
, c th di 1 triu /1mm
3
, huyt cu
t gim di 50% so vi mc bnh thng.
Tong mu ngoi vi, nhng bin i v cht ca hng cu biu hin r rt, km
theo c nhng bin i v cht v gim s lng bch cu v tiu cu. c bit,
xt hin trong mu nhng hng cu khng l megalo (mgaloblas, megalocyt).
Thiu mu c tnh cht c tnh, khng hi phc do s sn xut hng cu bnh
thng b c ch, ng thi pht trin dng hng cu bnh l mgalo. S lng
hng cu li gim rt thp hoc khng xut hin.
C cc ri lon thn kinh nh gim tr nh, cung sng, ri lon phn x, lit hai
chi di do tn thng ty hoc vim nhiu dy thn kinh, nht l cc dy s no.
iu tr c hiu bng sinh t B12 liu cao, bnh c th chuyn bin tt, ngc li
ko di hoc iu tr khng hp l c th chuyn nghim trng dn ti t
vong.
b) Bnh thiu mu do thiu B12 th pht, nguyn nhn thng do cung cp
khng y ( tr nui bng sa bt, thiu dng ) ri lon hp thu ( thiu GMP,
trong cc bnh vim toe nim mc d dy ), giang mai, ng th d dy, ct on
d dy, ri lon hp thu rut do sn, vim rut mn, ct mt on rut ln )
nhu cu B12 cao ( cha nhiu ln, nhim c, nhim khun mn ) hoc trong
bnh phng x
Thiu B12 th pht thng kt hp vi thiu protit v thiu st nn tnh cht
thng l thiu mu nhc sc vi nhng c im tung t nh thiu mu do
thiu protit v thiu st. Thiu mu c th hi phc tt nu kp thi iu tr bng
sinh t B12 kt hp vi cung cp st v protit, bi dng hp l cho bnh nhn.
2. Thiu mu do ty xng b c ch:
Ty xng c th b c ch tm thi hoc lu di gy trng hp nhc ty hoc
suy ty, do nhiu nguyn nhn phc tp:
Do nhim khun nng, cc c t vi sinh vt c c lc mnh tc ng ln ty
xng, thng ch c ch tm thi. C th do tc dng ca k sinh khun ( nhoc,
suy ty sau st rt ).
Do nhim c cc ha cht nh ch, phenyl hydrazin, hoc cc cht c trong qa
trnh bnh l{ ( x gan, vim thn mn ) do nhim x nng : dng quang tuyn X
liu cao, bnh phng x cp v mn tnh.
Do lon sn ty hoc ty xng b c ch, chn p trong mt s bnh c tnh:
bnh bch cu, ung th cc loi, x ha ty xng.
Do ni tit: cng lch do thiu mu km gim tiu cu; thiu Erythropoietin
trong vim thn mn; thiu bng tuyn gip, tuyn sinh dc, tuyn yn
c im ca loi thiu mu ny l: thiu mu nhc sc nng, c th u sc (
cn c tnh ), nhiu bin i v cht lng hng cu v ti sinh chm c th khng
hi phc. Do chc nng ca ty xng b c ch nn c gim sn xut c ba dng
t bo mu hng cu, bch cu v tiu cu dn ti trng thi nhc hoc suy ty.
Phn loi trn ta thy r gi tr, v tr ca tng loi thiu mu ring bit, nhng
trong thc t thiu mu cn do nhiu nguyn nhn phc tp kt hp vi nhau,
ngi thy thuc phi bit phn tch tnh trng mu ngoi vi, chc nng ty
xng, ri cng vi cc du hiu lm sng khc xc nh c yu t bnh sinh
ch yu th iu tr mi c kt qu tt. V d : thiu mu trong bnh gan, nguyn
nhn do bnh nhn c ri lon tiu ha, chn n, kh nng hp thu km; chc
nng tng hp protit gim; d tr st v sinh t B
12
gim ( thiu nguyn liu )
ng thi c c ri lon ng mu gy hi chng chy mu do chc nng tng
hp prothrombin v cc yu t ng mu khc b ri lon ( mt mu ), chc nng
gii c ca gan gim, cc cht c c th tc ng ti ty xng ( ri lon chc
nng to hng cu ). Thiu mu trong bnh thn cng do nhiu nguyn nhn phi
hp: mt protein qua nc tiu ( thiu nguyn liu ); chy mu ng tit niu
( mt mu ); gim Erythropoietin v c nhim c ty xng do cc cht c
khng c bi tit ra ngoi ( ri lon chc nng to hng cu ).
15.
C CH THCH NGHI KHI THIU MU

Khi thiu mu do gim s lng hng cu v huyt cu t c th lm vo tnh
trng thiu Oxy, s kch thch cc c ch thch ng ca c th b p li.
A- PHN NG TNG TO HNG CU
Phn ng tng to hng cu ca ty xng xut hin nhanh v nhy nht trong
tt c cc trng hp thiu mu thng thng. C ch bnh sinh l do tnh trng
thiu Oxy hoc cc sn phm hy hoi hng cu c tc dng kch thch ty xng
tng hot ng. Mt khc, thiu Oxy cn kch thch cc t bo gn cu thn sn
sinh ra cht kch hng cu t ( Erythropoietin ) c tc dng lm tng chc nng
to v trng thnh hng cu ca ty xng.
Phn ng trn nhm to mt cn bng mi duy tr s sng khi no ty xng
b tn thng, c ch mnh th phn ng ny mi khng thc hin c.
B- CC PHN NG P KHC
1. Tng tun hon: tim p nhanh v mnh, lng mu qua tim cng tng. Phn
x ny pht sinh do tnh trng thiu Oxy mu kch thch cc th cm huyt qun
v do mu t hng cu, gim nht nn lu lng mu qua tim cng tng
cng.
2. Tng h hp: th nhanh v su do phn p oxy mu gim CO
2
mu tng kch
thch phn x v trc tip h hp.
Thiu oxy cn nh hng n chuyn ha t chc gy nhim toan lm cho nhp
th cng nhanh.
3. Tng tn dng oxy: khi thiu mu, ch s s dng oxy t chc c tnh theo
cng thc:
= 0,3

( Ka l oxy trong mu ng mch, Kv l oxy trong mu tnh mch )
Nh vy, khi ch s ny tng, c th ti 0,85 kh thiu mu, nng oxy trong
mu tnh mch s gim, mu tnh mch thnh mu tm sm. Mt khc v bnh
thng ch s s dng oxy cc c quan quan trng nh no, tim, c rt cao (
0,6- 0,67 ) nn khi thiu mu cc t chc ny b e da trc tin v cc triu
chng thiu oxy cng xut hin rt sm : chng mt, hoa mt, chong vng khi
ng ln ngi xung, nh trng ngc, au vng trc tim, mt mi, au nhc c
v chut rt l nhng triu chng ph bin ngi thiu mu.
Ni chung, trong thu mu phn ng b p c hiu nht v hiu lc nht l
phn ng ty xng. Trong theo di v iu tr thiu mu phi c bit ch { n
phn ng ty xng, tn trng bo v v tng cng mt cch hp l. Nu phn
ng ny yu t tr thnh v hiu lc th thiu mu s din bn nghim trng gy
nhiu hu qu nguy him cho i sng.
16.
THAY I BNH L CA BCH CU

I. I CNG V CC DNG BCH CU

Bch cu c nhim v chung l bo v c th i vi cc nhn t bnh l khc
nhau, ch yu l nhn t nhim khun. Trong c th c nhiu loi bch cu ( bch
cu ht hay bch cu ty, bch cu lympho, bch cu mono), mi loi u c th
pht sinh nhng bin i bnh l{ tng sinh hoc nhc sinh t chc vi nhng
thay i v s lng v cht lng t bo.
A- DNG BCH CU HT HAY BCH CU TY
Sn sinh ty xng , cng vi dng hng cu v dng tiu cu qua cc giai
on:
Nguyn ty bo ( myloblast )
Tin ty bo ( promylocyt )
Ty bo N, E, B (mylocyt N, E, B )
Hu ty bo N, E, B ( metamylocyt N, E, B )
Bch cu a N, E, ( Stab N, E, )
Bch cu nhn tht khc ( a nhn ) N, E, )
T nguyn ty bo dn hu ty bo l cc t bo non ch trong ty xng. Giai
on ty bo, bo tng bt u xut hin cc ht c hiu N ( trung tnh ),
kim tnh ( B ) v toan tnh ( E ). Bch cu a l t bo gn trng thnh, xut
hin mu ngoi vi l ch tiu ca s tng sinh dng bch cu ty ( cng nh
hng cu li l ch tiu theo di s tng sinh dng hng cu )
1. Bch cu ty trung tnh (N)
Cc ht c hiu trong bo tng l ht trung tnh nh nh ht bi, l cc tiu
thc bo n cc di vt nh nh vi khun, v l t bo xut hin v pht huy tc
dng ngay trong giai on u tin ca bnh nhim khun. Bch cu N c h men
rt phong ph ( leucoproteaza, catalaza, peroxydaza, photphattaza kim) v cc
axit amin ( histidin, arginin, tryptophan) nn cn tham gia vo thnh phn dch
di vim, trng cho t chc b hy hoi v tham gia vo cc qu trnh lm lnh
cc tn thng t chc. Cc loi sinh t B rt cn cho to bch cu ty. Trong
gim bch cu N do thiu dng, iu tr bng sinh t B6 v axit foltc c tc dng
tt.
2. Bch cu toan tnh (E)
Cc ht trong bo tng to, trn, dy c, bt mu da cam, hay mu nu gch.
Bch cu toan tnh (a axit) E c chc phn gii c sn sinh trong qu trnh bnh
lmin dch (d ng)
3. Bch cu kim tnh (B)
Cc ht c hiu thng to nh khng u, nm che c nhn t bo, mu tm
sm. Chc phn ca loi bch cu ny cha c xc nh r rng. Theo mt s
tc gi, bch cu B c cha histamin v heparin. mu ngi bnh thng, hu
nh khng c bch cu B (0- 0,5%) v ch xut hin trong mt s bnh l nng
hoc bnh c tnh.
Dng bch cu ty ni chung i sng ngn, ch t 8-10 ngy cho nn c sn
xut trong ty xng nhiu hn dng hng cu 2-3 ln (t l BC\HC ty xng
bng 2-3)
B- DNG BCH CU LYMPHO

Cn gi l bch cu n nhn nh, c sn sinh t tuyn c khi cn bo thai v
khi ra i ch yu lch v cc hch bch huyt, qua cc giai on :
Nguyn lympho bo ( Lymphoblast )
Tin lympho bo ( Prolymphocyt )
Cc lympho ln v nh.
Bch cu lympho c mt vai tr quan trng trong cc phn ng min dch, c th
tr thnh cc lympho mn cm hay lympho cm th tiu dit cc khng
nguyn l ( min dch t bo ), hoc chuyn dng thnh cc t bo tr ( lympho-
plasmocytaire ) c kh nng sn sinh gamma- globulin v khng th ( min dch
dch th ).
Bch cu lympho c t men, thng thy xung quanh cc vim, nhim khun,
bao quanh cc tn thng cn st li. Trong nhim khun cp giai on u bch
cu trung tnh tng v khi bnh c nhng din bin tt mi thy tng bch cu
lympho. S lng bch cu lympho trong mu ngoi vi cao ngang vi t l % bch
cu trung tnh tr em t 1- 12 tui ( 43- 45% ), t trn 12 tui tng t nh
ngi trng thnh ( 20- 30% ). i sng ca bch cu lympho di hay ngn ty
theo loi, c loi i sng rt ngn ch vi ngy nhng c loi i sng di 100-
200 ngy, c bit lympho c tr nh min dch c th tn ti nhiu
nm.
C- BCH CU MONO ( M ) HAY N NHN TO

c sn sinh t h lin vng, chia thnh nhiu loi:
Bch cu mono mu sn sinh t t chc vng ni m ty xng. ch cu mono
c sn sinh t t chc lin vng hch v lch, thng tng trong cc bnh l v
hch- bnh tng mono nhim khun, loi ny kh nng thc bo yu.
Bch cu mono sn sinh l t chc lin vng khc nhau, xut hin trong cc bnh
l vim nhim khun, c kh nng thc bo mnh nht.
Chc nng ca bch cu mono l i thc bo, n cc vt ln nh cht m l,
cc t bo cht, cc mnh t chc b phn hy v c kh nng chuyn ng kiu
amip, ngoi ra cn c kh nng truyn thng tin min dch cho bch cu lympho
tip xc vi khng nguyn l. i sng ca bch cu mono l 8- 10 ngy.

II. NHNG THAY I V S LNG BCH CU

A. THAY I S LNG CHUNG BCH CU

S lng chung ca bch cu gii hn t 5.000-9.000/mm
3
. Trong trng hp
bnh l, bch cu c th thay i theo hai hng:
1. Bch cu tng khi s lng tng trn 9000/mm
3
, l phn ng tch cc ca c
th i vi nhn t gy bnh, ch yu l nhn t nhim khn. Bch cu tng cao
trn 25000/mm
3
thng thy xut hin cc bch cu non nn c gi l phn
ng dng bnh bch cu, gp trong cc trng hp nhim khun nng. Tng cao
hn na thng l bnh ca c quan to mu (bnh bch cu).
2, Bch cu gim khi s lng gim di 4000/mm
3
, l hin tng xu do bch
cu b hy nhiu hoc ty xng b c ch gim hoc khng sn xut c bch
cu, do sc khng vi bnh tt gim.
3. Nhng nhn t nh hng n s lng bch cu:
a)Cc thay i sinh l ca c th:
- Tr s sinh s lng BC 18000- 20000/mm
3
ko di hng tun.
- Lao ng, tiu ha, cm xccng gy tng bch cu ngoi vi do tc ng ch
yu trn khu vc d tr bch cu nm trong cc xong tnh mch ca ty xng.
b) Vim, nhim khun: l nguyn nhn hng u gy thay i s lng : cc vi
khun gram kch thch gy tng bch cu ht, cc khun gram (-) li thng gy
gim bch cu. Virut nh hng ti h vng ni m nn lm tng bch cu Mono.
c t vi khun thng hn thng gy gim bch cu ht.
c) Nhim c: nhiu cht c l, ha, sinh vt khc nhau, c tc dng vi s lng
bch cu: tia phng x liu nh kch thch, mt s cht nh: Asen, benzen,
pyramidon, sulfamid, chlorocitc th lm gim bch cu v c ch ty xng.
Bch cu c th hy di nh hng ca khng th khng bch cu c to
thnh khi truyn mu nhiu ln, hoc khi b d ng vi thuc, ha cht.
d) Thn kinh, ni tit:
- Chn thng s no hoc c tn thng vng di th thng c tng bch cu
r rt. Metanhicop cn c th gy c tng bch cu bng phng php phn x
c iu kin.
- Gn y ngi ta cn pht hin cht ha hc to bch cu leucopotein tng
trong mu ngi v ng vt b nhim khun, vim c tng phn hy bch cu.
Bn cht v { ngha ca cht ny cn ang c nghin cu.

B- THAY I S LNG TNG LOI BCH CU

Nhng bin i tng loi bch cu ( tng hoc gim s lng ) thng c { ngha
nht nh trong chun on, theo di v iu tr bnh. Thng theo di s lng
% tng loi bch cu, cng thc bch cu v chnh xc hn, phi quan st s
lng tuyt i hay s lng tng loi bch cu trong 1mm
3
mu.
1. Bch cu trung tnh N :
Tng trong tt c cc trng hp nhim khun cp, c vim m; c th gp 5- 10
ln so vi bnh thng. C th tng c trong chn thng s no, nhi mu tm
c, mt mu cp do tnh trng kch thch ty xng to bch cu ht nn t l S
tng nhng N ch mc bnh thng hoc gim do bch cu N b hy qu mc
hoc sn xut bch cu b ri lon.
Gim N c th gp khi dng mt s thuc ( sulfamit, atophan, pyramidon,
chloroxit ) C th gp trong mt s bnh c c ch trng thnh bch cu ht (
thng hn, si, cm ), trong suy dinh dng, trong cc phn ng t min dch
lm suy yu sc khng ca c th v d pht sinh cc qu trnh nhim khun
nng v vim hng, lot hoi t ( angina agranulocytica ). Gim bch cu t ngt
trong giai on din bin nng ca nhim c, nhim khun do ty xng b c
ch. Gim bch cu N v c bch cu Lympho trong bnh phng x cp.
2. Bch cu toan tnh E :
Tng E gp trong cc bnh nhim k{ sinh trng giun sn ng rut, t l thng
trn 10%. Trong bnh giun mc, u trng ecchinococcus gan, giun a giai on
pht trin u trng, bch cu E c th tng ti 30% v hn na. Bch cu E cn
tng trong cc trng hp d ng ( hen ph qun, st ma ) v cc phn ng d
ng nhim khun do E c kh nng hp th hittamin v cc cht tng ng gii
phng trong cc giai on din bin ca bnh. Tng E cn l c im ca bnh
bch cu ty mn.
Gim E thy trong cc giai on u ca nhim khun cp cng nh trong giai
on u ca bt kz mt strees no c th do E ti ti ch tn thng lm
nhim v gii c hoc do tang hot ni tit tuyn thng thn, tng tit corticoit
c tc dng c ch E ( nguyn l ca xt ngim Thorn thm d chc nng tuyn
thng thn ). Cho nn trong bnh l nhim khun, khi E tr li mc bnh
thng l du hiu tt.
3. Bch cu Lympho :
Tng tuyt i trong mt s bnh tr em : ho g, si, cm, st hch thng
hn, trong mt s bnh nhim khun mn nh hng ti h thng hch, lch ( st
rt, lao, giang mai ) trong bnh asedow trong cc trng hp nhim khun
cp, Lympho thng tng trong giai on mun do tng, kch hot h thng min
dch ca c th. ngi trng thnh, bch cu Lympho c th tng ti trn 35%.
Gim Lympho c th tng i trong giai on u ca nhim khun cp v gim
tuyt i khi c tn thng h thng to Lympho ( bnh Lympho ht c tnh,
Lympho sac- cm )
4. Bch cu Mono:
Tng bch cu Mono trn 8% gp trong mt s bnh nhim khun v virt cp (
thy u, si, rubole, vim hng, st ban do rickettsia) tng ko di trong cc
bnh vim mng trong tim, st rt, tng Mono nhim trng, bnh do Leishmania
l du hiu kch thch ng k h vng ni m. Tng Mono trong giai on cui
ca nhim khun lm nhim v thc bo v tham gia vo phn ng tng sinh
t chc lin kt lm lnh cc tn thng vim ( chuyn thnh t bo s non )
Gim bch cu Mono trong cc bnh nhim khun, nhim c nng v nhim
khun m lu di, nhim khun huyt l du hiu h vng ni m b c ch, sc
khng ca c th suy yu.

III. THAY I CHT LNG BCH CU

Cht lung bch cu thng b bin i trong cc trng hp nhim khun,
nhim c nng v trong cc bnh l c tnh.

A- CC DNG THOI HA CA BCH CU

Ht c xut hin trong bo tng ca t bo, l cc ht bt mu tm sm to
nh khng u do ng c cht m ca bo tng di nh hng ca c t
vi khun, cht c, tia x
Khng bo hay cc l trng bo tng l du hiu thoi ha m, khi c nh
tiu bn bng cn, cht m b ha tan nn nhum khng bt mu nn li l
hng. C th gp trong nhim khun nng, vim p- xe m, bnh phng x
Ngoi ra cn gp mt s du hiu khc: t bo to nh khng bnh thng, nhn b
ng c(pycnose), nhn tan, v hoc phng ln mt nhim sc

B- BIN I CH S NHN CA BCH CU

Ch s nhn l ch s tng quan gia bch cu tr v bch cu trng thnh
trong mu ngoi vi c th hin bng cng thc ca Schilling hay ch s nhn
ca bch cu:
CSN = Ty Bo Hu ty boStab = 0,03- 0,08
BCN
Trong bnh l, ch s nhn c th b bin i theo hai hng :
1. Chuyn tri CSN : l tng ch s nhn trn 0,08, l biu hin tng sinh cc t bo
bch cu tr, do ty xng b kch thch tng hot ng p ng nhu cu c
th. Tuz mc c th phn bit .
Chuyn tri va phi, khi ch s nhn tng 0,08- 0,25 do cc t bo tr c tng
sinh va phi, thng ch tng Stab, mc nhim khun khng nng lm v
chc nng ty xng hot ng tt.
Chuyn tri mnh, khi CSN 0,25- 0,5 do cc t bo tr tng nhiu, mu ngoi vi
xut hin nhiu Stab, c th gp c hu ty bo, i khi c ty bo, thng l
bnh nhim khun nng, chc nng ty xng b ri lon, kh nng bit ha t
bo gim st, sc khng c th cng gim ( phn ng dng bnh bch cu )
Chuyn tri qu mnh, CSN trn 0,5- 1 hoc hn na, thng l bnh ca c
quan to mu, kh nng bt ha ca ty xng b ri lon.
2. Chuyn phi CSN :
Khi CSN gim ti di 0,02, rt t hoc khng c bch cu tr Stab l biu hin ty
xng b c ch, thng km theo gim s lng bch cu v ni chung tin
lng xu. Cn c th xc nh chuyn phi bng tnh cng thc Arneth : m
ring 100 bch cu trung tnh tnh t l % cc bch cu phn nhnh, bnh thng
cc t bo mt nhnh ( Stab ) chim 2-5%, hai nhnh 35%, ba nhnh 41%, bn
nhnh 17%, nm nhnh 2%.
Chuyn phi biu hin gim t l cc t bo t nhnh v tng cc t bo nhiu
nhnh, c th xut hin cc t bo tng phn nhnh ti trn 10 nhnh, nh trong
mt s bnh nhim c nng, bnh phng x.
Ni chung, theo di ch s nhn bch cu c s dng trong lm sng, ch yu
trong lm sng ngoi khoa v trong nghin cu khoa hc nh gi tnh trng
chc nng to bch cu ca ty xng.

IV. BNH BCH CU ( LEUCOSE )

Bnh bch cu l mt bnh c tnh ca c quan to mu, l mt bnh rt him
ngho, t l t vong rt cao v t l mc bnh ngy cng nhiu. Theo thng k ca
OMS, nm 1960 t l mc bnh bch cu l 5,8 trn 10 vn dn trn ton th gii,
chim 10% ca tng s t vong do cc bnh c tnh, cao nht tui di 30.
Vit Nam cha c thng k chnh xc nhng nhng nm gn y do nh hng
ca chin tranh ( v kh hin i, thuc c loi tr su dit c ca ch ) t l mc
bnh bch cu cng cao hn so vi nhng nm trc y.

A- QUY LUT DIN BIN V C IM CA BNH BC

Trong bnh bch cu cc t bo nu khng pht trin theo quy lut bnh thng
m c nhng c im ring sau:
1. Tng sn qu mc hay qu sn :
Tng sn qu mc mt dng t bo, t chc to bch cu c biu hin ph i,
tng sinh lan trn ( tng sinh qu mc dng bch cu ht th ty v ty vng
u trn ngp cc t bo ) ng thi c hin tng c ch bit ha nn mu
ngoi vi xut hin rt nhiu bch cu non ( bnh thng ch trong ty xng ).
Bp nght, c ch cc dng t bo khc: khi cc t bo bch cu ht tng sinh th
to hng cu b c ch, tng huyt tn nn gy thiu mu nng, dng tiu cu
cng b c ch gy gim tiu cu v hi chng chy mu ( chy mu rng, li, di
da, nim mc mi, mt, vng mc, ni tng... ) Bnh cng c tnh cc biu hin
trn cng r rt.
2. D sn, sn xut khng theo quy lut bnh thng m lan trn sang cc t chc
ln cn, hoc sang cc t chc to mu khc m bnh thng khng sn xut ra
dng t bo . Nh trong bnh bch cu ty hay t chc hch, lch cng sn
xut cc bch cu ht, xm nhp chn p ct mc gy au xng, au khp; xm
nhp chn p t chc thn kinh gy lit, hi chng chn p ty sng Trong bnh
bch cu Lympho ty xng trn ngp t bo lympho , t chc lympho cn xm
nhp t chc da, nm trong trung b vng mt, mi, m, gy bin dng din mo,
xm nhp nhu m phi, thnh d dy, rut gy cc u cc ri rc, gy xut huyt
lot v hoi t
Lon sn, tc l sn xut nhng t bo bnh l{ khng in hnh c v hnh thi v
chc nng. Chc nng thc bo, min dch ca cc t bo gim lm gim sc
khng chng ca c th. Cc t bo thng c du hiu thoi ha, hnh
dng bt thng, c khng bo, pht trin khng ng u gia nhn v nguyn
sinh cht. Cc nguyn ty bo khng in hnh c gi l cn nguyn ty bo (
paramyloblast ) hoc nguyn ty bo nh ( micromyloblast ), c trng hp
kh xc nh l nguyn bo ca dng no nn gi chung l cc nguyn bch cu (
Leucoblast ).

B- NGUYN TC PHN LOI BNH BCH CU ( C TH PHN BIT )

Theo t chc, t bo b bnh : bnh ca t bo dng ty gi l bnh bch cu ty
( mylo- leucose ); bnh ca t chc t bo lympho bnh bch cu lympho (
lympho- leucose )
Theo s lng bch cu ngoi vi: chia cc th tng bch cu trn 50000/ mm
3
(
bnh bch cu a sinh ), khng tng bch cu c gi l th n, ch pht hin
c khi c nhng kch thch bt thng gy tng s lng v xut hin cc bch
cu non mu ngoi vi; th gim bch cu di 4000/ mm
3
thng l th cp
tnh, nghim trng.
Theo hnh thi din bin ca bnh: th cp tnh thng din bin trm trng,
cht nhanh trong vng vi thng, c khi vi tun v trong mu xut hin nhiu
nguyn bo do kh nng bit ha b c ch khng chuyn thnh cc t bo trung
gian nn bng mu c khong trng bch cu . Th mn tnh th din bin c
th ko di hn hng nm v trong mu xut hin nhu loi t bo t nguyn
bo, cc t bo trung gian ti cc t bo trng thnh, s lng bch cu thng
tng rt cao song song vi din bin nghim trng ca bnh.

C- BNH SINH CA BNH BCH CU

C nhiu thuyt c xut nhng cng nh bnh sinh ca ung th, cho n
nay vn cha hon ton sng t.
1. Thuyt virt gy bnh bch cu :
Thuyt ny da trn s pht hin cc virt gy bnh bch cu g, chim, chut v
mt s ng vt c sng ( tru, b... ) c th truyn bnh bng cch tim cho
ng vt lnh cht lc t chc khng c t bo ca ng vt b bnh. Cc virt ny
thng l cc virt c ARN, c th khng gy bnh ngay m truyn qua trng hay
tinh trng n i sau mi pht bnh, hoc virt xm nhp vo trong t bo,
chuyn thnh t bo ung th ng, cho n khi c mt kch thch bn ngoi ph
hp, bnh mi xut hin. Nhng ngi vic phn lp virt gy bnh cha thc
hin c, dng cht lc khng t bo ca bnh nhn khng gy c bnh bch
cu thc nghim cng nh bnh khng thy xut hin tr b sa m b bnh
bch cu.
2. Thuyt tia x:
Rt nhiu nhn xt lm sng v thc nghim xc nhn bnh bch cu c th do tia
X, tia x ion ha gy ra:
Nhng ngi cng tc vi quang tuyn X, t l mc bnh bch cu cao hn so vi
ngi bnh thng. Nghin cu trn 278 bnh nhn bch cu c ti 14 ngi
trc chiu tia roentgen liu cao, v c vi tr khi cn trong bo thai.
Cc nn nhn Nht- bn ( Hiroshima, Nagasaki ), t l mc bnh bch cu rt cao
vng bn knh 1500m xung quanh trung tm n bom nguyn t ( nm 1945 ).
3. Thuyt cht c ha hc:
Ngi ta thy Benzen v mt s cht c ha hc khc xm nhp vo c th c
kh nng c ch bit ha v pht trin tng sinh c tnh cc t bo mu gy bnh
bch cu ngi v ng vt. Cng c th cc cht ny cng nh tia x ch to
iu kin kch thch cc virt dng n gy bnh v pht trin.
4. Thuyt ni sinh chuyn ha :
Thuyt ny da vo cc c s :
T bo mu c tnh c h thng men v chuyn ha khc hn vi t bo mu bnh
thng, khng c kh nng tng hp men asparaginaza cho nn d chuyn thnh
t bo tng sinh c tnh ( iu tr bng men )
Ngay giai on sm ca bnh thy c ri lon chuyn ha tryptophan.
Nhng ngi b bnh di truyn ( hi chng Down, Turner ) c ri lon tng hp,
hp th sinh t B, cn thit cho s chuyn ha trytophan cng d mc bnh ny.
Ni chung, cc nguyn nhn trn c th lm thay i cu trc ARN, AND, gy bin
d zen v cromozm, lm cho cc t bo mu pht trin c tnh v gy bnh
bch cu ( cromozm 21 b gy on 21p v c nhiu t bo tha cromozm ) .

17.
THAY I BNH L CA TIU CU


CN BNG NG MU

I. I CNG V DNG TIU CU.

Tiu cu c sn sinh trong ty xng, t t bo m l nguyn mu tiu cu
(Megacaryoblast), qua t bo trung gian. Mu tiu cu (Megacaryocyt), ri cho
cc tiu cu. Tiu cu l nhng t bo nh nht mu ngoi vi, hnh trn hoc hi
bu dc, phn ngoi mu hng, hp ( hyalomre ) phn gia c nhiu ht (
granulomre ) ng knh 1,5- 2 micromet, t bo non hn mu xanh v t ht,
ng knh 3- 5 micromet. S lng trung bnh trong 1 mm
3
ngi bnh thng
c t 200.000- 400.000/ mm
3
, sng c t 5- 7 ngy nhng i sng chc phn
ch 2- 4 ngy.
Tiu cu c nhim v bo v c th chng nhim khun, do c tnh d bm vo
cc vt l khng bng phng, tiu cu c kh nng bm vo cc vi khun gy
ngng kt hoc a n h vng ni m tiu dit hoc c th hp thu cc
khng th nn trong giai on u cc bnh nhim khun, Megacaryocyt sinh tiu
cu trong ty xng tng v khi nhim khun nng thng gy gim tiu cu dn
n nhng bin chng chy mu nguy him. Nhng chc nng chnh ca tiu cu
l tham gia vo qu trnh ng mu do nhng yu t TC gn b mt t bo (
exo- enzyme ) hoc xut hin ngay t trong lng cc tiu cu ( endo- enzyme ).
Cc tc gi a ra 9 yu t TC nhng ni chung quan nim v cc yu t TC cng
c nhiu kin tri ngc nhau, mt s tc gi cho rng mt s yu t ch l
nhng cht c hp th t huyt tng bm vo b mt tiu cu ch khng
phi l nhng yu t thc s ca tiu cu. a s tc gi ( Croizat, Levol, Lejeune)
cng nhn tiu cu c nhng hot tnh tham gia vo qu trnh ng mu:
Tnh bm ( adhsivit ) bm vo b mt m nc c th lm t v c th bm
vo ni mc tn thng, do cht thrombocytozyme .
Tnh kt dnh lm vn tiu cu li vi nhau, t thnh ( metamorphose viskqueuse
). Thrombin to iu kin thun li v heparin, dicoumarin lm tr ngi cho dnh
vn tiu cu.
Tc dng co mch, co cc ng tnh mch v gin cc mao mch do hot cht ca
tiu cu l serotonin .
Tc dng to thromboplastin do cht photpholipit thc nhm cephalin, cn gi
l thrombokinaza tiu cu.
Tc dng co cc mu ng do tc dng c gii hoc men retractozym.
Trong mu d tr c vi iu kin c bo v bng silicon nhng tiu cu tn
ti cng mt mt s chc phn ca n ( gim kh nng kt dnh, gim ATP,
gim thrombokinaza tiu cu ) cho nn khi cn tip t tiu cu cn phi truyn
mu ti, hoc truyn mu trc tip t ngi cho sang ngi nhn.

II. QU TRNH NG MU V VAI TR CA TIU CU

C ch ng mu ngy cng phc tp v s yu t tm thy tham gia vo qu
trnh ny ngy cng nhiu ( trn 30 nguyn t ).

A- GIAI ON CM MU HAY GIAI ON THNH MCH

Khi thnh mch b tn thng, ngay tc khc c phn ng thn kinh vn mch ti
ch gy co mch hn ch chy mu, ng thi cc tiu cu bm vo thnh ni
mc tn thng to thnh cc mu trng bt li hoc tiu cu dnh vn tit ra
mt s yu t TC khi ng cho qu trnh ng mu.

GIAI ON HUYT TNG HAY QU TRNH NG MU CHNH THC

Giai on ny phc tp nht, tin hnh trong huyt qun vi s tham gia ca rt
nhiu yu t v qua 3 bc: ( hnh 4 )
1. To thromboplastin hot tnh :
To thrompeplastin t chc t m v photpholipit ca t chc b tn thng,
c kch hot bi cc yu t IV ( Ca
++
), VI ( axlerin), VII ( convectin ), X ( Stuart
prower ). To rt nhanh, ch vi giy- 30 giy. To thromboplastin mu t cephalin
tiu cu ( thrombokinaza, yu t TC
3
) v cc yu t chng chy mu VIII (
antihemophilic factor A), IV ( antihemophilic factor B ),XI (antihemophilic factor C)
XII ( yu t Hageman ). C tc gi gii thch tc dng ca thromboplastin t chc
s to mt lng nh thrombin ch gy dnh vn tiu cu v chuyn yu t
V ( proaxlerin ) thnh VI ( axlerin ). Qu trnh dnh vn tiu cu s gii phng
yu t TC
3
c tc dng lm bin i thromboplastinogen ( yu t VIII ) thnh
thromboplastin hat ng ( yu t III ). Cc yu t IX, XI, XII lm tng tc to
thnh v yu t IV, VI, VII, X c tc dng xc tc to thromboplastin. Giai on
to thromboplastin mu ko di 5- 8 pht.
2. To thrombin ( yu t 11 ):
Thromboplastin sau khi hnh thnh s tc ng ln Prothrombin chuyn thnh
Thrombin, cn c s xc tc ca cc yu t IV, VI, VII, X v yu t TC
1
. C tc gi
cho rng yu t TC
1
chnh l proaselrin ca huyt tng m cc tiu cu hp thu
vo b mt ca chng. V vai tr ca yu t IV ( Ca
++
) cng c { kin khc nhau :
c tc gi cho rng Ca
++
ch cn thit lc u trong phn ng to thromboplastin
v c th tc dng theo phn ng dy truyn trn b mt tip xc, mt s tc gi
khc li cho rng Ca
++
c l cn thit c trong cc phn ng to thrombin v to
fibrin, v cn c tc dng khng thng xuyn v khng ct ngha c vi thnh
mch, gim Ca
++
c th dn ti tng tnh thm mao mch v lm mao mch d v.
Phn ng to thrombin b c ch bi cc cht khng thrombin c 6 cht khng
thrombin m cht khng thrombin II c to thnh bi heparin. Tc dng
heparin li b c ch bi yu t TC
4
.
3. To Fibrin ( cc mu ):
Sau khi thrombin c to thnh, ngay lp tc ( 2- 5 giy ) c tc dng chuyn
fibrinogen ( yu t I ) thnh fibrin to thnh cu trc cc mu ng. Phn ng ny
c thc y bi yu t XIII ( FSF, fibrinstabilizingfactor, yu t lm bn vng
fibrin v c th c yu t TC
2
. Nh vy bt u to fibrin ha tan ( monomere, tan
trong ure) sau tin hnh trng hp v to ra fibrin khng ha tan ( polymere
bn vng ). n y l kt thc qu trnh ng mu.

C- GIAI ON TIU FIBRIN ( FIBRINOLYSE )

Khi cc mu ng hnh thnh, huyt thanh trc ht b giam hm trong nhng
li fibrin , sau cc mu ng co li v gii phng huyt thanh. Quan st
knh him vi in t thy nhng m tiu cu ko nhng si fibrin, do trc
kia Fuchs v Ponio cho l tiu cu tc dng mt cch c hc, nhng ti nay nhiu
tc gi thng nht do tc dng ha hc thng qua mt yu t TC
8
hay men co cc
mu retractozyme. Hin tng nytin hnh trong 30 pht n 3 gi.
Nu cc mu c bo qun 37
0
C trong iu kin v khun, ta thy cc mu b
dn i ri bin mt, l hin tng tiu cc mu ( fibrinolyse ), phn hy men
fibrin thnh cc polypeptit, do tc dng ca men tiu fibrin ( fibrinolysin hay
plasmin. Plasmin bnh thng c sn trong huyt tng, l mt protein thuc loi
btaglobulin, phn t lng 140.000, dng khng hot ng. Plasminogen di
tc dng ca cc men tiu m kinaza, mi chuyn thnh plasmin.
nh thng hin tng ny khng xy ra qu mc do tc dng c bng ca cc
yu t km hm la cc khng plmin huyt thanh va c yu t TC
7


III. KHI NIM V CN BNG NG MU

Trong cc iu kin sinh l bnh thng, h ng mu v h khng ng trong
trng thi cn bng ng c iu ho bi cc c ch thn kinh v dch th.
ng mu v chy mu (khng ng )l 2 mt ca mt phn ng phng ngsinh
vt bo v c th khi b chy mu lan trn, to iu kin lm lnh vt thng do
ngn chn xm nhp ca cc yu t gy bnh. ngc li khng ng lm cho
mu lun trng thi lng, ho tan c cc cc mu c to thnh ngn nh
s ng mu t pht gy tc mch, huyt khi Hai qu trnh ny khng th
thiu c trong s sng, lun b sung v cn bng vi nhau, cho nn khng th
ni n qu trnh ng mu m khng ni n h khng ng trong c th ton
vn, mt tnh trng mu thun nhng thng nht gia 2 h thng cc cht gy
ng mu v cc cht khng ng u c sn trong c th sinh vt:
-Trong mu c sn nhng cht gy ng mu t yeeus t I n XIII huy
tng, cc yu t TC.. S lnh ln ca thnh mch mu thun vi tnh cht d
bm, d dnh vn ca tiu cu cng l mt yu t chng ng trong mu cng c
sn cc cht khng ng nh khng sinh thrombin, heparin, plasmin,Flasmin
ngoi tc dng tiu fibrin cn tiu mt s cht m khc, v cc yu t ng mu
tha. Nhng ngay i vi cc tnh cht ny cng c cht khng li khi c qu
nhiu mc: yu t TC
6
hm tc dng qu mc ca heprin, cc khn plasmin va
yu t TC
7
c ch tc dng qu mc ca plasmin.
C ch iu ho cn bng ong mu cn ang oc tip tc nghin cu
nhng nhiu s kin cho php ngh n vai tr ca h thn kinh: kch thch thn
kinh giao cm lm mu d ng, ngc li kch thch ph giao cm li c ch qu
trnh ng mu d ng mu. Khi tha cht ng mu (tha thrombin ) s tc
dng ln c quan cm th huyt qun gy ra tng cc cht khn ng (heparin,
plasmin)theo c ch phn x. Ct t ng phn x , cht khng ng
khng xut hin. Do trong iu nguyn tc c bn l phi n nh cn bng
ng mu: khi b chy mu, ngi ta thng dng nhng cht thc y qu trnh
ng mu (Ca
++
, sinh t K). Nhng phu thut ln lng ngc-tim, ct b i
trng , kh, bin chng khi sinh mu gim ng gy chy mu nghim
trongj do s phng thch nhiu men kinaza co tc dng chuyn plasmino thnh
plasmin, nn khi iu tr phi dung cht c ch hot ha plasmin (EC,
hemcapron). Ngc li trong iu tr huyt khi, tng ng th phi dng
heparin hoc cc men tiu m (strptokinaza) tng hot ho plasmin.

IV.RI LON CN BNG NG MU

Trong cc diu kin bnh l khc nhau, cn bng iing mu b ri lon theo 2
hn ch yu :
Tng ng c th dn ti huyt khi tc mch
gim ng hay cc hi chng chy mu
1.sinh l bnh cc hin tng gim ng:
Ni chun, hi chng chy mu pht sinh theo 3 c ch ch yu thiu mt hoc vi
yu t ng mu huyt tng , bnh l tiu cu tha cht khng ng hoc kch
hot h tiu fibrin.
a)Cc bnh do thiu mt vi yu t iing mu:
- Bnh hemophili:hay gp nht la hemophili A la bnh di truyn do xut hin khi
gum nng yu t VIII trn 30% so vi mc bnh thng sau nhng chn
thng khng ng k, phu thut nh (nh rng, ct ami-dan.). Cc trng
hp ng hp t bnh l{ thng gy chy mu bt thng, t nhin v d cht
do thiu mu nghim trng. Mt s bnh hemophili hm gp hn:hemophili do
thiu yu t , hemophili C thiu yu t XI, bnh hageman
- bh gim prothrembin mu do suy gan, khng hp thu dc sinh t K bm sinh ,
i lng ko di, bnh bch cu
- thiu yu t V,VII do bnh gan , vng da tc m, lon sinh vi khun rut, dng
qu mc dicoumol c ch tng hp cc yu t ny t sinh t K
- thiu hoc khng co fibrinogen bm sinh hoc tn hp khng y gan (th
pht).
2.Bnh l tiu cu:
- gim tiu cu triu chng hay th pht (s lng TC di 100000/
mm3
c th gp
trong cc bnh co lch to ( st rt , nhim k sinh trng lihmania ), bnh bch
cu, suy tu, thiu mu khng hi phc...
- gim tiu cu nhuyn pht, bnh Vnh, din bin ko di v nhuyn nhn
bnh sinh cn c im ch sng t, tiu cu co th gim ti 3000mm
3
.
- gim tiu cu min dch do c khng th khng tiu cu, pht hin bng cc bin
php ngng kt khi co mt b th, Boyden hoc ngng kt hng cu th ng(cc
hng cu gn thnh cht tiu cu s ngng kt khi tip sc vi huyt thanh c
khng th khng tiu cu ). C th gp khi truyn mu nhiu ln, bnh ban xut
hin tr s sinh(m b bnh, co khng th t sinh) Trong cc bnh ny c th
gim ti s lng tiu cu v ch yu gim cht lng tiu cu(nhiu tiu cu
non, mt cu trc,kt li tng chui)
gim tiu cu gy d mt mu v nim mc di da. Hi chng chy mu thng
biu hin tng tnh thm mao mch v gim chng lc mch mu do thiu yu
t TC
3
mu chm ng, lm chm hin tng co cc mu so thiu rtactozym tiu
cu. Thi gian chy mu(theo phng php Duke)ko di ti 10 pht v hn th
na.
3. Tha cht khng ng hoc kch hot h tiu ho fibrin:
- tha heparin do iu tr qu liu, hoc tng heparin t do trong bnh phng x,
sc qu mn
- can thip phu thut hoc tn thng rng cc t chc(phi , c t cung , tuyn
tin lit,)gy tng gii phng cc men fibrinnokinaz dn ti tng hot ho
plasmin v chy mu khng cm c.
cn phn bit cc hi chng do chy mu do nguyn nhn mao mch nh hi
chng chy mu di truyn (bnh Von Willebrantd)bnh xut huyt mao mch d
ng (bnh Schoenlein Henoch)do c khng th chng ni mc mch mu, hoc
bnh mc phi do thiu sinh t C. Nhng bnh ny ch chy mu ko di, d chy
mu cn cc xt nghim ng mu co th t thay i.
Bng tng hp nguyn nhn v bnh sinh ca hin tng gim ng
Yu t gy bnh C ch bnh sinh
Hemophil A
gim s lng tiu cu (bnh
Verihof, phng x, bch cu , do
min dch )
tn thng lan rng nh m
gan(vim gan , ng c phtpho)
Thiu v khng tng hp c St, K(
vng da tc mt , ri lon tiu ho)
Qu liu heparin
Qu liu dicoumarin
Sc qua mn v pepton
Tn thng rng t chc, bnh k
khi sinh , phu thut phi
thiu yu t VIII
Thiu cc yu t tiu cu (TC,
retractozym)
Thiu thrombin,prcnveccin. Fibrinogen
Gim prothrombin, thrombin,
thromboplastin mu
c ch tng hp prthmbin.VII tng
heprin, antithrombin
Tng gii phng fibrinokinaza t chc, tan
fibrin mnh, fim nng fibrinogen

B-SINH L BNH CC HIN TNG TNG NG MU

Tng dng pht sinh do 3 c ch ch yu : tng trong mu nng cc yu t
thromboplin, thrombin.. gim hot tnh cc cht chng ng t nhin (hepin.
antithrombin), c ch h tiu tiu fibrin.
1.tng ong do tng cc yu t ng mu :
- tng ng tm thi thong qua nhng ngi trong trng thi hng phn hoc
au n, khip s. Trong c th khi khng c nguy to thnh cc mu v tng
ng c b p bng kch hot h tiu fibrin,s cn bng ny ch b ri lon
trong cc trng hp bnh l
-Tng ng do tng hot tnh thrmppltin dn ti bin 1 s lng ln
prothrombin gy ng mu trong lng cc huyt qun. C th gp trong cc
trng hp bnh l c tn thng t chc rng (bng, cc phu thut ln, chn
thng), ng mu c th tin hnh trong lng mch v b mt ni mc b tn
thng to iu kin gy kt vn cc yu t hu hnh mu trong long mch lm
tr ngi cho vi tun hon v dinh dng t chc. C th phi hp vi tiu th qu
mc cc yu t ng mu v tn thng ni mc gy ra chy mu ri rc trong
lng mch.
2.tng ng do thiu , gim hot tnh cc cht ng t nhin va c ch qu trnh
tiu fibrin:
L c ch khng km phn quan trng. Trong ng mu trong lng mch khng
phi l lzc no cng dn ti to thnh cc mu , tuy nhin kt qu cui cng ca
ng mu trong lng mch thng l tng to fibrin bn vng v c ch qu
trnh tiu fibrin,to iu kin hnh thnh trng thi tin cuc mu .Nguy c ny
gp cc bnh nhn x va ng mch , huyt p cao, vim khp , vim tc ng
mch.
Trong x va ng mch v bnh huyt p cao thy co c ch mnh qu trnh
tiu fibrin lm tr ngi s ho tan cc mu v ang hnh thnh dn n to
nhiu cc mu gy tc nghn mch. c m ton phn cholesterol v bta-
lipoprorein mu tng cao nn phi s dng mt s lng ln heparin t do dn
n tng ng v c ch h tiu fibrin , c ch ny cng c gii thch trong tng
ng do n nhiu m.
Hin tng c ch h tiu fibrin cn c th thy cc cng nhn cc xng my
nng , x nghip thuc l , nhng ngi ln vic tr c nhiu v khi ng c
ru.
Bng tng hp nguyn nhn v bnh sinh cc hin tng tng ng.
Yu t gy bnh C ch bnh sinh
Tn thng thnh mch mu
Vim lan rng, vt thng hu phu
, bng , chy mu
Ri lon chuyn ho m ,x va
ng mch, bo ph
Dng tha sinh t K
Ng c ru, thuc l
Kch hot yu t XII ng mu
To tha thromboplastin gim
heparin t do,tng thromboplastin,
c ch h tiu fibrin
Tng to prothrombin, thrombin
c ch h tiu fibrin

CHNG 2. TRIU CHNG HC



18. HI CHNG THIU MU

1. i cng.
1.1. nh ngha:
Thiu mu l hin tng gim lng huyt sc t (HST) v s lng hng cu (HC)
trong mu ngoi vi dn n thiu oxy cung cp cho cc m t bo trong c th,
trong gim huyt sc t c { ngha quan trng nht.
T chc Y t Th gii nh ngha: thiu mu xy ra khi mc huyt sc t lu
hnh ca mt ngi no thp hn mc ca mt ngi kho mnh cng
gii, cng tui, cng mt mi trng sng. Bi vy, thc cht thiu mu l s
thiu ht lng huyt sc t trong mu lu hnh. S lng hng cu v
hematocrit l mt ch s phn nh khng trung thnh ca thiu mu v nng
huyt sc t trung bnh ca mi hng cu, th tch trung bnh ca hng cu d
thay i theo tnh cht thiu mu v do nhng tc ng ca nhng yu t khc, v
d: tnh trng c c mu (trong mt nc do a lng, nn, bng), hoc mu b
ho long...
Thiu mu l mt hi chng hay gp trong nhiu bnh, nht l cc bnh v mu.
Chn on hi chng thiu mu, phn loi v tm nguyn nhn phi da vo cc
triu chng lm sng v xt nghim, nhng ch yu v quyt nh phi da vo
cc xt nghim.
1.2. Mt s c im v sinh l hng cu v huyt sc t:
Hng cu l nhng t bo khng nhn, xem ti nh nhng chic a lm hai
mt, mu vng r. Trn phin knh nhum giemsa thy hng cu hnh trn, mu
hng, gia nht hn.
Kch thc: ng knh 7-7,5 micromet , dy 2,3 micromet.
Th tch 90-100 m
3
.
i sng trung bnh: 100-120 ngy.
Ni sinh sn: ty xng.
Ni phn hy: hng cu gi b phn hy ch yu ti lch, ty xng, gan. Hng
ngy c khong 0,85-1% tng s hng cu (HC gi) b phn hy (huyt tn sinh l)
v mt t l tng t hng cu tr c sinh ra thay th.
Nhim v c bn ca hng cu l vn chuyn oxy ti cc t chc thng qua vai tr
ca huyt sc t cha trong hng cu.
Huyt sc t c cu to bi heme c cha st v 4 chui globine ging nhau
tng i mt (2 chui alpha v 2 chui beta). Tnh cht ho hc ch yu ca n l
c kh nng kt hp hai chiu vi phn t oxy, v th n ng vai tr vn chuyn
oxy ti t chc.
2. Triu chng lm sng.
2.1. Triu chng c nng:
+ tai, hoa mt, chng mt thng xuyn hay khi thay i t th hoc khi gng
sc. C th ngt lm nht l khi thiu mu nhiu.
+ Nhc u, gim tr nh, mt ng hoc ng g, thay i tnh tnh (hay cu gt), t
tay chn, gim st sc lao ng tr c v chn tay.
+ Hi hp nh trng ngc, kh th, c th au vng trc tim do thiu mu c
tim.
+ Chn n, y bng, au bng, a lng hoc to bn.
2.2. Triu chng thc th:
+ Da xanh xao, nim mc nht nht; c th km theo vng da, nim mc nu
thiu mu huyt tn; c th km theo xm da, nim mc, nu thiu mu do ri
lon chuyn ho st. Ch khm da v tr da mng, trng nh mt, lng bn
tay...khm nim mc mt, mi, li, vm ming....mu sc ca nim mc phn
nh trung thnh hn mu sc ca da.
+ Li : mu nht, c th nht vng trong huyt tn, b bn trong thiu mu do
nhim khun, li l v dy ln trong thiu mu Biermer.
Gai li mn hay mt lm li nhn bng, c th c vt n rng, (thng gp
trong thiu mu mn v nhc sc). Ngoi ra cn ch cc nt chy mu li
trong cc bnh xut huyt, vt nt, rp lot, rch hm li trong cc trng hp
thiu vitamin (B
2
, PP...).
+ Tc rng, mng tay gin d gy, chn mng bt hoc lm, mu c, c kha, b,
d gy, c bit hay gp trong thiu mu thiu st mn tnh.
+ Mch nhanh, tim c ting thi tm thu thiu mu, thng nghe r gia tim,
c th nghe thy mm tim, l ting thi c nng do mu long gy ra. Thiu
mu lu c th dn n suy tim.
3. Triu chng xt nghim.
3.1. Xt nghim mu:
+ S lng HC: ngi Vit Nam bnh thng c s lng hng cu trong khong
3,8 - 4,5 T/l. N thp hn nam.
Nu HC di 3,8 T/l l thiu mu.
Nu HC trn 5,5 T/l l a hoc.
+ Hnh thi hng cu: thng ngi ta quan st hnh thi HC trn phin knh
nhum giemsa, ti nhng v tr HC tri u khng chng cht ln nhau. Bnh
thng HC hnh trn mu hng, gia hi nht hn.
Trong bnh l thiu mu c th thy :
- Hng cu nht mu, hnh nhn, HC bng ma trong thiu mu nhc sc nng.
- Hng cu a hnh th: hnh qu l, hnh bu dc, qu chy, rng ca... trong
thiu mu nng.
- Hng cu hnh bia bn, hnh li lim, hnh bi... trong thiu mu huyt tn bm
sinh di truyn.
- C nhng th bt thng trong hng cu : nh th Jolly, vng Cabott l nhng di
st ca nhn do qu trnh chuyn ho qu vi vng ca HC non trong ty xng,
gp trong thiu mu huyt tn hoc th Heinz, ht kim... gp trong thiu mu do
nhim c mt s ho cht (nhim c TNT, ch v c...).
- C th thy nguyn hng cu trong mu ngoi vi, gp trong thiu mu huyt tn,
thiu mu sau chy mu cp, bnh lch sinh ty...
+ Kch thc HC: hng cu bnh thng c ng knh khong 7micromet . Trong
thiu mu c th thy :
. Hng cu b (microcyte) d = 5 - 6 micromet, gp trong thiu mu thiu st
. Hng cu to (macrocyte) d = 9 - 12 micromet, gp trong thiu mu do thiu acid
folic, vitamin B
12
.
- Hng cu khng l (megalocyte): d > 12 micromet , gp trong bnh Biermer.
Nu ng knh HC < 5 micromet th thng l cc mnh HC v.
- nh lng huyt sc t: ngi Vit Nam trng thnh c lng huyt sc t
bnh thng t 140g/l - 160g/l, tr s sinh c nhiu hn (195g/l), tr em t c
hn (1 tui: 112g/l ; 10 tui: 120g/l). Nu tnh theo nng phn t th bnh
thng HST = 8,1 - 9,3mcmol/l .
Thiu mu l khi HST nam < 130g/l; n < 120g/l; ph n c mang < 110g/l.
y l ch s quan trng nht nh gi thiu mu.
+ Hematocrit: l th tch khi HC chim ch so vi lng mu bit, biu th
bng l/l hoc bng t l % gia khi HC v mu ton phn.
Bnh thng nam : 0,45 - 0,50 l/l hoc 45 - 50%.
n : 0,40 - 0,45 l/l hoc 40 - 45%.
Trong thiu mu hematocrit thng gim.
+ HC li: l hng cu tr va trng thnh t nguyn hng cu i toan trong qu
trnh sinh HC, l dng chuyn tip gia HC non trong ty xng v HC trng
thnh ngoi vi; thi gian tn ti dng chuyn tip (i sng HC li) khong
24 - 48 gi.
Hng cu li c nhn ra bng phng php nhum ti new methylen blu
hoc xanh sng crezyl: hng cu li l nhng HC c cha cc ht mu xanh sm
nm thnh hnh dy li. m s lng HC li cho php nh gi trng thi v
kh nng sinh HC ca ty xng.
Bnh thng hng cu li = 0,5 - 1% hoc 0,025 - 0,050 T/l.
HC li gim trong suy ty..., tng trong huyt tn, trong giai on phc hi ca
thiu mu...
+ Tnh ton cc ch s HC:
Tnh ton cc ch s hng cu rt quan trng, v t ngi ta c th xc nh
c tnh cht thiu mu (nhc sc, ng sc, u sc), qua s gip tm hiu
nguyn nhn thiu mu mt cch d dng hn.
- Th tch trung bnh HC (MCV: mean corpuscular volume):
n v tnh l femtolit hoc micromet khi (1 femtolit = 10
-15
lt).
Hematocrit(l/l)
Cng thc tnh : MCV = 10
3

HC(Tera /l)
Bnh thng MCV= 90 5 femtolit.
Th tch trung bnh HC trn 100 femtolit l thiu mu hng cu to, gp trong thiu
mu do thiu B
12
, acid folic, thiu mu trong ung th.
Th tch trung bnh HC di 80 femtolit l thiu mu HC nh gp trong thiu mu
do huyt tn HC hnh bi, thiu mu do thiu st...
- Lng HST trung bnh HC (MCH: mean corpuscular hemoglobin): l lng HST
trung bnh cha trong mt HC tnh bng picrogam (1pg = 10
-12
g).
HST (g/l)
Cng thc tnh: MCH =
HC(Tera/l)
Bnh thng MCH = 30 3pg . Tng trong thiu mu u sc(thiu B
12
, acid folic),
gim trong thiu mu nhc sc.
- Nng HST trung bnh HC (MCHC: mean corpuscular hemoglobin
concentration): l lng HST bo ho trong mt th tch HC.

HST(g/l)
Cng thc tnh : MCHC =
Hematocritl l/l)
Bnh thng MCHC = 290 - 360g/l. Thc t khng bao gi c tng trn 360g/l v
l lng HST bo ho, do vy ngi ta ni: khng c u sc tuyt i.
Nu gim di 290g/l l thiu mu nhc sc.
- Xc nh mc thiu mu: ngi ta da vo lng HST xc nh mc
thiu mu: c 3 mc thiu mu:
. Thiu mu mc nng : HST 60g/l.
. Thiu mu mc trung bnh : HST: 70- 90g/l.
. Thiu mu mc nh : 90 g/l < HST< bnh thng.
+ Sc bn HC (trong mi trng nc mui nhc trng):
nh thng : HC bt u v nng : 0,46%
HC v hon ton nng : 0,34%
Nu v sm hn ( nng nc mui cao hn) l sc bn HC gim , thng gp
trong bnh HC hnh bi.
Nu v mun hn ( nng nc mui thp hn) l tng sc bn HC thng
gp trong bnh thalassemie.
+ St huyt thanh:
Bnh thng: Nam: 15 - 27 mcmol/l.
N : 11 - 22 mcmol/l.
St huyt thanh gim trong thiu mu nhc sc do thiu st, tng trong thiu
mu do huyt tn, suy ty, ri lon chuyn ho st ...
+ Nghim php Coombs (Coombs HC): pht hin khng th khng hon ton
khng HC. Coombs trc tip pht hin khng th bm vo HC, Coombs gin
tip pht hin khng th cn t do trong huyt thanh.
Nghim php Coombs dng tnh r trong thiu mu huyt tn t min.
3.2. Ty :
+ Ch nh chc ty:
- Cc thiu mu khng thy nguyn nhn c th.
- Thiu mu dai dng kh hi phc.
- Cc trng thi gim BC, tng C khng do nguyn nhn vi khun hoc virus.
- Cc bnh mu c tnh, hch c tnh, cc trng thi ri lon globulin mu
(paraprotein), mt s trng hp ung th...
- Xut huyt do gim tiu cu.
+ Chng ch nh: Tuyt i: khng c.
Tng i: cc trng thi e do chy mu nng, suy tim nng, qu s hi...
- Ty bnh thng ngi Vit Nam:
Trong mi trng hp thiu mu, xt nghim ty l rt cn thit tm hiu
nguyn gy thiu mu v nh gi kh nng phc hi trong v sau iu tr (xem
phn ty bnh thng trong phn: mt s xt nghim huyt hc s dng trong
lm sng).
4. Phn loi thiu mu.
* C rt nhiu cch phn loi thiu mu nh:
+ Phn loi theo tnh cht tin trin: thiu mu cp tnh, thiu mu mn tnh.
+ Theo kch thc HC: thiu mu HC to, nh, trung bnh.
+ Theo tnh cht thiu mu: ta c: thiu mu nhc sc, ng sc, u sc)...
Tuy nhin cch phn loi nh trn l n gin, d ng dng trong lm sng nhng
khng y .
* Cch phn loi khoa hc v y hn c l phn loi theo nguyn nhn v c
ch bnh sinh. Theo cch ny ngi ta chia thiu mu lm 4 loi sau:
+ Thiu mu do chy mu:
- Cp tnh: sau chn thng, chy mu d dy- t trng...
- Mn tnh: do giun mc, tr chy mu...
+ Thiu mu do thiu yu t to mu:
Cc cht cn thit cho to mu hay b thiu thng l: st, vitamin B
12
, acid folic,
vitamin C, protein, ni tit... thng hay gp nht l thiu mu dinh dng.
+ Thiu mu do ri lon to mu:
- Suy nhc ty xng.
- Lon sn ty xng .
- Ty xng b ln t, chn p do cc t chc c tnh hoc di cn ung th vo ty
xng.
+ Thiu mu do huyt tn:
- Nguyn nhn ti HC: nh bt thng cu trc mng HC (bnh HC hnh bi...),
thiu ht men (G6PD...), ri lon HST (thalasemie, bnh HC hnh li lim..).
- Nguyn nhn ngoi HC : nh min dch, nhim c, nhim trng, bng...
* Ngi ta cng c th chia thiu mu lm 3 loi :
+ Do chy mu
+ Do ri lon to HC:
- Do thiu yu t to hoc.
- Do ri lon to HC ty xng.
+ Do huyt tn.
5. Nhng im cn lu { khi hi v khm bnh nhn c thiu mu.
Thiu mu l mt hi chng gp nhiu trong cc bnh l ni khoa, ngoi khoa, sn
khoa v chuyn khoa, v nguyn nhn thiu mu l rt a dng khng ch gp
trong bnh l ca mu v c quan to mu, bi vy khi hi v khm bnh nhn b
thiu mu cn lu { my im sau y:
* Hi bnh:
+ Ngh nghip bnh nhn: lm rung? (dng phn ti d b nhim giun mc);
tip xc cc yu t c hi nh: benzen, ch, cc bc x ion ho (tia X, gama)...
+ Ch n ung.
+ Nhng ho cht, thuc s dng?: clorocid, cc thuc chng ung th...
+ Gia nh c ai mc bnh tng t hay khng?
+ Cc bnh l{ mc: bnh thn, cc bnh gy tnh trng chy mu, d dy- t
trng, cc bnh ph khoa...
* Khm bnh cn lu {:
Khm mt cch ton din c h thng i vi tt c cc c quan, nhng c bit
lu { ti:
+ C quan to mu.
+ Gan, lch (hay gp thiu mu do cng lch hoc huyt tn).
+ Bnh l ca thn.
+ Bnh l d dy- t trng (lin quan n tnh trng chy mu).
+ Bnh l ph khoa (lin quan n tnh trng mt mu do kinh nguyt ko di)...
Tm li: hi chng thiu mu bao gm nhiu triu chng lm sng ch yu do
thiu oxy t chc gy nn. Mun iu tr khi thiu mu phi xc nh c c
ch v nguyn nhn ca n bng nhiu th nghim lm sng v cn lm sng khc
nhau t n gin n phc tp.

19. HI CHNG TAN MU

1. nh ngha.
Hi chng tan mu (cn c gi l huyt tn) l tnh trng hng cu v qu
nhanh, qu nhiu so vi mc v sinh l ca hng cu v i sng ca hng cu b
ngn li.
nh thng khong 1% tng s hng cu (ch yu l hng cu gi) ca c th
cht i (gi l tan mu sinh l{) v tng ng c mt s lng hng cu mi c
sinh ra t ty xng b li. Do nhiu nguyn nhn, s lng hng cu cht
nhiu hn s gy ra huyt tn bnh l. Nu huyt tn nhiu hoc ko di, ty
xng khng sn xut kp hng cu mi b p, c th s b thiu mu v
thiu mu ny c gi l thiu mu tan mu.
Cn ch : ty xng c kh nng b p gp 6 ln bnh thng, nn mt s
bnh nhn c tan mu nhng vn c th cha c cc triu chng ca thiu mu.
ngi b tan mu cp tnh, c th c th tri qua giai on suy ty tm thi.
2. C ch bnh sinh tan mu.
S tn ti hng cu ph thuc vo nht v tnh do dai ca mng hng cu; t
l din tch v th tch ca hng cu; nng huyt sc t (hemoglobin) ca hng
cu; v cc men chuyn ho glucoza, chuyn ho nucleotid ca hng cu.. do
nhiu nguyn nhn khc nhau, hng cu c th b tan v, i sng hng cu b rt
ngn li (bnh thng l 120 ngy).
Hng cu c th b tan v theo hai c ch:
- Tan mu trong lng mch: thng gp do hng cu c hnh thi khng bnh
thng, hoc do tc nhn bm vo mng v ph v hng cu. Hng cu b v gii
phng huyt sc t t do trong mu, mt phn o thi qua thn (gy huyt sc
t niu), mt phn c gan chuyn ho to bilirubin.
- Tan mu trong t chc: hng cu b tan v trong lch, gan v cc t chc lin
vng. Nguyn nhn hay gp l do cc hng cu c bin i v hnh thi hoc
trng thi b ngng kt d b bt gi bi i thc bo v cc t bo c thm quyn
min dch trong t chc lin vng, gan lch... thng khng c huyt sc t t do
trong mu, bilirubin mu t hoc khng tng, gan lch c th to.
3. Phn loi tan mu.
C th xp loi hi chng tan mu theo nguyn nhn hoc theo c ch bnh sinh.
Tuy nhin, theo cch no th kt qu cng u nh nhau. tan mu bm sinh,
nguyn nhn bnh bn trong hng cu; tan mu mc phi, nguyn nhn bnh
ngoi hng cu.
3.1. Tan mu do nguyn nhn ti hng cu: Thng gp do bnh l tan mu di
truyn, bm sinh.
3.1.1. Do bt thng mng hng cu:
- Bnh hng cu nh Minkowski-Chaufard: bnh di truyn, sc bn hng cu
gim, hng cu hnh bi.
- Bnh hng cu hnh gai, hnh thoi...
- Bnh huyt sc t niu kch pht ban m.
3.1.2. Do bt thng v men ca hng cu:
- Thiu men G
6
PD (glucoza-6-photphat-dehydrogenaza): thng tan mu sau
dng thuc (c bit l quinin)
- Thiu men pyruvatkinaza (PK); thiu cc men trong qu trnh thoi ho glucoza.
- Thiu men gluthation reductaza
3.1.3. Do bt thng ca huyt sc t:
- Do bt thng v s lng cc chui polypeptid trong cc globin ca huyt sc
t:
+ Bnh beta-thalassemie (bnh huyt sc t F v huyt sc t A
2
).
. Th nng: ng hp t (bnh Colley).
. Th nh: d hp t (bnh Rieth- Greppi- Michel).
+ Bnh anpha-thalasemi (bnh huyt sc t H).
- Do bt thng v cht lng v ri lon v cu trc cc chui polypeptid trong
globin ca huyt sc t.
+ Bnh hng cu hnh bia (HbS ).
+ Cc bnh v huyt sc t khc (HbC, HbD, HbE, HbG...).
3.2. Tan mu nguyn nhn ngoi hng cu:
3.2.1. Nhm khng do min dch:
- Do nhim c cc thuc (chng st rt, nitrit, sulfamid...) v ho cht (benzen,
toluen, TNT...), cc sn phm t thc vt (nm c...) hoc ng vt (nc rn...),
cng c th do nhit (bng nng hay bng lnh)...
- Do nhim trng v k sinh trng: nhim khun huyt (lin cu khun tan huyt,
t cu...), k sinh trng (st rt...).
- Do cc nguyn nhn khc: tan mu do c hc nh trong tim nhn to, tun hon
ngoi c th, do van tim nhn to...
3.2.2. Nhm do min dch:
- Tan mu min dch do ng min dch:
. Truyn nhm nhm mu.
. Bt ng mu m con h ABO, h Rh...
- Tan mu min dch t min dch.
4. Triu chng chung ca hi chng tan mu.
4.1. Triu chng lm sng:
- Hi chng thiu mu: ty theo nguyn nhn v c ch bnh sinh, tnh trng
thiu mu din ra t t hoc l t ngt v thng c tnh cht ng sc. Mc
thiu mu nng hay nh ph thuc vo tan mu nhiu hoc t, bnh nhn cm
thy kh chu, nhc u, bn chn, hoa mt, chng mt, mt mi, gim sc lao
ng, hi hp nh trng ngc, kh th t hay nhiu, ri lon tiu ho... Khm
thy cc du hiu ca thiu mu nh: da xanh, nim mc nht, bin i lng tc,
mng, nhp tim nhanh v c th thy ting thi tm thu c nng, li nht nhng
cn gai li...
- C hi chng vng da, vng da nhiu hay t ph thuc mc tan mu nhiu hay
t, da mu vng rm khng km theo nga; nc tiu mu vng sm v phn sm
mu.
- Lch to: thng bao gi cng gp; to nhiu hay t, au nhiu hoc khng au
ph thuc nguyn nhn v din bin ca tan mu, lch thng c mt chc
nhng c th mm trong tan mu cp.
- Bnh nhn c th khng st, st nh trong tan mu mn hoc c th c st cao
d di khi tan mu cp. Ngoi ra c th c gan to (hay gp trong tan mu bm
sinh), tc tnh mch...
4.2. Triu chng xt nghim:
4.2.1. Cc triu chng do phn hu hng cu qu mc:
- S lng hng cu v lng huyt sc t trong mu gim; hng cu bnh
thng v ng sc ( cc ch s hng cu nm trong mc bnh thng); cng c
th gp hng cu to, khng ng u hoc c ht a kim (thng thy trong tan
mu bm sinh).
- Bilirubin gin tip v hemoglobin t do tng trong mu, haptoglobin mu gim;
stercobilin trong phn tng (bnh thng khong t 200-300mg/ 24 gi); urobilin
nc tiu tng, c th thy hemosiderin niu.
- St huyt thanh tng, nhng c th bnh thng nu huyt tn nh hay ty
xng tng cng hot ng.
- i sng hng cu gim, xt nghim na i sng hng cu bng ng v phng
x crm 51 c T
1/2
gim (bnh thng l 30 3 ngy); sc bn hng cu gim hay
tng tuz theo nguyn nhn, thng gp l gim, nhng tng trong bnh
thalassemi.
- Gii phu bnh: Lch to gp 1,5 -2 ln bnh thng, xung huyt v c nhiu i
thc bo, ng nhiu hemosiderin; trong gan cng c nhiu i thc bo v
ng hemosiderin; ty xng xung huyt, c nhiu i thc bo, tng sinh
nguyn hng cu v ng hemosiderin; thn c biu hin thoi ho cc ng
thn( hay gp trong tan mu do truyn nhm nhm mu hoc tan mu bm sinh).
4.2.2. Cc triu chng do ty xng tng hot ng:
- Hng cu li tng (c th ln hn 30%, khong 50-100G/l).
- C nguyn hng cu trong mu ngoi vi, thng l dng a sc v i toan.
- Ty xng tng sinh mnh, nguyn hng cu trong ty ln hn 30-40% ch yu
l nguyn hng cu a sc v i toan.
5. Triu chng ca cn tan mu cp.
Do hng cu v qu nhanh, qu nhiu nn trn c s cc triu chng chung cn
tan mu cp thng c:
5.1. Triu chng lm sng:
- St cao rt run tng cn.
- Thiu mu t ngt tng nhanh.
- au bng, au vng tht lng d di
- Vng da, nim mc tng ln r rt.
- Lch to nhanh, au nhiu.
- Nc tiu nu, vi gi sau tr thnh mu en c (do c huyt sc t t
do trong nc tiu)
- C th c chong v tru tim mch, thiu niu, v niu, huyt khi ...
5.2. Triu chng xt nghim:
- S lng hng cu, lng huyt sc t gim nhanh; xut hin nhiu nguyn
hng cu trong mu.
- Hng cu li tng cao.
- Huyt sc t t do trong mu tng cao, gim nng haptoglobin mu.
- C huyt sc t trong nc tiu.

20. HI CHNG XUT HUYT

1. Khi nim
Khi mu thot ra khi thnh mch do mch mu b tn thng hoc do tnh thm
thnh mch gy nn xut huyt.
2. Nhng lu { khi hi.

- Thi gian xut hin xut huyt.
- Xut huyt u: ch { rong kinh, i ra mu, a phn en. Tnh cht: tm,
ni cc phng, au..
- Xut huyt t nhin hay va chm, khi thay i thi tit, sau qu trnh vim
nhim
- Cc triu chng km theo.
- Hay dng thuc g? iu tr thuc g tr xut huyt?
- Tin s mc bnh.
- Tin s gia nh.

3. Triu chng.
a) Xut huyt di da.
- Hnh thi xut huyt.
+ Nt xut huyt ng knh < 1cm, phng n phin knh khng mt. Phn
bit vi nt mui t, nt rui son.
+ Mng xut huyt: ng knh > 1cm: mu sc thay i theo thi gian, phng,
n phin knh khng mt. Phn bit vi:
Ban d ng: hng, nga, ni g ln mt da, cng da n phin knh mt mu.
Ban nhim sc c nh: tn ti nhiu thng nhiu nm.
U mch mu phng: tn ti lu, n phin knh mt mu.
+ mu t di da: ni g au, trong cha y mu.
- Xc nh v tr xut huyt.
+ Xut huyt di da.
+ Xut huyt trong khp, mu t trong c.
+ Xut huyt nim mc.
- Tnh cht xut huyt.
+ Xut huyt i xng l c im ca vim thnh mch d ng.
+ Mu sc cc nt c ng u khng.
- Kim tra sc bn thnh mch..
+ Nghim php p lc dng: nghim php dy tht.
Mc nh: nh gi sc bn thnh mch.
Nguyn l{: lm tng p lc lng TM thay i mt cch t ngt thnh mch km
bn vng HC s b y ra ngoi.
Cch tin hnh: duy tr p lc trung bnh trong 10 pht tho hi nhanh, quan st
phn di dy tht
Kt qu: nu xut huyt mi phn di dy l nghim php dng tnh.
+ Nghim php p lc m: nghim php gic ht.
t gic ht vo vng cng tay cnh tay vi p lc tng dn n khi xut
hin nt xut huyt th ngng. nh thng 20 cm Hg, nu di 15 cm Hg l sc
bn thnh mch gim.
b) Xut huyt nim mc ni tng.
4. C ch gy xut huyt.
- Do tn thng thnh mch.
- Do gim cht lng v s lng tiu cu.
Do ri lon ng mu.
5. Cc xt nghim cn lm
xt nghim Bnh thng ngha
Thi gian
mu chy
3 - 4 pht 6 pht l ko di trong bnh l tiu cu,
bnh ca thn mch
S lng
tiu cu
150 - 300 G/l < 150 l gim trong gim tiu cu min
dch, bnh BC, suy ty
Cht Hnh thi bt thng > 10% l c bnh l.
lng tiu
cu
tp trung bnh thng > 10 TC/1 vi trng, nu di l
bnh l.
Thi gian co cc mu bnh thng 37
0
sau 1 - 3 gi cc
mu co hon ton di tc dng ca men retractozyme ca
tiu cu. Bnh l cc mu khng co hoc co khng hon
ton.
Thi gian
mu ng
7 - 10 pht Thm d cc yu t ng mu
Thi gian
aPTT
Thi gian ng
ca huyt
tng ly
canxi nay canxi
ha tr li
nh thng 1p30
,
- 2p15. Bnh l khi ko
di qu 15% so vi ngi bnh thng.
L xt nghim thm d yu t ng mu.
nh lng
fibrinogen
Nh trn
nhng trong
mi trng d
tha
thromboplastin.
nh thng Qick 11 - 16 giy, t l
prothombin 80 - 100%, di 75% l gim.
Mc ch thm d cc yu t ng mu
ngoi sinh: II, V, VII v X.
Nghim
php ru
50 - 55 giy L test thm d cc yu t ng mu ni
sinh: IX, XI, XIII. Thi gian aTPP ko di
trong bnh hemophilie.
2 - 4g/l Di 2g/l l gim. Trong ng mu ri rc
lng mch, x gan,
Huyt thanh cho thm cn ethylic 70
0
v t 4
0
C th phc
hp fibrinmonomer v cc sn phm thoi bin
fibrin/fibrinogen ang dng ha tan s tr ln khng ha
tan na b gen ha. Nghim php (+) trong ng mu ri rc
lng mch.

21. HI CHNG HEMOGLOBIN

Hemoglobin l thnh phn quan trng ca hng cu, c nhim v vn chuyn O
2

t phi n t chc v nhn CO
2
a v phi khuch tn ra khng kh.
Hemoglobin l mt h thng m tham gia vo qu trnh thng bng kim-toan
ca c th. Khi tan mu, hemoglobin xut hin trong mu v c thi trong
nc tiu.
1. Biu hin lm sng.
i huyt sc t (hemoglobulin) do bnh huyt tn. Nguyn nhn ca i huyt
sc t rt phc tp. Biu hin lm sng ch yu cu i huyt sc t:
- Nc tiu mu nu en nhng khi ly tm khng c hng cu. i huyt sc t
din bin thnh tng t.
- Bnh nhn cm gic mt mi chng mt, au c, au lng, au bng, st cao rt
run.
- Thiu mu cp tnh hoc thiu mu mn tnh: da xanh, nim mc nht.
- Mt vng, da vng.
- Lch to, au.
- Mch nhanh, huyt p gim.
Ngoi nhng triu chng trn, i huyt sc t c th dn n suy thn cp tnh
do tc ng thn, gy toan ho trong ng thn, tn thng t bo biu m ng
thn.
- Thiu mu ng sc, tng hng cu li mu ngoi vi.
- Tng bilirubin mu, ch yu l tng bilirubin gin tip.
2. Nguyn nhn i huyt sc t.
2.1. Bnh l hng cu:
- Bnh hng cu hnh bi (bnh Minkowski - Chauffard).
- Thiu men glucose- 6 phosphat dehydrogenase.
- Thiu men pyruvatkinase.
- Bnh thalassemie.
- Thiu men glutathion reductase.
2.2. Bnh l min dch:
- Truyn nhm nhm mu.
- i huyt sc t kch pht ban m: Phosphotydilinositol ca mng hng cu c
tc dng lin kt vi cc protein mng. Bnh sinh ca i huyt sc t kch pht
ban m l do thiu ht phosphotydilinositol trn mng hng cu dn n gim
s lng protein gn trn mng hng cu, c bit thiu cc protein c ch b
th ca mng hng cu (nh MIRL: membrante inhibitor of reactive lysis). Do
thiu ht yu t c ch b th, thc y hot ng ca b th lm tng phn gii
hng cu.
- i huyt sc t do lnh:
i huyt sc t do lnh c th bm sinh hoc mc phi, di tc ng ca yu t
bnh l (nhim khun, nhim virus) c th s hnh thnh mt loi khng th c
bit gi l Donath-Landsteiner. Khi hng cu ra mu ngoi vi tip xc vi kh
lnh, mng hng cu s gn vi khng th Donath-Landsteiner v b th. Khi hng
cu vo trong mch mu ln nhit 37
o
C s b b th ph hy v s xut hin
i huyt sc t do lnh.
- Bnh l min dch: bnh l t min, xut hin khng th khng hng cu, phn
ng Coomb (+) nhit 4
o
C.
2.3. Do nhim khun v nhim c:
- Nhim khun ym kh (Bacille perfringens), nhim Salmonella typhi, Cytomegalo
virus, k sinh trng st rt.
- Nhim c ho cht: bezen, nhim c ch, hydrocarbon, quinin, nc rn.

22. HI CHNG LCH TO

1. i cng.
1.1. Mt s c im gii phu ca lch:
+ Lch l mt tng nh, trng lng khong 120 - 150g, nm su trong bng,
np di vm honh tri. nh thng khng th s thy c lch. Hnh chiu
ca lch trn thnh ngc hay ni cch khc l din c sinh l ca lch c trc dc
theo xng sn X bn tri. Gii hn trn - di nm trong khong xng sn
IX - XI. Cc sau ca lch cch ng gai sng 3 - 4cm, cc trc gn st ng
nch sau.
+ Cung lch c cu to bi cc tnh mch, ng mch lch, bch mch v thn
kinh ca lch xp thnh tng tng t trn xung di. Tnh mch lch vo tnh
mch mc treo trng trn ri v tnh mch ca.
+ Lch c bao bi mt v lin kt v c trn.
+ Lch lin quan vi gc tri ca i trng ngang pha di; vi b cong ln v
ti hi d dy, thy tri ca gan pha trc; vi thn v tuyn thng thn tri
pha sau v vi thn v ui ty pha trong. Khi pht hin lch to cn phn
bit vi u ca cc tng k trn.
+ Lch c cu trc c bit, kt hp cht ch gia t chc lymph, gi l ty trng
v t chc huyt qun, gi l ty . Nh vy lch l mt c quan lymph - huyt
qun.
- T chc lymph (ty trng) bao bc cc nhnh ng mch (bao lymphoid) v
phnh ln tng ch thnh cc nt (nodule) to nn tiu th Malpighi. Ti y cc
lymphocyte nm gia cc mt li si reticulin, ti cc nt li si c cc t bo
lin vng bm vo. ng mch trung tm tiu th Malpighi chy t gia trung
tm sng to ra cc nhnh vo ty .
Ty bao gm cc xoang mch ngn cch bi dy Billroth, bao gm cc si
reticulin dy c v nhiu t bo lin vng, c c hng cu, lymphocyte, t chc
bo v i thc bo. Cc xoang ny thc cht l cc mao mch rng lng, thnh
xoang mch c cu to bi mt lp t bo ni mc khng tip lin nhau to
nn nhiu khe h, cc t bo ni mc nm trn mt li si reticulin chy dc v
vng trn to cc vch ngn tha thong.
1.2. Lch c nhng chc nng sinh l{ chnh sau:
+ Tham gia sn xut t bo lymph. giai on bo thai lch cn sn xut c bch
cu ht, hng cu, tiu cu.
+ Ph hy cc t bo mu gi ci, gi li st, protein v cc cht cn thit to t
bo mu mi.
- D tr mu cho c th. Khi lch co vo hoc gin ra tham gia iu ho khi
lng mu cng nh khi lng t bo mu trong tun hon.
+ Lch cn tham gia chng nhim trng cho c th bng cch thanh lc cc vi
khun v vt l mu.
2. Thao tc khm lch.
2.1. Thao tc khm lch vi t th bnh nhn nm nga:
2.1.1. T th bnh nhn v thy thuc:
+ Bnh nhn nm nga, hai tay dui thng, hai chn co 45
o
, u quay bn tri, th
su bng bng.
+ Thy thuc ngi bn phi bnh nhn, bc l vng khm: ko o ca bnh nhn
ln st ng v, qun ko st xung gai chu trc trn.
2.1.2. Kim tra xem lch c to khng v xc nh gii hn ca lch:
+ Tay tri thy thuc p mng sn tri ca bnh nhn, tay phi p c lng bn
tay vo bng bnh nhn s theo nhp th ln lt:
- T h chu phi hng ln h sn tri.
- Tip theo t h sn phi sang h sn tri.
- Cui cng t h chu tri ln h sn tri.
+ S nh nhng, lin tc, ch khng nhc hn bn tay khi thnh bng. Nu lch
to, b lch s chm vo ngn tay thy thuc theo nhp th, cn nh du v tr s
thy trn thnh bng.
+ T cc im nh du trn ngi ta v c gii hn ca lch trn thnh
bng. Thng thng lch to ra theo ng nch - rn. Khi lch to ra theo hng
sang phi th ngi ta gi l lch ngang, trong trng hp ny cn phn bit k
vi thy tri ca gan. Mt s trng hp lch to theo hng xung h chu tri,
nn ngi ta gi l lch dc.
2.1.3. Cch xc nh ln ca lch:
im xa nht trn gii hn ca lch thnh bng so vi b sn tri chnh l cc
trc ca lch. T cc trc k mt ng vung gc vi b sn tri, chiu di
ca ng ny tnh bng cm chnh l ln ca lch trn thnh bng. Sau g
t cc trc dc ra sau theo xng sn X hoc lin sn IX bn tri, gii hn
vng c ca lch v vng vang ca phi chnh l cc sau ca lch. Ni cc trc
vi cc sau th s c trc dc ca lch. Cn phi o chiu di ca trc ny tnh
bng cm. Cui cng cn g theo cc ng nch bn tri t trn xung di
xc nh din c ca lch trn thnh ngc.
2.1.4. Xc nh cc tnh cht ca lch:
Dng bn tay s dc theo gii hn trong ca lch, trong nhiu trng hp nu
lch rt to v chc s s thy b rng ca ca n. Tip theo day nh trn b mt
lch xem c nhn hay sn si hoc u cc. ng thi n nh xem lch mm hay
chc, rn v c au khng. Sau kim tra li tnh cht di ng theo nhp th ca
lch v dng hai bn tay kim tra xem c di ng sang cc pha khng ( phn
bit vi mt s u trong bng). Cui cng kim tra du hiu chm tht lng
phn bit vi mt u ngoi phc mc hoc thn to.
2.2. Thao tc khm lch vi t th bnh nhn nm nghing:
Khi thy thuc khng s thy lch t th nm bnh nhn nga th phi khm vi
t th nm nghing. t th ny lch s ra trc v xung di nhiu hn.
Bnh nhn nm nghing phi, chn phi dui, chn tri co tay ln u.
2.2.1. S lch:
Tay tri thy thuc mng sn tri bnh nhn v hi n nh, bn tay phi p
st vo thnh bng v bo bnh nhn th su bng bng, sau thy thuc n
cc u ngn tay su di b sn tri th th ra, th th vo nu lch to s
chm vo ngn tay thy thuc. Cng c th dng tay phi mc su vo di b
sn tri kim tra lch. Phi lm i lm li 2 - 3 ln cm gic chnh xc c
lch.
2.2.2. G lch:
G dc theo xng sn X v gian sn IX - X tri, t gai sng ra trc. Giao im
vng vang ca phi v vng c ca lch l cc sau hoc gii hn sau ca lch, cn
nh du li. Tip theo, giao im gia vng c ca lch v vng vang ca phi l
cc trc hoc gii hn trc ca lch, cn nh du li. Nu gii hn trc ca
din c lch vt qua ng nch sau th xc nh l lch c to.
2.3. Nghe lch:
Trng hp xc nh lch to, th cn phi nghe lch; vng nghe lch l ton b
din c ca lch v phn lch to trn thnh bng. Khi nghe cn ch pht hin:
c ting thi hay khng? (trng hp thng ng- tnh mch), c ting c mng
lch hay khng?. Ting c mng lch c th xut hin khi vim quanh lch (ta c
th nghe thy st sot nh x vi).
3. Chn on lch to.
Qua thm khm lm sng ngi thy thuc phi xc nh c:
+ C ng l lch to khng ? lch to thng c nhng c tnh lm sng chnh
sau:
- S thy vng h sn tr.
- S thy b rng ca (khi lch to nhiu).
- Di ng theo nhp th, khng di ng t do cc pha.
- G c v vng c lin tc vi vng c sinh l ca lch.
- Du hiu chm tht lng m tnh.
- Cc tnh cht khc ca lch nh: mt chc hay mm, b mt nhn hay c u
cc, c au hay khng au...
4. Chn on phn bit.
Lch to cn phn bit vi:
- U gc i trng tri: khi u thng trn, c th di ng cc pha, khng di ng
theo nhp th, g thng vang. Lm sng c hi chng bn tc rut (Koenig). Cn
chp khung i trng cn quang xc nh.
- Thn tri to: khi u nm su, du hiu chm tht lng (+), g c th vang (do
pha trc c rut), khng di ng theo nhp th. Cn siu m xc nh, c th
chp bm hi sau phc mc, chp thn thuc tnh mch, CT...
- U tuyn thng thn tri: lm sng c triu chng tng huyt p tng cn. S
khi u ging nh u thn. Cn siu m, chp bm hi sau phc mc, CT xc
nh.
- U d dy: thng nm thng v, khng di ng theo nhp th. Lm sng c
ri lon tiu ho. Cn chp d dy, soi v sinh thit d dy xc nh.
- U thy tri ca gan: g c lin tc vi vng c ca gan. Cn siu m v soi
bng xc nh.
Ngoi ra cn cn phn bit vi u tu, u mc treo...
5. Cc bnh thng c lch to (chn on nguyn nhn).
5.1. Cc bnh truyn nhim, k sinh trng v vim:
- St rt: l bnh ph bin nht gy lch to nc ta hin nay. Nu st rt tin
pht thng lch ch to va phi. Nu st rt ti pht dai dng lch c th rt to.
Nhng ngi sng lu vng st rt lu hnh nng d khng c biu hin st rt
nhng lch cng c th to. V vy nhng bnh nhn c lch to li c tin s st rt
hoc vng st rt lu hnh th nht thit phi kim tra k k sinh trng st rt
trong mu.
- Bnh Kala - azar: do k sinh trng Leishmania, lch rt to, tng bch cu n
nhn trong mu. Cn phi chc ty, chc lch tm k sinh trng.
- Lao lch: lch to va phi nhng au. C hi chng nhim c lao. C th kt
hp lao gan, X quang bng c th thy nt vi ho. Cn soi bng, siu m lch,
gan v nu c th th chc sinh thit gan, lch c chn on xc nh.
- Cc trng hp nhim khun huyt, thng hn, osler... lch thng to t, mm,
au. Lm sng thng c st ko di, suy kit, ri lon tiu ho, tim mch. Nhng
trng hp ny nht thit phi cy mu nhiu ln, lm phn ng huyt thanh (th-
ng hn), siu m tim (osler)...
- Mt s bnh nhim virus cng c th c lch to. c bit, bnh tng bch cu
n nhn truyn nhim lch to km theo hch to v st, trong mu xut hin
nhiu bch cu n nhn v lymph kch thch. Cn lm phn ng huyt thanh
PD (Paul unnell Davidsohn) chn on xc nh.
- Bnh l t min c th c lch to va phi:
+ Lupus ban (LED): st ko di, tn thng a c quan, ban cnh bm, t
bo hargraves (+), khng th khng nhn (+)...
+ Hi chng Felty: vim khp dng thp tr em, c lch to.
5.2. Lch to trong bnh mu v c quan to mu:
- Bnh bch cu ty mn: lch rt to, thng qu rn bch cu tng rt cao, trong
mu xut hin cc giai on pht trin ca dng bch cu ht t non n trng
thnh, nhim sc th Ph
1
(+).
- Bnh bch cu lymph mn: lch to trong 50% trng hp. Hch to ton thn,
i xng. Bch cu tng va phi, t l lymphocyte rt cao. Tnh trng thm ngm
lymph ty xng v cc c quan ph tng. Thng ch gp ngi trn 50
tui.
- Bnh bch cu cp: lch to r trong th lymph, to t v c th khng to trong
th ty, km theo gan to, au xng c, thiu mu, chy mu, st, nhim khun,
t l blaste trong ty > 30%.
- Thiu mu huyt tn:
. Huyt tn cp tnh hu pht thng lch to t v au, km theo thiu mu v
vng da nng.
. Huyt tn mn tnh bm sinh thng lch kh to km theo gan to, bin i x-
ng, thiu mu c khi nh hoc va phi, vng da t.
- Bnh a hng cu: da hng , c bit da mt, nim mc ming, kt mc mt
ti, nhiu tia huyt qun, lch to va phi. Xt nghim hng cu tng rt cao,
hematocrit tng, th tch khi hng cu ton th tng r.
- Cng lch: lch c th to t trong giai on u, to va phi vo giai on sau,
thng khng au, khng st, khng vng da, xt nghim mu c th gim ba
dng: hng cu li mu ngoi vi tng. Ty giu t bo tng sinh phn ng
mnh hng cu. Trong trng hp ny cn lm thm cc xt nghim v i sng
hng cu, ch s lch/gan, lch/mu, lch/tim, xc nh.
5.3. Lch to trong cc bnh ca h thng tnh mch ca:
- X gan: lch thng to va phi, cng c khi rt to km theo hi chng suy chc
nng gan. Cn siu m, soi bng, sinh thit gan xc nh.
- Bnh anti (x lch nguyn pht): lch to n c ko di km theo cc du hiu
cng chc nng lch (gim cc t bo mu ngoi vi, hng cu li tng, ty
xng giu t bo). Sau vi nm tin trin mi c gan to v x gan.
- Cc trng hp tng p lc tnh mch ca khc c lch to:
Trn gan:
+ Vim mng ngoi tim co tht.
+ Hi chng Budd Chiarri (tc tnh mch trn gan).
Di gan:
+ Tc tnh mch ca.
+ Hi chng Banti (x tnh mch lch, tnh mch ca trc, sau mi x lch).
5.4. U, nang lch:
+ U lnh:
- U mu
- Nang sau chn thng hoc v lch trong bao: c tin s chn thng ti vng
lch, au m ko di mng sn tri lan ln nch, c th st.
+ U c:
Ung th nguyn pht ti lch thng au nhiu, lch s cng chc, x x..., st
cn nhanh.
5.5. Bnh ri lon chuyn ho: nh bnh Gaucher (ri lon chuyn ho
glycozylxeramid), bnh Niemann-Pick (ri lon chuyn ho sphingomyelin) cng
thng c lch to hoc rt to.
Tm li: lch to l mt triu chng lm sng hay gp trong nhiu bnh ni - ngoi
khoa. Mun chn on chnh xc lch to cng nh nguyn nhn ca n phi thm
khm lm sng k lng v phi kt hp vi cc bin php cn lm sng thch hp
khc.

23. HI CHNG HCH TO

1. i cng.
Trong c th c khong 500 - 600 hch. H thng hch bch huyt nm ri rc
khp c th t nhng vng su trong trung tht, bng, dc theo cc ng mch,
tnh mch ln n vng ngoi vi nh c, nch, bn.
+ Cu trc hch lymph gm 2 vng:
- Vng v: cha cc nang lymph trn, pha ngoi l lymphocyte dy c sm
mu. Pha gia l vng trung tm mm cha cc lymphoblaste xp tha hn, sng
hn.
Cc xoang v ngoi vi di bao tip nhn bch huyt i ti, qua xoang trung gian
ti xoang ty.
- Vng ty: cu to bi cc dy ty cha cc lymphocyte, gia chng thnh
xoang c cu to bi mt lp t bo lin vng v t bo thc bo c nh.
+ Hch bch huyt c chc nng chnh l sn xut cc t bo lymph m nhn
chc nng min dch v thanh lc cc vt l nh vi khun ... xm nhp vo c th
qua ng bch huyt, bo v c th.
nh thng hch bch huyt ngoi vi rt nh v mm, bng cc phng php
lm sng khng pht hin c; ch khi c bnh, cc hch bch huyt mi sng to
ln v c th nhn thy hoc s thy c.
2. Khm lm sng.
2.1. Nguyn tc:
Khi thm khm lm sng h thng hch bch huyt ngoi vi cn tun th cc
nguyn tc chnh sau :
+ Thm khm c h thng t vng u c ti vng bn, khoeo chn.
+ Kt hp va nhn ,va s nn v hi.
+ Cc cn, c ca ngi bnh vng nh khm phi t th chng.
+ Khng c dng mt ngn tay s nn m phi dng nhiu ngn mi pht
hin c chnh xc tnh cht ca cc hch.
2.2. Cc v tr hch ngoi vi cn thm khm:
Khi c bnh th hch bch huyt ngoi vi thng sng to cc v tr sau:
+ Vng chm, trc v sau tai, cnh xng chm.
+ Vng dc theo b trc v sau c c- n- chm.
+ Vng di hm, di cm.
+ Vng h trn n v di n.
+ Vng h nch.
+ Vng khuu tay dc theo b trong c nh u.
+ Vng bn.
- Vng khoeo chn.
Hch su: hch trung tht, trong bng, dc theo ng mch ch bng... ch pht
hin c bng cc bin php cn lm sng (X quang, lymphography, CT, siu m,
cng hng t...) hoc m thm d.
2.3. Cc tnh cht ca hch cn pht hin qua thm khm lm sng:
* V tr hch:
+ Hch vng sau c c- n- chm: thng l hch lao...
+ Hch sau tai, xng chm: di cn K vm...
+ Hch h thng n: Hodgkin, lao, di cn K ph qun, K d dy (thng n
tri)...
+ Hch bn: bnh hoa liu...
* S lng hch:
+ Lc u t hch, sau nhiu v lan rng: hch Hodgkin, u lymph c tnh non -
Hodgkin...
+ Hch nhiu ngay t u: bnh bch cu lymph cp , mn...
* Kch thc hch:
- Hch nh nh ht xanh: hch th tng...
- Hch to bng qu nht, qu qu{t hay to hn thng l hch c tnh.
* Mt hch:
+ Hch mm: vim cp, lao...
+ Hch nhn: ang ho m, b u.
+ Hch chc: bnh bch cu, Hodgkin, non-Hodgkin (NHL)
+ Hch rn: di cn K.
+ Hch lao: mt cc hch khng ng u, ci th rn chc (vi ho, x ho),
ci th mn (vim lao), ci th nhn (b u).
* Mc di ng:
+ Hch di ng d dng: hch vim mn, hch th tng, hch bnh bch cu,
Hodgkin, u lymph c tnh non- Hodgkin...
+ Hch km di ng: do dnh vo da (bnh u lymph c tnh non - Hodgkin), do
dnh vo t chc di da (hch K di cn, bnh Hodgkin, u lymph c tnh non
Hodgkin...), do dnh vo nhau thnh mt khi (hch Hodgkin, u lymph c tnh
non- Hodgkin, hch lao...).
* au:
+ au tng khi s nn (hch vim cp), au t nhin v au tng v m (hch c
tnh, di cn).
+ Khng au: hch th tng, vim mn, bnh bch cu, hch c tnh thi kz u...
* S bin i da ph ngoi hch:
Ch cc tnh cht: nng, hng (hch vim cp), tm (bnh u lymph c tnh
non - Hodgkin), lot, l d, so (lao, giang mai, h cam...).
* S pht trin ca hch:
+ Nhanh hay chm: hch c tnh thng pht trin nhanh, hch lnh tnh thng
pht trin chm.
+ Thnh tng t hay lin tc: hch ca bnh Hodgkin thng pht trin thnh
tng t km theo cc triu chng ton thn.
+ Mi lin quan vi cc triu chng ton thn khc nh: st, gy st cn, m hi
trm, nga, chy mu, thiu mu, gan lch to...
2.4. Thao tc khm hch vng u, c:
Bnh nhn ngi i din vi thy thuc, u quay sang mt bn. Mt tay thy
thuc t ln nh u ngi bnh gi cho u ng t th, tay khc ln lt
s nn: vng chm, quanh xng chm, trc tai, sau tai, dc theo b trc, b
sau c c- n- chm, h thng n, vng di cm, di hm. Ch khi khm
hch vng di cm, di hm th u bnh nhn phi hi ci xung chng c
c, ngn tay ci ca thy thuc ta ln pha m, bn ngn cn li mc su vo
vng di hm, di cm tm hch.
Ngi thy thuc phi va s nn tm hch v xc nh cc tnh cht ca hch,
va nhn xem da pha ngoi hch c bin i g khng, va hi xem s pht trin
ca hch nh th no...
2.5. Khm hch h nch:
Bnh nhn ngi hoc ng i din vi thy thuc v xoay nghing 45
0
. Thy
thuc dng mt tay cm ly c tay ngi bnh v dng ra to mt gc nch
khong 60
0
- 90
0
; sau bn tay cn li p st vo h nch, dng cc ngn tay
day tm hch v pht hin cc tnh cht ca hch.
Bnh nhn cng c th hai tay ln u, thy thuc ngi hoc ng i din v
dng hai tay s nn hai h nch tm hch.
2.6. Khm hch khuu tay, b trong c nh u:
Bnh nhn ng hoc ngi i din vi thy thuc, tay dui v nga. Thy thuc
mt tay cm c tay bnh nhn, tay kia ln lt s nn vng mm trn rng rc,
mn trn li cu v dc theo b trong c nh u cnh tay. Ch y cn phn
bit vi u dy thn kinh tr gp trong bnh phong, trng hp ny dy thn kinh
tr s nh mt dy thng, cc u nh cc nt tht trn dy v bn tay co qup
hnh vut tr.
2.7. Thao tc khm hch t th bnh nhn nm:
+ Khm hch vng bn:
- Bnh nhn nm nga, hai chn dui thng.
- Thy thuc ng bn phi hoc bn tri, tay tri bc l vng khm tay, phi ln
lt nn vng np bn v vng tam gic Scarpar tm hch.Khm tng bn mt.
+ Khm hch vng khoeo chn:
- Bnh nhn nm nga, khm bn no th chn bn co li to mt gc 120
0

khoeo.
-Thy thuc mt tay gi cng chn bnh nhn, tay kia s nn khoeo chn tm hch
(phi s ton b vng trm khoeo).
3. Cc bin php cn lm sng.
Cc bin php cn lm sng thng ch p dng pht hin cc hch nm
vng su trong c th nh: hch trung tht, bng...
3.1. Chp X quang (XQ): thng chp phi v trung tht. Cn chp c t th
thng v nghing. C th chp XQ xng nhng vng c au xng nhiu
tm cc hnh nh: u xng, khuyt xng, long xng c th gp trong mt s
bnh l hch.
3.2. Chp ct lp in ton (CT):
Thng s dng khi trn phim X quang thng nghi ng c hch trung tht, hoc
pht hin cc hch trong bng, hoc di cn no...
3.3. Chp bch mch (lymphography):
Chp bch mch c th pht hin phn ln cc hch su t chi, dc theo
ng-tnh mch ch. y l mt th thut cn phi lm xc nh giai on lm
sng i vi bnh Hodgkin v bnh u lymph c tnh non- Hodgkin.
3.4. Siu m:
Thng dng siu m pht hin v chn on phn bit hch trong bng vi
u cc tng khc.
3.5. Chc hch lm hch :
L mt bin php d lm v rt c gi tr xc nh bnh l hch to.
+ Hch bnh thng: 90 - 98% lymphocyte
< 3% lymphoblaste v prolymphocyte
< 1% t bo li vng
< 4% monocyte v t chc bo
< 2% plasmoblaste v plasmocyte
Ngoi ra cn c th c mt s rt t bch cu trung tnh, toan tnh do mu ngoi vi
ln vo khi chc hch.
+ Hch bnh l :
- Nhiu bch cu trung tnh, bch cu trung tnh thoi ho, i thc bo: gp
trong hch vim cp.
- C t bo Langhangs, t bo dng biu m (bn lin), cht b u gp trong
hch lao.
- C t bo Sternberg, cng vi cc t bo N, E, tng bo, cc t bo lymph:
thng gp trong bnh Hodgkin.
- Nhiu plasmoblaste, plasmocyte bt thng: gp trong bnh Kahler
- Nhiu t bo lymphoblaste qui d: bnh u lymph c tnh non-Hodgkin
- Nhiu leucoblaste gp trong bnh bch cu cp
- C tng cm t bo hnh thi bt thng (khng phi l t bo ca hch) gp
trong bnh di cn K...
3.6. Sinh thit hch:
Sinh thit hch l xt nghim quan trng nht chn on quyt nh bnh l
hch, nht thit phi lm khi hch khng cho hnh nh in hnh.
3.7. Xt nghim huyt thanh hc:
Cn lm xt nghim huyt thanh hc khi nghi ng hch ca bnh truyn nhim,
hoa liu nh: HIV (AIDS), W (giang mai), PPD (tng bch cu n nhn truyn
nhim)...
Tm li: thm khm h thng hch bch huyt l mt vic lm bt buc ca ngi
thy thuc khi khm bnh nhn, c bit l cc bnh nhn nghi ng b bnh mu,
bnh truyn nhim, ung th hoc cc bnh nhi ... Cn phi khm mt cch h
thng v k lng mi pht hin c hch v cc tnh cht ca n nht l khi
bnh mi giai on khu tr v hch cn nh.
4. Cc bnh thng c hch to.
4.1. Hch vim cp do nhim trng ln cn:
+ Nhim trng vng da u: thng c hch to vng chm.
+ Vim hng, amydal, rng ming: hch to vng di hm, di cm.
Ch : hch vng ny cn phn bit vi vim tuyn nc bt, bu gip lc
ch...
+ Nht hoc vim cp vng bn chn, cng chn, i: hch to bn
+ Nht hoc vim cp vng bn tay, cng, cnh tay hoc vng ngc: hch sng
vng nch.
Ni chung hch vim cp thng au, au tng khi s nn, mm, di ng c,
vng da ph trn hch hng , nng; c khi s mm nhn do ho m.
4.2. Hch vim cp trong mt s bnh truyn nhim:
+ Bch hu: hch sng to ngay t khi mi pht bnh, ch yu hch di hm,
chc, au, km di ng, da khng nng nhng thng n t chc di da
nhng trng hp nng.
+ Si: c th hch to ton thn .
+ Dch hch th hch: hch khu tr ch yu bn, rt au, sng to nhanh, chc,
km di ng v vim quanh hch, da ph ngoi nng . Hch c th ho m tr
thnh mm nhn, lot v chy m ra ngoi.
+ Xon khun lepto: hch sng au ngay t khi pht bnh, chc, d di ng.
+ Tng bch cu n nhn truyn nhim: thng c hch to sau tai, khng au,
km theo st v vim hng. Hch to n thun khng c st thng do
toxoplasma gondii, hch to km theo st v vim hng thng do EBV.
4.3. Hch to trong bnh hoa liu:
- Giang mai (thi kz I): hch thng c to bn, chc, khng au, khng mng
m, c chance giang mai. Chc hch soi vi knh hin vi nn en c th thy xon
trng giang mai.
+ H cam: hch xut hin sau 2 - 3 tun vng bn c chance, nng, s lng
nhng (m), au. Hch d v gy lot. C th tm c trc khun Ducreyi.
+ Nicolas - Favre: hch vng bn, lc u t, sau pht trin nhiu c hai bn, vim
t chc xung quanh hch, cc hch dnh vo nhau thnh tng mng cng, giai
on mun hn hch s ho m v d m ra ngoi thnh tng l trng nh
hng sen.
4.4. Hch lao:
Hch lao thng hai bn c, sau c c- n- chm, cng c th nhng ni
khc. Hch lao thng b tr thnh tng chui to nh khng u nhau, c khuynh
hng dnh vo t chc xung quanh do vim quanh hch. Hch khng au... mt
hch thng khng ng u (ci mm, ci chc, ci rn, ci nhn). Chc hch
hoc sinh thit hch thy t chc b u, t bo dng biu m, t bo Langhangs,
nang lao.
4.5. Hch c tnh:
+ Hch ca bnh Hodgkin: thng lc u xut hin vng c, thng n (tri
nhiu hn phi) sau lan ra ton thn. Hch chc di ng, c khi dnh vo nhau
thnh chm, i khi hch xut hin sau to hn hch xut hin trc. Hch pht
trin thnh tng t thng km theo cc triu chng ton thn nh: st, m hi
trm, gy st cn, nga...
+ Hch ca bnh non-Hodgkin lymphoma (NHL): v tr xut hin hch lc u c
th bt c ni no: c, nch, bn hay hch trong bng, mt rn chc. Hch
xut hin v to dn khng thnh t, hay xm ln chn p gy au.
+ Hch di cn K: hch di cn t ung th tng no thng nm trn ng dn lu
bch huyt ca tng , th d : hch thng n tri ca K d dy; hch gc
trong h thng n ca K ph qun, hch cnh xng chm thng l di cn
ca K vm hng; hch nch ca di cn K v ... Tnh cht chung ca hch di cn ung
th l rn chc v thng dnh cht vo t chc xung quanh.
+ Hch trong bnh bch cu: thng c nhiu ni trong c th, chc, di dng d
dng, khng au. Triu chng hch to thng i km vi gan lch to, au xng
khp, thiu mu v nhim khun. Chn on quyt nh da vo huyt v ty
...
Tm li: hch to l mt triu chng thng gp trong lm sng, cn phi thm
khm k lng v p dng cc bin php cn lm sng cn thit theo nh hng
ca lm sng chn on ng nguyn nhn th iu tr mi c hiu qu.
Ni chung hch lnh tnh thng gp tr em, tui tr, thng l do nhim vi
khun, vi rus cp hoc mn tnh, c hiu hay khng c hiu, hch thng mm
hoc chc, kch thc nh, thng ch c ngoi vi t c su, hch pht trin
chm v du hiu ton thn t. Hch c tnh thng gp ngi gi, trung nin,
c th c tui tr. Hch thng rn hoc chc, km di ng, au do xm ln,
hay c hch su, pht trin nhanh, c th suy sp.

24. HI CHNG XUT HUYT

Bnh thng mu tun hon trong c th trong lng cc mch mu. Khi mu
(ch yu l HC) thot ra khi thnh mch do mch mu b tn thng (v, t
hoc do tng tnh thm thnh mch) s gy nn xut huyt.

Xut huyt l mt hi chng bnh l gp nhiu chuyn khoa nh: xut huyt
di da hay gp ni khoa, truyn nhim; xut huyt d dy gp khoa tiu ho;
rong kinh: khoa sn ; chy mu cam: khoa tai -mi - hng; chy mu rng li: khoa
rng- hm - mt...
nh thng khi mch mu b tn thng th lp tc c phn ng ca c ch cm
mu - ng mu (hemostasis) bt ngay vt thng li v mu ngng chy. Khi
c bt c ri lon no ca c ch ny (ch yu l ri lon v thnh mch, tiu cu
hoc ng mu) u c th dn n xut huyt.
1. C ch ng mu- cm mu.


2. Nhng iu cn lu trong khi hi bnh s.
+ Thi gian xut hin xut huyt (XH): lu ri hay mi b ? C triu chng xut
huyt t tui no ? Ln u tin hay nhiu ln xut huyt ?
+ Xut huyt nhng u?: da, nim mc (mt, mi, li), ch hi k tnh trng
rong kinh, , sy thai b bng huyt, i ra mu, a phn en... Nu l xut huyt
di da th di dng nt tm hay mng tm hay hn hp ? C ni cc phng ln
khng ? C au khng ?...
+ Xut huyt t nhin hay sau mt va chm ?
+ Xut huyt xut hin khi thay i thi tit? Sau qu trnh vim nhim (vim
hng, vim khp, st...) ? Sau tip xc vi cht c?
+ C hay khng c cc triu chng km theo: st, sng au khp, ban m ay,
thiu mu, hch to, lch to, gan to...?
+ Hay dng nhng thuc g ? dng thuc g iu tr xut huyt ? Ch cc
thuc c ch min dch, chng ung th, chng vim, chng ng...
+ Tin s cc bnh mn tnh khc: ch cc bnh gan mt, bnh h thng, d ng
...
+ Tin s v gia nh: c ai mc bnh tng t khng? (b, m, anh ch em rut).
3. Triu chng xut huyt.
3.1. Xut huyt di da:
3.1.1. Cc hnh thi xut huyt di da:
C 3 hnh thi XH di da chnh l:
+ Nt xut huyt: thng c ng knh khong mt vi milimet, c th to hn
nhng ng knh khng qu 1cm, mu , phng vi mt da, n phin knh hoc
cng da khng mt v bin mt trong 2-5 ngy.
Nt xut huyt di dacn phn bit vi:
- Nt mui t hoc cn trng t: cc nt ny thng ni g trn mt da, nga,
cng da hoc n phin knh th mt.
- Nt rui son: thng c mu , tn ti lu, khng mt i theo thi gian.
- Mng xut huyt: c ng knh ln hn 1cm, mu sc ca mng xut huyt
bin i theo thi gian: lc mi u c mu sm, sau tr thnh tm, ri chuyn
thnh mu xanh v cui cng chuyn thnh mu vng ri mt hn. Mng xut
huyt khng ni g trn mt da, khng nga, khng au, n phin knh v cng da
khng mt.
Nu nhiu nt xut huyt tp trung ti mt v tr cn gi l m xut huyt; nhng
nt xut huyt tp trung np gp khy tay, kheo chn cn gi l vt xut huyt.
Mng xut huyt di da phn bit vi:
- Ban d ng: mu hng , thng nga v c th g trn mt da, cng da hoc
n phin knh th mt mu (v y l tnh trng xung huyt).
- Ban nhim sc c nh: c mu sc sm en hoc hng, thng phng vi mt
da, khng nga, khng au, n phin knh hoc cng da khng mt mu v tn ti
lu nhiu thng hoc nhiu nm.
- U mch mu th phng: mu , tn ti lu nu khng c x l, khng nga,
khng au, n phin knh hoc cng da c th lm gim hoc mt mu.
- mu t di da: lm da ni phng ln thnh cc chc v au, bn trong cha
y mu.
3.1.2. Xc nh v tr xut huyt di da:
+ Xut huyt di da ch c t chi c bit l cng chn thng gp trong
vim thnh mch d ng; gp c t chi, thn mnh v c u, mt, thng gp
trong bnh l tiu cu hoc ri lon ng mu .
+ mu t trong c (c t u i, c i chu...) xut huyt trong khp thng
gp trong ri lon ng mu.
+ Xut huyt nim mc mt, mi, rng, li, t cung, tiu ho, no v cc t chc
c quan khc.
3.1.3. Tnh cht xut huyt di da:
+ Xut huyt i xng hai bn l c im ca vim thnh mch d ng.
+ Mu sc cc nt, mng xut huyt ng u ni ln tnh cht cp tnh hoc mi
mc, mu sc khng ng u ni ln tnh cht mn tnh.
3.1.4. Kim tra sc bn thnh mch:
Nghim php dy tht (p lc dng):
- Mc ch: nh gi sc bn thnh mch (ch yu thnh mao mch).
- Nguyn l{: lm tng p lc trong lng tnh mch lm tng p lc mao mch
bng cch cn tr tun hon v tim v thay i p lc mt cch t ngt, nu
thnh mch km bn vng th HC s b y ra khi thnh mch gy nn xut huyt
di da vi hnh thi nhng nt nh .
- Phng php tin hnh: dng huyt p k t trn cnh tay vi p lc trung
bnh (huyt p ti a + huyt p ti thiu) chia i, duy tr p lc ny trong 10
pht sau tho hi nhanh v b huyt p k ra, quan st cnh tay v cng tay
phn di dy tht.
- nh gi kt qu: nu xut hin mt s nt xut huyt mi phn di dy l
nghim php (dng tnh) v ty s lng cc nt xut huyt (v c thi gian xut
hin cng nh v tr nt xut huyt) m ngi ta nh gi (dng tnh +), dng
tnh(++) hoc dng tnh (+++).
+ Nghim php gic ht (p lc m): phi c my chuyn dng. t gic ht vo
vng da mng cnh tay, cng tay vi p lc tng dn n khi no bt u xut
hin nt xut huyt th ngng. Cng p lc thi im tng ng vi sc
bn thnh mch. Bnh thng sc bn thnh mch bng khong 20cm Hg. Nu d-
i 15cm Hg l sc bn thnh mch gim.
3.2. Xut huyt nim mc - ni tng v t chc:
Hi v quan st tnh trng xut huyt :
+ Xut huyt nim mc: mt, mi, ming, li; hi v quan st mu sc phn,
nc tiu hoc cht nn, nh gi.
+ Xut huyt ni tng: da vo cc triu chng lm sng xc nh tnh trng c
xut huyt c quan ni tng hay khng? V d: tnh trng m mt, nhc u, lit
na ngi hoc hn m xut hin nhanh hoc t ngt (thng do chy mu
no), ho ra mu.
+ Xut huyt trong t chc: trong c, trong bao khp...
4. Nguyn nhn v bnh sinh gy xut huyt.
+ C ch gy xut huyt thuc ba loi sau y:
- Do tn thng thnh mch bm sinh hoc mc phi
- Do gim s lng hoc cht lng tiu cu.
- Do ri lon ng mu.
+ Nhng nguyn nhn gy xut huyt:
- Do cc bnh nhim khun: nhim khun huyt do no m, bnh bch hu,
thng hn, bnh si, st xut huyt...
- Do thiu vitamin C, PP.
- Do bnh min dch, d ng, v d: vim thnh mch d ng.
- Mt s bnh ni khoa nh: lao, i tho ng, x gan, suy thn...
- Cc bnh do thiu ht cc yu t ng mu ca huyt tng, v d: hemophilie
A, B, C, ...gim prothrombin, proconvertin...
- Bnh tiu cu: gim tiu cu nguyn pht, suy nhc tiu cu (Glanzmann).
- Do xut hin hi chng ng mu ri rc trong lng mch (do nhiu nguyn
nhn khc nhau).
- Cn gp trong ngoi khoa, sn khoa, chuyn khoa khc.
5. Xt nghim cn lm.
5.1. Thi gian mu chy (MC):
Theo phng php Duke: rch di tai 1 vt di 0,5cm su 1mm. Thi gian mu
chy l thi gian t khi bt u rch da cho n khi mu t ngng chy.
Bnh thng thi gian MC = 3 - 4 pht, nu trn hoc bng 6 pht l ko di.
Mu chy ko di gp trong bnh ca thnh mch, ca tiu cu v bnh
Willerbrand.
5.2. S lng tiu cu:
nh thng ngi ta c s lng tiu cu: 150 - 300 G/l
+ Nu TC < 150 G/l l gim.
Gim tiu cu gp trong nhiu bnh khc nhau: gim tiu cu min dch, cng
lch, bnh suy ty, bnh bch cu...
+ Tng tiu cu thng gp trong hi chng tng sinh ty c tnh, sau chy mu...
5.3. Cht lng tiu cu:
C rt nhiu xt nghim nh gi cht lng tiu cu t n gin n rt phc
tp. Trong lm sng ch s dng mt s xt nghim sau:
+ Hnh thi tiu cu: bnh thng tiu cu l nhng mnh t bo nh hnh trn,
tam gic, hnh sao... c cha nhng ht bt mu tm khi nhum giemsa, ng
knh khong 2 - 3 m. Trong bnh l c th gp cc tiu cu khng l to bng hoc
hn HC, TC khng c ht... Khi c trn 10% TC c hnh thi bt thng nh trn l
chc chn c bnh l.
+ tp trung tiu cu: bnh thng trn phin knh nhum giemsa thy tiu cu
ng tp trung thnh tng m to nh khc nhau, ni chung mt vi trng nhn
thy trn 10 tiu cu. Khi bnh l th tiu cu nm ri rc, di 10 tiu cu mt vi
trng.
+ Thi gian co cc mu: Bnh thng mu ng b m 37
o
C sau 1-3 th gi
cc mu co li hon ton (di tc ng ca men retractozyme ca tiu cu);
trong bnh l tiu cu th cc mu khng co hoc co khng hon ton. Ngoi ra
cc mu co khng hon ton cn gp trong bnh a hng cu; co sn si gp
trong nhim c hay bnh gan, co nt vn trong gim fibrinogen; co nhanh, mnh
trong thiu mu, tc mch, sau m lch...
Ngoi ra cn nhiu xt nghim chc nng tiu cu khc nh: chuyn dng nht,
kt dnh, ngng tp (di tc dng ca ADP, collagen, epinephrin...) nhng nhng
xt nghim ny hin nay cn cha p dng thng quy a s cc bnh vin.
5.4. Thi gian mu ng (M):
L thi gian tnh t khi mu ly ra khi c th khng chng ng cho n khi ng
hon ton.
Phng php Milian: dng 2 phin knh, mi phin mt git mu nhit
phng.
Phng php Lee-White: dng hai ng nghim, mi ng 2ml mu khng chng
ng trong b m 37
o
C .
Bnh thng M = 7 - 10 pht.
Thi gian mu ng dng thm d tt c cc yu t ng mu .
5.5. Thi gian Howell:
L thi gian ng ca huyt tng ly mt canxi nay canxi ho tr li.
Bnh thng thi gian Howell = 1pht 30giy - 2pht 15giy. Ngi ta c th so
snh vi chng l huyt tng ngi bnh thng (c gi l bnh l khi thi
gian Howell ko di qu 15% so vi chng).
Thi gian Howell cng thm d tt c cc yu t ng mu .
5.6. Thi gian Quick v t l prothrombin:
Thi gian Quick l thi gian ng ca huyt tng ly mt canxi nay canxi ho
tr li trong mi trng d tha thromboplastin. V ph thuc vo mu
thromboplastin mi t xt nghim mt khc nn kt qu phi so snh vi chng
ngi bnh thng c thi gian Quick nm trong khong t 11-16 giy.
nh thng t l prothrombin = 80 - 100%, di 75% l gim.
Thi gian Quick hoc t l prothrombin dng thm d cc yu t ng mu II,
V, VII v X (nh gi ng mu ngoi sinh).
5.7. Thi gian aPTT (activative partial thromboplastin time):
L test thm d yu t XI, IX v XIII tc l thm d cc yu t ng mu ni
sinh.
nh thng thi gian aPTT khong 50-55 giy. C th so snh vi chng ngi
kho (c gi l bnh l khi thi gian aPTT ko di so vi chng qu 15%).
Thi gian aPTT ko di gp trong cc bnh hemophilie. Cn c th ko di khi
thiu ht yu t XII, prekallikrein, HMWK, nhng s thiu ht cc yu t ny
khng gy bnh l xut huyt.
5.8. nh lng fibrinogen:
Bnh thng fibrinogen = 2 - 4g/l. Di 2g/l l gim, thng gp trong cc bnh
gim fibrinogen bm sinh, x gan nng, tan fibrin tin pht, ng mu ri rc lng
mch ...
5.9. Nghim php ru:
Nguyn l: huyt thanh cho thm cn ethylic 70
o
v t 4
0
C th phc hp
fibrinmonomer v cc sn phm thoi bin fibrin/fibrinogen ang trng thi ho
tan s tr nn khng ho tan na (b gel ho).
Nghim php ru (+) trong ng mu ri rc trong lng mch.


25. S LC MU V H LYMPHO

Mu chy vo cc ng mch v tnh mch v n l cc phng tin vn chuyn
chnh trong c th. Mu mang oxy t phi n m v vn chuyn CO2 t m
n phi. Mu vn chuyn cht dinh dng, mui v cc hormone n cc c
quan, v ly i cc cht thi do cc c quan bi tit. H lympho hu nh hot
ng song song vi h tun hon. N tp hp cc dch tha t cc m v a
chng tr li mu, v lc b cc vt th l.


Mu

Mu thay i mu t mu chi trong cc ng mch sang mu sm hn
trong cc tnh mch. Mt ngi ln trung bnh c khong 5 lt mu. C th c th
thay th th tch mu mt cch nhanh chng, th d sau khi cho mu, ch mt
i ba ngy l to thnh 0,5 lt mu.

Thnh phn ca mu

Mu gm hai phn: Dch v cc t bo. Huyt tng l phn dch ging nh mu
tri du do n cha sc t c bit nh l haemoglobin. Chc nng chnh ca
cc hng cu l vn chuyn oxy khp c th. Bch cu ch yu c xem nh h
thng bo v c th, chng li vi nhim trng. C 6 loi bch cu khc nhau, mi
loi c mt vai tr c bit. Kch thc tiu cu khong 1/3 hng cu v chng
lin quan n ng mu: sau mt chn thng, chng kt li vi nhau ngng
chy mu

Nhm mu

Da vo cht ho hc c gi l cc khng nguyn hin din trn b mt hng
cu, mu ca mi ngi c th c xp thnh hoc nhm A, B, AB hay O. Cc
cht ho hc khc trong mu nh yu t Rhesus, phn bit hn na gia cc
nhm mu. Nhm mu thng thng nht l nhm O+, nhm ny c 38% dn
s M, v him nht l nhm AB- , ch chim 1% dn s.

S hnh thnh t bo mu

Tu xng l mt cht mm ging nh keo c thy trong cc hc ca mt s
xng trong c th, gm xng chu, xng s, xng c, cc xng cnh tay v
cng chn, xng sn v xng sng. Hng cu, bch cu v tiu cu tt c u
c sn xut trong tu xng t dng n l c bit gi l t bo gc.

Hng cu c i sng khong 4 thng, tu xng thay th tt c cc tiu cu trong
mu mi 10 ngy. Hng cu b ph hu bi cc bch cu c bit c gi l i
thc bo, v khong 180 triu hng cu b ph hu mi pht. St t cc hng cu
b ph hu c vn chuyn n lch ti sn xut li.

H lympho

Bch huyt l mt cht dch trong c th ging nh sa c cha cc t bo
lympho (cc bch cu lin quan n vic chng li s nhim trng), cc protein v
m. Dch d tha r khi dng mu c thu dn li bi h lympho v a tr li
mu qua hai mch mu chnh l ng bch huyt bn phi v ng ngc, n gip
duy tr cn bng dch trong c th .

H bch huyt gm mng li bch mch, cc m bch huyt v cc hch lympho.
Chc nng ch yu ca n l lc b cc sinh vt c th gy nhim trng, sn xut
cc t bo lympho, v dn lu dch v protein t cc m trnh ph. Cc bch
mch c cc cu trc nh hnh bu dc c gi l cc hch bch huyt, phn b
dc theo chiu di ca chng. Hu ht cc hch ny nm c, nch, bn v bng.

Lch, l c quan ln nht trong h bch huyt, c tm thy trong phn t trn
tri ca bng. N sn xut mt vi t bo bch cu, d tr mu, ph hy cc hng
cu gi v ng thi a st tr v dng mu.

CHNG 3. BNH L HUYT HC



26. HI CHNG DIC

ThS.BS.Huznh Th Thanh Trang
1. I CNG:
Cn gi l ng mu ri rc trong lng mch (DIC: Disseminated
Intravascular Coagulation)
nh ngha: ng mu ri rc trong lng mch c c trng bi s kch
hot h thng ng mu, hu qu to v lng ng Fibrin, thnh lp huyt
khi vi mch nhiu c quan trong c th dn ti tnh trng nghn tc
mch v xut huyt do gim trm trng cc yu t ng mu
Khng mt xt nghim duy nht no nhy v c hiu chn on
iu tr nguyn nhn l ch yu
2. SINH L BNH - NGUYN NHN:




AT III: Antithrombin III
IL: Interleukin
PAI-1: Plasminogen Activator Inhibitor-1
PDF: Fibrinogen Degradation Product
TNF: Tumor Necrosis Factor

3. CHN ON DIC:
3.1- C mt bnh chnh c th gy DIC nh:
Thai cht lu, ung th, sc, bnh bch cu, rn cn, tai bin truyn mu,
chn thng nng
3.2- Lm sng:
Hi chng xut huyt
Sc, hoi t u chi
Ri lon chc nng a c quan (gan, thn, phi)
3.3- Cn lm sng:
Khng mt xt nghim duy nht no nhy v c hiu chn on
Tng Fibrin ha tan: nhy 90-100% nhng c hiu rt thp
PDF: khng c hiu v dng tnh trong phn ng vim
D-Dimer: Khng phn bit c DIC vi chn thng, v sau phu thut
Chn on DIC khi c:
o S lng tiu cu: gim
o Thi gian Prothrombin (TP) ko di
o Thi gian thromboplastin tng phn hot ha (TCA) ko di
o Fibrinogen gim
o D-Dimer tng
o AT III gim
o PDF tng
o Nghim php ru dng tnh
3.4- Phc chn on:


3.5-Chn on phn bit:
Hi chng tn huyt
Ri lon ng mu, khng gim tiu cu
Ban xut huyt gim tiu cu min dch
Ban xut huyt gim tiu cu huyt khi
4. X TR:
4.1- Nguyn tc: iu tr nguyn do l ch yu
4.2- iu tr:
4.2.1-iu tr thay th:
Truyn huyt tng ti ng lnh: 10-15ml/kg/24 gi (# 3-4 n v/24 gi
cho ngi 50Kg). Truyn tnh mch nhanh 80-100 git pht sau khi r ng.
Kt ta lnh yu t VIII: truyn khi Fibrinogen < 1g/dl
Tiu cu: truyn khi tiu cu < 20G/l v / hoc c xut huyt nng
C mi 6 gi xt nghim kim tra TP, TCA, Fibrinogen, tiu cu mt ln

APC: Khng Protein C hot ha

4.2.2- Thuc chng ng:
Chng ng khi c to huyt khi l hp l
Cn bn ci khi bnh nhn c chy mu
Ch nh khi r rng bnh nhn c tc mch v c lng ng Fibrin lan ta
(nhim no m cu), xt nghim D- Dimer tng, nghim php ru dng
tnh v khi DIC xy ra > 6 gi
Thuc: Heparin TLPTT (Fraxiparine) 50-100 UI antiXa/kg/12 gi TDD 2
ln/24 gi
Ngng iu tr khi D-Dimer tr v bnh thng, nghim php ru m tnh,
s lng tiu cu tng tr li.
Thuc chng ng mi:
o TFPI (Tissue Factor Pathway Inhibitor) ti t hp
o NAP (Nematode Anticoagulant Protein)
4.2.3- Ti lp c ch chng ng:
S dng Antithrombin III m c, c hiu qu trong nhim trng, sc lm
gim thi gian DIC, ci thin chc nng cc c quan
Khng Protein C hot ha (APC) m c: ci thin ng mu, gim t vong
(nht l trong nhim trng)
4.2.4- Thuc chng tiu si huyt:
Khng hp l
Ch nh khi c tiu si huyt th pht r rng (Bch cu cp M3, ung th),
lm sng c xut huyt trm trng, xt nghim Fibrinogen tip tc gim, D-
Dimer tip tc tng
S dng Transamine tim tnh mch vi liu 10 mg /kg x 2-4 ln / 24 gi
(Tranex 250mg 1-2 ng x 2-4 ln/ 24 gi)
4.2.5- Cc liu php h tr khc:
Khi phc th tch tun hon
Duy tr thng bng kim toan
S dng Vitamin K v Folate
TI LIU THAM KHO:

1. Trn Vn (2003). nh bnh hi chng chy mu. Thc hnh huyt hc v
truyn mu. Tr 283
2. Trn Vn nh (2003). Nhng quan im mi v ng mu ni mch- Bi ging
sau i hc.
3. Levi M. et al (2006). Disseminated Intravascular Coagulation. eMedicine
Specialties.
4. Lichtman M.A. et al (2007). Disseminated Intravascular Coagulation: Overview.
Williams Hematology. Seven Edition
5. Michelson A.D. et al (2007). Platelet. Storage and transfusion. Platelets. Second
Edition. p 1278
6. Trn Th Ngc Thu (2004). Ri lon ng mu trong cp cu ni khoa-Hi chng
ng mu ni mch lan ta. Hi sc cp cu ni khoa. B mn ni i hc y dc
Tp HCM. Tr 105-113
7. Nguyn Anh Tr (2006). Phc chn on v iu tr ng mu ri rc trong
lng mch. Mt s chuyn huyt hc truyn mu. Tp 2. Tr 143-145


27. XUT HUYT GIM TIU CU T MIN

Ban xut huyt gim tiu cu t pht (ITP) l cc trng hp xut huyt gim
tiu cu tin pht, khng r nguyn nhn, loi tr cc trng hp gim tiu cu
th pht sau mt bnh r rng :
1. Chn on
1.1. Lm sng :
- Bnh xy ra t t, hoc nhanh, cp hoc mn tnh.
- Xut huyt :
+ Di da : Chm, nt, mng bm mu.
+ Nim mc : Chy mu mi, li, chn rng.
+ Ni tng : No, mng no, phi, tiu ho, tit niu, sinh dc (a kinh, rong
kinh).
+ Thiu mu tng xng vi mc chy mu.
+ Gan, lch, hch khng to.
1.2. Cn lm sng :
- Mu chy ko di.
- S lng tiu cu di 100 x 10
9
/l
- Tu bnh thng hoc tng mu tiu cu.
2. iu tr :
2.1. iu tr c hiu :
+ Trng hp cp :
- S lng tiu cu < 20 x 10
9
/l
Solumedrol 5mg/kg/ngy trong 5 ngy
Sau Prednisolon 2mg/kg/ngy trong 2 tun
Ri gim liu v ngng thuc sau 4 tun.
- S lng tiu cu > 20 x 10
9
/l
Prednisolon 2mg/kg/ngy trong 3 tun.
Ri gim liu v ngng thuc sau 4 tun.
+ Trng hp mn tnh : Gim tiu cu dai dng trn 6 thng
- S lng tiu cu < 50 x 10
9
/l
+ Xut huyt nng :
Dng li mt t nh xut huyt gim tiu cu cp hoc Imumunoglobulin tim
tnh mch 1g/kg/ngy truyn chm 8 12 gi trong 2 ngy.
Sau kt hp dng cc thuc gim min dch khc nh :
Azathioprin 2mg/kg/ngy trong 3 4 thng hoc
Sandimum Neoral 2mg/kg/ngy trong 4 6 thng.
+ Xut huyt nh :
Prednisolon 0,1mg/kg/ngy.
Kt hp vi cc thuc min dch khc (azathioprin, Sandimum Neoral).
- S lng tiu cu > 50 x 10
9
/l, khng xut huyt :
Khng dng thuc.
Theo di nh kz.
Hn ch hot ng mnh nh th dc th thao.
- Ch nh ct lch :
+ C nhiu t xut huyt nng e do tnh mng.
+ Dng thuc khng p ng sau 6 thng.
+ Tr trn 5 tui.
2.2. iu tr h tr :
- Cm mu ti ch :
+ Chy mu mi : nht gc hoc Gelaspon mi trc.
+ R mu chn rng : p cht bng c tm Adrenalin vo ni chy mu.
- Truyn khi tiu cu :
Khi xut huyt nng :Tiu ho, thn, tit niu
1v/5 10kg cn nng.
2.3. Chm sc v theo di :
- Ngh ngi ti ging, hn ch vn ng.
- V sinh rng ming.
- Trnh n nhng thc n gy xc nim mc ming, li nh ma
- Theo di tnh trng xut huyt, mc mt mu.
- Hn khm nh kz.

28. BNH THIU MEN G6PD

(G6PD = Glucose - 6 - Phosphate Dehydrogenase)
I. I CNG
1. Bi cnh:
Thiu Glucose - 6 - phosphatase dehydrogenase (G
6
PD) l bnh l v men thng
gp nht ngi. Di truyn theo nhim sc th X, thiu G
6
PD gy bnh cho
khong 400 triu ngi trn th gii. Bnh rt a dng vi hn 300 bin th
c bo co. Bnh mang li s bo v chng st rt c th do tn s gen cao ca
n.
2. Sinh bnh hc:
Men G
6
PD xc tc s oxy ho ca glucose - 6 - phosphate thnh 6 -
phosphogluconate v ng thi kh dng oxy ho ca nicotinamide adenine
dinucleotide phosphate (NADP+) thnh nicotinamide adenine dinucleotide
phosphate (NADPH). NADPH, mt ng yu t cn thit trong nhiu phn ng
sinh tng hp, gi glutathione dng kh oxy ca n.
Glutathione - kh ng vai tr dn dp cc cht chuyn ho c tnh oxy - ho
nguy him trong t bo. Vi s tr gip ca men glutathione peroxidase,
glutathione - kh cng chuyn cht hydrogen peroxide nguy hi thnh nc.
Hng cu l thuc rt nhiu vo hot ng ca G
6
PD v y l ngun NADPH duy
nht bo v t bo chng li nhng cht oxy - ho. Do , khng c k toa
thuc c tnh cht oxy - ho cho ngi b thiu G
6
PD v hng cu ca h s b tn
huyt nhanh chng di tc dng oxy-ho ny. Cc loi thiu G
6
PD bao gm loi
thp, loi trung bnh v loi c lng men tng cao.
3. Tn s xut hin:
T l mc bnh cao nht (vi tn s gen t 5-25%) gp Chu Phi nhit i, vng
Trung ng, Chu nhit i v cn nhit i, mt s vng quanh a Trung Hi
v Papua New Guinea.
4. T vong / Bnh Tt:
Khng triu chng l bnh cnh thng gp nht. Cc bnh nhn c triu chng
biu hin di dng vng da s sinh v thiu mu tn huyt cp.
- Vng da s sinh: Vng da thng xut hin trong vng t 1-4 ngy cng thi
gian hoc hi sm hn vng da sinh l{. Kernicterus l bin chng him gp.
- Thiu mu tn huyt cp: Biu hin lm sng l hu qu ca nhng tc nhn gy
stress trn hng cu nh thuc hoc cc ho cht c tnh oxy - ho, bnh nhim
trng hoc n mn u fve.
5. Chng tc
Thiu G
6
PD xy ra mi chng tc. Nhiu nht ngi Chu Phi, Chu hoc
nhng sc dn ven a Trung Hi. nng ca bnh thay i gia cc nhm sc
tc do c nhiu bin th ca men.
6. Gii tnh
Thiu G
6
PD l mt bnh di truyn lin quan n nhim sc th X gii tnh, gp ch
yu n ng.
Ph n ng hp t (Homozygous women) gp qun th c tn s G
6
PD cao.
Ph n d hp t (Heterozygous (carrier) women) c th b nhng t tn huyt.
II. LM SNG
1. Bnh s:
a s cc bnh nhn u khng triu chng. Mt s bnh nhn c vng da s sinh
hoc tin s vng da s sinh, i khi cn phi truyn i mu (exchange
transfusion). Tin s nhim trng hoc tn huyt do thuc cng thng gp. C
th c nhiu si mt, lch c th to.
2. Lm sng:
Vng da v lch to c th hin din trong cn.
3. Nguyn nhn:
Thiu G
6
PD l mt bnh l di truyn. C s phn t ca vic thiu G
6
PD l hu qu
ca t bin v tr G
6
PD ti Xq28. Gen ny di 18 kilobaz vi 13 exons (chui DNA
thng tin), dn n mt men c 515 acid amin. a s cc t bin l nhng thay
i baz n dn n kt qu thay th bng mt acid amin.
III. CHN ON PHN BIT
- Thiu mu tn huyt.
- Thiu mu hng cu lim.
- Bnh hng cu hnh cu, di truyn (spherocytosis).
IV. CN LM SNG
1. Xt nghim:
o hot ng hin ti ca men G
6
PD hn l lng protein G
6
PD. Thc hin cc xt
nghim v G
6
PD trong t tn huyt v phn ng hng cu li c th ch nh
hng n mc m khng phn nh gi tr c bn.
Xt nghim cng thc mu v m hng cu li xc nh mc thiu mu
v chc nng ca tu xng.
Bilirubine gin tip trong mu tng khi c phn hu hemoglobine qu mc v gy
vng da.
Lng haptoglobin trong huyt thanh, ch im ca tn huyt, s gim xung.
2. Chn on hnh nh: Siu m bng gip nh gi lch to v si mt.
3. M Hc: Tn huyt cp do thiu G
6
PD i km vi vic hnh thnh cc th Heinz
(Heinz bodies), do hemoglobin thoi ho to thnh.
V. IU TR
1. Ni Khoa: Ch yu l nhn dng v ngng ngay cc tc nhn gy tn huyt.
iu tr bng th oxygen v ngh ngi ti ging c th lm gim nh triu chng.
2. Hi chn:
- Chuyn khoa Huyt hc.
- Chuyn khoa Di truyn hc.
3. Ch n:
Trnh n u Fve. Bnh Favism (do n u Fve gy tn huyt ngi thiu
G
6
PD) ch xy ra th thiu G
6
PD a Trung Hi.
4. Hot ng: Hn ch hot ng th lc khi c thiu mu nng do tn huyt.
VI. THUC
Cc d liu cho thy vng da s sinh thiu G
6
PD l hu qu ca mt cn i gia
s sn xut v lin hp ca bilirubin (conjugation of bilirubin) vi khuynh hng
lin hp bilirubin khng theo kp vi tc tn huyt.
Tr sinh thiu thng c bit c nguy c cao mt cn i gia sn xut v lin hp
ca bilirubin. iu tr bao gm ung phenobarbital d phng, iu tr bng nh
sng (phototherapy) v truyn i mu tr s sinh thiu G
6
PD.
VII. THEO DI
1. Chm sc ni tr
- Tr em c vng da s sinh ko di c chiu n c bit (bili lights) bt
vng da.
- Truyn i mu c th cn thit trong trng hp vng da s sinh nng hoc
thiu mu tn huyt do thiu G
6
PD.
2. Thuc ni / Ngoi tr:
Cht tng t heme nh Sn-mesoporphyrin c ch sn xut bilirubin hiu qu
tr s sinh.
3. Phng trnh:
- Trnh cc thuc oxy - ho nh thuc khng st rt primaquine, chloroquine,
pamaquine v pentaquine.
- Trnh nitrofurantoin.
- Trnh nalidixic acid, ciprofloxacin, niridazole, norfloxacin, methylene blue,
chloramphenicol, phenazopyridine, v cc cht tng t vitamin K (vitamin K
analogs).
- Trnh sulfonamide nh sulfanilamide, sulfamethoxypyridazine, sulfacetamide,
sulfadimidine, sulfapyridine, sulfamerazine v sulfamethoxazole.
- Trnh tip xc vi mt s ho cht nh long no, cht dit mi.
- Cc cht sau y cng nn trnh khi thiu men G
6
PD:
. Acetanilid
. Doxorubicin
. Isobutyl nitrite
. Naphthalene
. Phenylhydrazine
. Pyridium
4. Danh mc cc thuc c nguy c gy tn huyt bnh nhn thiu men G
6
PD:
TT Tn thuc Cng thc
phn t
Mc
nguy c
Dng thiu
G6PD
1 Acetanilide (Acetanilid) C
8
H
9
NO Cao a Trung Hi
Chu
2 Acetylphenylhydrazine
(2-Phynylacetohydrazide)
C
8
H
10
N
2
O Cao Tt c
3 Aldesulfone sodium
(Sulfoxone)
C
14
H
14
N
2
Na
2
O
6
S
3
Cao Tt c
4 Aminophenazone
(Aminopyrine)
C
13
H
17
N
3
O Thp Tt c
5 Antazoline (Antistine) C
17
H
19
N
3
Thp Tt c
6 Arsenic As-H
3
Cao Tt c
7 Ascorbic Acid C
6
H
8
O
6
Thp Tt c
8 Beta-Naphthol
(2-Naphthol)
C
10
H
8
O Cao Tt c
9 Chloramphenicol C
11
H
12
C
12
N
2
O
5
Cao a Trung Hi
Chu
10 Chloroquine C
18
H
26
ClN
3
Cao a Trung Hi
Chu
11 Ciprofloxacin C
17
H
18
FN
3
O
3
Cao a Trung Hi
Chu
12 Colchicine C
22
H
25
NO
6
Thp Tt c
13 Dapsone
(Diaphenylsulfone)
C
12
H
12
N
2
O
2
S Cao Tt c
14 Dimercaprol C
3
H
8
OS
2
Cao Tt c
15 Diphenhydramine
(Difenilhydramine)
C
17
H
21
NO Thp Tt c
16 Dopamine (L-dopa) C
8
H
11
NO
2
Thp Tt c
17 Doxorubicin C
27
H
29
NO
11
Cao a Trung Hi
Chu
18 Furazolidone C
8
H
7
N
3
O
5
Cao Tt c
19 Glibenclamide C
32
H
28
ClN
3
O
5
S Cao a Trung Hi
Chu
20 Glucosulfone
(Glucosulfone sodium)
C
24
H
34
N
2
Na
2
O
18
S
3
Cao Tt c
21 Isobutyl Nitrite C
4
H
9
NO
2
Cao a Trung Hi
Chu
22 Isoniazid C
6
H
7
N
3
O Thp Tt c
23 Menadiol Sodium Sulfate
(Vitamin k4 sodium
sulfate)
C
11
H
8
Na
2
O
8
S
2
Cao Tt c
24 Menadione (Menaphtone) C
11
H
8
O
2
Cao Tt c
25 Menadione sodium
Bisulfite (Vitamin K3
sodium bisulfite)
C
11
H
8
O
2
NaHSO
3
Cao Tt c
26 Mepacrine (Quinacrine) C
23
H
3
OClN
3
O Cao a Trung Hi
Chu
27 Mesalazine -5-
Aminosalicylic Acid
(Paraminosalicylic acid)
C
7
H
7
NO
3
Cao a Trung Hi
Chu
28 Methyltioninium Chloride
(Methylene blue)
C
16
H
18
ClN
3
S Cao Tt c
29 Nalidixic Acidb C
12
H
12
N
2
O
3
Cao a Trung Hi
Chu
30 Naphtalene, Pure
(Naphtalin)
C
10
H
8
Cao Tt c
31 Niridazole C
6
H
6
N
4
O
3
S Cao Tt c
32 Nitrofural (Nitrofurazone) C
6
H
6
N
4
O
4
Cao Tt c
33 Nitrofurantoin C
8
H
6
N
4
O
5
Cao Tt c
34 Norfloxacin C
16
H
18
FN
3
O
3
Thp Tt c
35 O-Acetylsalicylic Acid
(Acetylsalicylic acid)
C9 H8 O4 Cao a Trung Hi
Chu
36 Oxidase, Urate
(Urate oxidase)
Cao a Trung Hi
Chu
37 Pamaquine C
42
H
45
N
3
O
7
Cao Tt c
38 Para-Aminobenzoic Acid
(4- Aminobenzoic Acid)
C
7
H
7
NO
2
Thp Tt c
39 Paracetamol
(Acetaminophen)
C
8
H
9
NO
2
Thp Tt c
40 Pentaquine C
18
H
27
N
3
O Cao Tt c
41 Phenacetin
(Acetophenetidin)
C
10
H
13
NO
2
Cao a Trung Hi
Chu
42 Phenazone (Antipyrine) C
11
H
12
N
2
O Thp Tt c
43 Phenazopyridine C
11
H
11
N
5
Cao a Trung Hi
Chu
44 Phenylbutazone C
19
H
20
N
2
O
2
Thp Tt c
45 Phenytoin C
19
H
20
N
2
O
2
Thp Tt c
46 Phynylhydrazine C
6
H
8
N
2
Cao Tt c
47 Phytomenadione
(Vitamin K1)
C
31
H
46
O
2
Thp Tt c
48 Primaquine C
15
H
21
N
3
O Cao Tt c
49 Probenecid C
13
H
19
NO
4
S Thp Tt c
50 Procainamide C
13
H
21
N
3
O Thp Tt c
51 Proguanil
(Chlorguanidine)
C
11
H
16
ClN
5
Thp Tt c
52 Pyrimethamine C
12
H
13
ClN
4
Thp Tt c
53 Quinidine C
20
H
24
N
2
O
2
Thp Tt c
54 Quinine C
20
H
24
N
2
O
2
Thp Tt c
55 Stibophen (2-Oxido-3,5-
Disulphonatophenoxy)-
1,3,2,Benzodioxastibole
4-6-Disulphonate)
C
12
H
4
Na
5
O
16
S
4
Sb Cao Tt c
56 Streptomycin C
21
H
39
N
7
O
12
Thp Tt c
57 Sulfacetamide C
8
H
10
N
2
O
3
S Cao Tt c
58 Sulfacytine C
12
H
14
N
4
O
3
S Thp Tt c
59 Sulfadiazine C
10
H
10
N
4
O
2
S Thp Tt c
60 Sulfadimidine C
12
H
14
N
4
O
2
S Cao Tt c
61 Sulfafurazole
(Sulfafurazone,
C
11
H
13
N
3
O
3
S Cao a Trung Hi
Sulfisoxazole) Chu
62 Sulfaguanidine C
7
H
10
N
4
O
2
S Thp Tt c
63 Sulfamerazine C
11
H
12
N
4
O
2
S Thp Tt c
64 Sulfamethoxazol C
10
H
11
N
3
O
3
S Cao Tt c
65 Sulfamethoxypyridazine C
11
H
12
N
4
O
3
S Thp Tt c
66 Sulfanilamide
(Sulphanilamide)
C
6
H
8
N
2
O
2
S Cao Tt c
67 Sulfapyridine C
11
H
11
N
3
O
2
S Cao Tt c
68 Sulfasalazine,
Salazosulfapyridine
(Salazopyrin)
C
18
H
14
N
4
O
5
S Cao Tt c
69 Thiazosulfone
(Thiazolesulfone)
C
9
H
9
N
3
O
2
S
2
Cao a Trung Hi
Chu
70 Tiaprofenic Acid C
14
H
12
O
3
S Thp Tt c
71 Tolonium Chloride,
Tolonium Chloride
(Toluidine blue)
C
15
H
16
ClN
3
S

Cao Tt c
72 Trihexyphynidyl
(Benzhexol)
C
20
H
31
NO Thp Tt c
73 Trimethoprim C
14
H
18
N
4
O
3
Thp Tt c
74 Trinitrotoluene
(2,4,6-Trinitrotoluene)
C
7
H
5
N
3
O
6
Cao a Trung Hi
Chu
75 Tripelennamine C
16
H
21
N
3
Cao a Trung Hi
Chu
5. Nhng thc phm trnh dng cho ngi thiu G
6
PD:
u Fve (mt s tc gi khuyn trnh dng ru vang , du xanhblueberries,
u nnh, nc tng lc).
6. Bin chng: Vng da s sinh nghim trng c th dn n kernicterus.
7. Tin lng: a s cc bnh nhn thiu G
6
PD khng cn iu tr.
8. Hng dn bnh nhn: Hng dn bnh nhn thiu G
6
PD trnh cc loi thuc
v ho cht c thgy tn huyt.
VIII. THNG TIN CN BIT
1. Ch : Trnh k n nhng thuc gy tn huyt.
2 Quan tm c bit
- Vng da s sinh i km vi thiu G
6
PD c th e do n tnh mng.
- Mt s bin th ca G
6
PD c th nguy him n tnh mng khi bnh nhn tip
xc vi cc loi thuc c tnh cht oxy - ho.

29. ULYMPHO C TNH

U lympho c tnh l bnh c tnh pht sinh t t chc lin vng lympho.
1. Khi nim v bnh.
- U lympho c tnh l bnh c tnh pht sinh t t chc lin vng lympho.
- U lympho c tnh c chia lm 2 loi:
+ U lympho c tnh khng Hodgkin - non Hodgkin: t bo c tnh thuc 3 loi: B, T,
i thc bo trong phn ln c ngun gc t Lympho B.
+ Hodgkin t bo c hiu Sternberg c ngun t bo lin vng.
2. Chn on xc nh.
a. Lm sng.
- Hch to: hch to nhanh mt nhn c xu hng dnh vo nhau thnh chm
chui km di ng do dnh vo t chc di da.
- St c th gp:
+ Vi Hodgkin st thng din ra tng t (2 - 7 ngy) sau mt thi kz li st
li kiu hi qui.
+ Vi non - Hodgkin: st thng xut hin mun, khng mang tnh hi qui.
- Ra m hi trm, thng v m ra nhiu khng lin quan n hot ng th lc.
- Gim st cn: st 10% trng lng c th trong 6 thng gn nht m khng l
gii c l mt triu chng quan trng tin lng bnh.
- Nga khng p ng vi khng Histamin.
- Cc triu chng khc:
+ Gan to, lch to, tn thng da c th gp nhng tn suet t.
+ au xng ri lon tiu ha i khi xut hin sm ngay t u.
+ Nhim khun thng gp giai on mun.
b.Cn lm sng.
- Sinh thit hch c { ngha quyt nh chn on bnh, th bnh v mc c
tnh:
+ Hodgkin: c trng l t bo Sternberg t bo kch thc ln nguyn sinh cht
rng, bt mu kim, co mt kay nhiu nhn, nhn to c ht nhn, c khong sng
quanh nhn, li nhn th.
+ Non - Hodgkin: thy tng mnh t bo dng lympho, hnh thi t bo mang c
im t bo ung th, ph v cu trc hch, cc bao hch b ph v..
3. Chn on giai on lm sng

Giai on Biu hin hch
Biu hin ton
thn: St, gy
st cn, m hi
trm
Giai on 1
Tn thng mt nhm hch
mt pha ca c honh
- Khi ch c hch
khng c triu
chng ton thn
l giai on A.
- C hch to v
c t nht mt
triu chng ton
thn l giai on
B.
Giai on 2
tn thng t 2 nhm hch tr
ln khng k nhau nhng vn
mt pha ca c honh
Giai on 3
Tn thng cc nhm hch
hai pha c honh
Giai on 4
Tn thng cc nhm hch
ngoi vi v tn thng ph
tng

4. Phn loi cc th theo lm sng.

- Th hch nng.
- Th hch trung tht.
- Th da.
- Th bng.
- Th d dy rut.
- Th thn kinh.
- Th xng.
- Th lch to.
5. Chn on phn bit.
- Lao hch.
- Ung th biu m di cn vo hch.
- Hch phn ng.
- Hch to trong bnh BC lympho cp mn.
- Hch trong bnh tng n nhn nhim khun.
6. Tin lng.
- Non - Hodgkin c tin lng xu hn Hodgkin.
- Tin lng cn ph thuc vo mc c tnh v th bnh v giai on bnh.
7. iu tr.
a. Cc phng php iu tr:
- Phu thut ct b hch b tn thng cng cc hch ln cn: ngy nay ch p
dng mt s trng hp: d dy rut, mc c tnh thp cn khu tr.
- Quang tuyn liu php.
- Ha tr liu.
- Lm tng kh nng min dch ca c th.
b.Phc iu tr ha tr liu.
- Phc VCP:
+ V: Vincristin 1mg x 2 l truyn vi HT mn x 1 tun 1 ln x 2 tun.
+ C: Cyclophosphamid 200 mg/ngy x 4 - 5 ngy. Hoc Endoxan 400mg/ngy x 2
ngy.
+ Prednisolon: Solumedrol 40mg x 2 l ~ 1.6mg/kg vi ngi 50kg hoc x 3 l ~
2mg/kg vi ngi 60kg.
iu tr trong 2 tun.
- Phc CHOP:
+ C: Cyclophosphamid 400 mg/ngy N1 v N2.
+ H: Hydroxydaunorubicin l 10mg x 3 l/ngy. N1 v N2.
+ O:Oncovin (Vincristin ) 1mg x 2 l. N1.
+ P: Prednisolon (Solumedrol) 40mg x 2 hoc 3 ng ( ~ 1.5 - 2mg/kg) truyn tnh
mch x 5 ngy.
Tt c cc thuc trn pha ring bit nhau: 500 ml nc mui sinh l b i 200 ml
pha thuc truyn ht thuc ny n thuc tip theo.
Prednisolon 2 l truyn trc tin mt l 1 l sau cng truyn trong mt ngy.
Ngy u tin dng 4 thuc. Ngy th 2 truyn nt theo ch nh. Ngy th 3, 4, 5
iu tr theo n cc thuc cn li.
Sau 2 - 3 tun tr li iu tr mt t tip theo. Mt liu trnh iu tr 6 - 8 thng.
- Cc tc dng khng mong mun:
+ Suy ty, gim sn ty.
+ Gim cc dng.
+ Da kh, rng tc.
+ Gy xng, tha xng, i tho ng, rng rng, HA cao, gim ham mun
tnh dc.




30. THIU MU

Dr.Thanh
I - I CNG :

1. nh ngha:
Thiu mu (TM) l hin tng gim lng huyt sc t (HST) v lng hng cu
(HC) trong mu ngoi vi , dn n thiu O2 cung cp cho cc m tb trong c th .
trong gim lng HST l quan trng nht v HST l Hem vn chuyn O2.
- HC v Hematocrit l nhng ch s phn nh khng trung thnh ca thiu mu v
nng HST trung bnh HC (MCHC), th tch trung bnh HC(MCV) d b thay i
theo tch cht TM v do nhng tc ng ca cc yu t khc nh: tnh trng c
c mu ( mt nc do i lng , nn ,bng ) mu b ha long vng ni cao, suy
tim kt sinh nhiu HC, a HC, HC khng l.

2. Mt s c im v sinh l hng cu v huyt sc t:
Hng cu l nhng t bo khng nhn, xem ti nh nhng chic a lm hai
mt, mu vng r. Trn phin knh nhum giemsa thy hng cu hnh trn, mu
hng, gia nht hn.
Kch thc: ng knh 7-7,5 m , dy 2,3 m.
Th tch 90-100 m3.
i sng trung bnh: 100-120 ngy.
Ni sinh sn: ty xng.
Ni phn hy: hng cu gi b phn hy ch yu ti lch, ty xng, gan. Hng
ngy c khong 0,85-1% tng s hng cu (HC gi) b phn hy (huyt tn sinh l)
v mt t l tng t hng cu tr c sinh ra thay th.
Nhim v c bn ca hng cu l vn chuyn oxy ti cc t chc thng qua vai tr
ca huyt sc t cha trong hng cu.
Huyt sc t c cu to bi heme c cha st v 4 chui globine ging nhau
tng i mt (2 chui alpha v 2 chui beta). Tnh cht ho hc ch yu ca n l
c kh nng kt hp hai chiu vi phn t oxy, v th n ng vai tr vn chuyn
oxy ti t chc.

3. Chc nng sinh l{ ca mu:
Mu l mt cht dch lu thng khp c th c cc chc nng rt quan trng v
phc tp, bao gm:
+ H hp: chuyn ch oxy v kh carbonic (oxy t phi ti cc t chc v carbonic
t t chc ti phi).
+ Dinh dng: vn chuyn cc cht dinh dng c bn: cht m, cht bo,
ng, vitamin... t rut ti t chc, t bo.
+ o thi: vn chuyn cc cht cn b ca chuyn ho ti cc t chc ti cc c
quan bi tit (thn, phi, tuyn m hi...).
+ iu ho hot ng cc c quan thng qua vn chuyn cc hormon v cc yu
t iu ho th dch khc.
+ iu ho thn nhit.
+ Bo v c th: thng qua chc nng ca bch cu, khng th v cc cht khc.
Khi lng mu trong c th ch chim 7-9% tng trng lng c th, ngi
trng thnh c khong 75ml mu trong mi kg trng lng c th.

II - NGUYN NHN TM:

1/ TM do chy mu :
- Cp tnh : sau chn thng , chy mu ng tiu ha
- Mn tnh : giun mc, tr

2/ TM do thiu yu t to mu:
2.1. Thiu mu do thiu protid hay thiu dinh dng
- Nguyn nhn : do cung cp khng ( i, suy dinh dng ) , do hp thu km(
bnh d dy, rut ) , do gim tng hp protid ( bnh gan , RLCH ) , tng thoi bin
protid , mt protid ( st , nhim khun ,bnh thn , bng ..)
- c im : Thiu mu nhc sc ,s lng HC v huyt sc t gim ph thuc
vo mc thiu mu v thiu protid , da nim mc nht nht, teo c , ph n .
Protid mu ton phn gim , Albumin gim , gamma globulin tng , C v TC ngoi
vi gim
2.2. Thiu mu do thiu st
- St l nguyn liu tng hp huyt cu t cn thit cho s trng thnh ca
HC . St t thc n dng Fe3+ ti d dy b kh bi HCl thnh Fe2+ sau hp
thu qu rut vo mu kt hp vi beta glubulin dng transferrin v c a v
d tr gan di dng Feritin
- Nguyn nhn :
+ Mt mu , chy mu ra ngoi c th
+ Cung cp thiu v nhu cu cao
+ Ri lon hp thu st : bnh DD , ct on DD hay rut ..
+ Ri lon chuyn ho st : Thiu nng tuyn gip, bnh l v gan ..
- c im:
+ Thiu mu c tnh cht nhc sc, s lng HC , huyt cu t ngoi vi gim , ch
s nhim sc gim c nhiu HC nh v HC hnh nhn
+ Trong tu xng t l nguyn HC kim tng , t l nguyn HC a sc v toan
gim
+ St huyt thanh gim
+ Thiu mu c ti sinh nhng tc v tnh trng ti sinh ph thuc vo s
cung cp nguyn liu v trng thi ca bnh nhn
2.3. Thiu mu do thiu B12 v acid folic
* Qu trnh to HC
* Thiu mu do thiu B12
- Thiu nguyn pht
+ Nguyn nhn : do thiu cht GMP d dy nn khng hp thu c B12
+ c im : Thiu mu c tnh u sc, s lng HC gim rt thp , huyt cu t
gim hn mc bnh thng, Hng cu to (macrocyte) d = 9 - 12 mm
+ Trong mu ngoi vi thy gim s lng BC v TC , xut hin HC khng l megalo
+ Thiu mu c tnh cht c tnh, s lng HC li gim thp hoc khng xut
hin
+ C RLTK nh gim tr nh , vim dy TK
- Thiu th pht :
+ Nguyn nhn : do cung cp khng y , RL hp thu ( Thiu GMP, cc bnh v
DD v rut ) .
+ c im : Thiu 12 thng kt hp vi thiu protid v thiu st nn tnh cht
thng l thiu mu nhc sc c c im nh thiu mu do thiu protid v
thiu st

3/ TM do RL c quan to mu:
- Nguyn nhn :
+ Do nhim khun nng, c t ca VSV tc ng mnh ln tu xng , thng
ch c ch tm thi
+ Do nhim c cc ho cht nh kim loi , cht c trong bnh l ca gan ,
nhim x
+ Suy nhc ty xng , lon sn tu hay tu xng b c ch, chn p trong mt
s bnh c tnh : bnh BC , K cc loi , x ho tu xng
+ Do ni tit : cng lch gy thiu mu km theo gim TC , thiu erthropoietin
vim thn mn , thiu nng tuyn gip , sinh dc , tuyn yn ..
- c im :
+ Thiu mu nhc sc , cht lng HC gim
+ Chc nng tu xng b c ch nn gim sn xut 3 dng t bo lm suy nhc
tu
- ngha
Qua thy r gi tr v v tr ca tng loi thiu mu ring bit , nhng thc t
th thiu mu thng do nhiu nguyn nhn kt hp chnh v th ngi thy
thuc phi bit phn tch tnh trng mu ngoi vi, chc nng tu xng v cc du
hiu lm sng khc xc nh yu t bnh sinh ch yu th iu tr mi c kt qu

4/ TM do huyt tn :
4.1. Tan mu nguyn nhn do yu t HC
a) Ri lon cu to mng HC
- Bnh HC hnh cu di truyn : l loi bnh do tn thng mng HC , nguyn nhn
l do khuyt thiu cht spectrin khung t bo HC v hu qu l cc HC d b bt
gi khi i qua vng tu v lch, i sng gn do mt nng lng nhanh v hnh
dng thay i
- Bnh HC hnh bu dc : him gp
b) Do ri lon Hb bm sinh
- Bnh thalassemia : l bnh do ri lon gen iu ho s tng hp protein ca Hb,
nguyn nhn l trong chui polypeptid th HbA ( alpha2 , beta2 ) b chuyn thnh
HbF ( alpha2 , gama2 ) loi huyt sc t thi kz bo thai do gen iu ho tng
tng hp chui thay cho
- Bnh do ri lon cu trc Hb : do bt thng ca gen cu trc mt aa b thay th
bi mt aa khc trong mt dy polypeptid s to nn mt loi Hb bt thng
V d bnh HC hnh lim do chui polypetid ca HbA , aa l glutamin v tr s
6 b thay th bng valin
c) Ri lon enzym ca HC
- Nguyn nhn l do thiu ht men G_6PDH v enzym pyruvatkinase bnh ny di
truyn ln lin quan n gii tnh (NST-X) thng l nam gii
4.2. Tan mu do nguyn nhn bn ngoi HC
- nguyn nhn do trong huyt tng c cc yu t chng HC
a) Do min dch
- Tan mu t nhin
+ Tan mu t min KT m : T KT m thng l IgG hot ng ti u 370C l loi
hay gp nht gy tan mu khi c hoc ngay c khi khng c c nh b th v
thng c hiu vi KN Rh
+ Tan mu t min KT lnh : T KT thng l IgM i khi l IgG. Tnh phn ng vi
lnh do KN ch khng phi do KT, t0 thp lm cho KN bc l r hn trn mng do
d tc dng vi b th
- Tan mu do truyn nhm loi : Do KT kt hp c hiu vi KN trn mng HC
ngi cho gy hot ho b th v tan HC
+ Do yu t Rh : Ngi m Rh(-) ,con Rh(+) , HC ca con s vo mu m trong lc
kch thch c th m to KT ,ln sinh 2 KT m vo tun hon ca con kt hp
vi KN Rh(+) gy tan mu con
b) Do cc cht c c trong mu gy v HC
+ Cht ho hc , thuc , tho mc
+ Do KSTSR, VK, VR
+ Do yu t vt l : Bng, truyn dung dch nhc trng
* c im huyt tn:
+ Thiu mu c tnh cht ng sc nu tan mu va phi; chuyn thnh nhc sc
khi tan mu nghim trng, s lng HC gim nhanh, d di ngay trong giai on
u
+ Cht lng HC thay i r rt: HC a dng, mo m, a c, nhiu tiu HC v vi
HC, do mng HC b tn thng, HC b bin cht thoi ha. C nhiu HC bt thng
do chuyn ha vi vng khi HC b hu qu mc ( nguyn HC, th Joli, vng Cabo,
ht i kim...), sc bn HC v i sng HC gim.
+ Thiumu c hi phc: HC li tng rt mnh 10 30%; tc v tnh trng hi
phc ph thc vo mc mt mu v tnh cht ca nguyn nhn gy tan mu.
Nu c tnh trng nhim c tu xng th phn ng tng sinh yu t v hi phc
chm kh khn.
+ Cc du hiu ca tan mu: tng Hemoglobin t do, tng ilirubin t do trong
mu, tng Fe huyt thanh, tng sc t mt trong phn v nc tiu.
+ Din bin ca thiumu ph thuc nguyn nhn tan mu: tan mu trong huyt
qun th din bin thng rm r, cp tnh, cc du hiu tan mu biu hin r rt,
c huyt cu t niu v lch to mm v au.
Tan mu trong t bo th phn ng lng l, din bin mn tnh, ko di v ch c
huyt cu t niu, cc biu hin tan mu kn o,. Gan lch to, rn v khng au

III - BIN LUN CHN ON:

1/ Thiu mu:
1.1/ C nng :
- Hoa mt, chng mt, tai
- Nhc u, gim tr nh, mt ng, ng g,
- Hi hp nh trng ngc, kh th.
- Chn n, y bng, au bng, a lng, to bn.
1.2/ Thc th:
+ Da xanh nim mc nht( lng bn tay chn,mt trong i, nch, mi, nim mc
mt )
- Da nim mc vng trong TM huyt tn.
- Da xm, do xung huyt .
+ Gai li :
- TM nhc sc: gai li nht , mn hoc mt gai li.
- TM ng sc : gai li bnh thng , nht mu.
- TM u sc : gai li , ph i c vt t gy.
+ Tc d rng , gy. mng tay chn gn sng mt cong , b .
(mit ngn tay trn mt da, kp tc vo cc ngn tay chi trn u BN)
+ Tim mch : c ting thi tm thu c nng van 2 l v van MC: Do van tr
nn hp tng i so vi dng mu i qua v khi lng v tc dng mu.
1.3/ Cn lm sng :
1.3.1. Xt nghim mu:
+ S lng HC: ngi Vit Nam bnh th*ng c s lng hng cu trong khong
3,8 - 4,5 T/l. N thp hn nam.
Nu HC di 3,8 T/l l thiu mu.
Nu HC trn 5,5 T/l l a hoc.
+ Hnh thi hng cu: thng ngi ta quan st hnh thi HC trn phin knh
nhum giemsa, ti nhng v tr HC tri u khng chng cht ln nhau. Bnh
thng HC hnh trn mu hng, gia hi nht hn.
Trong bnh l thiu mu c th thy :
- Hng cu nht mu, hnh nhn, HC bng ma trong thiu mu nhc sc nng.
- Hng cu a hnh th: hnh qu l, hnh bu dc, qu chy, rng ca... trong
thiu mu nng.
- Hng cu hnh bia bn, hnh l*i lim, hnh bi... trong thiu mu huyt tn bm
sinh di truyn.
- C nhng th bt thng trong hng cu : nh th Jolly, vng Cabott l nhng di
st ca nhn do qu trnh chuyn ho qu vi vng ca HC non trong ty xng,
gp trong thiu mu huyt tn hoc th Heinz, ht kim... gp trong thiu mu do
nhim c mt s ho cht (nhim c TNT, ch v c...).
- C th thy nguyn hng cu trong mu ngoi vi, gp trong thiu mu huyt tn,
thiu mu sau chy mu cp, bnh lch sinh ty...
+ Kch thc HC: hng cu bnh thng c ng knh khong 7mm . Trong thiu
mu c th thy :
. Hng cu b (microcyte) d = 5 - 6 mm, gp trong thiu mu thiu st
. Hng cu to (macrocyte) d = 9 - 12 mm, gp trong thiu mu do thiu acid folic,
vitamin B12.
- Hng cu khng l (megalocyte): d > 12 mm , gp trong bnh Biermer.
Nu ng knh HC < 5 mm th thng l cc mnh HC v.
+ nh lng huyt sc t: ngi Vit Nam trng thnh c lng huyt sc t
bnh thng t 140g/l - 160g/l, tr s sinh c nhiu hn (195g/l), tr em t c
hn (1 tui: 112g/l ; 10 tui: 120g/l). Nu tnh theo nng phn t th bnh
thng HST = 8,1 - 9,3mcmol/l .
Thiu mu l khi HST nam < 130g/l; n < 120g/l; ph n c mang < 110g/l.
y l ch s quan trng nht nh gi thiu mu.
+ Hematocrit: l th tch khi HC chim ch so vi lng mu bit, biu th
bng l/l hoc bng t l % gia khi HC v mu ton phn.
nh thng nam : 0,45 - 0,50 l/l hoc 45 - 50%.
n : 0,40 - 0,45 l/l hoc 40 - 45%.
Trong thiu mu hematocrit thng gim.
+ HC li: l hng cu tr va trng thnh t nguyn hng cu i toan trong qu
trnh sinh HC, l dng chuyn tip gia HC non trong ty xng v HC trng
thnh ngoi vi; thi gian tn ti dng chuyn tip (i sng HC li) khong
24 - 48 gi.
Hng cu li c nhn ra bng phng php nhum ti new methylen blu
hoc xanh sng crezyl: hng cu li l nhng HC c cha cc ht mu xanh sm
nm thnh hnh dy li. m s lng HC li cho php nh gi trng thi v
kh nng sinh HC ca ty xng.
nh thng hng cu li = 0,5 - 1% hoc 0,025 - 0,050 T/l.
HC li gim trong suy ty...,
HC li tng trong huyt tn, trong giai on phc hi ca thiu mu...
+ Tnh ton cc ch s HC:
Tnh ton cc ch s hng cu rt quan trng, v t ngi ta c th xc nh
c tnh cht thiu mu (nhc sc, ng sc, u sc), qua s gip tm hiu
nguyn nhn thiu mu mt cch d dng hn.
- Nng HST trung bnh HC (MCHC: mean corpuscular hemoglobin
concentration): l lng HST bo ho trong mt th tch HC.
.....................HST(g/l)
MCHC=----------------------= 290-360 g/l.
................Hematocrit(l/l)

- Th tch trung bnh HC (MCV: mean corpuscular volume):
Hematocrit(l/l)
MCV = ---------------------- x 103 = 90 5 femtolit(fl)
HC (T/l)

- Lng HST trung bnh HC (MCH: mean corpuscular hemoglobin): l lng HST
trung bnh cha trong mt HC tnh bng picrogam (1pg = 10-12 g).
HST(g/l)
MCH =-------------------- = 30 3 picrogam(pg)
HC (T/l)
ch s nhim sc ca hng cu ( gi tr chc nng ca hng cu )
Ch s nhim sc l m huyt sc t trong hng cu th hin gi tr chc nng
ca hng cu v c tnh theo cng thc n gin
Hemoglobin%
CSNS = --------------------
2 s u HC x 2
Gii hn bnh thng ca ch s nhim sc l 0,9 1,1. Trong bnh l tuz theo s
thay i ca ch s nhim sc c th phn bit :
+ Thiu mu ng sc khi hng cu v huyt sc t gim tng ng ,cc
trng hp thiu mu c hu HC va phi, t hoc khng b thiu st do st c
gi li ti to HC
+ Thiu mu nhc sc khi CSNS gim di 0,9 do huyt sc t gim nhiu hn so
vi HC , gp bnh nhn suy nhc thiu protid, thiu st, hoc kh nng tiu
ho hp thu km kh nng tng hp protid b ri lon
+ Thiu mu u sc khi CSNS trn 1,1. y khng phi l tha d huyt cu t, s
lng Hb tuyt i trong mt n v th tch mu gim tuy s lng s lng Hb
trong tng HC c tng hn bnh thng, nguyn nhn l do th tch HC tng.
nh thng mi HC ch cha mt lng Hb nht nh khong 33% - 34%, khi th
tch HC tng th lng Hb trong HC cng tng, thiu mu u sc gp trong bnh
thiu mu c tnh .
+ Sc bn HC (trong mi trng nc mui nhc trng):
nh thng : HC bt u v nng : 0,46%
HC v hon ton nng : 0,34%
Nu v sm hn ( nng nc mui cao hn) l sc bn HC gim , thng gp
trong bnh HC hnh bi.
Nu v mun hn ( nng nc mui thp hn) l tng sc bn HC thng
gp trong bnh thalassemie.
+ St huyt thanh:
nh thng: Nam: 15 - 27 mcmol/l.
N : 11 - 22 mcmol/l.
St huyt thanh gim trong thiu mu nhc sc do thiu st, tng trong thiu
mu do huyt tn, suy ty, ri lon chuyn ho st ...
+ Nghim php Coombs (Coombs HC): pht hin khng th khng hon ton
khng HC. Coombs trc tip pht hin khng th bm vo HC, Coombs gin
tip pht hin khng th cn t do trong huyt thanh.
Nghim php Coombs dng tnh r trong thiu mu huyt tn t min.
1.3.2. Ty :
+ Ch nh chc ty:
- Cc thiu mu khng thy nguyn nhn c th.
- Thiu mu dai dng kh hi phc.
- Cc trng thi gim C, tng C khng do nguyn nhn vi khun hoc virus.
- Cc bnh mu c tnh, hch c tnh, cc trng thi ri lon globulin mu
(paraprotein), mt s trng hp ung th...
- Xut huyt do gim tiu cu.
+ Chng ch nh:
- Tuyt i: khng c.
- Tng i: cc trng thi e do chy mu nng, suy tim nng, qu s hi...
-> Ty bnh thng ngi Vit Nam:
Trong mi trng hp thiu mu, xt nghim ty l rt cn thit tm hiu
nguyn gy thiu mu v nh gi kh nng phc hi trong v sau iu tr (xem
phn ty bnh thng trong phn: mt s xt nghim huyt hc s dng trong
lm sng).

2/ Tch cht TM:
+ Lm sng : da vo gai li:
- TM nhc sc: gai li nht , mn hoc mt gai li.
- TM ng sc : gai li bnh thng , nht mu.
- TM u sc : gai li , ph i c vt t gy.
+ CLS: Da vo cc ch s HC: MCHC, MCV, MCH.
- TM nhc sc : 3 ch s u gim
- TM ng sc : 3 ch s bnh thng
- TM u sc: MCHCbt, MCH tng, MCV tng.
* Da vo MCHC l chnh xc nh tnh cht TM

3/ Mc TM:
Ngi ta cn c vo HST chn on TM v mc TM:

HST(g/l) ..............................Mc TM
90-<BT .......................................nh
90-60 ...........................................tb
<60 ............................................Nng

4/ Nhng xt nghm cn lm vi bnh nhn TM
i vi mt N TM trc ht phi ;
- XN mu ngoi vi
- Hi v khm LS
-> nh hng nguyn nhn cho lm cc XN tip theo.
4.1/ Nguyn nhn chy mu :
+ Cp tnh : sau chn thng , chy mu ng tiu ha
-> soi dd-htt, XN phn
- i ra mu: XQ thn tit niu, siu m.
- Chy mu ng sinh dc.
+ Mn tnh :
- Giun mc -> XN phn tm u trng giun mc.
-Tr-> soi trc trng
4.2/ TM do thiu yu t to mu:
- Do thiu Fe (giun mc , XHTH, ct dd, hp thu km , cung p thiu,).
-> XN mu : s lng HC gim, HC nht mu, (hnh bng ma , vnh khn) HC nh,
cc ch s HC gim, Fe huyt thanh gim.
Lm cc XN v CN gan, XN phn tm u trng giun mc
- Do thiu VTM B12,C (Biemen, gim hp thu , ct dd, U, lao ,sn ,bnh gan).
XN mu : thy nhiu HC khng l Megalocyte, cc ch s HC tng hoc bt
Ty : Tng nhiu Megaloplas. g kim tnh c ty xanh.
- Do thiu acid folic
- Do thiu Protein.
- Do thiu ni tit t.
-> thiu mu dinh dng .
4.3/ TM do RL c quan to mu:
- Suy nhc ty xng .
- Lon sn ty xng.
- Ty xng b ln t, chn p bi t chc K, di cn K vo.
-> sinh thit ty lm ty v XN tb hc.
4.4/ TM do huyt tn :
-> XN SHM : ilirubin tng cao ( ch yu l Bili GT),
Sc bn HC gim, Coombs(+), st huyt thanh tng.
-> XN phn : Stercobili tng
-> XN nc tiu: Urobilin nc tiu tng.
-> Ty dng HC tng sinh mnh, HC li tng.
+ Nguyn nhn ti HC:
- Tn thng mng HC (HC hnh bi )
- Gim men G6PD -> nh lng G6PD.
- RL HST(Thalassemie, HC li lim).
+ Nguyn nhn ngoi HC:
- Min dch
- Nhim c : thuc ha cht , nc c.
- Nhim trng: KST SR -> XN mu ngoi vi tm KST SR trong cn
- Bng.

IV - PHN LOI THIU MU.

* C rt nhiu cch phn loi thiu mu nh:
1 - Phn loi theo tnh cht tin trin:
- Thiu mu cp tnh,
- Thiu mu mn tnh.
2 - Theo kch thc HC: thiu mu HC to, nh, trung bnh.

3. Theo tnh cht thiu mu:
- Thiu mu nhc sc,
- Thiu mu ng sc,
- Thiu mu u sc

4 - Phn loi theo nguyn nhn v c ch bnh sinh.
Theo cch ny ngi ta chia thiu mu lm 4 loi sau:
+ Thiu mu do chy mu:
- Cp tnh: sau chn thng, chy mu d dy- t trng...
- Mn tnh: do giun mc, tr chy mu...
+ Thiu mu do thiu yu t to mu:
Cc cht cn thit cho to mu hay b thiu thng l: st, vitamin B12, acid folic,
vitamin C, protein, ni tit... thng hay gp nht l thiu mu dinh d*ng.
+ Thiu mu do ri lon to mu:
- Suy nhc ty xng.
- Lon sn ty xng .
- Ty xng b ln t, chn p do cc t chc c tnh hoc di cn ung th vo ty
xng.
+ Thiu mu do huyt tn:
- Nguyn nhn ti HC: nh bt thng cu trc mng HC (bnh HC hnh bi...),
thiu ht men (G6PD...), ri lon HST (thalasemie, bnh HC hnh li lim..).
- Nguyn nhn ngoi HC : nh min dch, nhim c, nhim trng, bng...

5. Ngi ta cng c th chia thiu mu lm 3 loi :
+ Do chy mu
+ Do ri lon to HC:
- Do thiu yu t to hoc.
- Do ri lon to HC ty x*ng.
+ Do huyt tn.

III - BIN LUN IU TR :

1/ iu tr nguyn nhn( quan trng nht i vi 1 BN TM)
VD: Thiu mu do thiu acid folic.
+ Acid folic 5mg x 4 vin/ngy.
+ Dng tim 1mg x 1 -3 ng/ngy tim bp.
+ Dng n khi ht tnh trng thiu mu ko di thm 1 thng cho nhu cu d
tr. Thng dng 3 - 6 thng
2/ iu tr theo c ch bnh sinh
VD: iu tr thiu mu huyt tn t min.
-Liu php corticoid: prednisolon 1 -1.5mg/kg/24 gi iu tr liu tn cng n khi
HST tr v bnh thng th gim liu t t trong 4 - 6 tun. Sau iu tr duy tr
30mg/ngy tng t trong 3 - 5 thng, c th gim liu mi t 10mg cho n khi
ngng hn thuc.
-Truyn khi HC, truyn HC ra.
-Ct lch l bin php c hiu qu.
-iu tr bng thuc c ch min dch: c ch nh trong trng hp ti pht
sau ct lch hoc khng ct lch c.
Cyclophosphamid 50 mg x 2 vin/ngy. Thi gian iu tr 4 - 12 thng ty tng
trng hp
3/ iu tr triu chng:
-Truyn mu cng nhm
- st -> h st
- Co git -> chng co git.

31. THIU MU DO DINH DNG

1. nh ngha:
L loi thiu mu nguyn nhn do thiu yu t dinh dng cn thit cho qu trnh
to mu, trong ch { ti thiu st, acid folic, vitamin B12, acid amin.
2. Thiu mu nhc sc do thiu st.

- Lm sng c hi chng thiu mu.
- Cn lm sng:
+ HST gim nhiu.
+ Cc ch s HC gim: gic tr HC < 0.9; MCV < 80 femtolit; MCH < 28 pg, MCHC <
280g/l.
+ St huyt thanh gim < 500 mcg/l.
+ Feritin huyt thanh huyt thanh gim (dng d tr) < 12 mcg/l.
+ Ch s bo ha Tranferin gim.
+ Ty : nguyn hng cu km trng thnh: nguyn sinh cht nht c xu hng
chuyn xang dng a acid.
3. Chn on phn bit.
- Thalassemie.
- Bnh HST E, HST H.
- Nhim c tr.
- Vim nhim mn tnh.
Nhng bnh ny thng c st huyt thanh tng.
4. Nguyn nhn.

- Hp thu st km: vim d dy gim toan, vim d dy teo, ct on d dy, ct
on rut non.
- Cc bnh l chy mu mn tnh: tr, polip, k trc trng, vim lot d dy, u x t
cung..
- Nhim giun mc.
- Mt cn bng cung cu: ph n mang thai, tr em ang ln..
5. iu tr.
- iu tr nguyn nhn.
- B sung st:
+ Dng dng mui l tt nht, kt hp vitamin C hp thu tt hn.
St sunfat, st oxalate 20mg/kg/24 gi. Ung trc ba n 1 gi thi gian dng
thng l 6 thng, cc thuc gim tit dch d dy lm gim hp thu st.
Vitamin C (Cevita) 0.5 x 1 - 2 vin.
+ Nu c ri lon tiu ha nng hp thu km cn dng dng tim.
Dextran st tim bp liu u < 50mg, tng liu 1.5 - 2 gam. Ch c th gy p
xe.
Nu khng tim bp c tim tnh mch ch th phn ng trc thi gian ch
5 pht, pha vi 20ml huyt thanh sinh l, c th tim mt lc vi tng liu cn
dng. Tc dng ph: st, gim HA, mch chm, nhc u, au bng bun nn..
6. Thiu mu do thiu vitamin B12.

- Vai tr vitamin B12:
+ Tham gia vo qu trnh chuyn ha acid nhn cn thit cho qu trnh to DNA v
trng thnh nhn t bo, gip cho s phn chia ti to t chc c bit l t bo
thn kinh.
- Lm sng c hi chng thiu mu.
- Cn lm sng:
+ Mu: s lng HC gim, BC, TC gim nh.
Lng HST trung bnh hng cu tng, th tch trung bnh HC tng, nng HST
trung bnh HC thng gim, gi tr HC tng.
+ Sinh ha: ilirubin mu tng, st huyt thanh tng, Vitamin 12 huyt thanh
gim r.
+ Ty : dng HC tng sn nhng ri lon trng thnh r: tng nhiu giai
on kim tnh to hnh nh ty xanh. c tnh khng l cn gp dng BC ht v
dng mu tiu cu.
+ Dch v thiu toan hoc v toan.
7. Nguyn nhn.
- Bnh Biermer: l bnh t min do khng th khng d dy, khng yu t ni
(yu t bo v B12 do d dy tit ra).
- Bnh ng tiu ha: ct on dy mt yu t ni, vim rut gim hp thu.
- Do thuc: c ch dng B12, gim hp thu.
- Bnh x gan, vim gan mn, nhim c nhim trng mn, ung th gy ri lon
chuyn ha v d tr B12.
- Ph n cha cho con b do tng nhu cu B12.
8. iu tr
- iu tr thiu mu.
+ Vitamin B12 100 - 200 mcg/24 gi tim bp x ngy/1 tun. Sau tim tun 2
ln. Tng liu trong 6 tun l 2000 mcg. Sau cng c mi thng 1 ln 100 mcg.
- iu tr triu chng thn kinh: 500 mcg - 1000 mcg hoc 5000 - 10000 tim bp
cch nht.
9. Thiu mu do thiu acid folic.
- Acid folic tham gia vo qu trnh tng hp acid nhn.
- Nguyn nhn: do hp thu km, cung cp thiu, tng nhu cu, do thuc.
- Lm sng: hi chng thiu mu bnh cnh ging thiu B12. Xt nghim acid folic
huyt thanh < 3 mcg/ml.
- iu tr:
+ Acid folic 5mg x 4 vin/ngy.
+ Dng tim 1mg x 1 -3 ng/ngy tim bp.
+ Dng n khi ht tnh trng thiu mu ko di thm 1 thng cho nhu cu d
tr. Thng dng 3 - 6 thng.

32. U LYMPHO KHNG HODGKIN

U lympho khng Hodgkin (ULKH) l cc khi u c tnh c ngun gc t h thng
li bch huyt khng phi l bnh Hodgkin.
1. Chn on
1.1. Lm sng :
Biu hin lm sng l triu chng u, thay i khc nhau tuz thuc vo v tr u tin
pht v s lan to ca bnh.
Khi u c th bng, trung tht, hch ngoi bin, vng tai mi hng v cc ni
khc nh da, di da, xng, thn
1.2. Xt nghim chn on xc nh :
Da vo kt qu m bnh hc v ho m min dch qua sinh thit hch hoc khi
u. Da vo xt nghim ho m min dch phn ra ULKH t bo B, t bo T, khng
B khng T.
1.3. Chn on giai on : Theo bnh vin tr em St. Jude
Giai on 1 : Ch c 1 khi u hoc 1 vng hch (ngoi tr trung tht v bng)
Giai on 2 : Khi u v hch nhng vng cng 1 pha ca c honh 2 hay nhiu
vng hch.
2 khi u + c/khng tn thng hch.
Khi u u tin ng tiu ho, thng vng hi manh trng, c/khng c
hch mc treo rut.
Giai on 3 : Khi u v hch tn thng c 2 pha ca c honh
2 khi u ring bit
2 hay nhiu vng hch
U tin pht trung tht, mng phi, tuyn c
U bng nhng khng ct ht c
U cnh ct sng
Giai on 4 : C biu hin thm tu xng v h thn kinh trung ng
2. iu tr ulkh t bo b
+ Cch s dng cc thuc trong phc nh sau :
- Prednisolone : 60mg/m
2
da, ung, 2 ln/ngy, ung lc no
- Vincristine : 1 2mg/m
2
da, tim tnh mch chm trn 10 pht
- Doxorubicine : 60mg/m
2
, truyn tnh mch trn 1 gi
- Methotrexate : 3g/m
2
da, truyn tnh mch trn 3 gi. Dch trc truyn
Methotrexate 4 gi : 125ml/m
2
da/gi vi 60mmol/l Natribicarbonate, 5mmol/l
KCl. Dch sau truyn Methotrexate : 31/m
2
da/24 gi.
- Acid Folinic : 15mg/m
2
da, tim tnh mch 6 gi/ln, bt u tim 24 gi sau
truyn Methotrexate, tim trong 3 ngy.
- Aracytine : 60mg/m
2
da, truyn tnh mch trong 24 gi.
- Endoxan : 500mg/m
2
/ln chia 2 ln/ngy, truyn tnh mch trn 30 pht, kt
hp vi truyn dch 31/m
2
/ngy.
- Mesna : 250mg/m
2
da, chia 2 ln trc mi ln Endoxan. Sau , 500mg/m
2

da/24 gi cng vi truyn dch sau truyn Endoxan.
- Etoposide : 200mg/m
2
da, truyn tnh mch trn 2 gi sau liu cao ca
Aracytine.
- Thuc tim tu sng :
Methotrexate
(MTX)
Hydrerocortisol
(HC)
Aracytine (Ar
C)
<1 tui 8mg 8mg 16mg
1 tui 10mg 10mg 20mg
2 tui 12mg 12mg 24mg
3 tui 15mg 15mg 30mg
2.1. Nhm A :
Bnh nhn c iu tr theo nhm A khi : Khi u khu tr bng giai on I v
II c ct b hon ton. Thi gian iu tr gm 2 t, mi t cch nhau 21
ngy. Thi gian iu tr nhm A ko di 5 tun.
Thuc cho mi t :
Ngy 1 2 3 4 5 6 7
Prednisolone * * * * * * * * * *
Vincristine #
Endoxan
Adriamycine
2.2. Nhm B
Bnh nhn c iu tr theo nhm khi : c xc nh chn on l giai on I
v II vi v tr u vng u v c ;
Giai on III v IV nhng cha c thm nhim h thng thn kinh trung ng.
* t 1 : COP
Ngy 1 2 3 4 5 6 7
Prdenisolone ngy 1 - 7
Vincristine 1,0mg/m
2 (ngy 1)















Endoxan 300mg/m2 (ngy 1)















Tim tu sng MTX + HC (ngy 1)















* t 2 : COPADM1
Ngy 1 2 3 4 5 6 7
Ngy th 1 l ngy th 8 ca
phc

Prednisolone ngy 1 5
Vincristine 2mg/m
2, ngy 1















Methotrexate ngy 1















Acid Folinic ngy 2 4















Endoxan ngy 2 4















Mesna















Adriamycine ngy 2















Tim tu sng MTX + HC (ngy 2, ngy 6)















Sau ngh 21 ngy, bt u dng t tip theo khi bch cu ht > 1000/mm
3
v
tiu cu > 100.000/mm
3
.
* t 3 : COPADM2
Ngy th nht ca t 3 l ngy th 35 ca phc . Thuc v cch dng nh
COPADM1 tr Endoxan liu tng gp i. Sau t 3 ngh 21 ngy.
* t 4 : CYM1
Ngy 1 2 3 4 5 6 7
Ngy th 63 ca phc
Prednisolone ngy 1 5
Vincristine 1,5mg/m
2, ngy 1















Methotrexate ngy 1















Acid Folinic















Cytarabine ngy 2 6















Tim tu sng ngy 2 : MTX+HC















ngy 7 : HC + Ar-C
















C th kim tra chc nng gan, thn, chp CT, chp xng, bnh nhn s c
phu thut ct ht khi u ln 2 nu phu thuth ln 1 cha ct ht trc khi bt
u CYM2.
* t 5 : CYM2 :
Ngy th 1 ca t 5 l ngy th 91 ca phc .Thuc v cch dng nh CYM1.
* t 6 : COPADM3 :
Ngy th 1 ca t 6 l ngy th 118 ca phc . Thuc v cch dng nh
COPADM1.
Sau khi hon thnh qu trnh iu tr, bnh nhn c th c kim tra chc nng
gan, thn, tu xng. Thi gian iu tr nhm B ko di 18 tun.
2.3. Nhm C :
Bnh nhn c iu tr theo nhm C khi c lymphoblast trong tu > 70% ; c
thm nhim h thng thn kinh trung ng.
* t 1 : COP :
Thuc v cch dng nh t 1 ca nhm B, tr tim tu sng ngy 1, 3, 5 vi
thuc : MTX + HC + Ar C.
* t 2 : COPADM1 :
Ngy th 1 ca t 2 l ngy th 8 ca phc . Thuc v cch dng nh
COPADM1 ca nhm B tr Methotrexate liu 8gm
2
da v tim tu sng ngy 1, 3,
5 vi thuc MTX + HC + Ar C.
* t 3 : COPADM2 :
Bt u t ngy th 35 ca phc . Thuc v cch dng nh COPADM1 ca
nhm C.
* t 4 : CYT/VP : Ngy th 1 ca t 4 l ngy th 63 ca phc .
Ngy 1 2 3 4 5 6 7
Ar-C 50mg/m2 ngy 1
5

Ar-C 3g/m2 ngy 1 4
Etoposide ngy 1 4

Truyn Ar-C 3g/m2 trn 3 gi, bt u v kt thc ca 12 gi truyn dch cng vi
truyn Ar-C 50mg/m2.
* t 5 : CYT/VP :
Bt u t ngy th 91 ca phc . Thuc v cch dng nh t 4.
* t 6 : COPADM3 :
Bt u t ngy th 118 ca phc . Thuc v cch dng nh t 2.
Sau t 6, bnh nhn c tia x vng s vi liu 18Gy.
* t 7 : CYT/VP
Ngy 1 2 3 4 5 6
Ar-C 100mg/m
2 , chia 2
ln, N1 5













Etoposide 150mg/m2, N2 - 4













Tim tu sng MTX + HC + Ar-C,
N2














* t 8 : COPAD :
Sau khi kt thc t 7 ba tun. Thuc v cch dng nh t 2 nhng khng c
Methotrexate.
* t 9 : CYT/VP : Thuc v cch dng nh t 7
Thi gian iu tr nhm C ko di 27 tun.
2.4. iu tr h tr :
iu tr nhng tc dng ph ca ho cht
- Nu bnh nhn gim sn tu nng, c th dng G-CSF (Neupogen) vi liu 5
microgam/kg/ngy cho n khi xt nghim cng thc mu ngoi bin mu tr v
mc bnh thng.
- Chng lot ming : Thuc bi ming Zytee, Glycerine Borate
- Chng nhim khun : Dng khng sinh
- Chng nn : Primperan tim tnh mch hoc t hu mn.
- Gim au
- Nu c duhiu ca c gan v thn : ngng iu tr ho cht

33. THIU MU THIU ST

Thiu mu thiu st c c im l thiu mu nhc sc, st v Ferritin huyt
thanh gim. Thiu mu thiu st rt ph bin v l thiu mu dinh dng ch
yu tr em.
1. Chn on :
Chn on da vo lm sng v xt nghim huyt hc, sinh ha.
1.1.Lm sng :
Thiu mu xy ra t t, mc thng nh n va, t khi thiu mu nng, da
xanh, nim mc nht ; mng tay v mng chn nht nht, c th c kha d gy.
Km theo thiu mu c mt s biu hin:
- Tr mt mi, t vn ng, chm pht trin, vi tr ln hc km tp trung.
- Chn n, vim teo gai li, km hp thu.
- Mch nhanh, tim to ra.
- Th nhanh.
1.2. Xt nghim :
- Hemoglobin gim.
- Hng cu nh, nhc sc : MCV < 80fl
MCH < 27pg
MCHC < 300g/L
RDW >17.
- St huyt thanh <9 mmol/L.
- Ferritin huyt thanh <12 ng/ml
- Ch s bo ha st <16%
- Porphyrin t do hng cu > 400mg/L
2. iu tr :
2.1.B xung st
- Ung ch phm st, tt nht l sulfat st :
4-6 mg Fe/kg/ngy, trong 6-8 tun l.

34. THIU MU HUYT TN T MIN

hiu mu tan mu t min l thiu mu do c th t sinh ra khng th khng li
trc tip vi khng nguyn hng cu. Bnh thng xy ra phi hp vi mt s
bnh nhim khun nh vim gan, vim phi do vius, tng bch cu n nhn
nhim khun, hoc trn c s b mt s bnh nh U lympho, Hodgkin, Lupus
ban , hi chng suy gim min dch.
1. Chn on :
1.1. Lm sng :
+ Th cp :
- t xy ra tr <1 nm
- Bnh t ngt
- Thiu mu
- Vng da, cng mc mt vng
- Lch to nhanh hoc khng to
- C th i Hb niu
+ Th mn :
- Bnh ko di, cn tan mu tip tc, ti din nhiu thng, nhiu nm
- Lch to.
1.2. Xt nghim :
+ Mu ngoi bin: - Hb gim
Mu ngoi bin: - Hb gim
- SLC bnh thng hoc gim
- SL tiu cu bnh thng (i khi gim, gp trong hi chng Evans).
- Hng cu li tng
+ Bilirubin ton phn v gin tip tng
+ Nc tiu : urobilinogen dng tnh, Hb niu c th dng tnh nu tan mu
trong mch.
urobilinogen dng tnh, Hb niu c th dng tnh nu tan mu trong mch.
+ Nghim php Coombs trc tip dng tnh, i khi nghim php Coombs gin
tip cng dng tnh. Khng th t min phn ln thuc nhm IgG (85%), ngoi
ra c th thuc nhm IgM, C
3,



+ Cn xt nghim Ure, Creatinin mu: c th bnh thng, hoc tng trong hi
chng huyt tn - ure huyt cao, pht hin bin chng thn do tan mu trong
mch.
Cn xt nghim Ure, Creatinin mu: c th bnh thng, hoc tng trong hi
chng huyt tn - ure huyt cao, pht hin bin chng thn do tan mu trong
mch.
2. iu tr :
2.1. iu tr c bn l quan trng :
2.2. iu tr c ch min dch :
+ Corticoid: Solu-medrol 5-10 mg/kg/24 gi trong 3-5 ngy. Sau dng tip
Prednisolon 2 mg/kg/ngy cho n khi triu chng tan mu ngng th gim liu v
ngng thuc (thng thng khong 2-4 tun)
+ Trng hp corticoid khng kt qu c th cho: Azathioprin hoc
Cyclophosphamid, Cyclosporin A.
2.3. iu tr h tr :
+ Truyn mu: hn ch truyn mu. Truyn khi Hb (50g/L) hoc khi c bin chng
do thiu mu gy ra.
Truyn khi hng cu: 10-15 ml/kg
Trng hp khng nh c nhm mu do mu bnh nhn t ngng kt, ch
nh truyn hng cu nhm "O".
+ Trng hp tan mu cp c biu hin thn, Hb niu:
- Truyn dch: Glucose 10%, Natri clorua 9%0 theo t l 3/ hay Ringer lactat 50-100
ml/kg/ngy.
- Lasix 2 mg/kg/ngy: 2-3 ngy
2.4. Ct lch : ch nh khi
ch nh khi
+ Bnh ko di mn tnh, xut hin nhiu t cp nng,
+ iu tr ni khoa khng kt qu
+ Lch to.

35. BNH SUY TY XNG

Suy tu xng l tnh trng gim sinh cc t bo mu tu, c th gim sinh
mt hay c ba dng t bo tu, bm sinh hay mc phi. y ch trnh by suy
tu xng ton b khng r nguyn nhn.
1. Chn on
1.1. Lm sng :
Biu hin triu chng gim ton b t bo mu ngoi bin :
- Thiu mu :T t, mc thng nng, kh hi phc.
- Xut huyt : C c im ca xut huyt do gim tiu cu, chm, nt, mng bm
mu da, chy mu nimmc, c th ni tng.
- D b nhim khun, do gim bch cu.
- Gan, lch, hch khng to.
1.2. Xt nghim huyt hc :
+ Mu ngoi bin :
- Hng cu : Gim nhiu, MCV, MCH, MCHC gii hn bnh thng, ng sc,
hng cu li gim < 0,5%.
- Hb gim nng.
- Bch cu : gim s lng, ch yu gim bch cu ht trung tnh, tng t l bch
cu lympho, khng c nguyn bch cu.
- Tiu cu gim nhiu, thng di 50 x 10
9/l.

+ Mu tu :

- S lng t bo tu gim < 30 x 109/l
- T l 3 dng t bo tu gim : dng hng cu di 15%, dng bch cu tu gim
di 40%, thng khng gp mu tiu cu.
- Cc t bo tu ch yu l t bo trng thnh, t bo non v trung gian t hoc
khng c.
- Khng c t bo bt thng di cn vo tu.
+ Sinh thit tu : (nu c iu kin) : Tu x ho, to mu rt t, tu nhim m.
2. iu tr
2.1. iu tr h tr :
- Chng thiu mu : Truyn khi hng cu, c duy tr Hb>80g/l.
- Trnh chy mu cc b phn nguy him (chy mu ni si, phi, tiu ho)
truyn khi tiu cu, duy tr tiu cu > 20 x 109/l.
- phng nhim khun :
phng nhim khun :
+ m bo v sinh, chm sc rng ming, khng cp nhit hu mn, khng
xc da, nim mc.
+ Nu c st, cn tm k nhim khun, cy cc dch nghi ngun bnh, cho khng
sinh c tc dng c vi vi khun gram dng v m.
2.2. iu tr c hiu :
Trong iu kin cha thc hin c ghp tu xng v cha c ATG
(Antithymocyte globulin) iu tr nh sau :
- Methylprednisolon liu cao, tim tnh mch :
Ngy 1 3 : 20mg/kg/ngy
Ngy 4 7 : 10mg/kg/ngy
Ngy 8 11 : 5mg/kg/ngy
Ngy 12 20 : 2mg/kg/ngy
Ngy 21 30 : 1mg/kg/ngy
Duy tr : 0,1 0,2mg/kg/ngy.
Nu c p ng, duy tr 3 6 thng
Nu khng p ng chuyn iu tr cyclosporin A.
- Cyclosporin A : 8 10mg/kg/ngy x 14 ngy sau gim liu dn trong 2 tun,
duy tr 2mg/kg/ngy trong 3 thng.
- G-CSF (Granulocyte colony Stimulating Factor) hay GM CSF : phi hp vi
Methylprednisolon hay Cyclosporin A : 5 mg/kg/ngy tim di da trong vng 2
tun.
- C th phi hp Androgen v Prednisolon :
Mythyltestosterone (Propionat testosterone)
Ung 2 5mg/kg/ngy
Tim bp 1 2mg/kg/tun
Prednisolon 2mg/kg/ngy, ung cch ngy.
Thi gian 3 thng.
- Phu thut ct lch : ch nh cho tr > 10 tui, iu tr bng cc bin php trn 6
thng khng kt qu.
2.3. Theo di iu tr :
+ Trong thi gian nm vin :
- Theo di tnh trng thiu mu, xut huyt, nhim trng.
- Kim tra cng thc mu tun 1 ln, kim tra tu sau 1 thng iu tr.
- Theo di tc dng ph ca thuc : Hi chng Cushing, nam ho nu iu tr
Androgen.
+ Theo di ngoi tr :
- Nu bnh nhn c Hb>80g/l, tiu cu > 30 x 109/l, khng c xut huyt.
- Khm nh kz 1 thng/1 ln, kim tra cng thc mu 1 thng/ln.

36. CHY MU DO IU TR TAN HUYT KHI

Biu hin LS: A. Chy mu sau iu tr tiu fibrin c biu hin LS rt bin i, t
tnh trng khim khuyt TK xy ra t ngt (chy mu ni s) n tnh trng mt
mt th tch mu ln (nh trong chy mu ng tiu ho) hay gim st dn
dn hemoglobin m khng c bng chng chy mu r rt B. Cc ngun gc mt
mu n phi lun c xem xt, nh mt chy mu vo khoang sau phc mc,
vo vng i (thng lin quan vi chc TM hay M i ), hoc vo phc mc
hay lng ngc
II. nh gi cn LS:
A. Tng thi gian thrrombin v PTT gip nhn din tnh trng tiu si huyt ko
di; Tuy vy, c hai thi gian ny b ko di khi ang dng heparin
B. Ko di thi gian reptilase gip nhn din tnh trng tiu si huyt ko di khi
ang dng heparin
C. Gim nng fibrinogen trong tnh trng tiu fibrin s c phn nh bng
tng PTT, thi gian thrombin hay thi gian reptilase. Nng fibrinogen sau
truyn mu l mt ch dn hu ch cho p ng i vi iu tr bi ph cc yu t
ng mu
D. Tng cc sn phm ging ho fibrin gip khng nh c tnh trng tiu fibrin
E. Thi gian chy mu nh mt ch dn chc nng tiu cu, c th l mt hng
dn hu ch i vi iu tr bi ph tiu cu, nu BN c thi gian chy mu ko
di mc d bi ph cc yu t ng mu bng cht kt ta lnh v huyt
tng ti ng lnh
III. X tr
A. Ngng dng ngay cht gy tan cc huyt khi, aspirin, v heparin, v xt dng
protamin trung ho tc dng ca heparin
. t 2 catheter khu knh ln vo TM bi ph th tch tun hon. Nu c th,
n ti ch i vi cc v tr chy mu
C. Gi cc mu mu XN PT/PTT, fibrinogen v thi gian thrombin. Kim tra thi
gian reptilase nu N ang dng heparin
D. BN phi c nh nhm mu v lm phn ng cho do c th cn phi truyn
mu cp cu
E. Truyn mu:
1. Cht kt ta lnh (10 n v trong vng 10 min) nn c truyn nh bin
php u tay iu chnh tnh trng tiu fibrin. C th cn truyn mu nhc li
ti khi nng fibrinogen > 100 mg/dl hay t c tnh trng cm mu tho
ng
2. Truyn huyt tng ti ng lnh cng rt quan trng bi ph cc yu t
VIII v V. Tuz mc chy mu, cn p dng mt cch thn trng iu tr truyn
mu trnh tng gnh th tch. Nu tnh trng chy mu tip tc sau khi bi
ph yu t kt ta lnh v huyt tng ti ng lnh, kim tra thi gian chy
mu v xt truyn tiu cu nu thi gian chy mu ko di > 9 min. Nu thi gian
chy mu < 9min, khi thuc chng tiu fibrin c l nn c dng
F. Thuc chng tiu fibrin
1. Acid aminocaproic (EACA) c ch gn ca plasmin vi fibrin v plasminogen vi
fibrinogen. Xt dng thuc ny khi bi ph li cc yu t ng mu khng
t c tnh trng cm mu tho ng. Nguy c tim tng l b cc bin chng
huyt khi nghim trng
2. Liu tn cng: 5g hay 0,1 g/kg truyn TM (pha trong 250 ml NaCl 0,9%) trong
vng 30-60 min, sau l truyn lin tc tc 0,5-1,0 g/h ti khi kim sot c
tnh trng chy mu. Cn s dng mt cch thn trng trong chy mu ng tit
niu trn do nguy c gy tc nghn ng dn tiu. Chng ch nh trong DIC
3. Nu tnh trng chy mu b nghi vn trn c s thy gim hemoglobin song
khng c cc bng chng mt mu r rt: Cc ngun gc n phi c xem
xt nh khoang sau phc mc, i (thng lin quan vi chc M hay TM bn),
chy mu vo cc khoang rng ca c th (phc mc, lng ngc)

37. BNH BCH CU TY MN

I. i cng.
Bnh biu hin bng hin tng tng sinh qu sn dng bach cu ht bit ha
nhiu nhng cht lng bch cu ht khng bnh thng. S lng bch cu ht
tng rt cao mu ngoi vi v ty xng, cc la tui t non, trung gian n
trng thnh. Trn 90% trng hp c NST Ph
i
(chuyn on 9 22)
Bnh c th gp mi la tui thng gp 30 50 tui, rt t gp tr em v
ngi gi trn 70 tui.
Cha tm c nguyn nhn r rng, c mt s yu t lin quan n bnh sinh l
: phng x, ha cht .
Tin trin kh hn CC, i sng trung bnh ca bnh t khi pht bnh la 4 5
nm.
S tin trin ca BCTM c chia lm hai giai on rt r rt: giai on tin trin
mn tnh c ko di t 20 40 thng. Giai on tin trin cp tnh vi cc biu
hin lm sng xt nghim ging nh CC dn n t vong. Mt s c iu tr
tch cc c th vt qua giai on tin trin cp v t lui bnh hon ton.
II. Giai on tin trin mn.
1. Lm sng.
- Lch to: L du hiu in hnh bao gi cng c, nu khng c lch to th cn xem
li chn on.Thng lch to n qu rn, mt chc, mt nhn khng au, nu
au c th c km vim quanh, nu au d di c th c nhi mu lch.
- Thiu mu t nh n va: Da xanh, nim mc nht, c th c ting thi tm
thu mn tim ( c nng), gy st cn, ri lon tiu ha.
- Gan c th to ( 30 40 trng hp )
- Thng khng c xut huyt trong giai on tin trin mn tnh.
- St : c th st tht thng khng r nguyn nhn.
- C th c mt s du hiu khc : au khp, cng cng dng vt. Ni chung v
lm sng ngoi lch to cc du hiu khc kn o, khng r.
2. Cn lm sng.
+ Huyt :
- S lng C thng trn 100 G/L, c trng hp BC ln ti 400 800 G/L.
- Cng thc C c cc giai on pht trin ca dng Bchatj t non (
nguyn bo, ty bo) n trung gian ( ty bo, tin ty bo )v trng thnh,
khng c khong trng bch cu thng t l nguyn ty bo rt t ( 2 5 %)ch
yu l BC ht trung gian v trng thnh, t l Lymphocyt thp.
- HC, HST gim nh, thiu mu ng sc, hnh thi HC bnh thng, HC li
tng nh.
- Tiu cu: s lng bnh thng hoc tng cao thi kz u.
+ Men Photphattaza kim BC: gim hoc khng c ( bt s im t 20 80)
+ Ty : Rt giu t bo, tng sinh mnh dng BC ht, c bit l ty bo, hu
ty bo. Nguyn ty bo, hu ty bo thng ch chim vi phn trm.
Khng c khong trng C, dng HC bnh thng hoc tng sinh nh, dng mu
tiu cu tng sinh r rt. Ty c gi tr khi huyt chua r rng.
+ Nhim sc th Ph
i
(+) chuyn on cnh di gia NST s 9 v s 22. y l yu
t quan trng chn on.
+ Sinh ha mu: Hm lng vitamin B12 huyt thanh gp 2 10 ln ( bt: 4500
8000 microgamm/L). A xt Uric huyt thanh tng.
III. Chn on.
1. Chn on:
- Lm sng: ch yu l lch to.
- Cn lm sng:
+ C trong mu tng rt cao, c cc giai on pht trin ca dng BC ht,
khng c khong trng BC.
+ Men Photphattaza kim BC gim r.
+ Nhim sc th Ph
i
(+).
2. Chn on giai on tin trin cp:
Giai on tin trin cp l giai on pht trin tt yu ca bnh d c iu tr
hay khng. c im cu giai on ny:
- Mt nhy cm vi iu tr.
- Mt kh nng bit ha t bo ty.
- Tnh trng lm sng nng ln: thiu mu tin trin nhanh, XH do gim TC,
nhim khun, hch to ( cc triu chng ging BC cp )
- Blast mu ngoi vi mu ngoi vi hay ty xng >= 30%.
- Vn c NST Ph
i
(+).
3. Chn on phn bit:
- Tng C do phn ng vim trong c th: SL BC khng cao qu 50x10
9
. t khi xut
hin nguyn ty bo, tin ty bo trong mu, BC ht a kim khng tng, men
Photphattaza kim C tng r, khng c NST Philadelphia, lch khng to hoc to
t, v c kt hp ca bnh chnh.
- Lch to sinh ty: Thng km gan to, s lng C < 50-60 G/L, thng c HC
non trong mu. Chc ty xng thy cng, s lng t bo ty gim, NST Ph
i
(-),
Vit B12 huyt thanh bnh thng.
IV. Bin chng:
- Tc mch nhiu ni, c bit tc mch th hang dng vt, nhi mu lch.
- Nhim khun nng.
- Xut huyt ( Khi TC gim).
- au khp, si thn do ng a xt Uric
V. iu tr:
A. Giai on mn tnh.
1. Ha tr liu:
a. Busulfan ( Mulban, Myleran, Myelosan )
Tc dng chng phn bo kiu Alkyl, c hiu lc tt trong BC ty mn, tc dng
chm, ko di
Vin 2mg ung 4-6mg/ ngy ( 0,1mg/kg)
Theo di huyt 1-2 tun mt ln. Khi s lng BC < 20 G/L th dng thuc.
Tc dng khng mong mun: mt king, ri lon sc t, suy ty, x phi.
b. Hydroxyure ( Hydrea)
Tc dng chng chuy ha, tc dng nhanh, t c, t gy suy ty hnn
Dng 40mg/kg/ngy. Khi BC < 20 G/L gim liu, khi BC < 10 G/L ngng thuc.
Theo di huyt hng tun.
c. Cc thuc khc.
- Dybomomanitol ( Myelobromol hm lng 100 200mg): Chng phn bo kiu
alkyl, tc dng nhanh nhng khng bn vng nh usulfan. Liu dng 200-
300mg/ngy, ung hng ngy, theo di BC 2 ln /tun iu chnh thuc.
- Cyclophosphamide ( Endoxan) Chng phn bo kiu alkylant, vin 50mg, ng
100-500mg. Liu dng 100-200mg/ngy. Dng hng ngy.
c tnh: rng tc, suy gan, suy ty, xut huyt bng quang.
2. Interferon alpha.
- Liu u 2x10
6 v
/ngy tim di da, sau tng ln 5x10
6 v
/ngy.
-Khi BC <10 G/L th gim liu.
Tc dng khng mong mun: gy st, rt, gim cn, ri lon gic ng, tan mu,
au khp.
3. Quang tuyn liu php.
- Tia x lch l mt cch lm gim BC, p dng khi ha tri liu khng h c BC
hoc lch qua to.
- Liu 3-4 Gy/ln. t iu tr khong 40 Gy.
4. Cc phng php khc:
Gn BC, ct lch, ghp ty
B. Giai on tin trin cp tnh iu tr nh BCC
Nu tng blast toi lymphoblast th thng dng phc VAD ( Vincristin +
Adriamycin + Dexamethazon).
Nu tng last loi myeloblast th thng iu tr rt kh khn. p dng phc
Daunorubicin + Cytarabin.
C. iu tr triu chng.
- Nu BC mu ngoi vi qu cao th phi dng Allopurinol 0,3-0,6mg/ngy phng
Gout
- Tc mch: c th dng aspirin, heparin, thn trng v trong trng hp ny d
chy mu.
- iu tr triu chng khc; chng nhim khun, chy mu, thiu mu nht l giai
on tin trin cp

38. BNH BCH CU LYMPHO MN

I. i cng.
Bnh BC Lympho mn l bnh l c tnh ca dng Lympho B ( ch di 2% l ca
dng Lympho T ) th hin l s xm ngm cc t bo Lympho nh mu ngoi vi,
ty xng hch v lch so vi s lng ln. Bnh tng sy ra la tui 50,
nhng c gp tui tr. Bnh khng lin quan n tia x ha cht, virut. Mt s
nghin cu thy in cho thy c lin quan n trng in t tn s cng
nghip.
BC Lympho mn gp nhiu M, chu u, l bnh mu c tnh t gp nht. chu
v VN bnh ny him gp.
II. Lm sng.
Hch to l ch yu.
+ Hch ngoi vi: To ton thn, gp nhiu vng c, nch, i xng hai bn. Chc
khng dau, di ng d dng, kch thc to nh khc nhau v c nhng hch rt
to.
+ Hch su:
Vng trung tht thng hch khng to lm.
Thng gp hch vng bng m dc theo ng tnh mch ch, chp h bch
mch thy r rng. C khi hch rt to, khm vng bng, tht lng c th cm gic
c hch, c th thy triu chng ph hai chi di, c trng do chn p ca
hch.
+ Lch to: va phi hay rt to gp khong 50% trng hp, c th c biu hin
cng lch.
Gan t khi to, c khi Amidal rt to.
III. Xt nghim.
- Mu: C tng va phi trong khong 50 G/L, trong lymphocyt chim n 70-
80% thm ch 99%. Lymphocyt nh hnh thi ni chung bnh thng, t l
lymphoblast v prolymphocyt thp, c khi khng c.
HC v TC thng gim nh hoc khng gim tr thi khz cui.
- Ty : Giu t bo, cng nh mu ngoi vi, t l lymphocyt rt cao thng trn
50% tng s tb c nhn trong ty xng, lymphoblast cng t.
XN nhim sc th: thng thy Trisomy 12 ( 50% ). Nu l BC lympho T ( hip gp
) th thng thy chuyn on 14-14.
- Biu hin ri ln min dch: Bnh BC Lympho mn l mt bnh suy gim min
dch mc phi, suy gim c min dch dch th v min dch t bo, cho nn bin
chng nhim khun l yu t e da t vong gian on cui.
- Thng gim IgG, IgA hay IgM huyt thanh, gim t l chuyn dng lympho vi
PHA.
- Huyt tn t min hoc XH gim TC t min rt hay gp vi Coombs (+) trn 20%
trng hp.
IV. Cc th bnh khng in hnh.
C rt nhiu, ng ch { n cc th sau:
- Th bng: Khng c hch ngoi vi, ch c hch bng vi cc triu chng ton
thn nng: st, thiu mu, s thy U bng, c trng. Bnh tin trin nng cn
chn on phn bit vi non Hodgkin lymphoma.
- Th lch: Khng c hch to, ch c lch to, chn on da vo huyt ty .
- Th mt b: Lch to, suy ty nng, tin lng xu.
- Th n: C khng tng hoc tng t, tin trin chm.Chn on da vo ty ,
sinh thit ty.
- Th da: Triu chng t da ni bt bi cc hn, cc dt sn da do thm nhim
BC lympho, c th c ban ton thn.
V. Giai on lm sng.
G Theo
Binet
Sng(nm) G Theo Rai
A.
Tng C
lympho
mu,
Di 3
nhm

>8
0
Hch khng
to
hch to,
Khng
gim HC,
TC
B
Trn 3
nhm
hch to,
Khng
gim HC,
TC
5-6 I Hch to
C
C thiu
mu hoc
Xut
huyt
gim TC
2-5
II
Gan to hoc
lch to
III Thiu mu
IV XH gim TC
Ghi ch: Nhm hch bao gm: Vng c, vng nch, vng bn, gan v lch
VI. Chn on phn bit.
- Tng C Lympho lnh tnh:
Thng gp tr em com v thng do nhim virut
Tng C Lympho do ho g: Trong mu tng C Lympho va phi 20-30 G/L,
trong ty xng bnh thng.
Bnh Carlsmith: Gp tr em, c vim mi hng, st, C tng ckhi ti 50-100
G/L trong ch yu l Lympho nh, ty xng T.
- Tng C lympho va phi cong gp mt s bnh truyn nhim nh: thng
hn, lao, rucellose, im cn ch l tt c cc trng hp tng Lympho lnh
tnh u l Lympho T.
- Bnh Waldenstron: LS ging BC lympho mn nhng trong mu v ty xng cc
t bo lympho plasmocytoid. Mu lng tng rt cao, HC xp hnh chui tin,
nht mu tng, in di min dch pht hin paraprotein IgM.
VII. Bin chng:
- Nhim khun: giai on cui do khng min dch gim.
- Thiu mu huyt tn t min.
- Xut huyt gim TC.
- Suy ty do xm ln t chc Lympho
- Kt hp vi mt s ung th khc ( 10%) K i trng, K v, K phi.
VIII. iu tr.
L mt bnh c i sng ni chung kh di, v vy trc iu tr cn phi tm
bin php chn on xc nh v chn on giai on. nhng bnh giai on
sm A hoc O, I th khng phi iu tr c hiu, ch yu l theo di nh kz. Ch
cn iu tr gian on B, C hoc II, III, IV.
- Ha tr liu:
Cc thuc kinh in: Chlorambucil 0,1-0,2 mg/kg/24 gi
Cyclophosphamid 2,5mg/kg/ngy ung hoc tim 200mg cch nht.
Thuc mi: Deoxycoformycin, 2-chlorodeoxyadenoxin, fludarabin.
- Corticoid:
Prednisolon1mg/kg/ngy ch dng vi cc th bnh c ri lon min dch r nh
Coombs(+), huyt tn t min, gim TC t min, suy ty.
- Quang tuyn: Tia ton thn, tia khu tr vo khu hch to kt hp vi ha cht, tia
ngoi c th thng qua mt Shunt ng tnh mch.
- Huyt thanh anti lymphocyt.
- Ha cht khc: khi cc ha cht trn khng p ng th th c th kt hp cc
alkylant khc v Vincristin, Doxorubicin.
- Ct lch: Ch nh khi c cng lch, thiu mu huyt tan t min, gim TC t
min.
- iu tri triu chng v bin chng: truyn cc thnh phm mu, khng sinh,
gamma gloobulin
39. U LYMPHO C TNH
Dr.Thanh
I - I CNG:
1/ nh ngha:
U lympho c tnh l cc bnh c tnh pht sinh t t chc lin vng lympho ( cn
gi l lympho li).
U lympho c tnh hay cn gi l: K hch h thng, hoc hch c tnh.
2/ Phn loi :2loi
- U lympho c tnh Hodgkin
- U lympho c tnh Non- Hodgkin
3/ Nguyn nhn & c ch bnh sinh:
Cho n nay nguyn nhn v c ch bnh sinh vn cha r rng.
- Do Virus Epstein- Barr(EBV) Gy bnh Lympho Burkitt
- Do suy gim MD.


II - TRIU CHNG :



1/ Lm sng :
* Ti ch: H/C hch to.
- V tr: Hay gp c ( gc hm, di cm, trc v sau c c chm, h thng
n, trc v sau tai, cnh xng chm.); H nch; khuu tay dc b trong c nh
u; vng bn; kheo chn; hch trung tht; hch trong bng; dc theo M ch
bng.
- S lng:S lng hch thng tng dn.
- Mt : Chc .
- Km di ng .
- Khng au.
- Da trn b mt hch : Khng bin i hoc tm .
- Tin trin ca hch: Thng tin trin nhanh, thng dnh vi nhau thnh chm.
* Ton thn:
+ St :
- Bnh Hodgkin st thng din ra tng t ( kiu st hi quy: tng t st ko
di nhiu ngy xen k nhng t ngh nhiu ngy khng st) xut hin sm, mi
ln st hch li to, sau st hch nh li nhng khng v v tr ban u.
- Bnh Non- Hodgkin Thng st lin tc, st nh, xut hin mun.
+ Ra m hi trm: M hi ra nhiu v ban m. khng lin quan n nng v hot
ng th lc.
+ Gy st cn: Gim st > 10% cn nng trong 6 thng.
+ Nga: Thng gp trong bnh Hodgkin ; t gp trong bnh Non- Hodgkin. Nga
khng p ng vi thuc khng Histamin. C ch cha r.
+ C th gp cc t/c: gan, lch to, tn thng da, au xng, ri lon tiu ha,
nhim khun .
2/ Cn lm sng:
XN m bnh hc chn on xc nh: Sinh thit hch lm GPBL
- Hodgkin: L t chc Stemberg, cn gi l t chc ht ( Granulom) t chc ny
gm tb Stemberg, lymphocyte, E(Eosinophile), N(Neutrophile), plasmocyte, tb
xc trng vn l tb Stemberg l tb kch thc ln 30-60m. Nguyn sinh cht
rng, c mt hoc nhiu nhn, nhn to c ht nhn, c khong sng quanh nhn,
li nhn th.
- Non-Hodgkin: Tng sinh mnh dng lympho B, hnh thi tb bin i mang c
im ca tb K( nhn qui, nhn chia), s tng sinh lm o ln v ph v cu trc
hch, v bao hch b ph v.

III - CHN ON :




1/ Chn on xc nh:
- LS: H/C hch to : mang tnh nh hng.
- CLS: GPBL chn on xc nh.
2/ Chn on giai on:
- Giai on 1:Tn thng 1 nhm hch 1 pha c honh.
- Giai on 2:Tn thng t 2 nhm hch tr ln khng k nhau 1 pha c
honh.
- Giai on 3:Tn thng 2 hoc nhiu nhm hch 2 pha c honh.
- Giai on 4:Tn thng cc nhm hch ngoi vi v tn thng ph tng( Gan,
thn, phi).
vNgi ta chia ra giai on A, B da vo T/C ton thn:
+ Khng c T/C ton thn l g A
+ C T/C ton thn l g ( st, gy st cn, ra m hi trm)
*Ch : Lch v vng Waldeyer c coi l nhng nhm hch m khng nh
gi nh mt tng.
3/ Chn on phn bit:
3.1/ Lao hch:
+ Ti ch: Hch
- V tr : H thng n, sau c c- n- chm, di hm, hch bn, hch nch,
- Kch thc: kch thc nh, thng to thnh chm
- Tnh cht : mt khng ng u ci rn chc ci mm, ci th nhn., di ng.
Da trn b mt bnh thng C th c lot, c l d( th b u). Tin trin tng
t.
+ Ton thn: st nh v chiu, mt mi , km n gy st cn .
+ XN:
- Phn ng Mantoux(+) mnh.
- Sinh thit lm GPBL: hnh nh nang Lao :Hoi t b u trung tm nang lao, t
bo khng l, t bo dng biu m(t bo bn lin), cc Lymphocyt ngoi vi
nang lao, cc nguyn bo si.
- Cy dch hoc m tm BK.
3.2/ K biu m di cn hch:
+ Hch: thng v tr gn tng K.
- V tr: Mi tng K thng c mt v tr di cn c hiu vd:
K dd, K ph qun di cn hch h thng n tri;
K vm hng di cn hch sau tai , xng chm
K tinh hon, bung trng, t cung di cn hch bn.
- Tch cht: ging tch cht hch U lympho
+ XN: GPBL: Thy t chc biu m ca tng di cn.
3.3/ Hch to trong bnh BCC, M dng Lympho:
- Hch :
- Triu chng ca bnh BC
- XN mu ngoi vi, XN ty cho ta chn on xc nh.
3.4/ Hch vim:
- Hch c tch cht : Sng, nng, , au. Da trn b mt hch bin i : , nng
ho m.
- Ton thn: c th c st.
- XN : GPBL t chc hch: xm nhp nhiu tb vim.
3.5/ Hch phn ng do nhim khun:
- Hch thng xut hin vng nch, bn
- Hch nh, di ng , rt au
4/ Chn on th v phn loi:
4.1/ Cc th lm sng:
- Th hch nng
- Th hch trung tht.
- Th da,
- Th bng .
- Th dd, rut.
- Th TK,
- Th xng.
- Th lch to
4.2/ Phn loi theo th gii phu bnh:
+ i vi Hodgkin: phn loi theo Paris Rye, c 4 th:
- Th Lymph tri (u th l t bo lymph).
- Th x hn (x cc).
- Th hn hp.
- Th suy thi lymph (vng t bo lymph).
+ i vi ulymph non- Hodgkin c phn theo mc c tnh.
- Mc c tnh thp.
- Mc c tnh trung bnh.
- Mc c tnh cao.

IV - TIN TRIN & BIN CHNG:




1 Tin trin:
Tin trin & tin lng ph thuc vo giai on , th bnh v phng php iu
tr.
U lympho c tnh Hodgkin tin lng tt hn Non- Hodgkin
2 Bin chng:
- Nhimkhun (do suy gim min dch).
- Suy kit.
- Chn p , gy tn th*ng nhiu c quan, ni tng khc nhau.
- Chuyn th sang bnh bch cu cp (1 th bnh khc c tin l*ng xu hn).

V - IU TR :




1/ Phu thut:
Cc b nhm hch b tn thng cng vi nhm hch k cn
Ch p dng giai on I,II v p dng vi mt s th nh ( Th dd, rut, th lch
to)
2/ Quang tuyn liu php:
- p dng giai on I,II,III.
- liu chiu: 4000-4500 rad
3/ Ha tr liu:Theo phc CHOP. Mi liu trnh gm 6-8 t: Mi t gm 2
tun ni tr v 3 tun ngoi tr. Nu sau mi liu trnh m cha ht hch th tip
tc liu trnh th 2.
+ C: Cyclophosphamide( BD: Endoxan, Cytoxan)
- DT: l 100mg.
- TD: c ch tb K pht trin; gim min dch.
- TDP: Gim C km theo nguy c nhim khun; gim HC, Hb
-> thiu mu; Bun nn, nn, tiu chy ,to bn, chn n, vim lot nim mc
ming. Vim i trng, vim Q. Thay i sc t lng bn tay, chn, mng tay, suy
gim tinh trng.
- C: U lympho c tnh Hodgkin, Non-Hodgkin; K Biu m( kv, K bung trng, K
tinh hon, K ph qun, ).
- CC: Gim TC, BC, suy ty ; nhim khun giai on tin trin, vim bng quang;
c thai , cho con b; qu mn vi thuc.
- LL&CD: 100mg x 8 l/24h pha HTM 0,9% truyn TM 1 liu duy nht/ 1 t. Hoc
800mg chia lm 2 ln :
400mg ngy th nht
400mg ngy th hai
+ H: Hydroxy Daunombicin( BD: Doxorubicin, Adriamycine, Farnombicin).
- DT: L 10mg, 50mg ; dd mu hng.
- TD: khng sinh km tb thuc h anthracylin; c ch qu trnh tng hp AND v
ARN.
- TDP: Tng c tnh trn c tim, ri lon nhp tim, ngng tim
Tng c tnh vi gan, thn, tng c tnh trn c quan to mu. Rng tc; chn
n, bun nn, nn, lot nim mc, a chy, tng acid uric huyt; gim tinh trng.
- C: U lympho c tnh Hodgkin , Non-Hodgkin; K Biu m ( k v, K ) bung trng,
K tinh hon, K BQ, K phi ) , BCC,M.
- CC: nh tim km theo suy tim., suy ty, ph n c thai , cho con b.
- LL&CD:10mg x 6 l/24h pha HTM 0,9% truyn TM 1 liu duy nht/ 1 t.
Hoc 60mg chia lm 2ln :
30mg ngy th nht
30mg ngy th hai .
+ O: Oncovin( Vincristine).
- DT: l bt ng kh: 0,5mg; 1mg
- TD: l 1Alcaloid chit xut t cy da cn. C t/d chng K, chng nguyn phn,
c ch s phn bo cc tb BC v tb K.
- TDP: Gy c trn TK ngoi vi ( d cm u chi ) gim , mt phn x , cm gic;
gim C, TC; Tng hoc gim HA; RLTH; Rng tc ; au xng hm, au c hng;
st , vim m tb, sng n; teo TK th gic gy m.
- C: U lympho c tnh Hodgkin, Non-Hodgkin; CC; U tb TK; Sarcom li.
- CC: Gim BC, qu mn vi thuc, c thai- cho con b.
- LL&CD: 1mg x 2 l pha HTM 0,9% truyn TM 1 liu duy nht/ 1 t.
+ P: Prednisolone( BD: Solu-Medron, Depedsolon, )
- Prednisolone: vin 5mg
+ C: Trn cc bnh v mu: U lympho c tnh, BCC, Suy ty, thiu mu tan huyt
MD, xut huyt gim TC,
+LL&CD:1-1,5mg/ kg/ 24h. => 5mg x 10v/24h ung s,c x 5ngy
- Solu-Medron: l 40mg,125mg, 500mg ( 40.000/l)
+ LL&CD: 40mg x2-4l/ 24h tim TM x 5 ngy
- Depersolon : 30mg x 2 ng/ 24h tim TM x 5 ngy ( 12.000/l)
* Ch : TD ph ca corticoid:
+ H/C Cushing
+ H/C DD-HTT: vim, xut huyt , thng.
+ THA
+ Tha xng, au nhc xng->gy xng bnh l.
+ c thy tinh th.
+ D nhim khun.
+ Vt thng chm lin, teo c.
+ Tng ng mu.
+ RL kinh nguyt, mc ru , ni trng c.
+ Ct thuc t ngt -> Suy tuyn thng thn.
+ n c th:
1.Endoxan :100mg x 8 l/24h pha HTM 0,9% truyn TM 1 liu duy nht/ 1 t
2.Doxorubicin:10mg x 6 l/24h pha HTM0,9% truyn TM 1 liu duy nht/ 1 t.
3. Oncovin: 1mg x 2 l pha HTM 0,9% truyn TM 1
Liu duy nht/ 1 t.
4.Solu-Medron: 40mg x2l/ 24h tim TM x 5 ngy

+ Nu BN c bnh tim mch; hoc c bin chng ca Doxorubicin trn tim mch
th dng phc : VCP
1. Vincristine:1mg x 2 l pha HTM 0,9% truyn TM
1 Liu duy nht/ 1 t.
2 Cyclophosphamide :100mg x 8 l/24h pha HTM
0,9% truyn TM 1 liu duy nht/ 1 t.
3. Prednisolone:5mg x 10v/ 24h ung s,c x 5 ngy
4/ Lm tng kh nng MD c th:
- ng Y: Tam tt, c inh lng, nm linh chi, phylamin, Flavonoid.
- Mt s cht khc: BCG, Interferon - 2B, TFX, Thymomodelin...
5/ Phi hp cc phng php trn :
+ Chiu x trc + ha tr liu + Tng kh nng MD.
+ Ha tr liu + Chiu x sau + Tng kh nng MD
6- Ghp t bo gc to mu:
Ghp t bo gc to mu t thn hoc ng loi c p dng trong nhng giai
on sm ca bnh (giai on I,II) sau khi c iu tr bng ho cht hay x
tr (hoc kt hp c hai bin php ny) m t c hiu qu lui bnh. y l mt
bin php c nh gi l c hiu qu tt lm tng thm i sng cho bnh
nhn mt cch ng k.
Phng php ny ngy nay ang c cc nh khoa hc lu { la chn, tuy nhin
cha c ng dng rng ri do i hi chi ph kh cao v ch thc hin c
mt s c s c trang thit b cn thit.
7- S dng khng th n clon: l mt phng php iu tr tt v mang tnh
chng u c hiu cao. Tuy nhin phi xc nh c khng nguyn ca t bo u
bng phng php ho m min dch. Khng th n clon cha c dng nhiu
nc ta v cn t tin v ph thuc vo kh nng chn on ca cc c s iu
tr

Tm tt phc iu tr
+ Giai on I,II v m rng IIIA:
- Tia x, sau iu tr ho cht
- Nng cao sc khng min dch ca c th .
- Nu c iu kin ghp t bo gc to mu
+ Giai on IIIB, IV:
- iu tr ho cht .
- Nng cao sc khng min dch ca c th

PHC IU TR K BIU M SAU PT
Caf- Paf- af
1.Cyclophosphamid 100mg x 8 l x 1ngy duy nht. Pha HTM 0,9% truyn TM
Hoc 400mg- ngy th nht.
400mg - ngy th hai
2.Adreamycin10mg x 6l x 1ngy duy nht- truyn TM
HocDoxorubicin10mg x 6 l c th dng:
30mg - ngy th nht
30mg - ngy th hai
3. 5-FU( Fluoro Uracil )0,25g x 2 l/24h x 5-7 ngy- truyn TM.
4. Plastin50-100mg


40. XUT HUYT GIM TIU CU MIN DCH
(IMMUNOGIC THROMBO CYTOPENIC PURPURA)

1- Khi nim v bnh.
Xut huyt gim tiu cu (TC) min dch l mt bnh xut huyt do s lng tiu
cu trong mu ngoi vi gim bi s c mt ca khng th chng tiu cu trong
huyt thanh, khng th ny bm ln mng tiu cu lm mng tiu cu b bin i
v do s b thc bo khi i qua t chc lin vng ni mc, hoc b tiu hu khi
c kt hp b th. Bnh gim tiu cu nguyn pht (werlhof) cn gi l xut huyt
gim tiu cu v cn.
Thng hay gp trn lm sng thuc nhm .

2- Nguyn nhn v c ch bnh sinh.
* Nguyn nhn:
+ Gim tiu cu do khng th ng chng:do truyn mu khc nhm tiu cu,(-)
+ Bt ng nhm tiu cu gia m v con (-).
+ Do thuc v ho cht v c loi cha r cn nguyn (xut huyt gim tiu cu t
min).
* C ch bnh sinh:
Trong huyt thanh xut hin khng th chng tiu cu, cc tiu cu b cm nhim
bi khng th ny v b cc i thc bo h lin vng ni mc (ch yu l lch)
phn hy. Cc khng th chng tiu cu phn ln l IgG, c th l khng th ng
chng, t khng th hoc phc hp khng nguyn - khng th. Ngi ta thy trn
cc bnh nhn c khng th chng tiu cu v khng th chng c mu tiu cu.

3- Triu chng lm sng(triu chng xut huyt l ni bt).
3.1. Xut huyt di da:
+ Mng xut huyt xen k vi nt xut huyt.
+ Xut hin mt cch t nhin (t pht).
+ Khng c tnh cht i xng, c th ri rc khp cc vng ca c th.
+ Cc mng v nt xut huyt khng cng la tui (khng ng thi).
+ C th ti din thnh tng t, hoc khng thnh t (thng gp gim tiu
cu t min).
+ Khi va chm c th lm xut hin mu t di da.
3.2. Xut huyt nim mc, ni tng hoc t chc:
+ Chy mu chn rng, chy mu nim mc mi.
+ Chy mu di kt mc.
+ Kinh nguyt ko di, a kinh, rong kinh ( ph n).
+ C th xut huyt tiu ho, vng mc, no, mng no.
+ i ra mu
3.3- Mt s du hiu lm sng khc:
+ Lch to: t gp (gp khong 10% cc trng hp), lch ch tng din c hoc
hi to.
+ Nghim php dy tht: thng dng tnh mnh.

4- Triu chng cn lm sng.
4.1- Cc xt nghim cm mu- ng mu:
+ S lng tiu cu mu ngoi vi gim.
+ Xt nghim co cc mu: sau 3 gi cc mu khng co hoc co khng hon ton.
+ Xt nghim co cc tiu cu : d 70%
+ Thi gian chy mu: ko di.
+ Mc tiu th prothrombin gim.
+ Thi gian mu ng v cc xt nghim ng mu khc trong gii hn bnh
thng.
4.2- Xt nghim min dch:
+ Xt nghim pht hin khng th chng tiu cu: nhiu xt nghim khc nhau c
th c tin hnh pht hin s c mt ca khng th tiu cu bm trn
mt tiu cu hoc t do trong huyt thanh.
- Xt nghim coombs tiu cu.
- Xt nghim Dison.
- Xt nghim Antiglobulin nh du bng peroxydaza
+ Xt nghim phng x
- T/2 i sng tiu cu: thng gim nng, ch cn vi gi.
- o hot ng phng x lch, gan: thng tng (nht l lch) v ti cc c
quan ny s tiu hu tiu cu xy ra nhiu nht.
4.3- Xt nghim ty: th*ng lm l ty
+ S lng mu tiu cu tng sinh (thng thi kz nhng nm u ca bnh).
+ S lng mu tiu cu gim (ch gp sau nhiu nm bnh tin trin).
+ S lng mu tiu cu c th bnh thng
+ Cng thc mu tiu cu th*ng thy: tng t l mu tiu cu i kim, nhn tr
v gim mu tiu cu c ht.

5- Bin chng.
+ Xut huyt ln cp tnh gy t vong: xut huyt no, xut huyt ng tiu ho,
xut huyt t cung ( ph n) nht l trong chu kz kinh nguyt.
+ Gy thiu mu: do chy mu cp hoc mn tnh.

6- Chn on: da vo:
6.1- Lm sng: ch yu l hi chng xut huyt vi cc dc im ca xut huyt
di da, nim mc v ni tng nh m t trong phn triu chng lm sng.
6.2- Xt nghim cn lm sng:
+ Cc xt nghim cm mu- ng mu:
- S lng tiu cu gim; thi gian mu chy ko di; co cc mu hoc co cc tiu
cu b ri lon ; mc tiu th prothrombin gim.
- Xt nghim khng th chng tiu cu: dng tnh.
- Cc xt nghim ng mu trong gii hn bnh thng.
+ Ty : S lng mu tiu cu ty xng tng (thng gp v c th l bnh
thng; tng t l mu tiu cu i kim v nhn tr, gim mu tiu cu c ht.
+ Xt nghim phng x: na i sng tiu cu (T/2 gim nng).

7- iu tr.
Vic thc hin cc bin php iu tr ty thuc vo nguyn nhn, th bnh (cp
hay mn) v mc xut huyt trn lm sng hoc mc gim tiu cu v k c
la tui.
7.1- Xut huyt gim tiu cu do khng th ng chng (do truyn mu khc
nhm tiu cu, do bt ng nhm tiu cu gia m v con (gim tiu cu tr s
sinh). Loi cn nguyn ny t gp.
+ Khng cn iu tr: nu xut huyt t, s lng tiu cu gim nh hoc trung
bnh (t 60-80%G/l).
+ iu tr nguyn nhn: kh thc hin
+ iu tr theo c ch bnh sinh:
- Liu php corticosid: prednisolon liu 1-3 mg/kg/ ngy: ung hoc tim tnh
mch hng ngy cho n khi gim v ht xut huyt, sau gim liu dn v tin
ti ngng thuc.
+ iu tr triu chng:
- Truyn tiu cu cng nhm (ch s dng trong trng hp xut huyt nng):
hiu qu mang tnh tm thi v khi truyn vo tiu cu b ph hy rt nhanh. S
lng c th t 1-2 n v tiu cu/10kg th trng.
7.2- Xut huyt gim tiu cu do thuc:
+ iu tr nguyn nhn: ngng thuc s dng.
+ Liu php corticod:
Prednisolon liu 1-3 mg/kg/ ngy: ung hoc tim tnh mch hng ngy cho n
khi gim v ht xut huyt, sau gim liu dn v tin ti ngng thuc.
+ iu tr triu chng:
- Truyn tiu cu cng nhm (ch s dng trong trng hp xut huyt nng)
Ch : iu tr bin chng suy thn (hay gp trong trng hp ny): truyn dch,
li tiu l ch yu.
7.3- Xut huyt gim tiu cu t min:
y l loi bnh l{ thng gp nht trn lm sng. Cn nguyn cha c xc
nh.
* iu tr theo c ch bnh sinh:
+ Liu php corticod: c hiu lc nhanh c ch kh nng thc bo ca cc i
thc bo h vng m, lm gim tng hp t khng th ca cc t bo lympho B,
tng cng bn vng thnh mch, lm gim kh nng ngng kt tiu cu.
Prednisolon: iu tr tn cng 20-30 ngy vi liu 1-2 mg/kg th trng bng
ng ung. Sau gim liu t t trong thi gian 1-2 thng.
Nu cn thit c th dng liu tr trong 1-2 thng tip theo vi liu ung:
0,25mg/kg th trng.
Phn ln cc trng hp tiu cu tng sau 3- 4 ngy iu tr v c th tr li gn
bnh thng hoc bnh thng sau 1- 4 tun.
- Trng hp chy mu nng, c bit l chy mu ni tng hoc e do xut
huyt no th s dng corticod liu cao hoc rt cao. Thng dng dng methyl
prednisolon (solu- medron) tim tnh mch vi liu t 3-10mg/ kg th trng/ 24h
thm ch cao hn. Tuy nhin ch nn dng 3-5 ngy, khi gim chy mu phi gim
liu dn v sau s dng tip mc liu nh ni trn.
- Trng hp khng thuc: ngi ta khuyn dng phng php iu tr ngt
qung tng t: Dexamethazon 40mg/ ngy ung lin tc trong 4-5 ngy. Mi
thng ung mt t nh vy. Cch s dng thuc ngt qung nh trn c th gy
c s p ng tch cc.
+ S dng immunoglobin (IgG) liu cao: s dng globulin min dch c th c
ch nh trong trng hp cn t kt qu nhanh, l cch iu tr chn lc cho
nhng trng hp chy mu cp, nng tr s sinh hay sn ph hoc chng ch
nh corticoid nhm gip bnh nhn thot khi cn nguy cp.
- Liu lng: dng liu cao: 2g/kg/24h vi ngi ln; 0,5g/kg/24h vi tr em; Liu
c hiu qu phi t c l: 20,4g/24h, tim truyn tnh mch lin tip trong 3-4
ngy
- Tc dng: hn 50% cc trng hp ln tui v hu ht cc bnh nhi (th cp)
tiu cu tr li bnh thng sau 4-5 ngy iu tr .
- C ch: IgG liu cao lm c ch sn xut t khng th chng tiu cu theo c ch
ngc (Feed- ack) ng thi lm gim tnh trng thc bo h thng vng ni
m (lm gim nhy cm ca cc receptor i thc bo).
+ Thuc c ch min dch:
- Ch nh: khi bnh khng p ng vi corticoid hoc ct lch v khng c ch
nh ct lch. Thuc ch nn s dng cho ngi ln. Cc loi thuc ny c hiu lc
lm gim t khng th chng tiu cu do c ch t bo lymph: th*ng s dng
mt trong cc thuc sau: khi cn thit c th kt hp 2 loi:
- Cc thuc:
. Imuran (azathioprin): liu ung 2,5-3mg/kg/24h. Lin tc trong 9-12 thng. 50%
s tr*ng hp c p ng v ch sau 2-3 thng mi nhn thy. Cn l*u { kh
nng gy c vi ty x*ng ca loi thuc ny.
Nu khng c hiu qu th nn phi hp vi mt trong cc thuc c ch min dch
khc nh* vincristin hoc vinblastin.
. Vincristin liu 1,5-2mg hoc vinblastin 8-10mg tim truyn tnh mch 1 tun 1
ln trong 3- 4 tun. V thuc c c tnh cao c bit vi ty xng, nn khng
nn dng qu 4 tun lin tc.
. Cyclophosphamid (Endoxan): liu ung 100mg-150mg/24h lin tc trong 9-12
tun, 50% cc trng hp c p ng vi thuc ny. Hiu qu nhn thy sau 2- 4
thng. C th s dng tim tnh mch ngt qung liu 1-1,5g/m2 c th/ 1 ln, c
1 thng tim 01 ln. 65% cc trng hp c kt qu tt sau 04 ln tim , thuc
c vi ty xng.
* Ct lch:
Va l phng php iu tr theo c ch bnh sinh, va iu tr triu chng.
y l bin php iu tr c hiu qu thng c ch nh trong xut huyt gim
tiu cu t min khi m mt s liu php khc khng t kt qu mong mun. Ct
lch c tc dng lm gim mnh tnh trng thc bo i vi tiu cu ; lm gim
sn xut khng th chng tiu cu.
+ Ch nh:
- Sau iu tr tch cc bng corticoid trong 3 tun m khng t c hiu qu
gim chy mu hoc khng tng c s lng tiu cu. Ct lch trong ch nh
ny c coi l cp cu.
- Sau 3 t iu tr tch cc bng corticoid nhng khng kt qu: khng ht chy
mu, tiu cu khng tr v bnh thng hoc gn bnh thng. C p ng vi
corticoid nhng ph thuc vo thuc ny (ti pht sau khi ngng thuc).
Ni chung khi bin php corticoid, IgG tnh mch tht bi, v sau 3-6 thng m s
lng tiu cu vn <50G/l, th ch nh ct lch.
Tuy nhin cn lu { l: khng nn (hoc thn trng) ct lch tr em di 6 tui
v nguy c nhim khun s rt cao.
* Chiu x lch: ch thc hin do l{ do no c ch nh ct lch m khng thc
hin c. Ngi ta chiu x vo lch trong thi gian t 1-6 tun. Tc dng
tng t ct lch nhng hiu qu thp hn v t c s dng hn ct lch.
* iu tr triu chng:
+ Truyn tiu cu :
Hin c nhng kin khc nhau khi s dng tiu cu. Thng thng ngi ta thc
hin truyn tiu cu khi gim tiu cu hoc c nguy c xut huyt no, mng no.
Nn truyn tiu cu cng nhm hoc ca cng mt ng*i cho mu trong sut
qu trnh iu tr trnh gy phn ng sinh khng th chng tiu cu. Cn
truyn tiu cu vi s lng ln nhanh chng t c hiu qu cm mu tm
thi hoc ngn c nguy c xut huyt nhng t chc quan trng (nh no).
Liu 2 n v tiu cu /10kg/8h. Tiu cu truyn vo nhanh chng b phn hu do
khng th bm vo, do truyn tiu cu c tc dng cm mu trc mt nhm
bo v bnh nhn qua cn nguy him ch i mt phng php iu tr hu
hiu khc.
+ Gn huyt tng:
C th gn huyt tng loi b bt khng th khi hiu gi khng th qu cao.
Phng php ny tn km , kh thc hin.
+ Thay huyt tng: c kh nng lm tng s lng tiu cu tm thi nhng
khng gii quyt c nguyn nhn v c ch sinh bnh. Phng php ny c
s dng trong mt s trng hp c bit.
+ Tng cng bn vng thnh mch:
- Vitamin C: ung hoc tt hn l tim tnh mch: 1g/24h- s dng hng ngy.
- Rutin, hoc nc chit sc hoa he: ung hng ngy.
Cc phng php iu tr xut huyt gim tiu cu v cn (bnh werllof) cn lu {
nguyn tc sau: ch iu tr khi s l*ng tiu cu gim nng hoc chy mu
nhiu. Nu bnh nhn khng chy mu hoc chy mu d*i da t v s lng
tiu cu 80G/l th khng nn s dng thuc.
+ iu tr hu qu (c coi l bin chng):
Hu qu ca xut huyt gim tiu cu thng gp nht l thiu mu do mt mu.
Nhng trng hp chy mu ko di, ti din (nht l ph n) hay gy thiu mu
vi tnh cht nhc sc do thiu st. Cn b sung vin st hng ngy liu 0,5-1
g/ngy trong 1-2 thng tuz mc thiu mu.

Tm tt mt s phc iu tr ch yu
* Xut huyt gim tiu cu do khng th ng chng:
+ Liuphp corticoid:
Prednisolon 1-3 mg/kg/24h, ung hoc tim tnh mch hng ngy cho n khi
gim v ht xut huyt. Sau gim dn liu v tin ti ngng thuc .
+ Truyn tiu cu (tt nht cng nhm) hoc cng mt ngi cho, ch nh khi
xut huyt hoc gim tiu cu nng.
Liu 1-2 n v tiu cu /10kg truyn tnh mch/ 8 gi.
* Xut huyt gim tiu cu do thuc:
+ Ngng thuc ang s dng
+ Liu php corticoid: Prednisolon 1-3 mg/kg/24h, ung hoc tim tnh mch hng
ngy cho n khi gim v ht xut huyt. Sau gim dn liu v tin ti ngng
thuc .
+Truyn tiu cu (cng nhm) ch nh khi xut huyt hoc gim tiu cu nng.
Liu nh trn.
+ iu tr bin chng bng truyn dch, thuc li tiu (nu c).
* Xut huyt gim tiu cu t min:
+ Liu php corticoid:
- Prednisolon 1-2 mg/kg/24h lin tc trong 20-30 ngy,sau gim dn liu t t
trong 1-2 thng. Cn thit c th dng liu duy tr liu 0,25 mg/kg/24h trong 1-2
thng tip theo.
- Solu-Medrol 3-10mg/kg/24h tim tnh mch trong 3-5 ngy. Ch nh khi xut
huyt no- mng no hoc xut huyt ln khc.
+ Imumuno globulin (IgG) liu cao: 2g/kg/24h cho ngi ln, 0,5g/kg/24h vi tr
em tim truyn tnh mch trong 3- 4 ngy. Ch nh khi xut huyt hoc tiu cu
gim nng m liu php corticoid khng t hiu qu.
+ Ct lch: khi mt s bin php iu tr ni khoa km hiu qu.

41. XUT HUYT GIM TIU CU MIN DCH

I/ nh ngha:
XHGTC min dch l tnh trng bnh l{ trong tiu cu ngoi vi b ph hu h
lin vng ni m do s c mt cu mt t khng th khng tiu cu.
II/ Sinh l bnh :
- T khng th chng li khng nguyn tiu cu c bn cht l Ig G, i khi kt hp
vi IgM v /hoc vi IgA, rt him khi l IgM n c (5%)
- T khng th c sn xut ch yu lch.
- Tiu cu c gn t khng th trn b mt s b i thc bo h lin vng ni
m ph hu. Hin tng ny xy ra ch yu lch
III/ Chn on xc nh :
3.1. Hon cnh pht hin :
- Bnh c th xy ra mi la tui, nhng thng gp nht tr em v ngi tr
tui.
- Bnh thng gp n nhiu hn nam.
- Du hiu gi l hi chng chy mu, hay gp nht da v nim mc
- Bnh c th c pht hin tnh c: lm xt nghim t bo mu ngoi vi thy c
s lng tiu cu gim
3.2.Triu chng lm sng:
- Hi chng xut huyt :
* XH di da a hnh thi,nhiu la tui( tnh cht ca xut huyt do cn nguyn
tiu cu )
* XH nim mc v cc tng
- Hi chng thiu mu : ph thuc vo mc chy mu.
- Gan,lch hch khng to.
3.3 . Triu chng xt nghim :
3.1.1 Huyt :
- S lng tiu cu: gim (nhiu mc )
- S lng hng cu bnh thng hoc gim tuz mc chy mu
- S lng bch cu bnh thng hoc tng ( ch yu BC ht do kch thch tu khi
mt mu nng)
3.1.2 Tu :
- Tng sinh dng mu tiu cu
- Dng hng cu , bch cu ht pht trin bnh thng ( hoc c th c phn ng
tng sinh khi c mt mu nng )
- Khng c hin tng xm ln tu xng
3.1.3 Xt nghim ng mu :
+ Xt nghim ng mu huyt tng:
- Howell bnh thng hoc c th ko di
- Cefalin kaolin bnh thng
- T l prothrombin : bnh thng
- Fibrinogen bnh thng
+ Cc xt nghim cho thy ch c cc ri lon lin quan n tiu cu
- Mu chy ko di
- Co cc mu : khng co hoc co khng hon ton
3.1.4 Xt nghim min dch:
- Tng immunoglobulin (nht l IgG) gn trn b mt tiu cu .
3.1.5 Xt nghim ng v phng x (s dng Cr51 ) :
- Cho thy tiu cu b gi v b tiu hu nhiu lch .
IV Chn on phn bit
4.1 Gim tiu cu gi :
Do hin tng kt vn tiu cu trong EDTA trn invitro. Trng hp ny cn kim
tra s lng tiu cu trn ng chng ng bng citrat.
C th do ng dy trong ng mu xt nghim.
4.2 Gim tiu cu do cc cn nguyn ti tu xng:
- Suy tu xng
- L x mi cp .
- a u tu xng
- K di cn tu xng.
- Hi chng ri lon sinh tu
4.3. Gim tiu cu ngoi vi do cn nguyn khc :
- Do dng thuc
- Do nhim virus : HIV, HBV, HCV, Dengue, si, thu u ...
- Do tiu th trong hi chng CIVD
- Bnh h thng
- Do cng lch
- Sau truyn mu .
V. Tin trin :
- T l t vong : 5% do gim tiu cu nng.
- Tin trin cp tnh : thng gp tr em. Khi trong 80% trong vng 2 thng
- Tin trin mn tnh : thng gp ngi ln , din bin trn 6 thng rt d ti
pht
VI. iu tr :
5.1. iu tr c hiu:
Nguyn tc: iu tr c ch min dch
5.1.1.Corticoid liu php
- Prednisolon liu :1 - 2mg/kg/ngy x 4 - 6 tun. Nu c p ng th gim liu dn
v duy tr
c th dng liu trung bnh: methylprednisolon 3-5mg/kg/ngy, gim dn liu
- Trng hp nng, nguy c chy mu e do tnh mng c th dng corticoid liu
cao (bolus): methylprdnisolon 1g/ngy x 3 ngy,
- Khi s dng corticoid cn lu { cc tc dng ph ca thuc
5.1.2. Ct lch :
+ Tiu chun ct lch:
- Ch nh khi iu tr 6 thng bng corticoid tht bi
- Sinh mu tiu cu trong tu cn tt.
- Tui di 45.
- Khng c cc bnh l ni khoa khc
- Bnh nhn t nguyn.
+ C th t lui bnh hon ton 80% bnh nhn
+ Nu tht bi c th dng li liu Corticoid ban u
5.1.3. iu tr bng thuc c ch min dch :
- Ch nh khi tiu cu vn gim mc d c iu tr bng corticoid v hoc
ct lch
- Cc thuc c th dng : Cyclosporin A, Immurel, Cyclosphamid, 6MP, Vincristin,
5.1.4. iu tr bng globulin
- Thng ch nh trong trng hp cp cu :
- Liu lng : 0,4g/kg/ngy x 5 ngy)
hoc: 1g/kg/ngy x 2 ngy
Nu c hiu qu, cn iu tr duy tr 10 ngy/ln trong vng 1->3 thng.
5.2. iu tr h tr:
- Truyn khi tiu cu l phng php iu tr h tr.
+ c ch nh trong trng hp c chy mu nng e da tnh mng BN hoc
gim tiu cu qu nng <20G/l
+ Nn truyn tiu cu ly t mt c th c chn HLA hoc t mt ngi cho trong
gia nh v c loi b bch cu
- Nn truyn khi lng ln ngay t u, liu lng c th ti 6-8 n v (vi KTC
pool)/ngy.
- Gn lc huyt tng

42. SUY TY XNG

Dr. Thanh

I - I CNG :

1/ nh ngha:
Suy ty l ty xng gim hoc khng cn chc nng sinh mu do bt thng ca
tb gc to mu ty xng. nh th hin bng s gim hoc khng c mt cc
tb mu dng BC ht, dng HC , dng MTC ti ty xng dn n gim BC trung
tnh, HC v TC mu ngoi vi v gy ra cc hu qu trn lm sng.
2/ Nguyn nhn :
+ Mc phi :
- Thuc : thuc chng chuyn ha , chng phn bo, mui vng, chloramphenicol,
sulfamit.
- Phng x: Ha cht, Benzen, thuc bo v thc vt..
- Virus : VRVG , EBV, MCV..
- HST niu kch pht ban m.
+ Bm sinh : Bnh Fanconi, dy sng bm sinh, H/C Shwachman.
+ Khng c nguyn nhn: 50-65% trng hp.
3/ Bnh sinh:phc tp.
Do bt thng mc phi tb gc to mu hoc do RL min dch( T min).

II - CHN ON :



1/ Bin lun chn on:
1.1/ Cn c chn on suy ty:
* Lm sng :
- Tin s : Tip xc ha cht, dng thuc?
- H/C XH do gim tiu cu: XH a v tr (XH di da, chy mu nim mc ming ,
mi, chn rng, chy mu tiu ho: nn ra mu , i ngoi phn en. i ra mu).
a hnh thi( nt, chm, mng), b mng XH u ( b mng XH do RLM khng
u , hnh bn ). Ngim php dy tht(+). XN : TC < 100 G/l ; khi TC< 20 G/l c
nguy c chy mu ln e da t vong .
- H/C TM: TM ng sc( Gai li cn , cc ch s HC trong gii hn bt), din bin
nhanh: da xanh , nim mc nht , hi hp nh trng ngc, hoa mt chng mt,
c ting thi tm thu c nng mm v nn tim.
- H/C NK: BC gim , BC ht gim(N) -> vi khun cng sinh hi sinh gy bnh: st,
vim lot ming, hng, amidal, mn nht, vim phi, vim ng tit niu, nhim
khun huyt.
- Khng c H/C xm ln: gan, lch , hch khng to, xng khp khng au.
* Cn lm sng:
+ XN mu ngoi vi:
- BC gim< 3 G/l,
- CTC o ngc: BC ht gim{N gim(bt N>2,5 G/l)}; t l %L tng(bt 25-30%)
thc cht s lng L khng tng(bt s lng L 6-7 G/l)-> L c th chim ti 70%, N
gim c th cn 30%.
- HC gim, Hematocrit gim, cc ch s HC bt-> TM ng sc.
Nu chy mu nhiu -> thiu mu nhc sc.
- HC li gim(< 2) y l XN c gi tr nh gi CN sinh HC ca ty xng.
- TC gim < 100G/l , Thi gian MC ko di, Gim kh nng co cc mu ng.
- Fe huyt thanh tng > 150mcgam%.( bt nam: 15-27mcmol/l
N: 11-22mcmol/l)
+ Ty :
- Cht ty long, nhiu vng m, tb ty ngho nn , s lng ty gim< 30G/l.
- Dng BC ht gim(bt: 65-70%), Dng HC gim( bt: 16% ), C n nhn tng( ch
yu l Lymphocyt: bt 16%), HC non gim, mu TC him gp.
-> Cc XN trn ch mi ni ln CN ty ( Suy ty H/C)
+ Sinh thit ty: Xc nh bnh suy ty
Cc hc ty t tb , t chc m pht trin thay th tu .
2/ Chn on th v mc :
+ Th bnh :
- Th cp tnh : Thng khng c cn nguyn , gp ngi tr, bnh tin trin
nng, din bin nhanh.
- Th mn tnh : Thng c cn nguyn, din bin t t,
+ Mc :
Ch xc nh mc th mn tnh( XN mu ngoi vi)
- Mc rt nng: C NTT< 0,2 G/l( bt N> 2,5 G/l)
- Mc nng: C NTT< 0,5 G/l
TC< 20G/l
HC li < 20 G/l
- Mc trung bnh, nh: C NTT = 0,5-1,5 G/l
TC = 20-100 G/l
HC li= 20-50 G/l
3/ Chn on phn bit :
- BCC th gim BC: ngoi 3 H/C : thiu mu, xut huyt, NK, cn c H/C xm ln
gan, lch, hch to, au xng khp.
+ XN c Blaste c tnh mu ngoi vi; ty tng sinh nhiu tb non( Blaste c tnh
> 30%: NTB,TTB), gim dng trung gian to khong trng BC.
- Cng lch: lch to, XN: gim ti thiu 1 hoc 2 hoc c 3 dng tb mu ngoi vi,
ty xng c tng sinh lnh tnh tb b p (HC li); iu tr ct lch th khi v
T/C v huyt hc.
- Bnh Colagen: tn thng a c quan , gim 3 dng
- Bnh Biermer: gim 3 dng trong mu ngoi vi v ty xng.; hnh thi tb thay
i: c megalocyt v megaloblast(khng l) c BC ht v TC; nh lng B12 ht
gim.
- H/C RL sinh ty th gim sn ty.
- NK huyt:

III - IU TR :



1/ iu tr nng , thay th:
1.1/ Truyn mu:
* Truyn mu ti cng nhm:
+ TD: - lng mu mt, tng nui dng , gii quyt tnh trnh thiu O2 t
chc
- Kch thch ty to mu
- Chng chy mu
+ CD: Truyn nhiu hay t ty mc thiu mu.( nu truyn nhiu ln vi liu
ln d dn ti bnh nhin st: Hemochromatose)
v trong 1 n v mu cha khong 200-250mg st .
* Truyn khi HC:
- TD: b sung HC, HST gii quyt tnh trng thiu O2 t chc, Kch thch ty xng
to HC.
- CD: Truyn nhiu hay t ty mc thiu mu.( nu truyn nhiu ln vi liu ln
d dn ti bnh nhin st: Hemochromatose)
* Truyn khi TC khi TC< 50 G/l)
-TD : Chng chy mu.
-CD: Nn ly ca 1 ngi cho.
1.2/ Thuc c ch min dch:
+ Corticoid:
TD: +Chng chy mu nh t/d: tng sc bn thnh mch,
+Tng bit ha tb
+ Depersolon ng 30mg
-LL&CD: 30mg x 1/ 24h Tim TM
+ Solu-Medrol: l 40mg
- TP: Methylpernisolon Natri succinate
- LD: 40mg x 2-3 l/ 24h Truyn TM.
+Prednisolon: vin nn: 5mg
-LL&CD: 1-1,5mg /kg/24h
5mg x 8-10v/24h g/24h
+ Anti thymocyt globulin(ATG):ly t huyt thanh Nga.
+ Cyclosporin( Sandimum): d phng thi ghp
+ Cyclophosphamide( Edoxan, cytoxan):
100mg x 8 l /24h tim 1liu duy nht / 1t t
1.3/ Khng sinh :
Dng khi c nhim khun(c st) v d phng nhim khun khi BC gim , N gim-
> nguy c nhim khun
+Cefotaxim: L 1g
- LL&CD: 1g x 2l/ 24h Tim TM s,c
1.4/ Thuc KT to tb mu:
+Testosteron:Agoverin 10mg x 5-6 vin/24h u x 3-6 thng.
Andriol 40mg x 1vin /24h ung
Testosteron 25mg x 1/ 24h tim bp
TD: kt tb cnh tiu cu thn tng tit Erythropoietin,tc ng ln TB gc sinh mu
hoc to cc CSF
+G.CSF:yu t kt to BC ht .
+CM.CSF , IL-1, IL-3, IL-6
+KT to HC: Epokin(Erythropoietin)1000-2000UI/24h IV,IM , dd
Eprex1000-2000UI/24h x 5 ngy
+KT to BC:
+ VTM B4 ( Leuco4; Leucogen)
+ Neupogen, Leucomax, Leucokin.
+KT to TC :Thrompoietin
1.5/ Ghp ty :
Ghp ty ng loi l phng php tt nht hin nay. Tuy nhin ngi cho ty
phi c HLA ph hp.
1.6/ Ct lch: C th ko di c i sng HC, TC c truyn vo.
1.8 H l{. Dinh dng:
- V khun trong iu tr
- V sinh rng ming ,thn th, thc n.
- n tng m, sinh t, calo, gim m.
- ng vin t tng, kin tr iu tr.
Ch : Hin nay m hnh iu tr tt nht l:liu cao Cyclophosphamid + ATG
trc ghp ty
Cyclosporin d phng thi ghp sau ghp ty
n tham kho:
1.Solu- Medrol 40mg x 3 l/ 24h truyn TM.
2.Vitamin C 0,5g x 2 / 24h truyn TM.
3.Cefotaxim 1g x 2l /24h tim TM s,c.
4.Epokin 2000UI x 1 /24h tim TM s,c.
5.Leucokin
6.Sarganin 0,2g x 2 v/24h ung s,c.( gii c tb gan)
7.Methionin 0,25g x 4v/24h.ung s,c( B Albumin).
8.VTM 3B x2v/24h.
9.VTM E 0,4g x 1v/24h.
10.Truyn mu, Truyn khi

43. BCH CU CP(LEUKEMIA)

Dr.Thanh

I - I CNG



1/ nh ngha:
BCC l mt bnh mu c tnh do tng sinh c tnh tb Gc hoc tb Tin thn to
mu km theo s RL bit ha trng thnh.
* Bnh ch c 2 qu trnh:
- Tng sinh nhiu : cc c quan tng sinh v khi lng : gan lch hch. au xng
khp, c nhiu BC ht trong phi.
- Thiu vng cc tb lnh, cc tb c chong ch.
2/ Nguyn nhn: 5 nhm nguyn nhn:
- Bc x ion ha
- Thuc iu tr K.
- Ha cht .
- Di truyn.
- Virus.
3/ C ch bnh sinh : Bnh hnh thnh trong ty
c gii thch bng tn thng Gen cu trc.
Proto- Oneogen(km hm)
Anti- Oncogen( iu chnh)
4/ Phn loi:
4.1/ BC ty cp:Myeloblaste
-Mo: Tb c tnh u dng cha bit ha:
nhum: Peroxydase(+), PAS(-){Perodic Acid Shiff}
-M1: nguyn ty bo, Blaste c tnh > 90%
nhum:Peroxydase(+),PAS(-)
-M2: nguyn ty bo, Blaste c tnh > 30-89%
nhum: Peroxydase(+), PAS(-)
-M3:Tin ty bo
nhum: Peroxydase(+) , PAS(-)
-M4: Ty bo ,Mono
nhum: Peroxydase(+) , PAS(-)
-M5: Mono Blaste( >80% M5a;< 80% M5b)
nhum: esterse khng c hiu (+)
-M6: c tnh dng HC.
nhum: Peroxydase(-) PAS(+)
- M7: BCC dng mu TC : blast > 30%
Nhum: Peroxydase TC (+)

4.2/ BC lympho cp:lympho blaste
-L1: c tnh tb nh; nhum Peroxydase(-) , PAS(+)
-L2: L-Blaste tb to nh khng u, Peroxydase(-), PAS(+)
-L3: L-Blaste TB ln, bo tng a kim mnh, Peroxydase(+) PAS(-)
=> phn loi BCC phi da vo ty {nhum Peroxydaza (hoc Sudan Black),
PAS: 2 phng php nhum ny cho kt qu tri ngc nhau : Nu Peroxydaza(+)
th PAS (-) v ngc li. Khi kq Peroxydaza (+),PAS (-) -> l BCC dng ty; khi kq
Peroxydaza (-),PAS (+) -> l BCC dng Lympho}. xem hnh thi tb v t l Blaste c
tnh.
* nh hng LS phn loi BBC dng Lympho v dng ty:
+ Dng lymph: c hch to, H/C xm ln r. Xn mu c Lymph tng cao.
+ Dng ty : t c hch to, H/C xm ln khng r, xn


II - TRIU CHNG



1/ Tm tt bnh n:
BN nam(n) c tin s (bn thn, gia nh) vo vin vi l do (st cao; hoa mt
chng mt, bnh BCC nu tng iu tr bnh CC). Qua thm khm thy cc
HC, TC sau:
- HC TM: Da xanh ,nim mc nht, hoa mt, chng mt
HC gim, Hb gim
- HC XH: a hnh thi, a v tr, i mu vi th, a phn en.
TC < 100 G/l c XH trn LS
- HC NK: St cao , mi kh li bn, hi th hi
C tng
- HC Xm ln: Gan , lch , hch to ( to va phi).
au xng khp( xng c , xng chu)
- XN mu ngoi vi: c Blaste c tnh ( ch yu l NTB v TTB). Vng mt cc giai
on trung gian. To khong trng BC.
HC gim , HST gim, TC gim.
- Ty :
. S lng TB ty tng : bt: 30-150 G/l
. Mu TC gim 50-80 G/l
. Tng sinh laste non c tnh > 30%
Gim trung gian-> to khong trng BC trong ty.
BC ht, MTC, HC non b suy gim nghim trng.
2/ Tin trin v tin lng:
2.1/ Tin trin: tin trin nhanh, nu khng c iu tr th tin trin ngy cng
nng -> t vong.
- iu tr n nh hon ton: LS v bt, mu ngoi vi ht blast , cc ch s v HC, BC,
TC ty ch cn< 5% blast.
- iu tr n nh khng hon ton: LS ci thin r rt, mu ngoi vi ht hoc ch
cn vi %. Ty cn 5- 25% blast
- Ti pht sau mt thi gian n nh.
2.2/ Tin lng:nhn chung tin lng xu
CC dng lympho tin lng tt hn dng ty.

III - CHN ON :



1/ Chn on xc inh :
LS : 4 HC : thiu mu, xut huyt , nhim khun(triu chng suy ty), xm ln ca
cc blast., bnh tin trin nhanh
XN: Mu ngoi vi: xut hin nhiu Blast c tnh
Ty xng: Blast tng cao > 30%, c khong trng BC
2/ Chn on th bnh :
Da vo hnh thi tb, ha hc tb , du n MD v bin i di truyn
3/ Chn on phn bit :
3.1/ Suy ty: phn bit vi BCC th gim BC:
Suy ty khng c H/C xm ln.Mu ngoi vi: BC gim , N gim, t l % L tng, gim
3 dng. Ty ngho tb, t l blast gim <30%, dng BC ht gim, %L tng, dng
HC gim, MTC gim. Sinh thit ty: t chc m thay th ty .

3.2/ t cp BC ty mn :
Bnh tin trin t t, T/C c bn l Lch rt to, c th c cc h/c TM, NK, XH, tc
mch (g mn ko theo tng TC); XN mu ngoi vi; s lng C tng cao>100G/l,
CTBC mu ngoi vi xut hin tt c cc g pht trin ca dng BC ht, tng cao
ch yu l g trung gian v g trng thnh (NTB,TTB> 30%) ; XN NST
Philadenphia(+), khi NK Phosphataza kim tng cao.
3.3/ Tng sinh ty phn ng:i vi mt s NK, KST c bit khi chng xm nhp
vo ty nh: lao, st rt, nhim khun huyt.


IV - IU TR:



1/ Nguyn tc iu tr BCC:
- Dng ha cht liu cao dung np ti a.
- Dng ho cht kt hp nh vo tng thi kz khc nhau ca qu trnh phn bo.
- iu tr tn cng kt hp iu tr cng c c h thng.
- Phng chng tch cc cc bin chng: XH, TM, NK
2/ iu tr c th:
2.1/ Ha cht:
* BCC dng Lympho:
-Phc VP:
.Vincristin 2mg/m2(ti a l 2mg) truyn tnh mch cc ngy 1,7,14, 21, 28, 35,
42.
. Prednisolon 20mg/m, ung t ngy 1n 35, gim dn liu v ngng thuc
ngy 42.
- Phc VP DNR ASP:
+Vincristin(Oncovin): l 1mg
1,5-2 mg/ m2 / tun => 1mg x 2 l/ tun pha HTM 0,9% TTM
+Corticoid: Prednisolon1,5-2mg / kg/ 24h x 7 ngy.
+ Depersolon30mg x 2-3 /24h x 7ngy(12.000/)
+ Solu-Medrol40mg x 2-3 l/24h x7ngy(40000/l)
+Asparaginsase5000UI/ m2/ 24h
Hoc : Daunorubicin45mg/m2/24h x 4 tun
*BCC dng ty
iu tr tn cng: phc 7+3 (Phc ARA-C DNR)
+Arabinosid-Cytosine(Cytoza, Cytarabine):
100mg/m2/24h x7ngy=> 150mg/ 24h x 7ngy
+Doxorubicine hoc Daunorubicine:
40mg/ m2/24h x 3ngy=> 60mg/ 24h x 3ngy.
L 10mg x 6l /24h x 3ngy pha HTM 0,9% truyn TM
*iu tr cng c:
Cng dng ho cht nh trn nhng ngn ngy hn:
2.2/ iu tr triu chng:
- Truyn mu ti ton phn cng nhm
- C th truyn khi HC duy tr HC > 3T/l, HST >90g/l.
- Truyn khi TC khi c chy mu nng.
- Chng nhim khun bng KS kt hp vi v sinh c nhn ,v sinh phng bnh,
dinh dng v khun.
- Allopurinol100-300mg /24h chia lm 2 ln s,c ( Phng tng acid Uric v cn au
dng Gout trong bnh BCC th tng BC).
- Gim au, an thn
- Vitamin C,B
2.3/ Ghp ty:
- Ghp ty t thn: ly ty trong t lui bnh hon ton , sau c tia x 10
Gy hay ha cht liu cao, sau truyn li ty cho ngi bnh.
- Ghp ty ca anh ch em, c bit l sinh i cng trng: t l ti pht 25%, sng
ko di 50%
- Truyn tb mm: ly t mu nhau thai hoc mu ngoi vi( thi kz lui bnh). C
nguy c ly nhm blast(c CD34) s gy ti pht sm.



44. BNH BETA THALASSEMIA

Thalasemia l hi chng bnh di truyn v Hb , do thiu ht tng hp mch
polypeptit trong globin ca Hb. L bnh l di truyn ln trn nhim sc th
thng. Bnh c trng bi s sn xut bt thng hemoglobin (l phn t
nm trong hng cu v cn thit vn chuyn oxy cho c th). T gy ra
gim sn xut hemoglobin v tng ph hy hng cu. Kt qu l hng cu gim
v s lng (thiu mu) v cht lng (hng cu nh, nhc sc).
- b thalassemia : thiu tng hp mch b
- Bnh b/ HbE thalassemia : thiu tng hp mch b v c HbE
1. Chn on :
1.1. Lm sng : thiu mu tan mu mn tnh : da xanh, vng da, lch to.
thiu mu tan mu mn tnh : da xanh, vng da, lch to.
1.2. Xt nghim :
- Huyt : Hb gim, HCL tng, HC nhc sc, bin dng hnh bia v git nc
- Sc bn thm thu HC tng
- Sinh ha : Bilirubin t do tng > 6 mg/l
Urobilirubin niu ( + )
- in di c Hb bt thng :
b - thalassemia ng hp t : HbF > 10% vi tr > 1 tui , c th ti 90%
> 25% vi tr t 6 thng 1 tui.
b - thalassemia / HbE : HbF > 10%
HbE ( + )
1.3 Phn loi
C 2 th Thalassemia chnh: alpha-thalassemia v beta-thalassemia.
Alpha-thalassemia: thng gp cc dn c vng Chu Phi, Trung ng, n ,
ng Nam , Trung Quc v Phi Lut Tn. C 4 loi alpha-thalassemia t nh n
nng. Dng nng nht ca alpha-thalassemia thng gy h thai hoc tr cht khi
sinh.
Beta-thalassemia: thng gp cc dn c vng a Trung Hi, Chu Phi, ng
Nam . C 3 loi beta-thalassemia bao gm t dng nh n nng.
2. iu tr
2.1.iu tr thiu mu
- Truyn mu khi Hb < 80g/l , nn duy tr Hb > 100g/ l
- Loi mu truyn : khi hng cu
- Liu lng truyn : 10 20 ml/kg
- Thi gian truyn : trong vng 4 gi
( Trng hp thiu mu qu nng, c suy tim : nn truyn liu lng thp , tc
t t , km theo li tiu Lasix 0.5 1 mg/kg ).
2.2.iu tr nhim st :
- Khi ferritin huyt thanh > 1000 mg /l
- Thuc : gm 2 loi : tim v ung
Loi tim : Desferal (Deferrioxamin B )
- Ch phm : ng 0.5 g, dng bt trng.
- Liu lng :
30 50 mg/kg/8h, tun 5 ln , di da
50 100 mg/kg/8h, TM nu suy tim cp do nhim c st.
- Tc dng ph : au ti ch tim, sng n , t khi gp phn ng d ng , chm nhp
tim, tng hoc gim huyt p
Nu dng lu di c th gim th lc v thnh lc.
- Theo di : nh lng ferritine 3 thng/l
Loi ung : Kelfer
- Ch phm : vin nang 0,25g v 0,5 g
- Liu lng : 25- 75 mg/kg/ngy, ung chia 2- 3 ln
- Tc dng ph : him gp : bun nn, mt mi, ra m hi trm, c th au khp
c bit khi dng liu cao ko dI
- Theo di : nh lng ferritine 3 thng /l iu chnh liu.
2.3.Thuc ph tr khc :
Vitamin E : vin 400 n v
Liu dng : ngy 1 vin
Tc dng : bo v t bo thaslasemia chng stress xy ha
Acide folic : vin nn 5 mg, ngy 2- 3 vin
Km : 1- 2 mg/ ngy
Vitamin C : ch cho trong trng hp c thi st u theo ng phc , v
bt u sau 2 tun thi st
Liu dng : 150 250 mg/ngy, cho qu liu ny s gy ng c c tim
Tc dng : b sung tnh trng thiu vitamin C cu c th Thalasemia, tng tc
dng thi st ca desferal v kelfer.
Hydroxyurea:
- Vin nn 0,5 g
- Liu dng : 15 20 mg/kg ngy, ung
- Tc dng : tng tng hp HbF , c ch nh bThalasemia/HbE nhm ko di
i sng hng cu
- Tc dng ph : ri lon tiu ha , c ch tu gy gim bch cu ht v tiu cu
2.4.Phu thut ct lch :
- Khi c biu hin cng lch lm tng thiu mu (nhu cu truyn mu tng)
- Tr trn 5 tui
3. Phng nga
Pht hin nhng ngi mang gen bnh th d hp t tham vn di truyn.
Chn on trc sanh cc th bnh ca thalassemia cho thai nhi nu cha m u
mang gen bnh d hp t. Nu thai nhi mc bnh th nng, c th chm dt sm
thai kz.

45. BNH A CHY MU(HEMOPHILIA)


1- Khi nim v bnh.
Bnh a chy mu cn gi l bnh Hemophilie, l bnh di truyn lin quan gii
tnh, di truyn gen ln, ch gp nam gii. Bnh biu hin bng triu chng chy
mu do thiu ht cc yu t to thnh Thromboplastin, ch yu l thiu yu t
chng Hemophilie A (yu t VIII) chim khong 85% s trng hp v thiu yu t
chng Hemophilie B (yu t IX) chim khong 15%.
Bnh Rosenthal, m trc y gi l Hemophilie C do thiu ht yu t XI cng l
mt yu t tham gia to thnh Thromboplastin, nhng gp c nam v n, di
truyn nhim sc th thng v l di truyn tri.
2- Nguyn nhn v bnh sinh.
+ Bnh di truyn, tn thng gen cu trc trn nhim sc th X, gen ln, hu qu
l to nn cc phn t protein chng Hemophilie khng bnh thng. Di truyn
ph h xy ra 3 trng hp nh sau:
- M mang gen bnh, b bnh thng: mt na s con gi, mt na s con trai
bnh thng; na s con gi cn li mang gen bnh (XhX), na s con trai cn li
mc bnh (XhY).
- B b bnh, m bnh thng: tt c con gi l ngi lnh mang gen bnh (XhX),
tt c con trai u bnh thng(XY).
- B b bnh, m mang gen bnh: mt na s con gi b bnh (XhXh), na cn li
l ngi lnh mang gen bnh(XhX). Mt na s con trai b bnh(XhY)., na cn li
bnh
thng(XY).
+ Ngoi ra c 1 t l nh Hemophilie khng c du hiu di truyn ph h, ngi ta
cho rng l do t bin.
3- Triu chng lm sng.
Xut huyt l triu chng ch yu vi cc c im:
+ Xut huyt thng thy t nh, lc chp chng tp di, lc rng rng sa, xut
huyt cng sm bnh cng nng.
+ Xut huyt xy ra sau mt va chm, d l nh, khng xut huyt t nhin.
+ Xut huyt khng t cm, xu hng hay ti pht ti v tr tng chy mu
trc .
+ Hnh thi xut huyt th*ng l mu t di da, mu t trong c, khp;
mu t ti khp hay li di chng teo c khp v ti pht nhiu ln, x ho.
4- Triu chng cn lm sng.
Thi gian mu ng ko di, thi giam Howell ko di, thi gian Cephalin- Kaolin
ko di. nh lng yu t VIII hoc IX, XI gim hoc mt (Mc nng khi yu t
VIII hoc IX hoc XI <5%; mc va khi cn 5-10%; v mc nh >10% n <
50%).
5- Bin chng.
+ Xut huyt l triu chng chnh ca bnh ng thi cng l bin chng v l
nguyn nhn gy t vong. Nhng trng hp nng thng t vong sm khi bnh
nhn cn b.
+ Nhng trng hp nh, th n c th xut huyt do va chm do phu thut khi
trng thnh v thng li cc di chng nh: cng khp, teo c
6- Chn on.
+ Lm sng: Nam gii: chy mu kh cm sau va chm chn thng, c th c yu
t di truyn gia nh (khng nht thit).
+ Xt nghim :
- Thi gian Cephalin- Kaolin (PTT) ko di.
- nh lng yu t VIII hoc IX hoc XI gim di 50%.
7- iu tr Hemophilie.
7.1- Nguyn tc iu tr:
+ Cm mu cng nhanh cng tt, kt hp iu tr ti ch v iu tr ton thn.
+ D phng cc bin chng c nguy c t vong v bin chng lu di v chc
nng vn ng.
7.2- iu tr ti ch chy mu:
+ Chy mu ngoi da, chy mu vt thng: bng p bng bt gelaspon, gelastin.
+ Chy mu mi: nht gc gelastin, c th tm adrenalin c tc dng co mch
lm gim chy mu ti ch.
+ T mu di da: bng p lnh ti ch mu t kt hp iu tr ton thn.
+ T mu trong c, t mu phc mc: bt ng kt hp iu tr ton thn.
+ Trn mu khp: rt thng gp trong Hemophilie, cn bng p vi lnh ti
khp, bo tn vn ng nn phi bt ng t th chc nng kt hp iu tr
ton thn.
+ T mu sau h mt: Khu sn mt phng nhn cu b y li gy m, bng
p.
+ T mu thnh hng m c nguy c chn p ng h hp gy kh th phi m
kh qun ngay.
7.3- iu tr ton thn:
Hemophilie l bnh bm sinh, di truyn v vy khng iu tr c nguyn nhn
v iu tr bnh sinh. iu tr triu chng, d phng bin chng ng vai tr ch
yu v quan trng.
+ iu tr triu chng: c th l iu tr thay th.
- Truyn mu ti ton phn: s dng cc ti c s y t cha tch c cc thnh
phm ca mu, hoc ch nh cho nhng bnh nhn chy mu mt mu nhiu gy
thiu mu mc trung bnh, nng.
Th*ng truyn 1,2,3 n v mu trong nhng ngy u, sau c th gim dn tuz
tnh trng bnh nhn .
- Huyt tng ng lnh: Thc hin tuyn chuyn khoa, ni tch c cc
thnh phn ca mu ring r v c bo qun nhit 600C c th truyn
1,2 n v /ngy.
- PPSB: l mt phc b cc yu t ng mu c iu ch t huyt tng gm
c Prothrombin ( yu t II) 25v/ml; Proconvertin (yu t VII) 14v/ml, Stuart
(yu t X) 14v/ml v Antihemophilie (yu t IX) 20v/ml. V PPS c cha
Antihemophiti B nn s dng tt cho bnh nhn Hemophilie B.
Liu dng 10v PPS/ngy, tim tnh mch chm vi th nh; 20-30v/ngy tim
tnh mch chm vi th nng.
40v/12h tnh mch chm trc m khi c ch nh phuu thut bnh nhn
Hemophilie B.
- Yu t VIII (IX, XI) ta lnh: s dng cc yu t ng mu l iu tr triu chng
trc tip, b sung yu t ng mu b thiu ht trong mu bnh nhn nn c tc
dng cm mu rt tt.
Khi b cc yu t ng mu, phi nng *c yu t ng mu b thiu ht, t
ti thiu 30%, nn s n v yu t ng mu *c s dng tnh theo cng thc
sau:
P 0,4 (X-x) trong P l trng l*ng c th bnh nhn ; X l s % cn t
c; x l s phn trm yu t m bnh nhn c; 0,4 l hng s.
V d: Mt bnh nhn Hemophilie A, c trng lng c th 50 kg, yu t VIII nh
lng c l 5%, ta cn nng yu t VIII ln 30%, th s n v yu t VIII cn
truyn cho bnh nhn l: 50 0,4 (30-5)= 20 25= 500 n v.
- Sau 12h truyn 1/2 tng s n v cn truyn (250v)
- 2 ngy tip theo mi ngy 125 n v, chia 1/2 sng, 1/2 chiu.
Xt nghim nh lng li yu t ng mu sau truyn c quyt nh cn
truyn tip hay khng?.
7. 4- iu tr phc hi chc nng:
Hemophilie c v tr chy mu hay gp khp v trong c l nhng ni d va
chm, chn thng nn thng li di chng teo c, cng khp, mt chc nng
vn ng chi th, nn ngi thy thuc cn lu {.
+ Bt ng chi theo t th chc nng cho bnh nhn trong t chy mu cp.
+ Tp vn ng khp th ng, ch ng sau khi cm mu, kt hp l liu
php (xoa bp, bm huyt, sng ngn).
+ Nu phi iu tr chnh hnh bng phu thut phi chn thi im thch hp v
phi kt hp cht ch gia chuyn khoa huyt hc lm sng v phu thut vin.
7.5- D phng:
+ Khi xc nh bnh nhn Hemophilie, cn phi t vn cho bnh nhn v c gia
nh h v bnh tt, nguy c chy mu. Phng trnh nguy c chy mu bng chn
ngnh ngh cng vic ph hp, khng lm nhng cng vic nng nhc, d va
chm chn th*ng: cc mn th thao
+ Trc nhng cuc phu thut bt kh khng, phi tin hnh phu thut
nhng c s c kh nng iu tr, cc nh ngoi khoa phi kt hp cht ch vi
chuyn khoa huyt hc xt nghim nh lng yu t VIII (IX, XI) v truyn cc
yu t ng mu trc, sau phu thut trnh s nguy him n tnh mng ca
bnh nhn .
+ Vic pht hin nhng ngi m l ng*i lnh mang bnh l kh khn ln nht
trong vic iu tr d phng bnh Hemophilie hin nay.

Tm tt phc iu tr ch yu


1- iu tr ti ch v tr chy mu:
+ ng p bt Gelaspon vt thng chy mu, nht gc gelastin nim mc
mi, kt hp thuc co mch (Adrenalin).
+ ng p nc lnh cc mu t ti c, khp, bt ng chi th.
+ Chy mu h mt phi khu sn phng mu t y nhn cu ra trc; chy
mu thnh hng phi d phng mu t chn kh qun, m kh qun kp thi khi
bnh nhn kh th.
2- iu tr ton thn:
B yu t thiu ht VIII (IX, XI)
+ Truyn mu ti ton phn, truyn huyt tng ng lnh c yu t chng
Hemophilie c c, PPSB. Ngoi ra ta cn dng yu t VIII ca ln, c c iu
tr cho bnh nhn Hemophilie c khng ng lu hnh.
+ X tr cp cu kp thi nhng bnh nhn mu t chn kh qun (m kh qun
cp cu); mu t h mt (khu sn mi, chng m).

46. VIM THNH MCH D NG
(Schonlein- Henoch purpura)

1- Khi nim v bnh.
+ Vim thnh mch d ng (Schonlesin- Henoch) cn gi l ban xut huyt dng
thp l bnh th pht, thng cp tnh m nguyn nhn l d ng nguyn gy ra.
Tuy nhin d ng nguyn khng phi lc no cng thy r.
+ Bnh thng gp tr em v ngi tr tui. C th gp ngi ln (t l thp)
rt t gp ngi gi.
- Ban xut huyt l do tn thng thnh mch, khng c ri lon ng mu huyt
tng v tiu cu.

2- Nguyn nhn v c ch bnh sinh.
* Nguyn nhn: a dng, l cc yu t gy d ng (d ng nguyn) c th:
+ Vi khun: gp trong nhim khun hng, mi, ming hoc cc nhim khun
khc trn c th. y l nguyn nhn thng gp.
+ Do protein trong thc n tm, cua, hn, c
+ Bi thc vt: bi lng, len, ay, phn hoa.
+ Cc yu t d ng nguyn nhn khc
+ i khi d ng nguyn khng thy r.
* C ch bnh sinh:
D ng nguyn l yu t kch thch sinh khng th. Phn ng khng nguyn khng
th xy ra ti lp ni mc mch mu (ch yu l mao mch), S gii phng cc
cht trung gian ha hc v s lng ng ca phc hp min dch (khng nguyn-
khng th) lm tn thng thnh mch (tng tnh thm thnh mch) gy tnh
trng thot qun

3- Triu chng lm sng.
* Xut huyt di da thng gp vi cc c im sau:
+ Nt xut huyt di da: nt, chm nh, khng c mng xut huyt, khng c
mu t.
+ Xut huyt t nhin, tng ln khi i li nhiu hoc ng lu.
+ V tr: thng gp cc chi, mang tnh i xng 2 bn, cc nt tp trung nhiu
gn ngn chi v chn thng nhiu hn tay. Rt him gp xut huyt cc
vng khc nh thn, mnh, u, mt v c.
+ Cc nt xut huyt th*ng xut hin ng thi, tng t do vy mu sc cc
nt ng u.
+ Thng ti din nhiu t.
* Xut huyt nim mc, ni tng.
+ C th xut huyt ng tiu ho, xut huyt thanh mc bng gy ra cc cn au
bng, c bit c tr*ng hp ging nh bng ngoi khoa khin i khi m nhm.
+ Xut huyt thn (th*ng kn o) vi tnh trng i mu vi th.
+ Xut huyt no, rng li, mi, thng khng gp.
+ Nghim php dy tht: dng tnh khi bnh tin trin.
* Cc triu chng khc: c th c hoc khng.
+ St.
+ au sng khp gi , c chn.
+ Biu hin d ng: mn nga, m ay.
+ au hng, sng amydal

4- Triu chng cn lm sng.
+ Cc xt nghim v ng mu, cm mu u bnh th*ng.
+ C th thy: s lng bch cu tng (nu l nguyn nhn do nhim khun) bch
cu i toan tng nh, tc mu lng tng.
+ C th c xut hin hng cu niu, protein niu.

5- Bin chng: him gp.
Tuy nhin c th c vim cu thn, hi chng thn h, thng rut

6- Th bnh.
* Phn theo din bin: th xut huyt ti cp, xut huyt cp tnh, xut huyt mn
tnh.
* Phn theo v tr tn thng:
+ Th xut huyt di da n thun (th thng thng in hnh) hay gp nht.
+ Th bng.
+ Th thn.
+ Th hn hp (c 2 v tr xut huyt tr ln).

7- Chn on: da vo:
* Tin triu: c th thy hoc khng thy: l yu t nguyn nhn.
* Lm sng:
+ Hi chng xut huyt l ch yu vi cc c im ( nu cu trn) khng
xut huyt nim mc hoc xut huyt ni tng (tr th bng).
+ Nghim php giy tht dng tnh.
* Xt nghim cn lm sng:
Cc xt nghim v cm mu v ng mu u bnh thng.
8- iu tr.
* iu tr nguyn nhn: ch yu tm ra d ng nguyn gy bnh gii quyt hoc
phng nga.
+ D ng nguyn l thc n hoc thc ung: ngng s dng cc loi thc n, thc
ung v sau ny trnh n hoc ung chng.
+ Nu l cc loi phn hoa hoc loi bi thc vt trong mi trng sng, mi
trng lm vic th c gng trnh hoc hn ch tip xc
+ D ng nguyn l vi khun (thng gp): th s dng khng sinh, c bit phi
gii quyt cc nhim khun mn tnh hay gp nh: vim tai gia, vim amydal,
vim hng, xoang, vim nhim, abces vng rng li.
+ Khi khng tm c nguyn nhn: ngi ta khuyn nn s dng 1 t khng
sinh (lc xem d ng nguyn l vi khun).
* iu tr c ch bnh sinh:
+ Corticoid liu php: thng dng khi bnh mc trung bnh hoc nng, s
dng ng tim hoc ung: depersolon, prednisolon .
Liu trung bnh t 1-2 mg/kg/ngy trong 7-15, lc cn s dng liu cao hn v
thi gian ko di hn.
Trong qu trnh s dng corticoid, nu xut huyt gim dn, liu corticoid cn
gim xung v tin ti ngng hn.
Lu {: s dng mt s thuc bo v d dy- t trng: thuc gim tit acid
chlorhydric nh cimetidin, omeprazol.., thuc bo v nim mc malox, pepsan..
+ Thuc c ch min dch:
Thuc c ch min dch ch nn dng khi corticoid liu php khng t kt qu.
Loi thuc ny th*ng tc dng chm nn khng p ng *c yu cu cm
mu nhanh, nn ban u cn kt hp vi corticoid.
- Imuran : 2- 2,5g/kg/24h x 20-30 ngy hoc
- Cyclophosphamid (Endoxan): Liu 2,5kg/24h x 20-30 ngy hoc
- 6M.P (6.Mercaptoparin) 2-2,5mg/kg/ngy x 20-30 ngy .
Lu {: cc thuc c ch min dch u c th c hi nht l vi ty xng gy ra
gim bch cu hoc tiu cu nn khi s dng cn kim tra s lng BC v tiu cu
5 ngy/ln.
+ Thuc khng histamin: nhng trng hp nh hoc bnh nhn c bnh l vim
lot d dy- t trng khng c s dng corticod th c th dng thuc khng
histamin.
- Chlorphenylramin 4 mg x 3-4 ln/ trong ngy x 5-7 ngy.
- Hismanal 10mg (histalong) x 1 ln / ngy, tr 12 tui tr ln bng 1/3- 1/2 ngi
ln (ung lc i) . Thi gian dng 7-10 ngy, chng ch nh i vi ph n c
thai
* Nhng bin php iu tr khc:
+ Ngh ngi: hn ch i li hoc ng lu.
+ Tng cng bn vng thnh mch:
- Vitamin C 1g/ ngy ung hoc tim tnh mch.
- Rutin- C, nc sc hoa ho ung hng ngy.
Tm tt phc iu tr:
+ Nm ngh, hn ch vn ng, trnh ng lu.
+ Loi b, trnh tip xc vi d ng nguyn (nu bit r).
+ Corticoid liu php:
- Depesolon 1-2 mg/kg/ ngy tim tnh mch: 7-15 ngy, hoc.
- Pednisolon 5mg 1-2mg/ ngy ung sau ba n 7-15 ngy.
+ Vitamin C 1 g/ ngy tim tnh mch hoc ung 15 ngy, hoc ung vin Rutin -
C 6-8 vin /ngy 15 ngy.
+ Trng hp khng r d ng nguyn, nn dng 1 t khng sinh phi hp (xem
nh d nguyn l vi khun).

CHNG 4. CN LM SNG HUYT HC


47. XT NGHIM HUYT HC

1. Xt nghim mu.
Tn Ch s bnh thng
HC 3.8 - 4.5 T/l
BC 4 - 9 G/l. N 55 - 75%, L 25 - 35%.
TC 150 - 300 G/l
HST 140 - 160 g/l
HC li. Nam 0.1 - 1%, n 0.5 - 1%
HCT Nam 0.45 - 0.5 l/l. N 0.4 - 0.45 l/l.
Tc
mu lng
Gi th nht 4mm; gi hai: 7mm, gi ba: 12mm,
sau 24 gi 45mm.

2. Ty .

a) Ty bnh thng ca ngi vit nam.
- Ty bnh thng ca ngi Vit Nam:
+ S lng t bo ty 30 - 100 G/l.
+ HC li ty 0.5 - 1%.
+ Mu tiu cu: 50 - 80 ci/mm
3
.
- Cng thc t bo c nhn trong ty xng (%) theo Lavergne n gin
Dng BC ht Nguyn ty bo
Tin ty bo
Ty bo
Hu ty bo
1-2%
1-2%
16% (trong i toan
2%)
16% (trong i toan
BC a nhn 2%)
32% (trong i toan
2%)

Dng HC

Nguyn HC (c
nhn)

16% (trong i kim
2%)

Dng n
nhn
n nhn 16% (lymphocyte 14 %
+ monocyte 2%)
- Cng thc mu tiu cu (t l %)
+ Nguyn mu tiu cu: 0 - 0.5.
+ Mu tiu cu a kim 5 - 20.
+ Mu tiu cu i toan 40 - 60.
+ Mu tiu cu c hot tnh tiu cu.
b) Cch nhn xt mt ty .
- Nhn nh chung.
+ Ty giu hay ngho: s lng, mt .
+ Cc loi t bo ng nht hay a dng.
+ C t bo hay nhm t bo bt thng khng.
- Nhn nh s pht trin ca tng dng t bo trong ty: BC ht, HC, n nhn,
mu tiu cu.
+ Cc giai on pht trin c cn i khng?
+ C hin tng tng sinh bt thng mt giai on no hay c ch trng
thnh giai on no?
+ C hin tng gim sinh giai on non khng.
- Nhn nh mi tng quan pht trin ca cc dng t bo trong ty.
+ BC ht/HC non = 3/1 - 4/1.
+ BC ht/C n nhn = 4/1 - 5/1.
+ HC non /C n nhn = 1.5/1 - 2/1.
- Nhn nh cht lng cc loi t bo ty:
+ Hnh thi t bo c thay i khng.
+ Cng thc t bo c nhn trong ty (% nh trn).
3. Xt nghim t bo hch.
.
a) Hch : ch thy c hnh thi t bo m khng thy c ton b cu trc
ca hch.
- Cng thc t bo hch bnh thng:
+ T bo li: 0.2 - 1%.
+ T bo dng lympho: 90 - 99%.
+ T bo n nhn: 0.5 -2%
+ Tng bo: 0.2 - 0.5%
+ i thc bo: 0.5 - 1%.
- Hnh nh mt s bnh l:
+ Hch vim cp do nhim khun: C a nhn trung tnh, lymphocyte, i thc
bo.
+ Bnh BC dng lympho: giu t bo, n dng phn ln l Lymophocyte, mt s
t l lyphoblast - BC lympho mn, ngc li l BC lympho cp.
+ Hodgkin: a dng t bo, c bit c t bo c hiu Stemberg: kch thc ln,
nhn mo m chia mi, trong nhn c ht nhn, nguyn sinh cht rng bt mu
kim.
+ U Lympho c tnh - Hodgkin:
Tng sinh mnh t bo dng lympho hu ht cng tui lymphocyte hoc
lymphoblast.
Hnh thi t bo mang c im t bo ung th.
+ Di cn ung th:nhiu t bo hnh thi ung th t ni khc n.
b) Sinh thit hch: cho bit c ton b s bin i cu trc cng nh hnh thi
t bo ca hch, c { ngha quyt n chn on.
4. Lch

- Lch bnh thng:
+ Khong 60% t bo dng lympho.
+ Mono 30%.
+ BC ht 20%.
- Khi nh gi mt lch cn xc nh:
+ D sn t bo khng?
+ C t bo bt thng khng.






48. CNG THC BCH CU

- Ch s chuyn nhn l ch s tng quan gia bch cu non v bch cu trng
thnh trong mu ngoi vi c biu hin bng cng thc sau
CSCN = (Tu bo + Hu tu bo + Bch cu a)/Bch cu a nhn trung tnh =
0,03 0,08
ngha
- CSCN chuyn tri (> 0,08): y l biu hin tng sinh ca cc t bo tr do tu
xng b kch thch tng hot ng p ng nhu cu ca c th.
Chuyn tri va phi: CSCN = 0,08 0,25 , cc t bo tr tng va phi
thng tng bch cu a. Mc nhim khun khng nng lm v chc
nng tu xng hot ng tt.
Chuyn tri mnh: Khi CSCN = 0,25 0,5 do t bo tr tng mnh , mu
ngoi vi xut hin nhiu bch a, c th c hu tu bo v tu bo.
Thng l nhim khun nng, chc nng tu b ri lon, kh nng bit ho
ca t bo gim.
Chuyn tri rt mnh: CSCN = 0,5 1 hoc hn, thng l bnh ca c
quan to mu, kh nng bit ho ca tu xng b ri lon.
- CSCN chuyn phi (< 0,03)
Gim di 0,02 thng rt t hay khng c bch cu a, l biu hin ca
tu xng b c ch.



49. MIN DCH - DI TRUYN

1. nh type ho hp t chc bng k thut vi c t bo (cha bao gm kt HLA
lp 1 v lp 2)
2. Phn ng cho; Tin mn cm
3. in di nh lng cc thnh phn protein huyt thanh; Lipoprotein; Protein
nc tiu; Dch no ty
4. in di HST
5. HLA B27
6. in di min dch
7. Test ng + Ham
8. m s lng CD3 CD4 CD8
9. Phn tch CD
10. Kt latex
11. Th phn ng d ng thuc
12. Xt nghim cng thc nhim sc th (Karyotype)
13. in di c tnh thnh phn huyt sc t
14. - in di c tnh thnh phn huyt sc t
15. nh lng men G6PD
16. nh lng men Pyruvat kinase
17. Xt nghim trao i nhim sc th ch em
18. Nhim sc th Philadelphia (c nh karyotype)
19. Xc nh gen bnh mu c tnh
20. Xt nghim xc nh gen Hemophilia
21. Xt nghim chuyn dng lympho vi PHA v cc khong nguyn khc
22. Xt nghim sc bn hng cu



50. T BO T CHC HC

I. ngha cc ch s t bo mu ngoi vi v ng dng lm sng
1. M u
- My m t bo ra i m ra thi kz mi cho cng tc xt nghim huyt
hc.
- Nguyn l{ c bn ca my m t bo theo dng (flow cytometry) l nguyn l
bin i in tr ca dng ht i qua ca s c t bo quang in v mt in
trng. Nguyn l ny gip phn tch s khc bit v kch thc cc loi t bo
khc nhau, nhng khng nhn din chnh xc tng loi t bo.
- Cc my m t bo hin ang c s dng c th chia lm hai loi:
My m t bo nguyn l tng tr: phn bit tng loi t bo da vo
kch thc t bo.
Cc my th h sau: ng dng laser v xung in a chiu nn c tc cao
v phn loi t bo chnh xc hn. Vi nhng my sn xut trc 1996 kh
nng phn loi chnh xc cc thnh phn bch cu ni chung khng qu
90%. Cc my model gn y, vi vic p dng tng hp cc c ch tng
tr, xung in a chiu, laser v scatter nn kh nng nhn din t bo
c nng n 95%. Mt s serie my c th phn bit c cc loi bch
cu a a xt, a baso, hng cu li bng vic kt hp vi cc phng php
nhum men peroxydase, nhum RNA/DNA, nhum huznh quang, phn tch
huyt sc t (CellDyn 4000 ca hng ABBOTT, SE-Advance ca hng
Sysmex).
2. Cc ch s my m t bo loi 8 ch s:
STT Ch s Ting Anh Ting Vit Gi tr bnh thng
1 WBC White blood cell S lng bch cu 4-10 G/l
2 RBC Red blood cell S lng hng cu
Nam : 4.2-5.4
N : 4.0-4.9
1012/l 1012/l
3 HGB Hemoglobin Lng huyt sc t
Nam : 130-160 g/l
N : 120-142 g/l
4 HCT Hematocrit
Th tch khi hng
cu
Nam : 0.40-0.47
l/l
N : 0.37-0.42 l/l
5 MCV Mean corpuscular volume
Th tch trung bnh
HC
85- 95 fl
6 MCH
Mean corpuscular
hemoglobin
Lng huyt sc t
trung bnh HC
28-32 pg
7 MCHC
Mean corpuscular
hemoglobin concentration
Nng HST trung
bnh HC
320-360 g/l
8 PTL platelet S lng tiu cu 150-500 G/l
3. Cc ch s ca my m t bo loi 18 ch s:
STT Ch s(ting Anh) Tn ch s Gi tr bnh thng
1 RBC(Red blood cell) S lng hng
cu
Nam: 4.2-5.4
1012/l - N: 4.0-4.9
x1012/l
2 WBC(White blood cell) S lng bch
cu
4.0-10.0 109
3 HGB(Hemoglobine) Lng huyt sc
t
Nam: 130-160 g/l -
N: 120-142 g/l
4 HC(Hematocrit) Th tch khi hng cu Nam: 0.40-0.47 l/l -
N: 0.37-0.42 l/l
5 MCV(Mean corpuscular volume) Th tch trung bnh
hng cu
85-95 fl (femtolit =
10-15lt)
6 MCH(Mean corpuscular
Hemoglobine)
Lng HST trung bnh
hng cu
28-32 pg (picogam
= 10-12 g)
7 MCHC (Mean
corpuscular hemoglobine
concentration)
Nng HST trung
bnh hng cu 320 360 g/l
8 PLT(Platelet) S lng tiu
cu
150-500 109/l
9 LY %(%Lymphocyte) T l % lymphocyte 25-40 %
10 LY(Lymphocyte) S lng lymphocyte 1.2-4.0 109/l
11 MO %(%Monocyte) T l % monocyte 1-4 %
12 MO(Monocyte) S lng monocyte 0.05-0.40 109/l
13 GR %(Granulocyte) T l % BC ht trung
tnh
55-70 %
14 GR(Granulocyte) S lng BC ht trung
tnh
2.8-6.5 109/l
15 RDW(Red distribution width) Di phn b kch
thc HC
11-14%
16 PCT(Plateletcrit) Th tch khi tiu cu 0,016 0,036 l/l
17 MPV(Mean platelet volume) Th tch trung bnh
tiu cu
5-8 fl
18 PDW(Platelet distribution width) Di phn b kch
thc TC
11-15%
Ghi ch: cc gi tr bnh thng p dng cho ngi trng thnh, khe mnh.
4.Vi my m t bo laser, ngoi cc thng s trn cn thm cc thng s sau:
STT Ch s Tn ch s Gi tr bnh
thng
1 EO %(% eosinophil ) T l % C on a a xt 4 8 %
2 EO ( eosinophil ) S lng bch cu ht a a xit 0,16 0,8 x 109/l
3 Baso % ( % basophil ) T l % C on a baso 0,1 1,2 %
4 Baso (basophil ) S lng bch cu ht a baso 0,01 0,12 x 109/l
5 RET % ( %
Reticulocyte )
T l % hng cu li 0,5 1,5 %
6 RET ( Reticulocyte ) S lng hng cu li 0,016 0,095 x
109/l
7 RDW SD Di phn b kch thc HC - lch
chun
35 46 fl
8 RDV - CV Di phn b kch thc HC - H s
bin thin
11 14,4 %
9 P LCR T l tiu cu c kch thc ln
10 IRF T l mnh hng cu
5. { ngha cc ch s:
5.1 S lng hng cu:
S lng hng cu c trong mt lt mu ton phn.
n v tnh Tera/lt ( T/l = 1012 /l ).
5.2 S lng bch cu:
S lng bch cu c trong mt lt mu ton phn.
n v tnh Giga/lt ( G/l = 109/l ).
5.3 S lng tiu cu:
S lng tiu cu c trong mt lt mu ton phn.
n v tnh Giga/ lt ( G/l = 109/l ).
5.4 Lng huyt sc t:
Hm lng huyt sc t c trong mt lt mu ton phn.
n v tnh gam/lt (g/l).
5.5 Th tch khi hng cu:
Th tch khi hng cu chim ch trong mt lt mu ton phn.
n v tnh lt/lt ( l/l ).
5.6 Lng huyt sc t trung bnh hng cu (LHSTTBHC) :
Cng thc tnh: lng huyt sc t/ s lng hng cu = 28 32 picogam (pg ).
5.7 Th tch trung bnh hng cu (TTTBHC):
Cng thc tnh: th tch khi hng cu/ s lng hng cu = 85 95 femtolit (fl).
5.8 Nng huyt sc t trung bnh hng cu (NHSTTBHC):
Cng thc tnh: lng huyt sc t/ th tch khi hng cu = 320 360
gam/lt(g/l).
6. ng dng lm sng.
6.1. Cc ch s hng cu.
6.1.1. S lng hng cu.
- S lng hng cu tng: c c mu (mt nc, nn nhiu, i ngoi), a
hng cu thc (bnh Vaquez).
- S lng hng cu gim: c th i km gim lng huyt sc t v hematocrit,
nhng khng phi mc lc no cng song hnh.
- Sai s v s lng hng cu:
Hng cu b ngng kt (tan mu t min): s lng hng cu gim, MCV
tng, MCHC cao trn 380 g/l. Trng hp ny s dng c kt qu lng
huyt sc t , cn hematocrit th s dng phng php ly tm vi th tch
hoc mu mu 370C trong vng 30 pht ri m li. Cn kim tra k
ng mu khi nhn bnh phm.
Tng nht huyt tng: vi thi gian v p lc ht thng thng ca
my m t bo c th gy ra gim ba dng ngoi vi gi to do mu b
qunh nn my ht khng mu.
Lc ng mu khng k: nu ht phn trn ca ng mu s gy hin tng
gim hng cu r rt v khng tng ng vi tnh trng lm sng. Nu ht
phn y ng s gy tng hng cu gi to, ng thi gy gim r rt s
lng tiu cu. Cn kim tra v i chiu s lng tiu cu trn lam nhum
giemsa.
Do hng cu nh, tiu cu to, cm tiu cu, mnh hng cu, tan mu, ri
lon ng mu, bch cu qu nhiu
Mu b ng, hng cu b v hoc lng mu ly lm xt nghim khng
u dn n sai kt qu.
6.1.2. Lng huyt sc t.
- Th hin trung thnh nht tnh trng thiu mu, c bit trong nhng tnh
trng thiu mu do nguyn nhn mn tnh. Theo nh ngha ca T chc y t gii
th Thiu mu l tnh trng gim lng huyt sc t lu hnh trong mu ngoi vi
so vi ngi bnh thng cng gii, cng la tui, sng trong cng mt mi
trng sng.
- y l ch s c bn, kh tin cy v chnh xc trn kt qu ca my m t bo
t ng nh gi tnh trng thiu mu.
- xut phn loi mc thiu mu mn tnh da vo lng huyt sc t [2] (
ch c tnh cht tham kho v cn phi hp vi tnh trng lm sng ca bnh nhn
).
Trn 100 g/l: thiu mu nh, khng cn truyn mu.
T 80-100 g/l: thiu mu va, cn nhc nhu cu truyn mu.
T 60-80 g/l: thiu mu nng, cn truyn mu.
Di 60 g/l: cn truyn mu cp cu.
- Sai s: lng huyt sc t c th b tng gi to do ly mu lm v hng cu,
huyt tng b c (ly mu ngay sau khi n, bnh paraprotein ) hoc s lng
bch cu tng cao.
6.1.3. Th tch khi hng cu (Hematocrit).
- Rt c gi tr trong vic nh gi v theo di cc tnh trng mt mu cp: thiu
mu do xut huyt tiu ha, gin v tnh mch thc qundo hin tng b tr
ca c th mu c huy ng t cc c quan d tr mu nh lch, h tnh mch
su nn gi tr huyt sc t thay i chm hn so vi lng mu mt.
- Sai s do ly mu garo qu lu lm mu b c c, do t l cht chng ng
khng ng, lc trn mu khng u, mu ly qu lu khng XN lm th tch t
bo thay i.
- Gi tr hematocrit cn c duy tr n nh mc ti thiu 0.25 l/l hoc mc
0.30 l/l nhng bnh nhn mc bnh tim hoc phi bng truyn khi hng cu
[3].
6.1.4. p dng phn loi thiu mu
- Phn loi thiu mu l nhu cu cn thit nh hng v tm nguyn nhn.
Trong cc yu t phn loi thiu mu, hnh thi hng cu v cc ch s hng
cu ng vai tr quan trng. Bn cnh , cc ch s hng cu cng rt c { ngha
trong qu trnh theo di p ng iu tr theo nguyn nhn.
- C nhiu cch phn loi thiu mu: theo mc thiu mu, theo tin trin ca
thiu mu, theo nguyn nhn (ti ty hay ngoi ty)Cch phn loi thiu mu
da vo hnh thi v cc ch s hng cu d p dng, ph bin trong thc t cng
nh trong cc sch gio khoa v huyt hc.
- Mt s ch s c bn dng trong phn loi thiu mu:
+ Th tch trung bnh hng cu (MCV):
MCV < 80 fl: hng cu nh.
MCV > 100 fl: hng cu to.
+ Lng huyt sc t trung bnh hng cu v nng huyt sc t trung bnh HC
(MCH, MCHC):
Thiu mu nhc sc: MCH <28pg v/hoc MCHC <280 g/l.
Thiu mu bnh sc: MCH v MCHC trong gii hn bnh thng.
Nu MCH>34 pg v/hoc MCHC >380 g/l: cn kim tra li.
+ Di phn b kch thc hng cu (RDW):
RDW = 11-14%: Hng cu kch thc ng u
RDW >14% : Hng cu to nh khng u
Phn loi thiu mu da vo kch thc hng cu (MCV) v di phn b kch
thc hng cu (RDW) [5]
Hng cu nh
(MCV < 80 fl)
Hng cu bnh thng
(MCV 80-100fl)
Hng cu to
(MCV>100 fl)
ng u Khng u ng u Khng u ng
u
Khng
u
Bnh mn tnh.
Thalassemia th
nh khng c tan
mu
Thiu st.
Thalassemia
HbS hoc
HbH
Bnh mn tnh.
Bt thng
enzym hoc
HST khng tan
Giai on sm
ca thiu mu
dinh dng.
X ty.
Ri lon sinh
Suy ty
xng.
Thiu
B12 hoc
folic.
Tan mu
t min.
mu ty. Ngng
kt lnh.
Tr s
sinh
Bnh gan mn tnh: MCV v RDW c th tng cao hoc bnh thng
C th mt s trng hp thiu mu thng gp:
A/ Thiu mu nhc sc hng cu nh:
1. Thalassemia th nng v trung bnh, n c hoc phi hp vi mt bnh
huyt sc t khc.
2. Thiu mu thiu st do mt mu mn, thiu dinh dng, km hp thu, tng
nhu cu.
3. Ri lon chuyn ho st
B/ Thiu mu bnh sc hng cu bnh thng:
1. Thiu mu trong bnh mn tnh.
2. Mt mu cp:
Giai on cp tnh: hu nh khng nh hng n MCV v
RDW.
Giai on sau: hin tng tng HC li v hin tng thiu st.
3. Tan mu
4. Tng th tch huyt tng qu mc (c thai, truyn dch qu nhiu).
5. Suy tu xng.
6. Thiu mu dinh dng giai on sm:
Lng huyt sc t cha gim.
Hng cu to nh khng u v RDW tng dn (do c mt qun th mi to
ra b thay i kch thc: nh hoc to hn - ty vo nguyn nhn). y
cng l ch s quan trng theo di p ng iu tr thiu mu dinh
dng.
7. Tu b xm ln
8. Cc bnh v gan, thn, ni tit.
C/ Thiu mu bnh sc hng cu to:
1. Suy ty xng
2. Thiu vitamin B12 v acid folic
3. Ri lon tng hp AND.
6.2. Cc ch s bch cu.
6.2.1. Thay i s lng bch cu
- S lng bch cu thay i theo tui, trong cc iu kin sinh l khc nhau v
bin i trong mt s bnh l{ (xc nh khi s lng bch cu vt qu hoc gim
thp hn gi tr bnh thng):
S lng bch cu gim ph n bt u kz kinh, ngi gi v trong mt
s tnh trng nhim c, bnh l to mu
S lng bch cu tng: ph n sau kz kinh, khi mang thai, tr s sinh
v trong cc tnh trng nhim trng, bnh l to mu
6.2.2. Thay i trong cng thc bch cu
- Bch cu ht trung tnh:
Tng khi s lng trn 6 G/l, c th tng sinh l{ sau ba n, sau vn ng
nng (tng t v tm thi). Tng bnh l trong nhim trng cp tnh (vim
phi, vim rut tha, vim ti mt, ap se), trong nhi mu c tim, nhi
mu phi cp, sau phu thut ln c mt nhiu mu v trong bnh l to
mu.
Gim khi s lng thp hn 1,5 G/l, c th gp trong nhng tnh trng
nhim c nng, nhim khun ti cp, st rt, sau iu tr mt s thuc v
bnh l to mu.
- Bch cu ht a acid:
Tng khi s lng tuyt i trn 0.8 G/l : nhim k sinh trng, d ng, mt
s bnh mu...
Gim: Nhim khun cp, tnh trng sc, iu tr corticoid, bnh Cushing...
- Bch cu ht a base:
Tng trn 0.15 G/l, gp trong nhim c, hi chng tng sinh ty.
Gim: suy ty xng, d ng.
- Bch cu mono tng khi s lng trn 0.4 G/l: nhim virus, gp sau tim
chng, st rt, bnh lxmi.
- Bch cu lympho:
Tng khi s lng trn 4 G/l: nhim trng mn tnh (lao, vim khp),
nhim virus, trong bnh mu c tnh.
Gim s lng di 1 G/l: nhim khun cp, sau x tr, bnh t min, bnh
to mu v sau iu tr ha cht
6.2.3. Cc thng bo bt thng trn kt qu ca my.
- Khi s lng bch cu tng, hoc tng tng thnh phn bch cu: kt qu hin
th du H (High) ngay sau s lng bch cu (WBC). Khi s lng hay t l gim:
kt qu km theo du L (Low).
- Khi kt qu s lng bch cu c du bo ! hoc F: c bt thng v cng
thc bch cu, cn kim tra li trn lam mu nhum giemsa.
- My bo OVER: s lng vt qu kh nng m ca my, cn kim tra li
trn lam mu v pha long mu xt nghim ri m li.
- S lng bch cu c th tng gi to:
Do tng sc bn hng cu nn dung dch ph v hng cu ca my khng
thi gian lm v hng cu, my s m ln vo bch cu. Cn kim tra
li v so snh trn tiu bn mu ngoi vi.
Do cryoglobulin, cryofibrinogen, m tiu cu, hng cu c nhn, hng cu
c KSTSR, tiu cu khng l my m ln vo s lng bch cu.
6.3. Cc ch s tiu cu.
Rt kh m do kch thc b, chu nhiu nh hng bi ting ng, in,
mi trng, bi bn
- Gim tiu cu gi to c th gp do tiu cu tng kt dnh: ly mu qu lu lm
hot ha tiu cu, ly mu vo ng thy tinh lm tiu cu kt dnh do thnh ng
lm hot ha v kt dnh tiu cu, tiu cu tp trung xung quanh bch cu
- Tng tiu cu gi to: do mnh hng cu v hoc hng cu kch thc qu nh
(MCV < 65 fl) lm my m nhm thnh tiu cu. Trong mu mu ln bi bn
cng c th lm my m nhm thnh tiu cu. Mt s trng hp do my ni
t khng tt gy hin tng nhiu nn cc xung in nh s c my ghi nhn
l cc tiu cu.
- Mt s trng hp do s lng tiu cu qu cao nn my cng khng m
c (my bo: OVER). Cn kim tra trn lam mu v pha long ri m li.
- S lng tiu cu gim: gim sn xut (suy ty xng, bnh mu c tnh ln t,
ung th di cn ty xng), tng tiu th (xut huyt gim tiu cu, ri lon ng
mu tiu th).
- S lng tiu cu tng: hi chng tng sinh ty, thiu mu thiu st, sau ct
lch, tng do phn ng sau mt s bnh l{: ung th di cn ty xng, u thn, u
gan
Ti liu tham kho
1. K thut xt nghim Huyt hc-Truyn mu. Ch bin: GS. Bch Quc Tuyn.
Nh xut bn Y hc. 1984.
2. Bi ging Huyt hc-Truyn mu. Ch bin: GS. TSKH. Trung Phn. Nh
xut bn Y hc. 2004.
3. Cm nang iu tr ni khoa. Ch bin: GS. Phm Khu. NXB Y hc. 1998.
4. Xt nghim s dng trong lm sng. Tc gi: GS. Nguyn Th Khnh v GS.
Phm T Dng. Nh xut bn Y hc. 2003.
5. Automated lood Counts and Differentials. J.D. essman, Trng i hc tng
hp Hopkins. 1986.
6. Hematology: basic principles and practice. 2nd edition (1995). R.
Hoffmann. NXB Churchill Livingstone. NewYork.
II T bo t chc hc
1. Tng phn tch t bo mu trn my m t ng
2. Tng phn tch t bo mu trn my m laser
3. Hng cu li
4. Huyt
5. tp trung tiu cu
6. Tm mnh v hng cu
7. Tm hng cu c chm a base
8. Tm k sinh trng st rt trong mu
9. Tm u trng giun ch trong mu
10. Tp trung bch cu
11. Thi gian mu lng
12. Thi gian mu lng (lm trn my t ng)
13. Ty
14. Sinh thit ty xng
15. Nhum x trong m ty xng
16. Lch
17. Hch
18. U
19. T bo Hargraves
20. Soi ti t bo nc tiu
21. Nhum t bo nc tiu
22. Soi ti t bo cc dch khc (dch mng bng, mng phi, dch no ty, dch
khp...)
23. Nhum t bo cc dch khc (dch mng bng, mng phi, dch no ty, dch
khp...)
24. Nhum Myeloperoxydase
25. Nhum Soudan en
26. Nhum Peryodic acid Schiff
27. Nhum Esterase khng c hiu
28. Nhum Esterase c hiu
29. Nhum Esterase khng c hiu c c ch bng NaF
30. Nhum Phosphatase kim bch cu
31. Nhum Hng cu st (Nhum Perls)

51. NG MU

1. Thi gian mu chy
2. Co cc mu
3. N.P. Dy tht
4. TP
5. APTT
6. TT
7. nh lng Fbrinogen
8. Xc nh khng ng lu hnh ng ni sinh
9. Xc nh khng ng lu hnh ng ngoi sinh
10. Xc nh khng ng lu hnh ng chung
11. N.P. Ru
12. N.P. Vonkaulla
13. nh lng cc yu t ng mu: II, V, VII, VIII, IX, X
14. nh lng c ch VIII
15. Xc nh c ch IX
16. nh lng D- Dimer
17. nh lng Antithrombin III
18. Ngng tp tiu cu vi cc cht kch tp: Ristocetin, ADP, Collagen

52. MIN DCH SNG LC

1. Anti HCV (ELISA)
2. Anti HIV (ELISA)
3. HbsAg (ELISA)
4. HbsAg (Kt nhanh)
5. Anti HCV (Kt nhanh)
6. Anti HIV (Kt nhanh)
7. Anti HBs (EL ISA)
8. Anti HBc lgG (EL ISA)
9. Anti HBc lgM (EL ISA)
10. Anti HBe (EL ISA)
11. HBeAg (EL ISA)
12. SFD HIV PA
13. Khng th k sinh trng st rt P.f/P.v (ELISA)
14. Khng th khng giang mai (ELISA)
15. Anti HTLV (ELISA)
16. Anti EBV lgG (ELISA)
17. Anti EBV lgM (EL ISA)
18. Anti CMV lgG (EL ISA)
19. Anti CMV lgM (EL ISA)
20. Xc nh DNA trong vim gan B
21. PCR k sinh trng st rt
22. HIV (PCR)
23. HCV (RT-PCR)
24. HIV (RT-PCR)
25. nh tup E, B HIV-1
26. nh lng virus vim gan B (HBV)
27. nh tp HLA bng k thut sinh hc phn t
28. nh nhm khng nguyn tiu cu bng k thut sinh hc phn t
29. nh nhm khng nguyn bch cu on trung tnh bng k thut sinh hc
phn t
30. Pht hin khng th khng HLA bng ELISA ( Xt nghim tin mn cm)
31. Pht hin khng th khng tiu cu bng ELISA
32. Pht hin khng th khng bch cu on trung tnh bng ELISA
33. Phn ng cho bng k thut vi c t bo



53. CH PHM MU

Cch tnh th tch mu:
Tng th tch mu ( tnh ra lt) = 7% trng lng c th (tnh theo kg)
Nam = 77 x Trng lng c th (kg) = Tng th tch mu (ml)
N = 67 x Trng lng c th (kg) = Tng th tch mu (ml)
Th tch huyt tng = Tng th tch mu - (Tng th tch mu x Hematocrit)
iu tr bng dung dch keo: Ch nh bi ph th tch tun hon
Albumin (5% hay 25%): Hu ch i vi gim th tch v gim protein mu; hoc
gy tnh trng tng bi niu bng furosemid cc N c tng th tch mu v
gim protein mu
Dch cha phn protein huyt tng 5% (Plasma protein fraction [plasmanate]):
Cha 130-160 mEq Na/l; c ch nh bi ph th tch trong lng mch.
Hetastarch (Hespan): Dung dch keo tng hp cha 6% hetastarch trong dung dch
mui ng trng. Ch nh dng tng t nh i vi albumin
Dung dch mui ng trng: NaCl 0,9%, dung dch Ringer lactat: c dng
bi ph cp cu th tch trong lng mch. 3ml dung dch mui ng trng =
1ml mu ton phn
Hng dn truyn khi hng cu trong iu tr mt mu cp :
1. c dng khng ch tnh trng chy mu v bi ph tnh trng mt bng
dung dch mui ng trng ti khi c c khi hng cu truyn cho BN
2. Nu sau khi truyn > 2l dung dch mui ng trng khng lm n nh c
huyt ng, cn truyn khi hng cu
3. Nu vic bi ph th tch v cc bin php cm mu lm n nh c tnh
trng huyt ng, ch th nhm mu v lm phn ng cho. Mt khc,
dng mu nhm O m tnh, hiu gi thp hay nhm mu c hiu (ph hp
nhm ABO), ph hp Rh c th c chun b trong vng 10 min v khng cn
lm phn ng cho.
Hng dn truyn mu trong thiu mu cp
Cn nhc truyn mu khi Hemoglobin < 8g v hematocrit < 24%, tr khi BN c
triu chng nh au ngc, kh th, nhim khun huyt, bin i tnh trng
thc. Xem xt tc gim ca hemoglobin, nng hemoglobin tuyt i, c
a chy mu tin trin, bnh l{ ng mu nguyn nhn, bnh M vnh hay
TMCB c t trc .
Cc sn phm ca mu
Khi hng cu: Mi khi hng cu (1 n v) cung cp khong 250ml th tch mu,
v mi n v s lm tng Hb thm 1g/dl v lm tng Hematocrit thm 3%
Nhm mu v cc test sng lc: Mu c test tm cc khng nguyn A, B v Rh
v cc khng th i vi hng cu ca ngi cho. Nu cn dng cc ch phm
mu, mu c th c chun b nhanh chng ti ngn hng mu.
Nhm mu v phn ng cho: Phi c lm cho cc n v khi hng cu ngi
cho. Nu d nh cn truyn mu trong bi cnh cp cu, khi ngi thy thuc
phi yu cu nh nhm v lm phn ng cho (ti c s pht mu).
Tiu cu: c ch nh trong xut huyt do gim s lng hoc cht lng tiu
cu trong bnh cnh biu hin chy mu khng kim sot c. Mi n
v huyt tng giu tiu cu lm tng con s tiu cu ln 5000 - 10000.
Thng mi ln truyn 8-10 n v v s lm tng c con s tiu cu thm 40
- 60.000
nh gi tnh trng gim tiu cu: Trc khi truyn khi tiu cu phi nh gi
bnh cn v cc nguyn nhn gy gim tiu cu c th iu chnh c, nh tu
gim sinh, tr mu hoc tng qu trnh ph hu. XN bnh phm mu ngoi vi
c nhum. Xt ch nh sinh thit tu xng. nh gi kch thc lch v xem
xt li tt c cc loi thuc N v ang dng c th gy gim tiu cu.
Huyt tng ti ng lnh (FFP): c dng iu tr cc chy mu tin
trin th pht do bnh gan, qu liu warfarin, bnh l{ ng mu do ho long
(do truyn mu nhiu ln), ng mu ri rc trong lng mch, thiu vitamin K v
cc yu t ng mu. Cn nh nhm mu ABO song khng cn phi lm phn
ng cho.
a. Mi n v huyt tng ng lnh cha tt c cc yu t ng mu nng
bnh thng, k c cc yu t ng mu khng bn (V, VIII).
b. Truyn bi ph tnh trng thiu ht: Liu huyt tng ng lnh cn truyn
c c tnh khong 8-10 ml/kg. Mi n v huyt tng ng lnh cha 200 -
280ml, v vy thng cn truyn 4-6 n v cho mi ln iu tr. S ln truyn
ph thuc vo p ng LS.
Cht kt ta lnh:
a. Ch nh cho BN b Hemophillie A, bnh ca Von Willebrand v tt c cc tnh
trng gim fibrin mu cn c bi ph (nh ng mu ri rc trong lng mch)
hay iu chnh bin chng ca iu tr tan cc mu ng.
b. Cht kt ta lnh bao gm cc thnh phn : Yu t VIII, Fibrinogen, v yu t
Von Willebrand
c. Truyn bi ph tnh trng thiu ht: ch iu tr l duy tr nng fibrinogen
> 100ml/dl. ch ny thng t c bng cch truyn 2-4 n v/10kg hoc 1-2
n v/ 10kg tuz thuc vo nng fibrinogen cha trong cht kt ta lnh cao
hay thp.

54. QU LIU THUC CHNG NG

I. Qu liu Heparin
A. Protamin sulfat hnh thnh mt phc hp heparin-protamin v trung ho tc
dng chng ng ca heparin. Protamin trung ho heparin trong vng 5 min
B. Ch nh: Protamin nn c cn nhc s dng nu heparin c cho trong
vng 4h trc khi bt u xut hin chy mu. Thi gian bn hu trong huyt
tng ca heparin l 1-2h v protamin c l khng cn hiu qu nu dng
qu 4h sau liu heparin cui cng
C. Liu dng
1. Va mi tim heparin kiu bolus: 1 mg protamin sulfat TM cho mi 100 UI
hearin va c dng
2. Truyn heparin lin tc: 1 mg protamin sulfat TM cho mi 100 n v heparin
va cho trong vng 4h trc
3. Nu heparin c ngng qu 30 min: Gim liu protamin xung mt na
4. Liu nn c truyn chm trong vng 1-3 minv khng nn vt qu 50 mg
trong tng giai on 10 min
D. Cc tc dng ph: Tt HA nh, phn ng phn v l cc tc dng ph him gp.
Nguy c b cc phn ng d ng ngi T tip xc vi protamin thng qua mt
s ch phm insulin c cha cht ny
II. Qu liu Warfarin
A. Cc bin phi thi tr: Ra d dy v dng than hot nu BN va mi ung
warfarin (Coumadin)
B. Trung ho tc dng chng ng ca coumadin: Bnh l{ ng mu c th c
iu chnh nhanh hay chm tuz thuc vo cc yu t sau:
1) Mc ca tnh trng gim ng
2) Mc nng hay nguy c chy mu
3) S cn thit phi dng li cht chng ng
C. iu tr cp cu trung ho tc dng ca thuc :
1. Huyt tng ti ng lnh: Cung cp cc yu t ph thuc vitamin K bng
huyt tng ti ng lnh 15-20 ml/kg sau l 5-7 ml/kg x 8-12h/ln
2. Vitamin K 25 mg pha trong 50 ml NaCl 0,9% truyn vi tc khng nhanh
qu 1 mg/min. Nguy c b phn ng dng phn v v sc; Cn truyn chm hn
ch nguy c k trn
D. Trung ho hon ton tc dng ca thuc chng ng trong vng 24-48h:
Vitamin K 10-25mg tim di da. Trung ho hon ton tc dng chng ng s
gy khng vi iu tr bng coumadin trong mt vi ngy
E. iu chnh mt cch tm thi: Liu vitamin K thp hn (0,5-1,0 mg) s lm thi
gian prothrombin h thp hn song khng c tc ng ti vic dng li coumadin

55. CC PHN NG TRUYN MU

I. Phn ng truyn mu gy tan mu cp
A. Biu hin LS: Phn ng him gp ny thng hay i km vi tnh trng khng
tng hp nhm mu AO v thng lin quan vi sai st khi bin chp. Cc triu
chng sm bao gm bt u t ngt tnh trng lo lng, bng, nhp nhanh v
tt HA. au ngc, au bng, st v kh th l cc biu hin thng gp
B. Cc biu hin c nguy c gy cht gm: Tru mch, suy thn, co tht ph qun
v DIC
C. Hemoglobin niu v hemoglobin mu c thy do tan hng cu trong lng
mch gy nn
D. Test khng globin trc tip (+) [Test Coomb trc tip (+)] s c thy sau
truyn mu. Mc nng ca phn ng thng c lin quan vi th tch khi
hng cu truyn
E. X tr
1. Ngng ngay truyn mu v thng bo ngay cho ngn hng mu. Gi li s mu
ngi cho cha truyn ht v mt mu mu TM ca ngi nhn nh li typ v
lm li phn ng cho, k c test Coomb trc tip v gin tip
2. XN nc tiu tm hemoglobin t do v kim tra huyt tng ly tm tm mu
tm (ch dn c Hb t do trong huyt tng)
3. iu tr tt HA bng dung dch NaCl 0,9% hoc cc dch cao phn t bi ph th
tch huyt tng. C th dng thuc vn mch nu bin php bi ph th tch
n c khng duy tr c HA mt cch tho ng. C th cn thit phi theo
di ALTM TT
4. Duy tr ti mu thn bng bi ph th tch tun hon nu LS c ch nh. C
th dng Mannitol v/hoc furosemid duy tr cung lng nc tiu sau khi
bi ph th tch tun hon y
5. Theo di PT/PTT, tiu cu, fibrinogen v sn phm ging ho fibrin tm bng
chng xc nhn tnh trng ng mu ri rc trong lng mch. Bi ph cc yu t
ng mu b thiu ht bng huyt tng ng lnh, tiu cu v /hoc cht kt ta
lnh nu c ch nh
6. Trong mt s tnh hung hn hu, truyn trao i mu iu tr tan mu t
trong lng mch

II. Phn ng st do truyn mu (khng c tan mu)
A. Biu hin LS: Phn ng ny xy ra 0,5-3% cc truyn mu v rt thng c
thy cc N c truyn mu nhiu ln. LS biu hin bng rt run sau l st,
thng xy ra trong hay sau truyn mu mt vi gi. Phn ng ny c th nng n
song thng ch l mt biu hin nh v t khi
B. X tr:
1. Tin hnh iu tr triu chng v h tr bng Acetaminophen v
diphenhydramine. Meperidine 50 mg TM hu ch iu tr tnh trng rt run
2. Cn loi tr cc phn ng truyn mu nghim trng hn (nh c km vi tan
mu)
III. Ph phi khng do tim lin quan vi truyn mu
A. Biu hin LS: Tnh trng SHH nng xut hin t ngt
B. Kt hp st, rt run, au ngc v tt HA
C. Film Xquang ngc cho thy c tnh trng ph phi lan to. Phn ng ny c th
trm trng v c nguy c gy t vong, song thng thuyn gim trong vng 48h
D. X tr
1. Tin hnh cc bin php iu tr h tr ph phi v gim Oxy mu bng TKNT
h tr v theo di huyt ng nu cn
2. Li tiu ch hu ch khi c tnh trng tng gnh th tch

CHNG 5. ATLAS HUYT HC


1. S HNH THNH CC DNG T BO MU
1.1 Cc tin thn t bo hng cu: Cc tin nguyn hng cu(Proerythroblasts)
v nguyn hng cu a baz(Basophilic Erythroblasts):

Fig 1: Giai on sm ca qu trnh to hng cu
a. Tin thn sm nht ca HC l tin nguyn hng cu(proerythroblast), t bo
ny ln, sm mu c cht nhim sc trong nhn sp xp khng cht(loosly
arranged nuclear chromatin)(1); Pha di c 2 nguyn HC chnh
sc(orthochromatic erythroblast)(2); bn phi c 1 t bo hu ty
bo(metamyelocyte)(3)
b. Tin nguyn HC(1)
c. Tin nguyn HC(1), nguyn ty bo(myeloblast)(2); tin ty
bo(promyelocyte)(3); hu ty bo(metamyelocyte)(4); bch cu ht trung tnh
nhn a(segmented neutrophilic granulocyte)(5)

1.2 Khi s lng hng cu tng cao, cc tin HC c nhn c th ra mu ngoi vi:

a. Hai nguyn HC a base(basephilic erythroblast) c cu trc cht nhim sc
c(condensed chromatin structure)(1) v mt nguyn hng cu a sc(
polychromactic erythroblast) c nhn hu nh bt mu ng
nht(homogenous)(2)
b. Qu trnh to hng cu ty xng thng din ra xung quanh mt i thc
bo vi 1 lp tng bo rng, sng mu(1). Xung quanh n l cc nguyn HC a
sc vi cc kch thc khc nhau. Nguyn HC phn bo(2)
c. Nguyn HC a sc(1) v nguyn hng cu chnh sc(orthochromatic
erythroblast)(nguyn bo bnh thng-normoblast)(2)
d. T trng cht nhim sc ca nhn ging nh cc t bo lympho(1) v nguyn
hng cu(2) nhng cht nguyn sinh ca nguyn hng cu rng v c mu ging
vi hng cu a sc(3).
e. T bo hng cu bnh thng vi nhiu kch c. Mt t bo lympho(1) v mt
vi t bo ng mu(2) cng c quan st thy. Cc t bo hng cu c cht
nhn hp hn cht nhn ca cc lymphocyte

1.3 Cc tin t bo bch cu: Nguyn ty bo(Myeloblasts) v tin ty
bo(Promyelocytes:

Fig 3: Tin thn ca bch cu ht
a. Tin thn mun nht ca dng bch cu ht l nguyn ty bo. Cc t bo ny
c cht nhim sc trong nhn rng, dng li cht v mt lp tng bo hp sng
mu khng c cc ht.
b. Nguyn ty bo v cc bch cu ht vi nhn dng a(mu phn tch mu
c ly t bnh nhn bch cu ty cp)
c. Nguyn ty bo(1), t bo bt u xut hin ht bt mu azuro(mi tn) v 1
tin ty bo(promyelocyte)(2) c nhiu ht azuro, cc ht ny thng thy
ngoi vi nhn
d. Tin ty bo(1) ln, ty bo(2), hu ty bo(metamyelocyte)(3) v hng cu a
sc(polychromatic erythroblast)(4)

1.4 Cc tin t bo bch cu: Nguyn ty bo v hu ty bo(Metamyelocytes)

Fig 4: Cc ty bo v hu ty bo
a. Cc ty bo non. Cu trc cht nhim sc c hn cht NS ca cc tin ty bo.
Mu mu ny ly bnh nhn b nhim khun, cc bch cu ht tng cao.
b. Ty bo c cu trc nhn thanh mnh(tng bo th vn bt mu bazo)
c. Ty bo(1) dng bch cu a(2)
d. Hu ty bo c dng ca ty bo mi chm hnh thnh dng thy

1.5 Tin bch cu trung tnh: Cc t bn band(Band Cells) v cc bch cu trung
tnh nhn a(Segmented Neutrophils)

Fig 5: Cc t bo bch cu trung tnh(Cc bch cu ht trung tnh-neutrophilic
granulocytes)a. Chuyn dng gia 1 hu ty bo(metamyelocyte) v 1 t bo
band(band cell)
b. T bo band(1) c rt nhiu ht
c. Hai t bo band
d. Cc t bo band cng c th xut hin thnh khi
e. C a
f. C a sau phn ng peroxidase
g. C a sau nhum mu alkaline leukocyte phosphatase

1.6 Thoi bin t bo, Cc ht c bit, v bin i nhn BC ht trung tnh:



Fig 6: Cc dng BC ht trung tnh.
a. Cc ht gy c thc s ca cc BC ht trung tnh(1)(2)(Hnh nh cc ht gy
c (1) r hn (2))
b. S nhim trng thy nhiu ht gy c, nhiu khng bo, v th Dohle(mi tn)
trong cc TB band(1) v 1 monocyte(2)
c. T bo gi Pelger nhn ging nh chic knh dm(cn nguyn do nhim c
hoc lon sn ty)
d. Th Dohle nhn ging th vi bt mu base(mi tn) khng c ht gy c.
Cng vi cc t bo ng mu gi bt thng May-Hegglin
e. Tng on bch cu ht trung tnh(6 on hoc nhiu hn). C s tng cc t
bo nh vy trong thiu mu hng cu to(megaloblastic anemia)
f. Th di trng(drumstick)(mi tn1) v t bo ng mu(mi tn 2)
g. Ht rt to mu sau khi ha tr liu
h. BC ht trung tnh ang thoi bin(degradation), thng xut hin sau lu tr
thi gian di( thng sau 8 gi)

1.7 BC ht bt mu acid-BC i toan(Eosinophilic Granulocytes (Eosinophils)) v
BC bt mu base- BC i kim(Basophilic Granulocytes (Basophils))

Fig 7: Cc bch cu i toan v i kim:
a-c: Cc BC E c cc tiu th, cc ht bt mu cam.
d. Ngc li, cc ht ca BC ht trung tnh khng xung quanh nhn nhng chm
li thnh chm.
e. BC ht a kim(Basinophil): Cc ht l cc tiu th ging nh nhng ht ca BC
ht a acid nhng bt mu xanh sm ti tm
f. Nhiu ht to trong 1 BC ht a kim bnh tng sn ty mn tnh

1.8 Monocytes:

Fig 8: Monocytes:
a-c: Th t xut hin cc loi monocyte c dng thy, nhn, bo tng bt mu
xm v cc ht sng mu.
d. T bo mono i thc bo(Phagocytic monocyte) c cc khng bo trong tng
bo
e. Monocyte(1) bn phi ca mt lymphocyte vi cc ht bt mu azuro(2)
f. Monocyte(1) vi cht nhn ging mt t bo C band nhng tng bo ca n
bt mu xanh xm. Lymphocyte(2)
g. Mt monocyte thc bo 2 hng cu v cha chng trong tng bo(mi tn)
h. Nhum mu esterase

1.9 Lymphocytes:

Fig 9: Lymphocytes:
a-c: Th t xut hin cc lymphocyte bnh thng
d: tr s sinh, nhn ca mt vi t bo lympho c th c hnh ch V hoc hnh
on.
e. Mt vi t bo lympho c cc ht c th xut hin ngi bnh thng
f. i khi thiu trigger, bo tng c th rng ra
g. Mt mu mu th sau khi nhim khun c th xut hin 1 vi t bo plasma,
cc t bo s pht trin thnh t bo lympho B

1.10 Cc t bo nhn khng l(Megakaryocytes) v cc tiu cu(Thrombocytes)

Fig 10: Megakaryocytes and thrombocytes.
a. Megakaryocytes trong mu XN ty xng. Tng bo rng, mn, cc m my
ht l 1 du hin bt u hnh thnh cc tiu cu
b. m bnh thng ca cc tiu cu ng gia cc t bo hng cu, cc tiu
cu nh vi cc kch c khc nhau
c-d: Mu mu ngoi vi vi s kt tp tiu cu bnh nhn ng mu ri rc lng
mch

CC T BO HNG CU BNH THNG CC GIAI ON PHT TRIN

1. Rubriblast(pronormoblast): Tin nguyn hng cu










2. Rubricyte(polychromatic normoblast): Nguyn hng cu a sc












2. Porubricyte(Basephilic normoblast): Nguyn hng cu a kim










3. Rubricyte(Polychromatic normoblast): Nguyn hng cu a sc










4. Metarubricyte(orthochromatic normoblast): Nguyn hng cu giai on cui(
Nguyn hng cu chnh sc)











5. Polychromatophilic erythrocyte(reiculocyte):Hng cu a sc(hng cu li)











6. Erythrocyte(discocyte): Hng cu trng thnh











CHNG 6. THUC CHNG NG MU


56. C CH CA S HNH THNH HUYT KHI

1.1 Sinh l ca qu trnh ng mu
ng mu bao gm mt giai on khi u l giai on tiu cu bm dnh ni mc
mch mu v mt giai on th 2 gi l hnh thnh cc mu ng
1.1.1 Giai on u ca qu trnh ng mu
nh thng trng thi khng hot ha tiu cu di chuyn t do trong lng
mch. Khi ni mc mch mu b tn thng tiu cu s di chuyn n v bm
dnh vo ch tn thng, ng thi gii phng ra cc cht trung gian co mch v
cc cht ha hng ng bch cu. Sau tiu cu s b phn hy v tp trung
cc tiu cu khc ti hnh thnh nn s ngng kt tiu cu.
S kt dnh tiu cu c vai tr ca lp ni m v di ni m, cc th th ca
mng tiu cu v mt s glycoprotein huyt tng. Khi ni mc mch mu b tn
thng n bc l lp collagene di ni mc v tiu cu dnh vo lp collagen
ny nh phc hp glycoprotein GP Ia/Iia v dnh vo fibronectine nh
glycoprotein GP Ic/IIa.
Sau khi kt dnh, cc tiu cu tri rng ra b mt b tn thng. Lc ny tiu cu
c hot ha bi cc yu t ngoi sinh nh l collagene hoc thrombine. Khi
tiu cu hot ha s gii phng cc thnh phn trong ht tiu cu: cc ht c
cha ADP v serotonin, cc ht alpha cha fibrinogen, fibronectine, yu t
vWF(von Willebrand factor) v yu t tng trng c ngun gc tiu cu(PDGF).
Sau khi hot ha nng calci trong tiu cu tng v do yu t tiu cu GP
Iib/IIIa b hot ha. Di tc ng ca yu t ny, cc tiu cu tin li gn nhau v
dnh vo nhau thnh tng lp v gia cc lp l fibrinogen v vWF. Cng trong
thi gian ny, acid arachidonic c gii phng t v tiu cu v c chuyn
dng bi oxyclo oxygenase thnh endoperoxydase. Thromboxan synthetase tc
ng vo mt trong cc endoperoxydase ny to nn thromboxan A2.
Thromboxan A2 chuyn vn dng calci trong tiu cu v tham gia hot ha th
th GP IIb/IIIa. y l mt yu tt lm gia tng phn ng co mch.
S kt dnh ca tiu cu b c ch bi mt prostaglandine dn xut t acid
arachidonic v t s tng hp ca thnh mch:prostaglandine l mt cht gin
mch.
1.1.2 ng mu th pht hay s hnh thnh cc mu ng
S hnh thnh cc mu ng lm cho huyt khi chc li do s chuyn fibrinogen
d tan thnh fibrinogen khng ha tan hay fibrin
Qu trnh ng mu b chi phi bi hng lot yu t m phn ln cc yu t ny
c tng hp t gan. N c gi theo tn hay theo s tng ng vi danh
php quc t. Cc yu t ny thuc 2 nhm:
- Cc enzym hay tin enzym c tng hp phn ln t gan. Tt c enzym ny tr
yu t XIIa, thuc nhm serin protease. Bn yu t II, VII, IX, X cn phi c vitamin
K tng hp chng t gan
- Cc yu t thc y phn ng enzym bao gm:
+ Proaccelerine(yu t V) tng hp t gan
+ Yu t chng hemophiline A(yu t VIII)
+ Kininogene c trng lng phn t cao ng vai tr b mt ca qu trnh hnh
thnh cc mu ng
Qu trnh hnh thnh cc mu ng tin trin theo 2 con ng: con ng ngoi
sinh v con ng ni sinh
Bng 1: Cc yu t ng mu



+ Con ng ngoi sinh: l con ng c trin khai nhanh chng trong thi
gain vi giy. Yu t VII(proconvertine) t gn vo phn phospholipide ca
thromboplastine t bo khi c mt ca calci. Khi hot ha, yu t VII tc ng
vo yu t X (Stuart). Yu t X hot ha(Xa) khi c mt ca yu t
V(proaccelerine) ct prothrombine(yu t II) thnh nhiu mnh gi l thrombine.
+ Con ng ni sinh: trin khai chm hn. im khi pht ca con ng ny l
cc b mt khng phi ni mc mch mu(di ni m, mng va x, b mt
nhn to) v c vai tr ca 4 yu t: yu t XII(yu t Hageman), kininogen trng
lng phn t cao, prekallicreine, yu t XI(plasma thromboplastine antecedent).
Yu t XI hot ha s tc ng vo yu t IX (yu t chng ng hemophilie ).
yu t IX sau khi c hot ha s gn vo mt phospholipide to thnh mt
phc hp vi yu t VIII(yu t chng hemophilie A). Phc hp ny s hot ha
yu t X lc cng gn vo phospholipid ny ca tiu cu. Hai con ng ni
sinh v ngoi sinh lc ny kt hp vi nhau: yu t Xa khi c mt ca yu t V s
ct prothrombine thnh thrombine
S hnh thnh fibrine l mt giai on nhanh nht ca qu trnh hnh thnh cc
mu ng. Thrombine ct cc peptid A v B v tr u ca chui A alpha v A
beta ca fibrinogen v bin i lin kt monomer mt cch t pht thnh
polymer. S n nh ca fibrin cn phi c s tc ng ca yu t XIII(yu t n
nh fibrin) hot ha bi fibrin khi c mt ca calci. Fibrin to thnh mt mng
li vy cc hng cu trong khu vc ny: l huyt khi . S co cc mu trong
c th cho php cng c vng chc qu trnh ng mu. Co cc mu ny l do cc
tiu cu c nh trn mng li fibrin co li.
1.2 C s tn ti ca cc cht c ch s hnh thnh cc mu ng?
Quan trng nht l antithrombine III do gan tng hp v c gi l ng yu t
ca heparin
Protein C l mt yu t c ch sinh l s hnh thnh cc mu ng ph thuc
vitamin K. Protein C c hot ha bi thrombin khi c mt ca
thrombomoduline ni mc v mt yu t ph thuc vitamin K huyt tng khc
na l protein S. Protein C bt hot yu t Va v yu t VIIIa.
Protein C hot ha b th b bt hot bi yu t bt hot plasminogen type I(PAI-
1).
H thng i thc bo c bit ca gan ngn nga s lan rn ca cc mu ng
bng cch ph hy cc phn t hot ha lu hnh trong tun hon.

Bng 2: S ng mu


1.3 Tiu si huyt
Qu trnh tiu si huyt cho php ha tan cc mu ng. N thc hin nh s
hot ha plasminogene thnh plasmine mt cht tiu hy protein ch yu ca h
thng tiu fibrin
Plasminogen l mt glycoprotein c tng hp t gan. i sng bn hy ca n
l 48h. Plasminogen c th gn vo c fibrin, s hot ha plasminogen c
thc hin theo con ng ni sinh v ngoi sinh
Con ng ngoi sinh c pht ng bi tPA. l mt sn phm hot ha sinh
l ca t bo ni mc. T l tPA gim i ngi c tui v 3 thng cui ca thai
kz, tng ln sau tr tnh mch, hot ng th lc v can thip phu thut.
Con ng ni sinh ph thuc vo yu t XII v c thc hin thng qua mt
protein trung gian c tn l ng yu t ca yu t Hagemann
Con ng ni sinh cng c th c hot ha bi prourokinase, tin cht ca
urokinase hnh thnh t chui phn hy fibrin
Plasmine bao gm 2 chui, mt chui nng(60000 dalton) v mt chui
nh(25000 dalton). N t tn cng khng nhng fibrin m cn c fibrinogen v
cc yu t V, VII, XII, XIII ca qu trnh hnh thnh cc mu ng.
Plasmine c th hot ha cc tiu cu v y l c s cho iu tr phi hp bng
cc cht chng ngng kt tiu cu khi s dng tr liu tiu si huyt ngn nga
hin tng ti tc nghn.




57.
SINH L BNH CA S HNH THNH HUYT
KHI


Huyt khi l mt qu trnh dn n s hnh thnh cc mu ng trong c th. 3
yu t ng vai tr xc nh trong c ch bnh sinh ca n
2.1 Yu t thnh mch: s khng ton vn ca lp ni m
T cc thng tn c bn cht t nhien khc nhau(chn thng, vim, d ng,
nhim c, do nguyn nhn dinh dng), cc thng tn ni mc gii phng ra
thromboplastin t chc. Di tc ng ca 3 yu t huyt tng: yu t VII, yu
t X, yu t V, thromboplastine t chc chuyn thnh prothrombinase(tc
thromboplastine hot ha). Cc tiu cu s c nh trn cc mp vt thng
to thnh cc huyt khi trng(nt tiu cu), tip theo l cc tc c thnh phn
fibrin-mu hay huyt khi
Do vy, vt lot ca lp ni mc ng mch do cc mng va x c th khi pht
mt h thng hnh thnh cc mu ng ngoi sinh gy ra huyt khi ng mch
2.2 Yu t mu
Mu tng ng c th do tng thi gian hnh thnh thromboplastine ngoi sinh,
do suy gim c ch c ch, nht l antithrombine, do ri lon fibrinogen. a hng
cu, tng tiu cu, ri lon chuyern ha lipid cng l cc yu t thun li cho s
hnh thnh huyt khi
2.3 Yu t huyt ng
Tc tun hon chm l mt yu t ch yu trong s hnh thnh huyt khi tnh
mch
Thc t cc yu t khng gy tc ng ring r m chc chn, n tng tc
nhng mc khc nhau, cc yu t thnh mch v tiu cu ng vai tr ch yu
trong nguyn nhn ca huyt khi ng mch, tc tun hon chm v ri lon
trong mi trng tun hon li l nguyn nhn ch yu ca huyt khi tnh mch
2.4 S bo v sinh l chng li huyt khi
C th c nhng cng c chng li hin tng ng mu ni mch:
- Prostaglandin(PGI2): c tng hp bi thnh mch bnh thng, chng li hin
tng kt dnh tiu cu, n phn tn cc tiu cu kt dnh li.
- Dng chy ca mu tun hon cun i v lm phn tn cc m tiu cu. N ha
tan thrombine b mt huyt khi
- Gan v h thng lin vng ni mc, mt mt sn xut ra cc cht c ch t
nhin(c bit l antithrombin) mt khc ph hy v trung ha cc yu t ng
mu hot ha.
- S tiu th fibrin sinh l lm ha tan cc mnh fibrin.

CC THUC CHNG NGNG KT TP TIU CU

3.1 Acid Acetylsalicylic
Acid Acetylsalicylic(Aspirin) c ch s gii phng v tp trung tiu cu do bt hot
men cyclooxygenase ca tiu cu. Aspirin c hp thu mt cch nhanh chng
d dy v t trng vi nng ti a trong huyt tng t c ngay sau 15
pht s dng thuc. Thuc cng c th c s dng theo ng tnh mch v
c tc dng chng ngng tp tiu cu ngay sau mt vi pht tim tnh mch. Tc
dng ph ca thuc gy ra ch yu ng tiu ha(xut huyt tiu ha do
thng hay lot d dy) v cc tc dng ph ny ph thuc vo liu lng s dng.
Ngc li, cc c tnh antithrombin xut hin ngay t liu 80mg/ngy v n cng
khng tng cao hn nhng liu ln hn.
3.2 Ticlopidine(Ticlid):
Ticlopidine(Ticlid) ngn chn s ngng t tiu cu bng cch c ch lin kt ph
thuc ADP ca fibrinogen mng tiu cu. Thuc c dng theo ng ung 2
vin 250mg/ngy v thi im tc ng ti a ca thuc bt u t ngy th 3.
Nguy c gim bch cu ht ca thuc l c th nn s theo di cng thc mu c
2 tun/ln trong 3 thng u iu tr l cn thit. Cc tc dng ph khc ca thuc
l gy nh hng trn h tiu ha(a chy, bun nn v vim gan), trn da(ban
nga) v s mt i khi ngng thuc.
Phi hp aspirin v tilclopidine s to nn mt s hip ng tc dng trong vic
chng to thnh huyt khi. Tr liu phi hp ny c p dng trong thng u
sau khi nong mch vnh c t stenn trnh hnh thnh huyt khi trong lng
stenn.
3.3 Mt s cht chng ngng tp tiu cu khc
Dipydamole(Persantine) trn thc nghim c kh nng c ch s ngng tp tiu
cu thng qua vic c ch ADP ca fibrinogen mng tiu cu.
Cc dung dch Dextran c s dng truyn tnh mch trong trng hp cn
ngn th tch tun hon. N cho php iu chnh tnh tng kt dnh v tng tp
trung tiu cu.

58.
CC THUC CHNG NG


HEPARIN THNG

c phn lp t nm 1916 bi Mac Lean v Howell v c s dng ln u tin
vo nm 1924, heparin l mt mucopolysarcharide c trng lng phn t
khong 17000 dalton. Ngi ta c th tm thy heparin trong nhiu c quan, c
bit trong phi v trong gan.

Cu trc khng gian 3 chiu ca heparin

Sau khi a vo c th, heparin gn vi alpha-2-globulin v khuych tn mt phn
vo khong quanh mch. Thuc khng vt qua lp thanh mc v rau thai(v vy
ra c th s dng cho ngi mang thai). N s mt hot tnh chng ng di tc
ng ca men heparinase c ngun gc t gan v thuc c o thi qua thn.
Suy gan v suy thn s to iu kienj cho s tch ly thuc trong mu. Khi tim
truyn tnh mch, i sng bn hy ca thuc rt ngn: 60-90 pht. Vi ng
tim di da, s hp thu thuc xy ra t t v tc dng ko di t 8-12h ty theo
liu lng s dng
* Kiu tc dng:
Tc ng trn s ng mu
Tc ng chnh ca thuc l chng thrombine. Thuc tng cng tc ng ca
ng yu t protein, antithrombine, trung ha thrombine v nh vy n chng li
s chuyn dng fibrinogen thnh fibrin. Tc dng ny xy ra tc th. Cng ca
n ph thuc vo t l gia s lng heparin lu hnh v nng thrombine hnh
thnh. nng huyt tng cao(trn 30 microgam/ml) heparin ngng chn
hon ton s chuyn dng ni trn. nng huyt tng thp hn(2-10
microgam/ml) n lm chm i s hnh thnh fibrin v to iu kin thun li cho
qu trnh t bo v sinh l chng li s ng mu ni mch v hnh thnh huyt
khi. Heparin b bt hot trong trng hp c th nhim toan.
Phc hp antithrombin III-heparin cng c tc dng chng thromboplastin. Phc
hp ny lm gim hot ng ca cc yu t XII, XI, IX v c ch yu t Xa.
Heparin gin tip to iu kin cho s tiu si huyt bng cch tng nng cc
cht hot ha plasminogen mc fibrin
* Cch dng:
Cc nguyn tc chung
Heparin c s dng theo ng tnh mch hay tim di da
Hai dng thuc c ng ng hin nay c th s dng c l:
Heparin natri 5%(1ml =50mg=5000UI)
Heparin canxi 25%(1ml =250mg=25000UI)
Liu lng c ch nh theo mg(h thng y t Php) hay bng n v quc t
(h thng anglo-sacxon): 1mg=100 n v

t hiu qu iu tr, tr liu heparin i hi phi t c mt s gim ng
vi TCA t 2 n 3 ln so vi chng. T 3 ln so vi chng tr i s c nguy c gy
chy mu. Nng heparin trong mu tun hon c th nh lng trc tip.
Phm vi iu chnh trong khong t 0,2 n 0,5U/ml huyt tng.
ngi bnh thng, heparin trong mu t 2 n 3 microgam/ml bo m
mt s gim ng c hiu qu. Liu heparin theo th t l 5mg/kg/ngy trong 2
ngy u tin sau gim liu xung 3 hoc 4mg/kg/ngy trong nhng ngy tip
theo.
Trong bnh l huyt khi, nhy cm ca c th i vi heparin b gim. Liu
iu tr khi u nen t c 10mg/kg/ngy. Trong qu trnh tin trin, nhy
cm ca c th i vi heparin dn v bnh thng.
Vic iu tr nh vy phi p ng ng tng giai on tin trin ca bnh
Thng thng, liu u tin, gi l liu phng on, c tnh ton da trn c
s 5-6mg/kg/ngy. Liu ny cho php th nhy cm ca c th ngi bnh vi
heparin. Nhng liu v sau c tnh ton da trn c s ca kt qu xt nghiemj
i chng.
Vi mt tr liu heparin d phng, liu phng on c th vo khong
4mg/kg/ngy
Trong trng hp c nguy c chy mu, liu phng on gim i mt na
Cho d bt c c s dng theo ng no, khi u ca vic s dng thuc
nn c p dng theo ng tnh mch vi liu t 0,5-1mg/kg i vi cc
trng hp bnh l huyt khi tc mch c th c nng heparin hiu
qu mt cch tc th.
Tr liu heparin ng tnh mch:
Thng thng ngi ta s dng heparinate natri
Truyn tnh mch lin tc l mt cch dng l{ tng cho ngi bnh. Heparin
hon ton n nh trong dung dch glucose 5% v nu s dng bm tim in th
cung lng heprarin truyn vo rt hng nh. Nu khng ta c th s dng cch
tim tnh mch qua catheter c mi 2h.
Khi cn phi dng heparin v bin chng chy mu hoc phi can thip phu
thut, s bnh thng v ng mu c th t c trung bnh sau 3h k t khi
ngng truyn heparin. Trong trng hp khn cp mt liu duy nht 0,5mg/kg
protamine sulfate hoc clohydrate trung ha heparin trong mu.
Tr liu heparin tim di da:
ng tim di da c s dng vi ch phm heparinate canxi(Calciparine
di da). Vi ng tim ny, heparin ngm vo mu nhanh chng v n nh v
tc dng ko di t 8-12h. Liu lng cng ging nh ch nh i vi ng tim
truyn tnh mch.
Liu lng phng on ni chung c ch nh cho 2 ln tim/ngy l
0,5mg/10kg
Trong trng hp b huyt khi tc mch, khi u ca iu tr nn tim di da
3 ln/24h(c mi 8h). Bt u t ngy th 6 hay th 7 c th p dng tim 2
ln/ngy(c mi 12h)
Trong trng hp s dng phng nga huyt khi, c th ch nh ngay cch
tim c mi 12h/ngy
Khi ngng tim heparin di da, s bnh thng v ng mu tr li sau 12-14h
k t khi tim mi sau cng. Trong trng hp khn cp cn t s bnh thng
ngay v ng mu, cn tim tnh mch protamine sulfate hay clohydrate vi liu
0,5mg/kg v c nh vy lp li sau mi 3h cho n gi th 12 k t thi im
tim mi cui cng.
Tr liu heparin tim di da l mt cch thc iu tr c th p dng lu di cho
ngi bnh. Cch thc iu tr ny c th tip theo cch thc iu tr truyn lin
tc tnh mch. Trong trng hp ny, liu u tin tim di da phi di 0,2ml
ca liu phng on chun(hoc 0,4ml cho mt bnh nhn 60kg). ng truyn
tnh mch c ngng sau khi tim mi ny 10 pht. Liu lng ca mi tim th
hai s ty thuc vo kt qu ca xt nghim kim tra tin hnh vo gi th 6.

* Theo di sinh ha ca iu tr chng ng bng heparin:
Hin nay 2 xt nghim c s dng theo di vic iu tr bng heparin l thi
gian cephaline- kaolin hot ha(TCA-temp de cphalin kaolin) v nh lng
heparin mu. t hiu qu iu tr, TCA phi t t 2-3 ln so vi chng v
heparin mu phi t t 0,2-0,5 n v/ml. Hin nay chng ta ch yu da vo
thi gian Howell. Theo di v nh gi thi gian Howell cng gn ging nh TCA.
Tuy nhin, khi s lng v/hoc tp trung tiu cu ca bnh nhn gim th thi
gian Howell khng phn nh ng hiu qu iu tr ca heparin.
Thi gian lm xt nghim kim tra ty thuc vo cch thc s dng heparin. Vi
heparin truyn tnh mch lin tc, xt nghim kim tra thc hin ln u tin sau
4h, sau c th thc hin xt nghim theo di vo bt c thi im no. Trong
trng hp heparin tim tnh mch c mi 2h, xt nghim theo di ln u tin
c thc hin 1h sau mi tim th hai. Vi heparin tim di da, xt nghim
thc hin 6h sau mi tim th nht. Cc ln xt nghim sau c th thc hin
trong khong thi gian t 2-6h sau cc ln tim. Lm li mt xt nghiemj sau 10h
k t lc bt u iu tr mt iu nn lm. N cho php bit c rng liu 2 ln
tim trong mt ngy c th duy tr c mt s gim ng c hiu qu mt cch
hng nh hay khng.
Cc xt nghim kim tra vo nhng ngy tip theo c tin hnh hng ngy hay
2 ngy/ln trong tun l u tin, ri tin hnh hng tun vo thi gian tip theo
khi iu tr cn bng liu thp hn hay bng 5mg/kg.
Liu lng c iu chnh ty theo kt qu xt nghim. Liu s gim xung t
20- 25% khi TCA trong khong t 3-4 ln so vi chng, 50% khi TCA > 4 ln so vi
chng. Liu cng s c tng ln t 20-25% khi TCA= 1,5-2,0 ln so vi chng,
tng ln 50% nu khng c s thay i no hay ch thay i khng ng k ca
TCA.


HEPARIN TRNG LNG PHN T THP

T heparin thng, ngi ta c th chit xut ra heparin trng lng phn t
thp(khong 2000- 10000 dalton). Hiu qu iu tr khng ph thuc vo kt qu
ca TCA. Cc xt nghiemj sinh ha khng nht thit phi tin hnh mt cch h
thng. Thuc c th s dng di ngy cho nhng bnh nhn cao tui hoc suy
thn. Xt nghiemj theo di i vi iu tr bng heparin trng lng phn t thp
l nh lng yu t khng Xa hot ha. Xt nghim c lm sau khi tim di
da 4h. Phm vi iu tr t 0,5-1 UI anti Xa nu khng c nguy c chy mu, 0,3-
0,6 trong nhng trng hp khc.
Nhiu loi heparin trng lng phn t thp hin nay c s dng trong phng
nga v iu tr bin chng huyt khi- tc mch:
- Nadroparine(Fraxiparine, ng 0,2; 0,3; 0,4; 0,6; 0,8 hay 1ml; 1ml= 10250UI anti-
Xa)
- Enoxaparine(Lovenox, ng 0,2; 0,4; 0,6; 0,8 hay 1ml; 1ml =10000UI anti Xa)
- Dalteparine(Fragmine, ng 0,2ml cha 2500 hay 5000UI anti-Xa)
- Tinzaparine(Innohep, ng 0,5; 0,7; 0,9 vi 1ml = 20000UI anti Xa)








Fraxiparine c ch nh trong iu tr phng nga bnh huyt khi tc mch vi
liu lng 1 ln tim di da 0,3ml trong ngy. Trong iu tr huyt khi tc
mch liu lng cn thit l 100UI/kg tim di da c mi 12h.
Khng nn ch nh dng thuc trong trng hp lot d dy t trng tin trin
bnh l chy mu v tai bin mch mu no(ngoi tr tai bin tc nghn mch
mu no). S dng thuc thn trng i vi nhng bnh nhn tng huyt p, suy
gan hoc suy thn, bnh l mch mu vng mc, tin s lot ng tiu ha, ph
n c thai, cc iu tr ang c ch nh c cc thuc chng vim gim au hay
acid acetylsalicylic, dextran, chng ngng tp tiu cu hay khng vitamin K(c th
tng cng tc dng chng ng).

THUC KHNG VITAMIN K

y l nhng thuc chng hnh thnh cc mu ng dng theo ng ung v c
th iu tr lu di cho ngi bnh. Tc dng ca chng ko di hn ca heparin
nhng xut hin mun. C th chia cc thuc khng vitamin K(AVK) ra lm 2
nhm theo thnh phn ha hc:
- Cc dn xut ca coumarine:
y l nhng thuc c bit n u tin(phn lp t dicoumarol bi Link nm
1941). Thuc nhm ny c sintrom, coumadine(mui warfarine), Apegmone ch
c mt nhn coumarine duy nht.
- Cc dn cht ca indanedione:
Cc thuc c s dng hin nay l Prviscan v Pindinone

5.1 C ch tc dng
Cc khng vitamin K c mt tc ng cnh tranh vi vitamin K trong t bo gan
m y l cc t bo ny tng hp nn cc yu t ng mu ca huyt tng: II,
VII, IX, X. Vitamin K c kh nng tc ng nh l mt nhm prosthetic ca enzym
cn thit cho s tng hp ny. Tc ng ca thuc ko theo s thiu ht dn dn
ca cc yu t khc nhau v lm gim nhiu nht l t l prothrombin. Gan lc ny
s tng hp nn cc protein khng hon chnh gi l PIVKA(protein induced by
vitamin K absence or antagonists). c im ca cc protein ny khng c mt s
lng ln cc v tr ca acid carboxy-glutamine cn thit gn calci.
V c kh nng lm gim t l thrombin v lm chm s hnh thnh thrombine, to
thun li cho tc dng antithrombine sinh l nn cc AVK c tc dng phng nga
s hnh thnh huyt khi.
Hiu qu iu tr khng c ngay tc th. tc ng trn t l prothrombine, thi
gian gn cn thit l 5 ngy, 36 gi i vi yu t X, 24h i vi yu t IX, 4 gi i
vi yu t VII. iu tr lu di l cn thit c c mt s gim ng n nh.
Tc dng ca cc AVK khng nhng b nh hng bi cc yu t ng mu
khc(yu t V, VII, tiu cu, antithrombine huyt tng) m cn chu nh hng
ca nhng yu t tham gia vo s chuyn ha protein: tc dng chng ng c
tng cng khi gan gim tng hp protein trong trng hp suy gan, suy kit
nng hoc trong trng hp tng cng chuyn ha protein(cng gip, nhim
trng, iu tr bng corticoid)

5.2 Chuyn ha
Cc AVK c hp thu nhanh chng trong ng tiu ha(di 24h nu nh
khng c cc ri lon tiu ha). N c vn chuyn bi albumin huyt tng v
s c nh ch yu trong gan. Thuc c o thi theo mt di dng cc cht
chuyn ha khng hot ng, ti hp thu theo chu trnh rut gan v bi tit theo
ng thn.
Tc dng chng ng thay i ty thuc tng c th v thay i ngay trn cng
mt c th. Chuyn ha AVK c th b nh hng bi nhiu yu t: thc n c
nhiu hay t vitamin K, c ung ru hay khng, tnh trng hp thu ca rut, cc
thuc: salycylat(nht l aspirin), noramidopyrine, phenylbutazone v cc dn xut
ca n, clofibrate, probenecide(Prototapen), cc sulfamid v khng sinh c ph
rng, propafenol(Rythmol), cimetidine, thyroxin, cc thuc chng ng kinh dn
xut ca hydantonine, quinine, quinidine, tolbutamid, allopurinol, amiodarone,
cephalosporin lm tng cng tc dng ca AVK. Ngc li cc bacbiturate,
meprobamate, ethinyl- oetradiol, rifampicine, thuc li tiu, digitalis cc khng
gip tng hp lm gim tc dng ca AVK. Suy thn lm tng cng tc dng ca
AVK, c bit l sintrom
Cc AVK qua c hng ro nhau thai v sa m. Thuc chng ch nh trong 3
thng u v 3 thng cui ca thi kz mang thai v trong giai on nui con bng
sa m.

5.3 p dng lm sng

La chn thuc khng vitamin K
Hin nay c kh nhiu li AVK, trn thc t lm sng ngi ta phn bit 3 loi:
- Loi tc ng nhanh(t 6-18h) nhng thi gian ko di tc dng ngn (1-2 ngy):
Tromexane, vin 300mg
- Loi tc ng bn nhanh(t 24- 48h) v thi gian tc dng trung bnh(2-3 ngy):
sintrom vin 4mg, Previscan vin 20mg
- Loi tc ng chm (2-3 ngy) nhng ko di (4-5 ngy) tc dng rt n nh vi
mt ln duy nht s dng thuc trong ngy. Coumadine(vin 2 v 10mg),
Apegmone(vin 4mg) thuc nhm ny.
S la chn AVK trc ht ph thuc vo thi quan v kinh nghim s dng ca
thy thuc. Tuy nhin vi nhng trng hp cn iu tr di ngy th chnh cc
AVK c tc dng n nh, thi gian ko di tc dng mc trung bnh l nhng
AVK c s dng nhiu nht.
Liu lng
Liu lng trong nhng ngy u tien c th cho - 1v/ngy v sau iu chnh
liu lng ty theo kt qu xt nghim lm vo ngy th 2 hay th 3 ty theo
thi gian tc ng ca loi AVK la chn
Khi mun ngng iu tr liu php heparin v thay th bng tr liu bng khng
vitamin K th trong thi gian t 36-48h trc khi ngng heparin, ngi bnh phi
c bt u cho dng AVK vi liu duy tr mc trung bnh khi ngng
heparin, AVK bt u c tc dng thc s.
Ngng iu tr AVK phi c tin hnh mt cch t t trnh mt phn ng
tng ng kch pht.

Theo di iu tr
Theo di sinh ha ca iu tr bng AVK bao gm s phi hp 2 xt nghim:
Thi gian Quick(t l prothrombine): bnh thng t l prothrombine coi nh
bng 100%. Hiu qu iu tr c ghi nhn khi t l prothrombine t 25-35%.
Mt t l prothrombine di 10% c coi l nguy him(tuy nhin tai bin chy
mu vn c th xy ra vi mt t l prothrombine cao hn). Trong iu tr bng
thuc khng vitamin K, t l prothrombine t 60% tr ln c coi nh thi gian
Quick bnh thng v nh vy, ng ngha vi hiu qu iefu tr bng 0.
Thi gian Quick hin nay c biu din bng International Normalized Ratio(INR)
l t l gia thi gian Quick ca bnh nhn v thi gian Quick ca ngi chng.
INR phi nm trong khong t 2-3 trong phng nga v iu tr huyt khi tnh
mch, tc mch phi, trong phng nga cc bin chng huyt khi tc mch
trong nhi mu c tim, trong rung nh v trong 3 thng u tin thay van tim sinh
hc. INR phi nm trong khong t 2,5-3,5 i vi van c hc ng mch ch
dng a, trong khong t 3,5-4,5 i vi van c hc thuc th h u tin
Thi gian ca cc xt nghim theo di ph thuc vo s n nh ca iu tr, vo
tinh thn ca bnh nhn m s gio dc ngi bnh l c bn. Theo di nh kz
hng thng thng thng l i vi nhng trng hp iu tr ko di v dung
np tt, tnh n nh cao. Khi tin hnh xt nghim nn cho kim tra thm v
hemoglobin pht hin kp thi cc trng hp chy mu kn o. Tt c cc
bnh nhn c iu tr bng AVK khi c bin chng chy mu u phi c
lm cc xt nghim v ng mu cp.

CH NH V CHNG CH NH CA THUC CHNG NG


6.1 Ch nh
6.1.1 Ch nh tuyt i
Tt c nhng triu chng v du hin ca bnh huyt khi- tc mch u cn phi
iu tr bng cc thuc chng ng. iu tr chng ng ny c th l iefu tr
bnh hay iu tr phng nga.
iu tr bnh
iu tr bnh ch yu dnh cho cc trng hp huyt khi sp xy ra hay huyt
khi va mi hnh thnh: vim tc tnh mch, nhi mu phi, tc cc ng mch
ngoi bin c ng knh nh, t huyt khi mi ca bnh ng mch chi di,
huyt khi mch vnh, tc mch no m c ch ca tai bin mch r rng.
Tr liu heparin c p dng sm nht nu c th
iu tr k tip bng khng vitamin K ch nn thc hin khi lm gim mt cch
chc chn s tng ng trong thi gian hnh thnh huyt khi.
iu tr phng nga
iu tr chng ng ngn hn hay thi hn trung bnh c ch nh trong thi
gian bt ng do gy xng, do can thip phu thut ngoi khoa hay sn khoa c
bit d xut hin huyt khi ha nhng giai on bt ng ca mt bnh l m c
nhiu kh nng hnh thnh huyt khi v d nh nhng giai on suy tim mt b.
iu tr chng ng cng ch nh cho nhng trng hp trc khi iu chnh
nhng lon nhp nh tr v nhp xoang v c sau khi nhp xoang c thit lp
nhng trng hp ny(t 4-6 tun l)
Trong ngoi khoa, tr liu heparin thng thng c tim di da theo phng
php Kakkar(tim 0,2ml heparin calci 2 gi trc khi can thip phu thut sau
tim di da c mi 12-8 gi). Hin nay, phng nga huyt khi tnh mch sau
phu thut bng heparin trng lng phn t thp mt ln tim di da/ngy(
Levonox 2000UI/ngy, Fragmine 2500UI/ngy). Liu lng c tng gp i
trong trng hp nguy c huyt khi cao.
iu r chng ng di ngy bng khng vitamin K phi c tin hnh mt cch
h thng:
- Trong nhng trng hp van tim nhn to(3 thng i vi van sinh hc, c i
i vi van c hc); nguy c huyt khi l 40% trong trng hp khng iu tr
chng ng, 5% trong trng hp mc d c chng ng mt cch hiu qu
- Trong cc bnh van tim nht l van 2 l c bin chng lon nhp tim hay suy tim
- Trong bnh l{ c tim nguyn pht c tim to hoc suy tim
- Trong rung nh kch pht hay rung nh mn tnh khi c nhng yu t nguy c v
huyt khi phi hp(tin s tai bin mch no, bnh l mch vnh, suy tim, tiu
ng, tng huyt p, bnh van tim, cng gip). INR nm trong khong 2-3.
6.1.2 Cc ch nh tng i
Trong bnh mch vnh sau khi nhi mu c tim, thuc chng ng ch nen ch
nh cho nhng bnh nhn b nhi mu c tim trc rng, phnh vch tht, ri
lon chc nng tht tri nng, rung nh, tin s c tc ng mch phi hay nhng
ng mch h thng. INR nn nm trong khong 2-3. i vi nhng bnh nhn
khc nn ch nh aspirin liu lng chng ngng tp tiu cu.
Trong cc bnh ng mch chi di, iu tr chng ng c ch nh cho nhng
bnh nhn b nhng t tin trin cp tnh v c th ch c tc dng i vi cc
bnh nhn iu tr ngoi khoa hay lm cu ni ng mch hoc c no
sch mng va x trong lng mch. Ch nh cn c p dng cho nhng trng
hp sau phu thut nhng ng mch hay cu ni ng mch b tc do huyt
khi. Cc bnh nhn khc, c bit sau phu thut cc ng mch c ng knh
trn 6mm, nn c iu tr bng cc thuc chng kt tp tiu cu.
Trong cc trng hp lon nhp hon ton khng r nguyn nhn, ch nh chng
ng c cn c vo tui ca bnh nhn, con s huyt p, mc gin cc
bung tim.

6.2 Chng ch nh
6.2.1 Chng ch nh tuyt i
- Cc c a chy mu(chy mu tiu ha, suy gan nng, bnh mu)
- Lot tin trin ng tiu ha
- Tng huyt p nng vi cc tn thng quan trng y mt
- Vim mng ngoi tim cp
- Phnh tch thnh ng mch ch
- X va ng mch no tin trin, nht l khi trong tin s c tai bin mch no
6.2.2 Cc chng ch nh tng i
- Tui trn 70
- Lot d dy, t trng c
- Polyp ng tiu ha hay thn
- i tho ng c vim vng mc
- Tng huyt p mc va phi
- Ri lon tm thn kinh

CC BIN CHNG CA IU TR CHNG NG

Bin chng thng gp nht l cc tai bin chy mu. Cc bin chng khc c th
c nhng thng him gp
7.1 Cc tai bin chy mu
Tai bin chy mu x ra i vi cc thuc khng vitamin K ln hn nhiu so vi
heparin
Cc nguyn nhn thun li:
Thng thng l ni sinh l:
- Gim ng do qu liu
- C cc ri lon ng mu phi hp: thiu yu t PTA, Hagemann, Stuart, hay
thiu ton b cc yu t ng mu do suy gan, gim tiu cu
- Cc c a thun li: tn thng ng tiu ha(lot, u, thot v c honh, tr),
vim nhim mn tnh(vim tai gia chy mu, vim mng ngoi tim do chy mu
mng ngoi tim)
- Cui cng l do sai lm trong iu tr: cc tai bin do tim truyn, chc vo ng
mch, chc d mng phi hay ty sng, nh rng, phi hp thm cc thuc c kh
nng lm tng cng nguy c chy mu(aspirin, phynylbutazon, thuc gim
cholesterol mu). Cn phi nhn mnh tc ng gy c i vi nim mc d
dy- t trng ca tr liu kt hp corticoid- chng ng.
Biu hin lm sng:
Th nh
Ni chung cc du hiu th hin mt s gim ng qu mc, cn phi kim tra li
cc xt nghim ng mu v iu chnh li liu lng thuc.
Cc du hiu lm sng thng l chy mu mi, chy mu rng li, nt chy mu
t nhin hay khi b chn thng nh, i mu
Th nng
i khi biu hin bng mt hi chng chy mu nng. Trng hp ny gp nhiu
trong iu tr bng AVK. Cc du hiu lm sng thng bao gm chy mu ni
tng kt hp vi chy mu mi, cc nt chy mu v t mu khp ni.
Cng c th chy mu ch khu tr nhng khng km phn nguy him:
- Chy mu no- mng no
- Chy mu tiu ha, tit niu, chy mu trong bng
- Chy mu bao hot dch, chy mu trong c, t mu quanh thn, t mu trong
rut gy hi chng tc hay bn tc rut.
- Trn mu thng thn hai bn c th gy nn mt hi chng suy tuyn thng
thn cp.
- Chy mu nhn cu, m o.
iu tr v phng nga tai bin
Thi iu tr ph thuc vo mc nghim trng ca tai bin bao gm cc
ng tc nh gim liu iu tr hay ngng iu tr, s dng cht i khng hay cc
bin php iu tr ph tr.
Cc tai bin chy mu do heparin thng t khi nghim trng. Ni chung ngng
iu tr c th l , sau mt vi gi cc thnh phn ng mu c th tr v bnh
thng.
Trong trng hp tai bin nng, vic trung ha cng khng qu kh khn bng
protamin(100UI protamin trung ha 100 UI heparin)
Cc tai bin chy mu do dng thuc khng vitamin K cng c th ch cn ngng
thuc l . Khi cc tai bin ny tr nn e da tnh mng ngi bnh, cn phi
s dng thuc i khng c hiu: vitamin K(10-50mg tnh mch), nhng trong
thi gian t 3-6 gi phi nng c prothrombin mu ln mc hiu qu. Trong
trng hp cp cu, phi truyn tnh mch huyt tng ti ng lnh
PPSB(cung cp trc tip cc yu t ng mu prothrombin, proconvertin, yu t
Stuart v yu t chng hemophilie B). Liu lng trung bnh l 0,5mg/kg
Phng nga tai bin chy mu bao gm tun th ng ch nh, tn trng cc
chng ch nh, theo di tt v lm sng v xt nghim, gio dc bnh nhn, ng
thi c s phi h cht ch gia bnh nhn v thy thuc.

7.2 Cc tai bin khng chy mu: rt him
Tai bin thuc vn nhy cm
- Sc do heparin
- Cc du hiu d ng: du hiu da, mu(gim tiu cu, gim bch cu..), tiu ha,
gan thn hay ton thn(st ko di): c ghi nhn mt s trng hp iu
tr bng cc AVK, nht l phylylindanedione
- Gim tiu cu khi iu tr bng heparin l mt tai bin him gp nhng li l mt
tai bin nng. Ngun gc do min dch. Tai bin ny c th gy chy mu v tc
mch do huyt khi m c ch c th do s hnh thnh cc m tiu cu.
Long xng do s dng heparin ko di
Gy xng t pht gp trong qu trnh iu tr bng heparin di ngy v tr liu
ny c th gy gy xng
Cc tai bin sn khoa
Khi s dng AVK c th gy t mu pha sau bnh ranu v gy qui thai, v vy nn
s dng heparin trong 3 thng u v 3 thng cui ca thai kz ch khng c s
dng cc thuc khng vitamin K trong thi gian ny.
Phn ln cc tai bin, bin chng khi iu tr bng thuc chng ng c th trnh
c bng s thn trng khi ch nh v khi s dng thuc.

CHNG 7. BO CO KHOA HC





59. BC U NH GI H THNG NG
CM MU BNH NHN A U TU XNG

Nguyn Th N, V Thanh Bnh,
Trn Th Minh Hng (Vin HH-TM TW)

Summary
The study aimed to investigate hemostasis system of myeloma patients. Platelet
, PT, APTT, TT, fibrinogen, Ethanol test, euglobulin lysis time, D- Dimer were
mesured in 45 patients with myeloma.
The result shows that patients with myeloma have disorders in the coagulant
balance with hypocoagulability.
There is a positive correlation between elevated blood protein and APTT, TT;
negative correlation between elevated blood protein and PT%
Tm tt
Nhm mc ch nh gi h thng ng cm mu bnh nhn a u tu xng,
chng ti tin hnh cc XN.. 45 bnh nhn a u tu c chn on v iu tr
ti Vin HHTMTW. Kt qu cho thy c ri lon ng cm mu theo hng gim
ng nhng bnh nhn ny. Tn ti mi tng quan thun gia APTT, TT vi
nng protit mu ton phn, tng quan nghch gia PT% vi nng protit
mu ton phn bnh nhn a u tu xng.

t vn :
a u tu xng l mt bnh l{ c tnh thng gp trong lm sng huyt hc.
Trn th gii cng nh Vit nam, c nhiu cng trnh nghin cu v bnh l
ny trn nhiu kha cnh khc nhau. Tuy nhin cn rt t nghin cu nh gi tnh
trng ng cm mu mc d trn thc t lm sng biu hin ri lon ng cm
mu khng phi him gp. Chnh v vy, chng ti tin hnh ti ny nhm mc
ch:
- c u nh gi tnh trng ng cm mu bnh nhn a u ty xng.
- Xc nh mi lin quan gia nhng bt thng ng cm mu (nu c) vi
mt s yu t nhng bnh nhn ny.
1. i tng phng php:
1.1. i tng: 45 bnh nhn a u tu c chn on xc nh ti Vin
HHTMTW. Gm 20 nam, 25 n. Khng c iu tr thuc c nh hng ng
cm mu t nht 10 ngy trc khi tin hnh cc xt nghim.
1.2. Phng php:
+ Tin hnh cc xt nghim ng cm mu: S lng tiu cu, co cc mu ng,
PT, APTT, TT, fibrinogen, nghim php ru, thi gian tiu euglobulin, nh lng
D- Dimer.
Chn on DIC, tiu si huyt tin pht theo phc v tiu chun hin ang p
dng ti vin HHTMTW.
+ Thu thp cc triu chng lm sng c lin quan n ri lon ng cm mu
+ X l s liu bng chng trnh epi info 6.04.
2. Kt qu

Bng 1: mt s c im chung nhm bnh nhn nghin cu

n % p
Gii tnh Nam 20 44,0
N 25 56,0 > 0,05
Th bnh IgG 41 91,0
< 0,01 Ig khc 4 9,0
Nhn xt:
Trong nghin cu ny, t l gia nam v n khc bit khng c { ngha thng k.
Chng ti gp ch yu l a u ty type IgG (91,0%)
Bng 2.2. Kt qu nghin cu s lng tiu cu
T l
SLTC
n %
Gim 5/45 11,1
Tng 0/45 0
Tng s 5/45 11,1
Nhn xt:
11,1% bnh nhn a u tu xng gim s lng tiu cu; Khng gp trng hp
no tng s lng tiu cu.

Bng 2.3: Kt qu nghin cu PT%

T l
Kt qu PT%
n %
nh thng 30 66,7
Gim 15 33,3
Tng 0 0
45 100


Nhn xt:
Gp 33,3% bnh nhn trong nhm nghin cu gim PT%.
Khng gp trng hp no tng PT%.

Bng 2.4: Kt qu nghin cu APTT

T l
Kt qu APTT
n %
nh thng 28 62,0
Ko di 17 38
Rt ngn 0 0
45 100

Nhn xt:
Gp 38,0% bnh nhn trong nhm nghin cu c APTT ko di.
Khng gp trng hp no APTT rt ngn.

Bng 2.5. Kt qu nghin cu TT

T l
Kt qu TT
n %
nh thng 29 64
Ko di 16 36
Rt ngn 0 0
45 100

Nhn xt:
Gp 36,0% bnh nhn trong nhm nghin cu c TT ko di.
Khng gp trng hp no TT rt ngn.

Bng 2.6. Kt qu nghin cu nng fibrinogen

T l
Nng firinogen
n %
nh thng 30 67,0
Tng 4 9,0
Gim 11 24,0
45 100


Nhn xt:
Gp 24,0% gim fibrinogen v 11,0 %tng fibrinogen.

Bng 2.7. Kt qu nghin cu v hi chng mt si huyt
T l
Loi ri lon
n %
DIC 1/18 6,0
Tiu si huyt tin pht 0/18 0

Nhn xt:
Gp 6,0% DIC bnh nhn nghin cu. Khng gp trng hp no tiu si huyt
tin pht.

Bng 2.8. Mi tng quan gia nng protit mu ton phn vi mt s ch s
ng cm mu
r p
SLTC (x 10
9
/l) 0,1 < 0,05
PT% - 0,45 <0,01
APTT (giy) 0,31 <0,01
TT (giy) 0,33 <0,01
Fibrinogen (g/l) - 0,11 <0,05

Nhn xt:
Tn ti mi tng quan thun gia APTT, TT, vi nng protit mu; Tng
quan nghch gia PT% (t l prothrombin ) vi nng protit mu ton phn

Bn lun
3.1. V kt qu cc xt nghim ng cm mu bnh nhn a u ty xng:
Cc kt qu nghin cu v s lng tiu cu, PT%, APTT, TT cho thy nhng
bnh nhn ny c tnh trng gim ng: s lng tiu cu gim, PT% gim, APTT ,
TT ko di. Vy bn cht ca tnh trng gim ng mu nhng bnh nhn ny l
g: Tiu cu gim do ty gim sinh, cc xt nghim ng mu ko di do cc
protein b mt chc nng ng mu hay do gim nng cc yu t ny v nu
vy y l mt tnh trng gim nng tht s hay gi to do thay i nht
mu gy nny l nhng vn gi m chng ti tip tc nghin cu tip.
3.2. V mi tng quan gia PT%, APTT, TT vi nng protit mu ton phn:
Kt qu bng 2.8 cho thy tn ti mi tng quan thun gia APTT, TT vi nng
protit mu ton phn; Gia PT% v nng protit mu ton phn c mi
tng quan nghch. iu ny c ngha l nng protit mu ton phn cng cao,
APTT, TT cng ko di, PT% cng gim. Nh vy tnh trng gim ng mu bnh
nhn a u ty rt c th c ci thin theo xu hng tch cc khi bnh nhn
c iu tr gim nng protit mu ton phn. Hy vng vn ny s c
gii p mt cch trn vn hn bng nhng bc tip theo ca ti ny:
Nghin cu dc, ngoi nng protit mu, cc thng s khc nh nng
albumin, globulin, cng s c nh gi


KT LUN
c u tin hnh kho st tnh trng ng cm mu 45 bnh nhn a u tu
xng, chng ti rt ra mt s kt lun sau y
- C mt t l kh cao bnh nhn a u tu xng ri lon ng cm mu. Loi ri
lon gp ch yu l tnh trng gim ng mu
- C mi tng quan thun gia APTT, TT vi tng nng protit; Tng quan
nghch gia PT% vi nng protit mu ton phn bnh nhn a u tu xng.

TI LIU THAM KHO
1. Anderson KC (2000), Recent advances in biology and treatment of multiple
myeloma, Americane hematology, pp 63-68.
2.arlogie (1995), plasma cell myeloma, Williams Hematology, 5
th
Edition, pp
1109- 1126.

60. BC U NGHIN CU MT S C
IM MU V TU XNG BNH NHN
GIM BA DNG MU NGOI VI

Nguyn Quang Tng, Nguyn Ngc Dng,
Nguyn Lan Phng, Nguyn Th Thu.

Tm tt
Nghin cu tin hnh trn 187 bnh nhn gim ba dng ngoi vi c vo
iu tr ln u ti Vin Huyt hc-Truyn mu trung ng trong nm 2005, kt
qu cho thy: T l gim ba dng chim 10.4% trong 1803 bnh nhn xt nghim
tu ln u, tui trung bnh 45 20 tui, t l nam/n: 1.03. S lng t bo
tu trung bnh l 32.4 G/l (t 1 n 931 G/l), trong 56.7% ngho t bo.
Nguyn nhn thng gp nht l: suy tu xng (33.2%), ri lon sinh tu (23.5%)
v l x mi cp (18.7%). Ngoi ra cng gp cc biu hin khc: x tu, a u tu
xng, u lympho hay ung th di cn...C 11.2% khng th kt lun.

Summary
This study was carried out on 187 patients with pancytopenia, the first time
came in Vietnam NIHBT in 2005. The results are: the percentage of pancytopenia
is 10.4 in the initial income patients ; mean of age: 45 20 years old. Medium of
cell in bone marrow is 32.4 G/l (1 to 931 G/l) and 56.7% hypoplasia. The
frequence causes are: Aplasia anemia (33.2%), Myelodysplasia syndrome (23.5%)
and acute leukemia (18.7%). In addition, we can see myelofibrosis, multiple
myeloma, lymphomas and bone marrow metastase of cancers. 11.2% of there
cases can not have conclusion.
1. t vn
Gim ba dng t bo mu ngoi vi (pancytopenia) l mt trong nhng biu hin
c th gp trong nhiu bnh l to mu khc nhau. Hin tng ny c nh
ngha khi c gim ng thi v s lng ca c hng cu, bch cu v tiu cu
mu ngoi vi trn xt nghim tng phn tch t bo mu, ng thi th hin cc
triu chng lm sng ca tnh trng thiu ht cc t bo mu.
Mc d gim c ba dng t bo mu ngoi vi nhng s lng t bo trong tu c
th khng gim hoc thm ch cn tng, iu ny l do bn cht tu sinh mu b
c ch do nguyn nhn bn ngoi hay bnh l nguyn pht ti tu. Vy, nguyn
nhn thng gp ca biu hin ny l g?
Trn th gii c vi cng trnh cng b v cc nguyn nhn gy ra tnh trng
gim ba dng t bo mu cng nh biu hin ca tu to mu. Hin nay nc
ta, cn cha c cng b no v tnh trng m bnh hc ca tu sinh mu trong
nhng trng hp ny. V vy chng ti tin hnh nghin cu ny nhm mc tiu:
M t mt s c im mu, tu xng v xc nh nguyn nhn nhng trng
hp gim ba dng ngoi vi ti Vin Huyt hc-Truyn mu.
2. i tng v phng php nghin cu
2.1. i tng nghin cu:
- 187 bnh nhn v iu tr ln u ti Vin Huyt hc-Truyn mu TW t thng
1/2005 n thng 12/2005.
- Cc bnh nhn ny c chn on gim ba dng mu ngoi vi bng xt
nghim tng phn tch mu ngoi vi trn my m t bo Celltac (Nht).
Tiu chun la chn khi c ng thi cc biu hin sau:
1. Huyt sc t di 120 g/l.
2. S lng bch cu di 4 G/l v/hoc
Bch cu ht trung tnh di 1.5 G/l.
3. S lng tiu cu di 150 G/l.
- c lm xt nghim tu v sinh thit tu xng.

2.2. Phng php nghin cu: nghin cu ngang m t
- Bnh nhn c chn on gim ba dng ngoi vi, sau thu thp kt qu xt
nghim mu, tu v sinh thit ty xng. Ghi nhn kt qu chn on cui
cng khi ra vin.
- X l s liu bng phng php thng k y hc.
3. Kt qu v bn lun
3.1. c im nhm nghin cu
Tng s 187 bnh nhn gim ba dng ngoi vi c sinh thit tu xng trong
1803 trng hp xt nghim tu ln u, trong nm 2005 ti Vin Huyt hc -
Truyn mu TW, chim t l 10.4%. tui trung bnh: 45 20 tui (t 15 n 85
tui). Phn b bnh nhn theo gii: Nam 95 bnh nhn, n: 92 bnh nhn, t l
nam/n: 1.03.
Kt qu ny cng tng t nh mt s cng trnh nghin cu c cng b:
Trong nghin cu ca M. Niazi, t l ny kh cao:19% (89 trng hp trong tng
s 472 bnh nhn), ng thi tc gi ny cng trch dn nghin cu ca bnh vin
Basawari tin hnh vi 11.9% bnh nhn gim ba dng trong 1813 trng hp xt
nghim tu [4]. Vi nghin cu ca O. Ishtiaq trong 1 nm (t 2001-2002), s
lng bnh nhn c biu hin gim ba dng l 100 trng hp *6+. Trong khi ,
theo di trong 6 thng (t 6-12/1999), Kishor ghi nhn c 50 bnh nhn gim ba
dng trong tng s 250 trng hp xt nghim tu (chim 20%). V tui v t
l nam/n, kt qu nghin cu ca chng ti c khc bit nh vi cc tc gi
nu trn v Vin Huyt hc-Truyn mu ch nhn v iu tr bnh l huyt hc cho
ngi trng thnh. C th: vi nghin cu ca O. Ishtiaq l 37 tui (t 12 n 82
tui), nam/n:1.13 [6]. Nghin cu ca M. Niazi tin hnh trn nhm i tng
t 1-75 tui, ch yu tui tr t 1 n 30 tui (71%), nam/n:1.7 *4+, cn i
tng nghin cu ca Kishor *3+ c tui t 3-69 tui, nam/n:1.3
3.2. c im mu ngoi vi
Bng 1. c im s lng mu ngoi vi
Ch s X SD Gi tr
Lng huyt sc t 81.9 19.5 18-118
S lng bch cu 2.63 2.57 0.3-3.9
S lng BC ht trung tnh 1.13 1.33 0-2.89
T l % BC ht trung tnh 41 22
S lng tiu cu 48 37 1-139
T l hng cu li 0.7 1.2 0.3-10
Nhn xt: Tt c bnh nhn nghin cu u c biu hin thiu mu, hu ht
mc nng (lng huyt sc t di 80g/l). S lng bch cu gim thp, c
bit bch cu ht trung tnh (1.08 0.76 G/l). S lng tiu cu cng gim r rt
di 50 G/l (46 6 G/l).
Kt qu nghin cu ca O. Ishtiaq cng gp 14% trng hp gim nng s lng
bch cu ht trung tnh di 0.5 G/l v 11% bnh nhn gim tiu cu di 10 G/l
[6].
3.3. c im tu to mu
Bng 2. Phn lp s lng t bo tu
S lng t bo tu n % % cng dn
T 1 n 10 G/l 35 18.7 18.7
T trn 10 n 20 G/l 48 25.7 44.4
T trn 20 n 30 G/l 23 12.3 56.7
T trn 30 n 40 G/l 14 7.6 64.3
T trn 40 n 50 G/l 10 5.3 69.6
Trn 50 G/l 57 30.4 100
Tng s 187 100

S lng t bo tu (median) ca nhm nghin cu l 32.4 G/l v thay i trong
mt khong rt ln: t 1 G/l n 931 G/l. Hin tng phn b rt khng ng
nht ny l do nguyn nhn bnh l gy gim ba dng rt khc bit. Trong t l
cc trng hp tu ngho t bo (di 30 G/l) chim t l kh cao 56.7%. Kt qu
trnh by trong bng 2.

3.4. Cc nguyn nhn gy gim ba dng ngoi vi

Bng 3. Nguyn nhn gy gim ba dng ngoi vi
Nguyn nhn n %
Suy tu xng 62 33.2
Ri lon sinh tu:
SLTB tu bnh thng hoc tng
SLTB tu gim
44
21
23
23.5
11.2
12.3
L x mi cp 35 18.7
Tng sinh, khng biu hin c tnh 12 6.4
X tu 2 1.1
a u tu xng 2 1.1
U lympho xm ln tu, tng sinh lympho 4 2.1
Ung th di cn tu 3 1.6
Hi chng thc bo tu 2 1.1
Khng kt lun 21 11.2
Tng s 187 100

Nhn xt: Suy tu xng l bnh l hay gp nht gy hin tng gim ba dng
ngoi vi (33.2%). T l ny tng t kt qu ca M.Niazi (38.3%), cao hn kt qu
ca O. Ishtiaq (8%) v Kishor (14%) [3,4,6]. Cc tc gi ny gp biu hin gy gim
ba dng nhiu nht l thiu mu nguyn hng cu khng l (megaloblastic
anaemia). Chng ti cng c gp nhng trng hp bnh l{ ny nhng khng ghi
nhn trng hp no c biu hin gim ba dng.
Biu hin ri lon sinh tu c ghi nhn trn tiu bn sinh thit tu xng chim
t l rt cao (23.5%), trong hn 50% th hin tu ngho t bo khi chc ht
(23/44 trng hp). Kt qu ny cao hn nhiu so vi mt s tc gi khc: O.
Ishtiaq (5%) v Kishor (2%) [3,6].
Biu hin l x mi cp chim t l kh cao (18.7%), tng t M. Niazi (16%) [4].
Tuy tiu chun m bnh hc khng phi l quyt nh nhng do tnh trng gim
ba dng ngoi vi hoc t bo tu ngho nn bnh nhn c ch nh sinh thit
gp thm thng tin chn on. Chng ti gp hu ht cc th bnh l x mi
trong nhm nghin cu ny (bng 4), trong khi O. Ishtiaq (2%), Kishor *3,6+
cng ghi nhn kt qu ny nhng vi t l thp hn nhiu.
Bng 4. Th bnh l x mi cp c biu hin gim ba dng ngoi vi
Th bnh S lng T l %
LXM cp th L2 8 22.8
LXM cp th M0 6 17.1
LXM cp th M1, M2 6 17.1
LXM cp th M3 6 17.1
LXM cp th M4, M5 5 14.4
LXM cp th M6 3 8.6
LXM cp th M7 1 2.9
Tng s 35 100

Ngoi ra, chng ti cng ghi nhn mt s nguyn nhn gy gim ba dng nhng
vi t l thp (bng 3). Bn cnh l tnh trng tng sinh tu m khng c biu
hin bnh l to mu vi t l cao (6.4%), nguyn nhn c th l do cng lch, s
dng thuc...v cn kh nhiu (11.2%) trng hp sinh thit tu xng m khng
c kt lun: mnh sinh thit qu ngn (do k thut), cc tnh trng ri lon sinh
tu th pht hoc ch tr li c bng cc thng tin gi nguyn nhn. O.
Ishtiaq cng khng th kt lun trong 4% trng hp [6].

4. Kt lun
Qua tin hnh nghin cu trn 187 bnh nhn c biu hin gim ba dng ngoi vi
vo iu tr ln u c lm xt nghim tu v sinh thit tu xng ti Vin
Huyt hc-Truyn mu TW trong nm 2005, chng ti rt ra nhng kt lun sau:
- Biu hin gim ba dng chim 10.4% trong nhng bnh nhn lm xt
nghim tu ln u, tui trung bnh 45 20 tui, t l nam/n: 1.03.
- S lng t bo tu dao ng rt rng: t 1 n 931 G/l, trung bnh l 32.4
G/l. Trong 56.7% trng hp tu ngho t bo.
- Cc bnh l{ thng gp nht ca biu hin gim ba dng ngoi vi ln lt
l: suy tu xng (33.2%), ri lon sinh tu (23.5%) v l x mi cp (18.7%).
Ngoi ra cng gp cc biu hin khc: x tu, a u tu xng, u lympho hay
ung th di cn...C 11.2% khng th kt lun.
5. Kin ngh
Gim ba dng ngoi vi l biu hin c th gp trong nhiu bnh l nhiu chuyn
khoa khc nhau, do nhiu nguyn nhn khc nhau. Kt qu nghin cu bc u
v t bo mu v tu rt khng ng nht, do vy cn tip tc trin khai cc
nghin cu su hn, i vo tng nhm nguyn nhn c th tm ra cc c
im mang tnh c trng cho bnh l.
Chng ti s tip tc nghin cu, tng kt c th dn hon thin din mo cc
bnh l nguyn nhn gy gim ba dng, ng thi xut cch tip cn chn
on hp l cho tng nhm nguyn nhn, cc tuyn c s c th s dng hp
l{ hn cc k thut trong tp hp xt nghim hnh thi hc: huyt , tu , sinh
thit tu xng.
Ti liu tham kho
1. Faramarz Naeim. Pathology of Bone marrow. Williams and Wilkins. 1998
2. Neal S. Young. Bone Marrow Failure Syndromes. W.B. Sounders Company.
2000
3. Kishor Khodke et al. Bone Marrow Examination in cases of pancytopenia.
Journal, Indian Academy of Clinical Medecine. Vol.2, No.1, pp. 55-59.
4. Mussarrat Niazi, Fazl-i-Raziq, The incidence of underlying pathology in
pancytopenia-an experience of 89 cases. Journal of Postgraduate Medical
Instiutute. Vol 18. No.1. pp. 76-79.
5. Pancytopenia. Laboratory of Hematology-University Hospital- Angers
France.
6. Osama Ishtiaq, Haider Z Baqai et al. Patterns of pancytopenia patients in a
general medical ward and a proposed diagnostic approach. Medical Unit II,
Holy Family Hospital, Rawalpindi, Pakistan.

61. NH GI TNH HNH NGI HIN MU
TNH NGUYN CA VIN HUYT HC - TRUYN
MU TRUNG NG NM 2005

Nguyn c Thun, C Th Lan Anh, Ng Mnh Qun, L Th Ho, Bi Ngc Dng,
Nguyn Vn Nh, Trn Quc Tun, Nguyn Xun Thi, m Nhn Vng, L
Thanh Nam, Khut Minh Tin, Bch Khnh Ha,Phm Quang Vinh, Nguyn Anh
Tr

I - T VN :
Xy dng ngun ngi hin mu c cht lng, thng xuyn v an ton p ng
nhu cu mu iu tr l nhim v trng tm hng u ca tt c cc ngn hng
mu trn th gii. thc hin tt nhim v ny th vic nh gi kt qu hot
ng tuyn m ngi hin mu hng nm l rt cn thit. Hin nay, nh ng
dng cng ngh thng tin m hu ht cc ngn hng mu u c c nhng
nh gi y v kp thi cc thng tin v ngun ngi hin mu ca mnh. Nh
iu chnh c kp thi cc hot ng tuyn m ngi hin mu, p ng vi
yu cu v s lng, cht lng v m bo an ton truyn mu.
nc ta, phong tro hin mu nhn o ang pht trin mnh, s lng v t l
ngi hin mu tnh nguyn (HMTN) tng nhanh ang dn thay th ngi cho
mu chuyn nghip (CMCN). gp phn nh gi kt qu hot ng nm 2005
v xy dng cc ch tiu ca cng tc t chc hin mu cho nhng nm sau,
Chng ti tin hnh ti nhm cc mc tiu:
1. Xc nh s lng v c cu theo tui, gii, ngh nghip, t l nhm mu ABO
v Rh, t l hin mu nhc li ngi hin mu tnh nguyn ti cc im hin
mu ca Vin Huyt hc - Truyn mu Trung ng nm 2005.
2. nh gi mt s ch s huyt hc mu ngoi vi v t l nhim cc bnh nhim
trng c sng lc ngi hin mu tnh nguyn ca Vin nm 2005.
II - I TNG V PHNG PHP NGHIN CU:
1. i tng nghin cu: Chia lm 2 nhm.
- Nhm 1: Tt c ngi HMTN c bc s khm kt lun l iu kin hin
mu ti cc im c nh v lu ng ca Vin nm 2005.
Chn ngu nhin 120 ngi HMTN nhc li t 3 ln tr ln (60 nam, 60 n) xt
nghim cc ch s huyt hc mu ngoi vi trc khi cho mu.
- Nhm 2: chn ngu nhin 120 ngi CMCN nhc li t 3 ln tr (60 nam, 60 n)
ln xt nghim cc ch s huyt hc mu ngoi vi trc khi cho mu.
C mu xt nghim cc ch s huyt hc mu ngoi vi c tnh da theo
cng thc:
n = Z
2
1-/2
x S
2
/
2

Trong :
Z
2
1-/2
l h s tin cy = 1,96 s l lch chun hemoglobin = 16
n l c mu nghin cu l sai s c lng = 3
2. Phng php nghin cu:
- Thit k nghin cu : theo phng php m t ct ngang.
- Phng php thu thp s liu:
+ ng k{ hin mu, t vn hin mu v khm lm sng.
+ Xt nghim HBV bng test nhanh v xt nghim cc ch s huyt hc mu
ngoi vi ca ngi cho mu bng my m t bo t ng Celltac .
+ Xt nghim HBV, HCV, HIV n v mu bng k thut Elisa; xt nghim tm st
rt mu ngoi vi bng k thut nhum soi trc tip; xt nghim giang mai bng
k thut PRR.
+ Thu thp thng tin v ngi hin mu theo phiu ng k{ hin mu tnh nguyn
v h s t chc cc im hin mu ca Vin.
+ ng dng phn mm qun l{ ngi hin mu tnh nguyn ca Trung tm hin
mu nhn o Thnh ph H Ch Minh.
+ Nhp liu thng tin v ngi hin mu tnh nguyn ti cc im hin mu, phn
tch v tng hp s liu bng phn mm qun l{ ngi hin mu.
- X l s liu bng cc phn mm qun l{ ngi hin mu tnh nguyn, Epi Info
6.0 v Microsof EXCEL.
3. Thi gian nghin cu: t thng 01/2005 n thng 03/2006.
4. a im nghin cu: ti Vin Huyt hc - Truyn mu Trung ng.
III - KT QU V BN LUN:
1. Lng mu thu gom c ca Vin nm 2005
Bng 1.1. S n v mu thu gom c cc i tng cho mu nm 2005
Nm
i tng
Nm 2005 % so vi nm 2004
S lng T l
HMTN 29.297 55,75% 250,4%
CMCN 23.247 44,25% 94%
Tng cng 52.544 100% 143,8%
Nhn xt: So vi nm 2004 th trong nm 2005, s n v mu thu gom c tng
gn 1,5 ln trong t l mu thu gom t ngi HMTN tng 250,4%, t l mu
thu gom t ngi CMCN gim ch bng 94%.
2. Tnh hnh v s lng v c cu ngi HMTN nm 2005
Bng 2.1. S lng v t l theo gii tnh ngi HMTN
Gii
Ni dung
Nam N Tng cng
S lng ngi 13.808 13.838 27.646
T l 49,9% 50,1% 100%
Nhn xt: T l gia nam v n ngi HMTN khng c s khc bit c { ngha
thng k (p > 0,05).
Bng 2.2. S lng v t l theo tui ngi HMTN
STT tui (tui) Tng s (ngi) T l (%)
1 18 - 25 23.105 83,6
2 26 - 35 3.823 13,8
3 36 - 60 718 2,6
4 Tng s 27.646 100
Nhn xt: tui ca ngi HMTN ch yu t 18 n 25 (83,6%), tip n l t
26 n 35 (13,8%) v ch c 2,6% l trn 35 tui (p<0,05).
Bng 2.3. C cu ngh nghip ca ngi HMTN nm 2005
STT Ngh nghip S lng T l %
1 Hc sinh - sinh vin 20.066 72,6
2 Cn b cng nhn vin 4.753 17,2
3 Lc lng v trang 931 3,4
4 Nng dn 840 3,0
5 Tiu thng 372 1,3
6 Khc 684 2,5
7 Tng s 27.646 100
Nhn xt:
- Ngi HMTN ch yu l hc sinh - sinh vin (chim 72,6%); cn b cng nhn
vin chim t l 17,2%; lc lng v trang hoc nng dn chim t l thp (gn
3,0%), thp nht l tiu thng (1,3%) v nhng ngi c ngh nghip khng n
nh nh lao ng t do hoc ni tr ( p< 0,05).
- Nm 2005 l nm m Vin c ch trng tip tc m rng i tng hin mu
nn t l ngi hin mu l cn b cng nhn vin t 17,2%. Tuy vy, t l ngi
hin mu l nng dn cn rt thp (1,3%) trong khi c cu dn s li cao (trn
70%).
Bng 2.4. T l hin mu nhc li ngi HMTN nm 2005
i tng
Ni dung
HMTN 1 ln trong nm HMTN 2 ln
tr ln trong
nm
Tng cng
HM ln u HM nhc li
S lng 19.388 7.216 1.050 27.646
T l % 70,1 26,2 3,7 100
Nhn xt:
- T l ngi hin mu ch 1 ln trong nm cn rt cao (96,3%). Theo chng ti th
nguyn nhn ch yu l do hu ht cc n v t chc hin mu ch t chc c 1
ln trong nm nn ngi hin mu khng c iu kin HM nhc li. Bn cnh
mt s n v c t chc hin mu 2 n 3 ln trong nm 2005 nhng li c
nhiu bnh vin khc nhau n thu gom mu trong khi phn mm ch thng k
ngi HMTN do Vin thu gom.
- Trong nm 2005, ngi HMTN ch yu l ngi HM ln u v ch 1 ln trong
nm (chim 70,1%). Nguyn nhn l do s lng ngi HMTN tng mnh trong
nm 2005, nhiu tnh Vin mi m rng v thu gom mu ti a phng trong
nm 2005 (Ph Th, Bc Giang, Hng Yn, Ninh Bnh, Ha Bnh...) v nhiu a
bn mi ( cc khu cng nghip) c m rng v pht trin mnh trong nm.
Bng 2.5. T l ngi HMTN theo nhm mu h ABO
Nhm
Ni dung
A B O AB Tng cng
S lng 5.521 7.982 12.587 1.556 27.646
T l % 20 28,9 45,5 5,6 100
Nhn xt: T l phn b cc nhm mu ngi HMTN nm trong gii hn bnh
thng v phn b nhm mu h ABO ngi Vit Nam.
Bng 2.6. T l ngi HMTN theo nhm mu h Rh
STT Nhm mu S lng T l
1 Rh dng 27.624 99,92%
2 Rh m 22 0.08%
3 Tng cng 27.646 100%
Nhn xt:
- T l phn b cc nhm mu ngi HMTN nm trong gii hn bnh thng v
phn b nhm mu h Rh ngi Vit Nam.
- S ngi nhm mu Rh m l 22 ngi. Cn thnh lp lc lng hin mu d b
l ngi c nhm mu Rh m.
Bng 2.7. T l ngi HMTN theo hnh thc t chc hin mu
Ni dung
im
Hin mu
Lng mu t ngi
HMTN
Lng ngi HMTN
S lng
(n v)
T l
(%)
S lng
(n v)
T l
( %)
C nh 7.979 27,23 6.853 24,8
Lu ng 21.318 72,77 20.793 75,2
Tng cng 29.297 100 27.646 100
Nhn xt: Nm 2005, lng mu thu gom c t ngi HMTN ch yu c thu
gom t cc im hin mu lu ng (72,77%). T l ngi HMTN ti im lu
ng li cao hn (75,2%) so vi t l v s lng mu m h hin. Nguyn
nhn l do t l HMTN nhc li im c nh cao hn im lu ng.
3. Kt qu v xt nghim cc ch s huyt hc mu ngoi vi v t l nhim cc
bnh nhim trng c sng lc ngi HMTN
Bng 3.1. Cc ch s huyt hc ngi CMCN v ngi HMTN 3 ln tr ln
i tng
Ch s
Ngi CMCN
(n = 125)
Ngi HMTN
(n = 120)
Nam N Nam N
Hemoglobin (gam/lit) 136 18 125 19 146 17 133 19
Hematocrite (lit/lit) 0,420,04 0,390,03 0,430,03 0,390,03
S lng hng cu (Tera/lit) 4,230,47 4,120,41 4,830,33 4,540,38
S lng bch cu (Giga/lit) 7,631,51 7,431,45 7,661,35 7,461,14
S lng tiu cu (Giga/lit) 24450 23146 24544 23347
Nhn xt:
- Cc ch s huyt hc mu ngoi vi ca ngi cho mu 3 ln tr ln c 2 i
tng CMCN v HMTN u nm trong gii hn ca ngi bnh thng.
- S khc bit cc ch s huyt hc mu ngoi vi gia ngi CMCN v ngi
HMTN trn 3 ln l : hm lng hemoglobin v s lng hng cu ngi HMTN
cao hn so vi ngi CMCN (p<0,05). Kt qu nghin cu ca chng ti tng t
nh cc tc gi khc v ngi CMCN v ngi HMTN[3] [6] [8].
- Cc ch s v s lng bch cu, s lng tiu cu, hematocrite khng c s khc
bit gia ngi CMCN v ngi HMTN (p>0,05). Kt qu ca chng ti cng
tng t nh cc tc gi khc [3] [6] [8].
Bng 3.2. T l HV dng c sng lc trc v sau khi HMTN
Ni
dung
i tng
S lng T l Tng s
XN
T l HV dng NHMTN ln u
c xt nghim trc khi HM
1.865 8,77% 21.253
T l HV dng n v mu t
NHMTN ln u
860 3,23% 26.604
T l HV dng n v mu t
NHMTN nhc li
6 0,07% 8.266
Tng s 2.731 4,87% 56.123
Nhn xt:
- Bng k thut test nhanh sng lc trc khi hin mu m nm 2005 loi
c 1.865 ngi c HBV dng tnh c bc s khm lm sng kt lun l
iu kin v lm sng tham gia hin mu (chim t l 8,77%) do vy gim
c t l n v mu nhim HBV xung cn 3,23% so vi trc y l 15% [3] [6]
[8].
- Ngi HMTN nhc li c HBV dng l 06 ngi trong tng s 8.266 ngi
HMTN nhc li ( 0,07%) trong ch yu l c pht hin HBV dng ln
hin mu trc nhng do khng c t vn nn tip tc ng k{ hin mu v
b loi khi xt nghim trc khi HMTN. Chng ti ch gp 01 trng hp hin
mu 4 ln th 3 ln trc xt nghim m tnh, ln th 4 xt nghim HBV dng.
Bng 3.3. T l nhim cc bnh nhim trng ngi HMTN
Tui
i tng
Ngi HMTN ln u
(n= 19.380)
Ngi HMTN nhc li
(n = 8.266)
HV dng 12% 0,07%
HCV dng 2,6% 0
HIV dng 0,015% 0,012%
Giang mai 0,05% 0
St rt 0 0
Nhn xt:
- T l nhim HBV, HCV ngi HMTN ln u nm trong gii hn bnh thng
ca t l nhim bnh trong cng ng v t l ny rt thp ngi HMTN nhc
li.
- T l nhim HIV, Giang mai v st rt ngi HMTN ln u v nhc li u
thp hn so vi cc tc gi khc khi nghin cu v t l ny ngi HMTN ca
Vin nhng nm trc y *1+ *2+ *13+ *14+. Theo chng ti, v HMTN hin nay
khng c tin bi dng nn vic vic t sng lc ngi HMTN tt hn, cc
i tng cn tin nn cho mu khng tham gia HMTN.
Bng 3.4. T l ngi HMTN theo t l mu hy do sng lc ti n v mu
STT Kt qu xt nghim sng lc S lng T l
1 Tt 26.655 96,42
2 Nhim bnh 991 3,58
3 Tng cng 27.646 100
Nhn xt: T l mu hy do nhim bnh c sng lc ti n v mu thp
(3,58%). Nguyn nhn l do Vin tin hnh sng lc HBsAg trc khi hin mu
nn loi c ch yu ngi b nhim HBV.
IV - KT LUN:
1. T l ngi HMTN l 55,75%, tng 250% so vi nm 2004; khng c s khc
bit gia t l nam v n hin mu tnh nguyn. Trong , 97,4% ngi
hin mu tnh nguyn l trong tui thanh nin (t 18 n 35); Sinh vin -
hc chim t l 72,6%; ngi HMTN l cn b cng nhn vin chim t l
17,2%. C 22 ngi HMTNc nhm mu Rh m (0,075%). Ch yu ngi
HMTN ch hin mu 1 ln trong nm (96,3%), t l hin mu nhc li t
29,9%.
2. Cc ch s huyt hc mu ngoi vi ca ngi CMCN v ngi HMTN t 3
ln tr ln u nm trong gii hn ca ngi Vit nam bnh thng. Tuy
vy, ngi HMTN c hm lng hemoglobin, s lng hng cu v
hematocrite cao hn so vi ngi CMCN.
3. T l nhim cc bnh nhim HV, HCV c sng lc ngi HMTN tng
ng vi t l nhim ca cng ng v ca ngi HMTN nhng nm
trc. Nhng t l nhim HIV, giang mai ngi HMTN ln u nm 2006
thp hn so vi cc nghin cu v ngi HMTN ca nhng nm trc y.
Ngi HMTN nhc li c t l nhim bnh rt thp.
4. Vic t chc sng lc HBV trc khi hin mu loi c 1.865 ngi
(chim 8,77%) c bc s khm tuyn kt lun l iu kin hin
mu gp phn tch cc vo vic m bo an ton truyn mu v gim t l
mu hy do nhim bnh xung ch cn 3,58%.
Qua kt qu nghin cu, chng ti xin kin ngh:
- Tip tc m rng i tng HMTN l cn b cng nhn vin,
lc lng v trang, nng dn v cc lc lng khc.
- y mnh vn ng hin mu nhc li v vn ng ngi
HMTN tham gia hin mu trn 1 ln trong nm.
- Duy tr vic xt sng lc HV trc khi HMTN bng test
nhanh m bo an ton truyn mu v gim t l mu hy
do nhim bnh.
- Vin nn thnh lp cu lc b nhng ngi HMTN c nhm
mu Rh m.
Tm tt
nh gi tnh hnh ngi hin mu tnh nguyn ti Vin huyt hc Truyn mu
Trung ng nm 2005, chng ti thu c kt qu sau:
1. T l ngi HMTN l 55,75%, tng 250% so vi nm 2004; khng c
s khc bit gia t l nam v n hin mu tnh nguyn. Trong ,
97,4% ngi hin mu tnh nguyn l trong tui thanh nin (t 18
n 35); Sinh vin - hc chim t l 72,6%; ngi HMTN l cn b
cng nhn vin chim t l 17,2%. C 22 ngi HMTNc nhm mu
Rh m (0,075%). Ch yu ngi HMTN ch hin mu 1 ln trong nm
(96,3%), t l hin mu nhc li t 29,9%.
2. Cc ch s huyt hc mu ngoi vi ca ngi CMCN v ngi HMTN
t 3 ln tr ln u nm trong gii hn bnh thng ca ngi Vit
Nam. Ngi HMTN c hm lng hemoglobin, s lng hng cu v
hematocrite cao hn so vi ngi CMCN.
3. Vic t chc sng lc HV trc khi hin mu loi c 1.865
ngi (chim 8,77%), t l mu hy do nhim bnh l 3,58%.

Summary
We studied the results of collection from voluntary un paid blood donors in
National institute of hematology and blood transfusion in 2005. From this study,
we have some comment as follow:
1. The percentage of voluntary un paid donor was 55,75%, almost of them
were young people (from 18 to 35 years old). The incidence of donors with
Rh
(-)
group was 0,075%. The percentage of repeat donors was 29,9% and
96,3% of donors donated just one times a year.
2. The quality of blood from donors who donated more then 3 times was very
good, and was on normal range of Vietnamese people. Hemoglobin level,
hematocrit, number of red cell among voluntary blood donor was higher
then paid donors.
3. Taking pre-donation test of HBV had important role in selection safe
donors. We rejected 1.865 donor with HBV infection in 2005.
TI LIU THAM KHO
1. Bi Th Mai An v cng s, (2002), Kho st t l khng th HIV, khng th
HCV, HBsAg trong cc mu mu ca ngi cho ti Vin Huyt hc - Truyn mu
trung ng, Tp ch Y hc thc hnh (s 497/2004), H Ni, 203-205.
2. H B Khim, (2003), Bo co ti Bin php c bn trong gim st dch t
hc v y hc d phng nhm khng ch v kim sot c cc bnh nhim
trng ch yu, ti khoa hc cp Nh nc m s KH.11.03, 46- 57.
3. Trung Phn, (2000), An ton truyn mu, NXB Khoa hc k thut, H Ni.
4. Trung Phn, (2003), Bo co tng kt D n cp Nh nc Hon thin
cng ngh sn xut v chun ha mt s sn phm mu s dng trong iu tr
bnh, D n khoa hc cng ngh m s KHCN 11-DA 5.
5. Ng Mnh Qun, (2004), Vn ng cho mu nhc li: bin php m bo an
ton truyn mu c hiu qu, Y hc thc hnh (s 497/2004), H Ni,187-
190.
6. Trn Ngc Qu, (2004), Tnh hnh sinh vin cho mu ti Vin Huyt hc -
Truyn mu trong 5 nm (1998- 2003) v t l nhim HIV, HV, HCV, Y hc
thc hnh ( 497/2004), H Ni, 191- 193.
7. Nguyn Anh Tr, (2004), An ton truyn mu v nhng bin php m bo
truyn mu an ton, Mt s chuyn Huyt hc - truyn mu (tp I), NXB Y
hc, 87- 93.
8. Nguyn c Thun, (2004), Kt qu nghin cu xy dng m hnh im hin
mu c nh, thng xuyn v an ton ti cng ng, Y hc thc hnh (s
497/2004), H Ni, 180-184.
9. John J.Macionis, (2004), Hnh vi tp th v vn ng x hi, X hi hc, NXB
Thng k, 703- 734.
10. T chc Y t th gii (WHO), (2001), Cho mu an ton, NXB Y hc, H Ni.
11. AABB, (1993), Standards for Blood Banks and Transfusion Services, 15
th
Ed. by
AABB.
12. Australian Red Cross, (2003), Blood Service, Annual Report 2002/2003
Australian Red Cross Blood Service.

62. GP PHN CHNH L K THUT XT
NGHIM SC BN HNG CU

TS. Phm Quang Vinh,
BS.Trng Th Nh ,
CN.Trn Cng Hong

TM TT
65 ngi bnh thng c tin hnh xt nghim sc bn hng cu mt s iu
kin k thut khc nhau (5ml, 3ml dung dch nhc trng v 1 hay 2 git hng
cu). X l s liu bng phng php so snh trung bnh. Kt qu cho thy mc
bt u tan cc iu kin k thut (3ml dd nhc trng v 5ml dd nhc
trng vi 1 git HC hoc 2 git HC) l khng c s khc bit, nhng mc tan
hon ton vi 3ml dd nhc trng v cho 2 git HC l 2,85 0,129, vi 3ml dd
nhc trng, 1 git HC l 2,875 0,132, u thp hn c { ngha so vi 5ml
dd nhc trng, 1 git HC l 3,075 0,168 (p < 0,001).Nh vy kt qu xn sc
bn hng cu khi s dng 3ml dd nhc trng c khc kt qu khi s dng 5 ml
dd nhc trng.
SUMMARY

The study was carried out on 65 healthy people with osmotic fracgility test in
four different conditions ( A: 1 red cell pack drop added to 5 ml hypotonic solution;
B: 2 red cell pack drops added to 5 ml hypotonic solution; C: 1 red cell pack drop
added to 3 ml hypotonic solution; D: 2 red cell pack drops added to 3 ml hypotonic
solution).The results show that mean of the OD of beginning lysis tubes at each
technique condition are no different but mean of the OD of complete lysis tubes
are different:
- D: mean of complete lysis tubes is 2,85 0,129.
- C: mean of complete lysis tubes is 2,875 0,132.
They are all less significant (p< 0,001) than mean of the OD of complete lysis
tubes in A condition (3,075 0,168) .
From the results above that we suggest that: Osmotic fracgility test should be
carried out by 1 red cell pack added to 5 ml hypotonic solution.





T VN
Xt nghim sc bn hng cu da trn nguyn l l: mng hng cu l mng
mng bn thm, do vy khi cho hng cu vo dung dch nhc trng, nc s t
ngoi vo lm trng to hng cu. Dung dch cng nhc trng nc s vo
cng nhiu v hng cu cng d v. Li dng tnh cht ngi ta cho hng cu
vo mt lot cc dung dch nhc trng c nng khc nhau v quan st mc
tan ca hng cu nh gi tnh bn vng ca mng hng cu. Hin nay
cha thng nht mt s im k thut l cho 1 hay 2 git hng cu vo 3 hay 5
ml dung dch nhc trng. tin hnh xt nghim cn chun b cc dung dch
mui nhc trng pH=7,4 c nng chnh lch nhau 0,25 ,nh vy vic cho
1 hay 2 git hng cu vo 3 hay 5 ml c lm thay i tnh nhc trng ca dung
dch hay khng, kt qu xt nghim khi khng thng nht cc tiu ch k thut
trn c b nh hng khng? gii quyt cu hi ny, chng ti tin hnh so
snh sc bn hng cu ngi bnh thng v mt s bnh nhn thiu mu
trong cc iu kin k thut khc nhau nhm 2 mc tiu sau:
1. nh gi vai tr ca mt s yu t k thut lin quan n kt qu xt
nghim sc bn hng cu.
2. Tm hiu sc bn hng cu ngi Vit Nam bnh thng.
I TNG V PHNG PHP NGHIN CU
I TNG NGHIN CU:
65 ngi bnh thng (l ngi tnh nguyn hin mu ti Vin huyt hc Truyn
mu Trung ng) c tin hnh o sc bn hng cu ti Khoa Di truyn Vin
Huyt hc Truyn mu Trung ng ti 4 iu kin k thut khc nhau (3 hoc 5 ml
dung dch mui nhc trng + 1 hoc 2 git hng cu).
PHNG PHP NGHIN CU:
o sc bn hng cu theo k thut ca h v g.dicono( c chnh l)
DNG C,HO CHT:
Dung dch m c p lc thm thu tng ng vi dung dch Natri Chlorua 10%
(bo qun c hng thng) bao gm cc mui sau y:
-Natri chlorua : 180 gr
-Natri dihydrophophat
(NaH
2
PO
4
2H
2
O):
4,86gr
-Di natri hydro photphat (Na
2
HPO
4
): 27,31 gr
-Nc ct va : 2000ml

Khi pha nu dung dch khng trong th phi lc. T dung dch m 10% pha thnh
dung dch con 5% v pha tip thnh cc dung dch1,2,2,5,2,756,7
(T nng 2,75 n 6 c mi nng cch nhau 0,25).

Nng

1 2 2,5 2,75 3 3,25
S ml d
2

5%
2 4 5 5,5 6 6,5
Nng

3,5 3,75 4 4,25 4,5 4,75
S ml d
2

5%
7 7,5 8 8,5 9 9,5
Nng

5 5,5 6 7
S ml d
2

5%
10 11 12 14
-Ly s ml dung dch con 5% cho vo bnh mc (theo s lng trn) thm nc
ct va 100 ml.
CCH TIN HNH XT NGHIM:
Ly 3 - 4 ml mu tnh mch c chng ng bng heparin hay natri oxalate
hoc natri citrate.
Chun b 64 ng nghim cho mt mu nghin cu u nhau, loi ng
nghim ly tm ng knh 1 cm x 6 cm,xp thnh 4 dy. nh s t 1 n
16 cho mi dy. Cho vo mi ng nghim 3 ml hoc 5 ml cc dung dch
m pha long ra phn nghn nh trn theo nng gim dn ( ng s 1
nng 7 ng s 16 nng 1).
- Cho vo mi ng nghim 1 git hng cu hoc 2 git hng cu (sau khi
ng mu gn b phn huyt tng).
- Lc nh 2-3 ln cho u hng cu trong cc ng nghim.
- nhit phng xt nghim 22
0
C t 1h2h th c kt qu(c th
quay ly tm ri c kt qu v tnh t l phn trm huyt tn.
Kt qu nh gi bao gm mc bt u tan (phn trn dung dch c mu hng, c
lng cn) v mc tan hon ton (ton b dung dch c mu trong sut).
So snh kt qu gia cc iu kin k thut khc nhau bng phng php
so snh trung bnh.

KT QU NGHIN CU V BN LUN:

1. Kt qu sc bn hng cu ngi bnh thng mc bt u tan:
Bng 1: Kt qu sc bn hng cu ngi bnh thng mc bt u tan:
HC
ml
1 git 2git p
3 ml dd nhc
trng
4,725 0,218 4,725 0,218 > 0,05
5 ml dd nhc
trng
4,778 0,150 4,725 0,218 > 0,05
p > 0,05 > 0,05
Mc bt u tan ca hng cu cc iu kin c trnh by trong bng 1. Theo
mc bt u tan ca hng cu khng c s khc bit gia cc iu kin k
thut (vi p > 0,05).Gi tr ca mc bt u tan trong nghin cu ca chng ti
nm trong gii hn bnh thng 4,5 - 5. So snh vi mt s nghin cu trc
nh Nguyn Thu Nga (2005), kt qu mc bt u tan ca chng ti cao hn
(4,778 0,15 so vi 4,13 0,34). Khi so snh mc bt u tan ca hng cu gia
cc iu kin k thut, chng ti khng thy c s khc bit. Kt qu ny tng t
vi nghin cu ca tc gi Nguyn Thu Nga (2005).

2. Kt qu sc bn hng cu ngi bnh thng mc tan hon ton:
Bng 2: Kt qu sc bn hng cu ngi bnh thng mc tan hon ton:
HC
ml
1 git 2 git p
3 ml dd nhc trng 2,875 0,132 2,85 0,129 > 0,05
5 ml dd nhc trng 3,075 0,168 3,025 0,132 > 0,05
p < 0,05 < 0,05
Mc tan hon ton ca hng cu ngi bnh thng trong nghin cu ca
chng ti c trnh by trong bng 2. Theo , mc tan hon ton ca hng cu
iu kin 3ml dd nhc trng, mt git hng cu v 3ml dd nhc trng, 2
git HC thp hn c { ngha so vi iu kin 5 ml dd nhc trng, 1 git HC
(p< 0,05). Tng t nh vy mc tan hon ton ca hng cu cc iu kin ni
trn cng thp hn so vi iu kin 5 ml dd nhc trng, 2 git HC. Kt qu
ny ca chng ti c khc bit so vi nghin cu trc ca tc gi Nguyn
Thu Nga (2005). Tuy nhin mc tan hon ton trong nghin cu ca chng ti
cng nh nghin cu trc ca tc gi Nguyn Thu Nga (2005) c thp hn
icht so vi gii hn 3- 3,5 c cng b trong cc tI liu chun trc
y. c mt s liu thng nht ngi Vit Nam bnh thng, cn c thm
nhng nghin cu vi qui m ln hn.
KT LUN
1. Vai tr ca cc iu kin k thut:
+ Mc bt u tan ca hng cu khng c s khc bit gia cc iu kin k thut
(3 hoc 5 ml dung dch mui nhc trng + 1 hoc 2 git hng cu).
+ Mc tan hon ton c s khc bit gia iu kin 3ml dd nhc trng, 2 git
HC v 5ml dd nhc trng, 1 git HC.
2. Sc bn hng cu ngi bnh thng :
Hng cu bt u tan nng mui 4,507- 4,928
Tan hon ton nng mui 2,721- 3,243.


KIN NGH
T nhng kt qu ny, chng ti xin kin ngh nn thc hin k thut o sc bn
hng cu iu kin 5 ml dung dch mui nhc trng + 1 git hng cu.



TI LIU THAM KHO
1. B Y t, K thut xt nghim c bn huyt hc, Nh xut bn Y hc, H
ni, tr. 93-101, 175-176.
2. Nguyn Cng Khanh (1985), Mt s c im lm sng v huyt hc bnh
thalassemia ngi Vit nam, ch yu ngi Min Bc Vit nam, Lun
n Ph Tin s Y hc, Trng i hc Y H ni.
3. Nguyn Thu{ Nga (2005), Sc bn hng cu ngi bnh thng v mt
s bnh nhn thiu mu ti Vin Huyt hc Truyn mu trung ng, Kho
lun tt nghip C nhn k thut y hc, Trng i hc Y H ni.
4. Phm Quang Vinh (2003), nh huyt sc t, i ging Huyt hc
Truyn mu, Nh xut bn Y hc, tr. 171.
5. Modell ., erpouk Asv. (1984), Celular pathology, The clinical approach
to thalassemia, Grune-Stratton, pp. 35-52.

63. NGHIN CU SNG LC KHNG TH BT
H HNG CU BNH NHN B BNH MU
TI VIN HUYT HC - TRUYN MU TW
(2004-2005)
Bi Th Mai An, Nguyn Th Quznh Nga, Vi nh Tun v CS

Tm tt bo co

Qua sng lc KTBT cho 244 BN b bnh mu ti Vin HHTM trung ng 2004-
2005, chng ti rt ra cc kt lun sau:
1. T l KTBT bnh nhn b bnh mu ti Vin Huyt hc Truyn mu Trung
ng qua thc hin xt nghim sng lc khng th bt thng l 8,9%.
2. T l KTT c lin quan n tui, gii, s ln truyn mu, thnh phn mu
truyn v chn on lm sng.
Sumary

Through identifying irregular antibody of 244 blood disease patients hospitalized
at National Institute of Heamtology and Blood Transfusion in 2004 and 2005, we
have the following remarks:
1. Proportion of patients with irregular antibody is 9,8%
2. There were relationships of proportion of patients with irregular antibody
among age groups, sex, number of times receiving blood and types of
clinical diagnosis, but the significant relationship was found only among
types of clinical diagnosis.


I. t vn :
Mu rt quan trng v cn thit cho s sng, nh c mu m nhiu ngi bnh
c cu sng, mu quan trng nh vy nhng truyn mu cng c th gy ra
nhng tai bin nghim trng nu cc nguyn tc v an ton truyn mu khng
c tn trng. S pht hin ra nhm mu h ABO, Rh v cc h nhm mu hng
cu khc gip cho vic truyn mu hiu qu v an ton hn. Ti cc nc tin
tin an ton truyn mu c thc hin mt cch trit , nhm mu ca h
ABO, Rh, v mt s nhm mu khc, sng lc khng th bt thng (KTBT) [5], [6],
*7+. Trong khi ti nc ta vic thc hin an ton truyn mu v mt min dch
cn rt hn ch, chng ta mi ch nh nhm mu h ABO, lm phn ng cho
iu kin nhit phng th nghim, do vy vic sinh khng th bt thng
nhng bnh nhn truyn mu nhiu ln l kh trnh khi *1+. m bo an
ton truyn mu v mt min dch th sng lc khng th bt thng cho bnh
nhn c truyn mu, c bit bnh nhn truyn mu nhiu ln l rt cn
thit. Chng ti tin hnh ti vi hai mc tiu sau:
1. Xc nh t l KTBT bnh nhn b bnh mu ti Vin Huyt hc truyn mu
trung ng (2004-2005)
2. Xc nh t l KTBT lin quan n tui, gii, s ln truyn mu v chn on
lm sng.
II. i tng v phng php nghin cu:
1. i tng nghin cu: 244 bnh nhn (BN) b bnh mu tui t 10 -86
tui, nm iu tr ti khoa bnh mu Vin HHTM trung ng t 10/2004
n 5/2005 bao gm: 70 BN Leucemie cp v kinh, 38 BN xut huyt gim
TC, 26 BN RLST, 40 BN suy tu xng, 21 BN thiu mu, 10 BN hemophilia
v 38 BN b bnh mu khc.
2. Vt liu v thuc th:
10 ml mu ca cc bnh nhn trn c ly vo mt ng nghim khng
chng ng, ly tm tch huyt thanh lm xt nghim sng lc KTBT
ngay hoc bo qun ti quy lnh 30C cho n khi c tin hnh xt
nghim.
Thuc th: - Panel hng cu a gi v n gi ca ngn hng mu
Singapore, ca hng Diamed bao gm khng nguyn ca cc h Rh, Kell,
Duffy, Kidd, Lutheran, MNSs, P1, Mia, Xg, Lewis.
- Huyt thanh Coombs, anti D, m Liss v cc khng huyt thanh chun xc
nh nhm mu ca hng BIO-RAD
3. Phng php nghin cu:
3.1. Thit k nghin cu: Nghin cu ct ngang
3.2. Tin hnh k thut:
Huyt thanh ca bnh nhn b bnh mu c sng lc khng th bt thng vi
Panel hng cu ca ngn hng mu Singapore, ca hng Diamed bng k thut
ng nghim 22C, 37 C, Coombs gin tip. Kt qu c nhn nh bng mt
thng v trn knh hin vi quang hc.
3. X l cc kt qu nghin cu bng cc phng php thng k ton hc
III. Kt qu nghin cu v bn lun:
3.1. c im KTBT BN b bnh mu
Bng 3. 1. T l KTBT (%) bnh nhn b bnh mu
S mu nghin cu S mu dng tnh T l (%)
244 24 9,8

T l khng th bt thng bnh nhn b bnh mu l 9,8%, kt qu ny thp
hn so vi kt qu nghin cu ca Trnh Xun Kim (1990: 11,4 %), Bi Th Mai An
(1995:13,04 % ), Trn Th Thu H (1999: 12,76%) v Nguyn Th Thanh Mai (2000:
27,4%) [1], [2], [3], [4]. S d kt qu nghin cu ca chng ti thp hn cc so vi
tc gi trn l do i tng nghin cu khc nhau. Chng ti nghin cu trn
bnh nhn b bnh mu, trong khi cc tc gi trn nghin cu bnh nhn
c nhn mu nhiu ln.
Bng 3. 2. T l bnh nhn c KTBT xc nh c bn cht
Kiu XH khng th S mu (+) T l (%)
Xc nh c bn cht 14 58,33
Cha xc nh c bn cht 10 41,67
Tng s 24 100

Trong s 24 bnh nhn c KTT dng tnh, chng ti xc nh c bn
cht khng th ca 14 mu cho t l l 58,33%. vic xc nh bn cht KTBT
c tt hn trong giai on ti chng tI cn trin khai thm mt s k thut
nh k thut pha long huyt thanh, k thut tch khng th



3.2. T l KTBT lin quan n tui, gii, s ln truyn mu, chn on lm
sng

Bng 3. 3. T l KTBT lin quan n tui
Nhm tui S mu NC S mu (+) T l (%)
10-20 28 2 7,14
21-40 89 7 7,86
41-60 70 6 8,57
> 60 57 9 15,79
Tng s 244 24 9,8
(p=0,39)
nhm bnh nhn > 60 tui c t l KTBT cao nht (15,78%), nhn xt ny ca
chng ti cng chng ti ph hp vi nhn xt ca Trn Thi Thu H (1999) [5].
Mc d c s khc bit ca t l KTBT gia cc nhm tui nhng s khc bit ny
khng c { ngha thng k vi p = 0,39.

Bng 3. 4. T l KTBT lin quan n gii

Gii S mu NC S mu (+) T l (%)
Nam 122 9 7,38
N 122 15 12,29
Tng s 244 24 9,8
(p=0,19)
T l KTBT gp n cao hn nam, nhn xt ny ca chng ti ph hp vi nhn
xt ca Trn Thi Thu H; Nguyn Th Thanh Mai [3], [5]. S d c kt qu trn l
n ngoi truyn mu, khng th bt thng cn c th xut hin do qu trnh
cha . Mc d c s khc bit ca t l KTBT gia nam v n cc nhm tui
nhng s khc bit ny khng c { ngha thng k vi p = 0,19.

Bng 3. 5. T l KTBT lin quan n s ln truyn mu
S ln nhn mu S mu NC S mu (+) T l (%)
Cha truyn mu 20 0 0
Nhn mu < 5 ln 102 8 7 ,8
Nhn mu > 5 ln 122 16 13,2
Tng s 244 24 9,8
(p=0,13)
Nhng bnh nhn cha truyn mu th khng gp khng th bt thng, Bnh
nhn truyn mu trn 5 ln th c t l KTT cao hn nhng bnh nhn truyn
mu di 5 ln, nhn xt ny ca chng ti cng tng t vi nhn xt ca Trn
Thi Thu H [3]. Mc d c s khc bit ca t l KTBT gia s ln truyn mu
nhng s khc bit ny khng c { ngha thng k vi p = 0,13.
Bng 3. 9. T l KTBT lin quan n chn on lm sng

Nhm bnh l S mu NC S mu (+) T l (%)
TM 21 6 28,57
RLST 26 5 19,2
XHGTC 38 5 12,3
STX 40 5 12,5
LXM 70 2 2,9
Bnh khc 38 1 2,6
Hemophilia 10 0 0
Tng s 244 24 9,8
(p=0,005)
Nhm bnh nhn thiu mu, thiu mu cha r nguyn nhn l c t l KTBT cao
nht (28,57%). Sau th t n nhm bnh nhn c chn on RLST, xut
huyt gim tiu cu, suy tu. Nhm bnh nhn hemophilia khng gp bnh nhn
no c KTBT. S khc bit ca t l KTBT gia cc nhm bnh c s khc bit c
ngha thng k vi p = 0,005. Nhn xt ny ca chng ti ph hp vi nhn xt
ca cc tc gi Bi Th Mai An (1995), Trn Th Thu H (1999) [1], [5].

IV. Kt lun:
Qua sng lc KTBT cho 261 BN b bnh mu ti Vin HHTM trung ng bc u
chng ti rt ra 2 kt lun sau:
1. T l KTBT bnh nhn b bnh mu ti Vin Huyt hc Truyn mu Trung ng
(nm 2004-2004) qua thc hin xt nghim sng lc khng th bt thng l 9,8
%.
2. T l KTBT c lin quan n tui, gii, s ln truyn mu v chn on lm
sng.

V. Kin ngh
Ti cc c s truyn mu nu iu kin c s vt cht v cn b cn trin khai
xt nghim sng lc KTT nng cao cht lng an ton truyn mu v mt
min dch

VI. Ti liu tham kho
Ting Vit:
1. Bi Th Mai An, Bch Khnh Ho, Nguyn Th Y Lng, Nguyn Triu Vn,
Trung Phn v cng s (1995), Khng th bt thng ngi cho mu v
nhn mu nhiu ln ti Vin Huyt hc Truyn mu, Y hc Vit Nam s 9 tp
196, tr.35-39.
2. Trn Th Thu H (1999), Nghin cu khng th bt thng h hng cu
bnh nhn nhn mu nhiu ln, Lun vn tt nghip thc s y hc.
3. Trnh Xun Kim, Bch Quc Tuyn, Trnh Kim nh (1990), Khng th bt
thng, nguyn nhn phn ng tan mu mun ti Bnh vin Ch Ry, Y hc
thc hnh s 5 tp 228, tr.14-15.
4. Nguyn Th Thanh Mai (2005), Nghin cu cc khng th bt thng khng
hng cu mt s i tng ti Bnh vin nhi trung ng, Lun n tin s
sinh hc, Tr. 11-20.
Ting Anh
5. Denise M. Harmening (1999), Modern blood banking and transfusion
practise, Book promotion & service, fourth edition, pp: 90-213.
6. Helmut Schenkel Brunner (2000), Human Blood Groups- Chemical and
Biochemical- Basis of Antigen specificifi, pp. 54-622.
7. Peter D. Issitt; Charla H. Issitt (1970), Applied Blood Group Serology,
Spectra Biologicals, pp. 73-251


64. TM HIU MT S YU T NH HNG
TI S XUT HIN NHNG PHN NG LM
SNG KHNG MONG MUN NGI HIN
MU TNH NGUYN

Ng Mnh Qun, Nguyn c Thun, Bi Ngc Dng, C Th Lan Anh, Nguyn Vn
Nh , Nguyn Xun Thi, m Nhn Vng, L{ Th Ho, Khut Minh Tin, V
Quang Hng,H Hu Nguyn, Trn Ngc Qu, Phm Quang Vinh, Nguyn Anh Tr
v cs


I. T VN
m bo an ton cho ngi hin mu l mt trong nhng ni dung quan trng
ca m bo an ton truyn mu. Trong , vic d phng, pht hin sm, x l
ng v kp thi nhng phn ng lm sng khng mong mun xy ra ngi hin
mu l mt bin php rt quan trng. Phn ng lm sng khng mong mun
(PLSKMM) ngi hin mu l nhng biu hin lm sng xut hin do s tc
ng ca vic hin mu trong v sau khi hin mu. Thc cht y l nhng phn
ng ca c th trc vic mt mu hoc nhng tc ng t vic hin mu.
PLSKMM ngi hin mu c chia lm 3 mc : nh, trung bnh v nng
[8]. S xut hin nhng phn ng ny l ngoi s mong i ca ngi thy thuc
cng nh ca chnh ngi hin mu. Mc d chng ta thc hin ng cc quy
trnh k thut trong vic tuyn chn, khm sc kho v chm sc ngi hin mu,
vic xy ra cc PLSKMM ngi hin mu vn c th xy ra ti cc im hin
mu. Nhm gp phn m bo an ton cho ngi hin mu, loi tr cc nguyn
nhn gy ra cc PKSKMM ngi hin mu tnh nguyn, chng ti tin hnh
nghin cu ny nhm cc mc tiu sau:
1. Xc nh t l xy ra cc PLSKMM ngi hin mu tnh nguyn ti Vin
Huyt hc - truyn mu Trung ng trong qu trnh tham gia hin mu tnh
nguyn.
2. Xc nh mt s yu t nh hng n s xut hin cc PLSKMM ngi
hin mu tnh nguyn.
II. I TNG V PHNG PHP NGHIN CU
1. i tng nghin cu:
Ngi hin mu tnh nguyn ti Vin Huyt hc Truyn mu Trung ng trong 4
thng (11/2005 02/2006), tham gia hin mu ti cc im c nh, lu ng v
xe ly mu chuyn dng.
Tiu chun la chn i tng :
Tnh nguyn ng k{ hin mu.
C iu kin sc kho theo quy nh, c t vn, khm tuyn
v c cc bc s kt lun l iu kin hin mu, tham gia hin
mu theo ng cc quy trnh .
2 . Phng php nghin cu
2.1 Thit k nghin cu: nghin cu m t ct ngang.
2.2 Tiu chun nh gi mc xut hin PLSKMM ngi hin mu trong qu
trnh tham gia hin mu [8], [9], [10]:
+ Mc nh: hi hp, lo lng, nht nht, cm gic nng bng, v m hi,
chong vng, bun nn, nn, cm gic kh th, cm gic n lnh, mch nhanh
(tng thm trn 10 ln/pht).
+ Mc trung bnh: Mt nhn bit (ngt xu), th nhanh nng (trn 28ln/pht),
co git kiu tetanie, mch chm v kh bt, h huyt p >15mmHg, co cng c.
+ Mc nng: Cc biu hin nh hoc trung bnh km theo mt trong cc biu
hin sau: co git, i tiu tin khng t ch, try tim mch.
2.3 Phng vn trc tip v s dng bng hi tm hiu cc yu t nh
hng ti s xut hin cc PULSKMM.
2.4 Thng k v x l s liu bng phn mm Epi Info 6.04, SPSS.
3. Thi gian nghin cu: t thng 11/2005 2/2006.
4. a im nghin cu: ti Vin Huyt hc - Truyn mu Trung ng v cc im
hin mu do Vin t chc thu gom.

III. KT QA NGHIN CU V BN LUN
1. Nhng kt qu chung
1.1 S lng v t l ngi hin mu theo hai gii:
Bng 1.1 S lng v t l ngi hin mu theo gii
Gii
i tng
Nam N Tng s
n % n % n %
S ngi hin mu 3257 51,3 3090 48,7 6347 100
Trong : Hin mu ln
u
1627 49,9 1593 51,4 3220 50,7
Hin mu nhc
li
1630 50,1 1497 48,6 3127 49,3
Nhn xt: T l gia nam v n tham gia hin mu khng c s khc bit c
ngha thng k vi p<0,05. T l hin mu nhc li chung cho hai gii l 49,3%, t
l ny tng ng k so vi nghin cu ca chng ti v ngi hin mu tnh
nguyn nhc li ti Vin huyt hc Truyn mu Trung ng nm 2003 l 38,3%
[4].

2. T l xut hin PLSKMM ngi hin mu
Bng 2.1: T l xut hin PLSKMM hai gii
Gii

Phn ng
Nam N Tng s
n % n % n %
C phn ng 61 1,87 105 3,40 166 2,62
Khng phn ng 3196 98,13 2985 96,60 6181 97,40
Tng s 3257 100 3090 100 6347 100
Nhn xt bng 2.1: T l xut hin phn ng ngi hin mu (c hai gii) l
2,62%, khng c s khc bit c { ngha thng k (p>0,05) so vi nghin cu ca
Trn Bch Hp l 2,86% [4]. T l theo gii gp n (3,40%) cao hn so vi t l
xut hin phn ng nam (1,87%), s khc bit c { ngha thng k vi p < 0,05.
2.2 Tn sut xut hin cc PLSKMM:
Bng 2.2.1: Tn sut xut hin nhng biu hin lm sng ghi nhn c 166
ngi hin mu tnh nguyn c PLSKMM:

STT Biu hin lm sng S trng
hp (n)
Tn xut xut
hin (%)
1. Hi hp, lo lng 121 72,9
2. Cm gic nng bng 120 72,3
3. Nht nht, v m hi 98 59,0
4. Mch nhanh (tng thm 10ln/pht) 87 52,4
5. Th nhanh 76 45,8
6. Nhp th > 28ln/pht 75 45,5
7. Bun nn 61 36,7
8. Cm gic n lnh 46 27,7
9. Bn rn chn tay 45 27,1
10. Cm thy kh th 22 13,3
11. Xu 18 10,8
12. Huyt p ti a gim >10mmHg 16 9,6
13. T u chi 15 9,0
14. Mch chm (gim 10 ln/pht) 14 8,4
15. Nn 02 1,2
16. Co git 02 1,2
17. Tiu tin khng t ch 0 0

Nhn xt: Cc biu hin thng gp ngi hin mu tnh nguyn c PLSKMM
l hi hp lo lng sau khi hin mu, cm gic nng bng, nht nht v m hi,
mch nhanh. Chng ti gp 02 trng hp xut hin phn ng co git, 01 nam,
01 n.
Bng 2.2.2 : T l cc mc phn ng:
Mc Nh Trung bnh Nng
Xut hin phn ng
(n=166)
n % n % n %
147 88,6 17 10,2 2 1,2
Nhn xt: Trong tng s ngi c PLSKMM ngi hin mu tnh nguyn,
chng ti thy ch yu gp phn ng mc nh (88,6%); mc trung bnh l
10,2% v mc nng ch c 02 trng hp (1,2%).
3. Tm hiu mt s yu t c lin quan ti vic xy ra PLSKMM
Bng 3.1: T l xut hin phn ng nhng ln hin mu khc nhau
Ln HM

Xut hin P
Ln u
(n=3220)
Ln 2
(n=2423)
Ln 3
(n=423)
Hin mu
>3 ln
(n=281)
Tng s
(n=6347)
n 106 49 9 2 166
% 3,292 2,022 2,128 0,007 2,60
Nhn xt: Trong s nhng ngi hin mu tnh nguyn c PLSKMM, gp t l
cao nht ngi hin mu ln u (3,292%). T l ny gim r rt cc ln hin
mu sau (khc bit c { ngha thng k vi p<0,001); Gp 02 ngi hin mu 3
ln c phn ng mc nh. Khng gp trng hp no c phn ng nhng
ngi hin mu > 4 ln. Kt qu ny ph hp vi cc nghin cu khc v vic
xut hin PULSKMM ngi hin mu tnh nguyn [4].
3.2 T l xut hin phn ng cc hnh thc t chc hin mu
im HM
S lng
Lu ng
(n= 5118)
C nh
(n= 954)
Xe but ly
mu
(n= 275)
S lng ngi hin mu c
phn ng
147 14 5
T l xut hin phn ng 2,87 1,47 1,81
Nhn xt: T l xut hin PLSKMM ngi hin mu tnh nguyn ti cc im
hin mu lu ng cao hn so vi im hin mu c nh, khc bit c { ngha
thng k vi p<0,05. Theo chng ti, c th l nh vic chun b ly mu ti im
c nh tt hn, thi gian ch i ca ngi hin mu ngn, t l ngi hin mu
nhc li cao hn ti im lu ng nn t l xy ra PLSKMM thp hn *9+.
3.3 Thi im xut hin PLSKMM
Bng 3.3 : Thi im xut hin phn ng
Thi im
xut hin P

Lng mu hin
ang hin
mu
Sau khi ly mu Tng s
n % n % n %
250ml/n v 10 58,82 92 61,74 102 61,45
350ml/n v 7 41,15 57 38,26 64 38,55
Tng s trng hp 17 100 149 100 166 100

Nhn xt: Phn ng gp ch yu vo thi im sau khi hon tt vic ly mu
(149/166 trng hp); ngi hin mu 250ml c t l xut hin phn ng cao
hn so vi ngi hin 350ml (c { ngha thng k vi p<0,05). C th do vic hin
350ml ch yu c thc hin ngi hin mu nhc li, c t vn k trc
khi hin mu.
3.4 Mt s yu t thuc v ngi hin mu c lin quan ti vic xut hin
PLSKMM ngi hin mu tnh nguyn
Tm hiu mi lin quan gia hai nhm ngi hin mu: c xy ra phn ng v
khng xy ra P LSKMM vi cc yu t nh: khng n sng, thc khuya/ng t,
hi hp, lo lng khi hin mu, nhn thy mu xy ra, c tin s ngt, nh n thy ng
i khc xu/ngt, chng ti thu c kt qu sau:
Bng 3.3: Mt s yu t c lin quan ti vic xut hin cc PLSKMM:
Xut hin P

Mt s yu
t c lin quan
Xut hin
phn ng
(n = 166)
Khng xut hin
phn ng
(n= 6181)
n % n %
Khng n sng
(n=1847)
103 62,05 1744 28,22
Thc khuya/thiu ng trc khi hin
mu (ng <6gi)
(n=1531)
96 57,83 1435 23,22
Hi hp, lo lng, s (n=
1546)
69 41,57 1477 23,90
Nhn thy mu (n=
1680)
45 27,33 1635 26,45
Nhn thy ngi khc xu/ngt
(n= 466)
25 15,06 441 7,13
tng b xu, ngt v l do khc
(n=03)
0 0 3 0,49
Nhn xt: t l ngi c PLSKMM c lin quan ti cc yu t nh khng n sng
(62,05%), thc khuya, thiu ng (57,83%), hi hp, lo lng trc v trong qu
trnh hin mu (41,47%) cao hn hn nhm khng xy ra phn ng, s khc bit
c { ngha thng k vi p<0,05.

IV. KT LUN
Qua nghin cu trn 6347 ngi hin mu tnh nguyn ti cc im hin
mu ngoi vin ti Vin Huyt hc Truyn mu trung ng, tn sut xut hin
PLSKMM ngi hin mu tnh nguyn l 2,60%, trong ch yu l mc
nh 86,6%.
1. PLSKMM gp vi t l cao hn n (3,4%, so vi
nam l 1,87 %), gp t l cao hn ti cc im hin
mu lu ng; phn ng thng xy ra sau khi
hon thnh vic ly mu (77,11%). Khng c s
khc bit r rt v t l xy ra phn ng nhm
hin 250ml v 350ml.
2. T l kh cao ngi hin mu c PLSKMM c lin
quan ti cc yu t nh: thc khuya, khng n
sng, ng t (di 6 gi), lo lng/hi hp khi hin
mu.
Qua nghin cu bc u, chng ti xut:
1. Gip ngi hin mu chun b tt v mt tm l, th cht trc khi hin
mu l bin php quan trng nhm gim thiu s xut hin nhng
PLSKMM, c bit l ngi hin mu ln u, ngi hin mu l n.
l vic thc hin tt cng tc t vn, ng vin, chm sc ngi
hin mu trong sut qu trnh tham gia hin mu.
2. Cn c hng m rng v tip tc nghin cu su hn nhm tm hiu
s xut hin nhng PLSKMM ng o cc i tng ngi hin
mu, qua gp phn hon thin quy trnh chn on, x tr nhng
phn ng ny ngay ti cc im hin mu, nht l hin mu ngoi vin;
ng thi tm hiu nhng yu t tc ng nhm tip tc xut nhng
gii php hn ch s xut hin nhng phn ng ny.


Tm tt
Qua nghin cu trn 6347 ngi hin mu tnh nguyn ti cc im hin mu
ngoi vin ti Vin Huyt hc Truyn mu trung ng t thng 11/2005-
2/2006, chng ti thu c kt qu sau:
1. Tn sut xut hin PLSKMM
ngi hin mu tnh nguyn l
2,60%, trong 86,6% l mc
nh.
2. PLSKMM gp vi t l cao hn
n (3,4%, so vi nam l 1,87
%), gp t l cao hn ti cc
im hin mu lu ng; phn
ng thng xy ra sau khi
hon thnh vic ly mu
(77,11%). Khng c s khc bit
r rt v t l xy ra phn ng
nhm hin 250ml v 350ml.
3. T l kh cao ngi hin mu c
PLSKMM c lin quan ti cc
yu t nh: thc khuya, khng
n sng, ng t (di 6 gi), lo
lng/hi hp khi hin mu.
SUMARY
We studied about adverse reactions on 6347 voluntary un paid blood donors in
National Institute of Hematology and blood transfusion from Nov 2005 to Feb
2006. The results showed that:
1. The percentage of adverse reaction was 2,60%, in which, almost of
reactions were mild reaction (86,6%).
2. The percentage of adverse reaction among female donors was higher
then male donors (3,4% and 1,87 %). The reaction happened more
often after completing of donation (77,11%). We did not find the
differences of percentage of reaction between two groups of 250ml
and 350ml blood volume donated.
3. We recognized that high percentage of donor with reaction related
with factors, such as not sleep enough the night before, not having
breakfast...

Danh mc ti liu tham kho
1. Trn Vn B. Kho st ngi cho mu ti Thnh ph H Ch Minh. Y hc
Vit Nam 1996, 5: 31 33.
2. Phm Tun Dng. c u tm hiu mt s ch tiu sinh vt ngi
gn huyt tng ti Vin huyt hc Truyn mu. Lun vn tt nghip
Bc s ni tr bnh vin 83 84. H Ni 1984: 25
3. Trn Bch Hp. Nghin cu mt s ch s sc khe ngi cho mu. Lun
n thc s y hc. H Ni. 1999: 36-37, 53-54,60-64, 74.
4. V Th Kim Hoa Nguyn Th M Ha. c u kho st cc ch s
huyt hc ngi cho mu ti Thnh ph H Ch Minh. Y hc Vit Nam
1998, 26: 23 25.
5. Nhm nh Hng. Hin trng vn ngi cho mu ti bnh vin a
khoa tnh Thi Bnh. Mt s kin ngh v gii php. Lun vn bc s
chuyn khoa cp II, 1996: 49.
6. Trung Phn. An ton truyn mu NXB khoa hc k thut. H Ni.
2000
7. Ng Mnh Qun, Nguyn c Thun. Hin mu nhc li bin php
quan trng m bo an ton truyn mu. Y hc thc hnh 2004,
497:187-191.
8. Nguyn c Thun, Trn Ngc Qu. Xy dng m hnh im hin mu
c nh an ton ti cng ng.
9. T chc y t th gii. Cho mu an ton, Quyn 1. Nh xut bn y hc,
2001: 180-184.
10. AABB. Standards for Blood Banks and Transfusion Services, 1993. 15
th

Ed. by AABB.
11. Center for transfusion medicine, Health Singapore Authority, 2004.
Procedures for Blood collection site.
12. Australian Red Cross Blood Service, Annual Report 2002/2003
Australian Red Cross Blood Service. 2003.


65. NG DNG PHNG PHP MIN DCH
TRONG CHN ON PHN LOI MT S TH
BNH CA L X MI CP
Nguyn Triu Vn, Trung Phn, Nguyn Anh Tr v cng s

1. T VN
L x mi cp (acute leukemia, AL) l nhm bnh mu c tnh ca h thng
to mu bao gm l x mi cp dng tu (acute myelogenous leukemia, AML) v
l x mi cp dng lympho (acute lymphoblasic leukemia, ALL). Bnh bt u
c m t t u th k XIX v t n nay, c rt nhiu nghin cu v
bnh ny [8].
Bnh gp mi la tui, biu hin bnh a dng, t l b bnh cao. Ti M,
hng nm xut hin mi khong 2,2 trng hp AML trn 100.000 dn v c
khong 3.000 trng hp ALL mi trn ton quc. Ti Vit Nam, tuy cha c
nghin cu no tin hnh y v dch t hc ca bnh l x mi cp trn ton
quc nhng theo tng kt ti Vin Huyt hc-Truyn mu, Bnh vin Bch mai th
thy bnh l x mi gp t l cao nht (32.1%) trong s cc bnh mu n khm v
iu tr ti Bnh vin Bch mai [1].
Cc nghin cu v sinh bnh hc cho thy ri lon c bn trong bnh l x
mi l s tng sinh khng kim sot c ca mt hoc vi dng t bo non
(blast), bt u v ch yu ti tu xng. S tng sinh khi t bo non gy tn
thng cc c quan to mu, h thng min dch v mt s c quan khc *5+.
Da trn nhng tin b trong vic chn on ng v phn loi chnh xc
cc th bnh, vic iu tr l x mi cp c nhng tin b r rt.
Vit nam, c nhiu nghin cu v l x mi cp c tin hnh di
nhiu gc khc nhau: nghin cu v dch t hc ca bnh, nghin cu v phn
loi, nghin cu v iu tr, nghin cu phi hp gia phn loi, cc ri lon min
dch v tin lng [1] [2] [4]. V vy, vic nghin cu p dng cc k thut mi
cho phn loi chnh xc cc th bnh l x mi cp l rt cn thit.
V vy chng ti tin hnh nghin cu ny vi cc mc tiu sau:
- Tm hiu gi tr ca mt s du n min dch trong vic phn loi cc th
bnh c bit ca bnh L x mi cp.
- Gp phn tm hiu m hnh bnh l x mi cp gp ti Vin Huyt hc
Truyn mu Trung ng.
2. I TNG V PHNG PHP NGHIN CU
2.1. i tng nghin cu:
- i tng nghin cu l 306 bnh nhn (nhp vin v iu tr t nm 2000-
2004) c chn on l l x mi cp vi cc tiu chun sau y :
2.1.1. Cc du hiu lm sng:
- St ko di, gim cn, ton thn suy sp
- Thiu mu nhanh
- Xut huyt di da, ni tng
- Gan lch c th to
2.1.2. Cc ch tiu xt nghim
- Huyt : Mu ngoi vi c t bo blast, thiu mu.
- Tu : T bo blast tng trn 30%.
- Ho hc t bo: S dng 4 xt nghim nhum ho hc t bo: Peroxydase,
Sudan en, PAS, Esteraza khng c hiu.

2.2. Vt liu nghin cu
- Dch ht ty xng: lm ty , nhum ha hc t bo ng thi phn loi min
dch hc
- My m t bo t ng
- Knh hin vi huznh quang hiu Nikon
- Ly tm lnh
- Ha cht
+ B kit min dch huznh quang s dng cho phn loi l x mi cp dng lympho
bao gm: Anti-CD3, Anti-CD5, Anti-CD7, Anti-CD10, Anti-CD19 v b kt chng
+ Cc ha cht khc: m PBS, dung dch ph hng cu, dung dch c nh t bo,
ficoll

2.3. Phng php nghin cu
S dng cc phng php (hnh thi hc, ho hc t bo) phn loi l x mi
cp theo tiu chun FAB v b sung cc phng php nh sau:
- Phng php Min dch: S dng khng th n dng (monoclonal antibodies)
pht hin cc du n (CD) c hiu trn b mt t bo (CD Clutter of
Diffirentiation) [4].
+ T bo gc sinh mu : CD 34
+ T bo nh hng dng tu : CD 13, CD33, CD34
+ T bo nh hng dng lympho : CD5, CD7,CD10, CD19, CD34
+ T bo u dng:
- T Lympho: CD3, CD4, CD8, CD7, CD5
- Bch cu ht : CD13, CD33 - B Lympho: CD19, CD20, CD10
- Bch cu mono : CD14 - T bo NK : CD15/56
- Tiu cu : CD61
- Phng php Di truyn t bo: Cc bt thng NST: S dng phng php nui
cy lympho, lm tiu bn NST, phn tch bin i NST.
3. KT QU NGHIN CU
Bng vic phi hp p dng cc phng php phn loi l x mi cp theo phn
loi FAB b sung, kt qu phn loi nh sau:



BNG 1. M HNH PHN LOI L X MI CP

Th bnh L x mi cp S lng T l %
1. L x mi cp t bo cha bit ho (Null-cells), cc
du n (-):
12/306 3,9
2. L xmi cp t bo gc sinh mu c CD34 +, cc CD
khc (-)
24/306 7,8
3. L x mi cp t bo lai: 19/306 6,2
4. L x mi cp t bo gc sinh mu bit ho Dng
tu: CD13+, CD33+, CD34+:
166/306 54,3
5. L x mi cp t bo gc sinh mu bit ho Dng
lympho:
85/306 27,8

NHN XT

- Vic p dng ng thi 4 phng php chn on v phn loi bnh l x
mi cp pht hin c nhng th bnh mi m cc phng php c in kh
pht hin hoc khng pht hin c, l: l x mi t bo gc cha bit ha, l
x mi t bo gc sinh mu.
- Ngoi ra vic p dng phng php min dch hc trong chn on v phn loi
l x mi cp cn pht c cc th bnh c bit: l x mi cp t bo lai: lai ty-
lympho B v lai ty- lympho T.

Bng 2. Phn loi chi tit l x mi cp dng ty, p dng phng php FAB v b
sung bng phng php min dch hc:
Th bnh l x mi cp S lng T l %
L x mi cp t bo ngun sinh mu bit ho
dng tu: CD13+, CD33+, CD34+:
166/306 54,3
- Mo: 11 6,6
- M1: 23 14,0
- M2: 44 26,5
- M3: M3V 26 15,7
- M4 25 15,1
- M5: M5a, M5b 27 16,3
- M6: 6 3,6
- M7: 4 2,4
NHN XT
- Vic p dng phng php min dch hc b sung tt cho phn loi FAB trong
vic xc nh cc th bnh l x mi cp dng ty nh th Mo, th M7. Phng
php Min dch hc cng gp phn phn bit chnh xc gia th M4 v M5 bng
vic s dng marker CD14.
Bng 3. Phn loi chi tit l x mi cp dng lympho, p dng phng php FAB v
b sung bng phng php min dch hc:

Th bnh l x mi cp S lng T l %
L x mi cp t bo gc sinh mu bit ho dng
lympho
85/306 27,8
a. Theo ngun gc t bo:
- T lympho 23 27,1
+ Tin T (CD7+, CD34+, CD19-) 17 73,9
+ T chn (CD3+, CD7+, CD19- ) 6 26,1
- B lympho 62 72,9
+ B sm (CD10+, CD34+, CD19) 9 14,5
+ Tin B (CD10+, CD19+) 28 45,2
+ B chn (CD19+) 25 40,3
b. Theo hnh thi t bo: c 3 th
L1 14 16,4
L2 69 81,2
L3 2 2,4

NHN XT
- Phng php phn loi min dch hc gp phn phn loi chi tit l x mi cp
dng lympho. Nu phn loi FAB ch phn loi c 3 th bnh l L1, L2, L3 th
phn loi FAB b sung (Min dch hc) gp phn phn loi c chi tit l x
mi cp dng lympho T v l x mi cp dng lympho B.
- Trong l x mi cp dng lympho B, bao gm 3 di nhm: B sm, tin B, B
trng thnh. Trong l x mi cp dng lympho T bao gm 2 di nhm: Tin T v
T trng thnh.

Bng 4. Phn loi chi tit l x mi cp t bo lai, p dng phng php FAB v b
sung bng phng php min dch hc:

Th bnh L x mi cp S lng T l %
L x mi cp t bo lai: 19/306 6,2
1. Lai tu-B lympho 12 63,2
2. Lai tu-T lympho 7 36,8
NHN XT

- Trong th bnh l x mi cp c bit: l x mi cp t bo lai, chng ti gp 2 loi:
lai ty-lympho B v lai ty- lympho T.

4. BN LUN

Vic p dng ng b 4 phng php: Hnh thi hc, Ha hc t bo, min dch
hc v di truyn t bo trong chn on v phn loi l x mi cp (phn loi FAB
b sung) gp phn nng cao cht lng chn on v hiu bit y hn v m
hnh bnh hc ca l x mi cp [4].
V t l cc nhm bnh trong chn on phn loi l x mi cp ngi ln, so snh
vi kt qu nghin cu bnh nhn tr em ti Bnh vin Nhi Trung ng, t l l
x mi cp dng lymho T chim 26% v dng lympho B chim 68%. Nh vy, t l
l x mi cp dng lympho T ngi ln cao hn (27%). Theo ti liu gn y
Chu u, i vi l x mi cp dng lympho, t l l x mi cp dng lympho T tr
em l 10-15%, ngi ln 20-30%. Dng B lympho tr em l 70%, ngi ln l
50-60%. Kt qu nghin cu ca chng ti cng tng ng.
Trong phn loi l x mi cp dng ty, phng php phn loi min dch b
sung tt cho phn loi FAB cc th bnh Mo, M7, M4 v M5 thng qua cc du
n c hiu trn mng t bo blast trong qu trnh bit ha. Trong phn loi l x
mi cp dng lympho, xc nh chnh xc dng t bo v giai on bit ha ca
t bo blast trong qu trnh tng sinh c tnh (vn m phng php hnh thi
hc v ha hc t bo cn hn ch, khng gii quyt c) [3] [4].
Mt gi tr quan trng khc ca phng php min dch hc l pht hin ra
c cc th bnh c bit: l x mi cp t bo gc cha bit ha, l x mi cp t
bo gc sinh mu v l x mi cp t bo lai.
Nh vy, t kt qu nghin cu, chng ta c th phn loi l x mi cp c th tm
tt 5 nhm bnh l x mi cp ch yu sau y: l x mi cp t bo gc cha bit
ha, l x mi cp t bo gc to mu, l x mi cp dng ty, l x mi cp dng
lympho v l x mi cp t bo lai. Kt qu nghin cu trn cng gp phn lm
sng t gi thuyt v bnh l{ n dng (clonal pathology) [3] trong bnh l ca l
x mi cp. Vic p dng ng b cc phng php chn on v phn loi l x
mi cp gip chn on xc nh chnh xc cc th bnh, pht hin cc th bnh
mi v qua thy c l L x mi cp c th xy ra tt c cc giai on khc
nhau ca qu trnh bit ho t bo mu *7+ *8+. ng thi vic phn loi chnh xc
c tc dng hng dn iu tr t hiu qu cao hn. Chng ti ang tip tc tin
hnh nghin cu, kt hp vi theo di lm sng tm ra cc yu t min dch c
gi tr trong theo di kt qu iu tr v tin lng bnh [5].

5. KT LUN

Bng vic p dng phn loi FAB b sung cho 306 bnh nhn l x mi cp ti vin
Huyt hc Truyn mu, kt qu thu c nh sau:
- T l l x mi cp t bo cha bit ha (cc CD - ) l: 3,9%
- T l l x mi cp t bo gc sinh mu c CD34+ l: 7,8 %
- T l l x mi cp t bo bit ha dng ty c CD33+ v/hoc CD13+ l: 54,3%
- T l l x mi cp t bo bit ha dng lympho c CD3+, CD7+, CD10+, CD19+ l:
27,7% (trong l x mi cp dng lympho B chim 72,9% v l x mi cp dng
lympho T chim 27,1%).
- T l l x mi cp t bo lai (cng mang du n bit ha ca 2 dng t bo) l:
6,2% (trong l x mi cp t bo lai dng ty vi dng lympho B chim 63,2% v
l x mi cp t bo lai dng ty vi dng lympho T chim 36,8%).
Nhng kt qa nghin cu trn gp phn mt cch hiu qu trong nghin cu
bnh hc ca bnh, gp phn iu tr tt hn bnh l x mi cp dng ty v l x
mi cp dng lympho ti Vin Huyt hc Truyn mu trung ng.

Tm tt
Bng vic p dng phn loi FAB b sung cho 306 bnh nhn l x mi cp ti vin
Huyt hc Truyn mu, kt qu thu c nh sau:
- T l l x mi cp t bo cha bit ha (cc CD - ) l: 3,9%
- T l l x mi cp t bo gc sinh mu c CD34+ l: 7,8 %
- T l l x mi cp t bo bit ha dng ty c CD33+ v/hoc CD13+ l:
54,3%
- T l l x mi cp t bo bit ha dng lympho c CD3+, CD7+, CD10+,
CD19+ l: 27,7% (trong l x mi cp dng lympho B chim 72,9% v
l x mi cp dng lympho T chim 27,1%).
- T l l x mi cp t bo lai (cng mang du n bit ha ca 2 dng t
bo) l: 6,2% (trong l x mi cp t bo lai dng ty vi dng lympho
B chim 63,2% v l x mi cp t bo lai dng ty vi dng lympho T
chim 36,8%).
Nhng kt qa nghin cu trn gp phn mt cch hiu qu trong nghin cu
bnh hc ca bnh, gp phn iu tr tt hn bnh l x mi cp dng ty v l x
mi cp dng lympho ti Vin Huyt hc Truyn mu Trung ng.







Summary

THE VALUE OF MARKERS (CLUSTER OF DIFFERENTIATION ) ON DIAGNOSIS
ACUTE LEUKEMIA AT THE NATIONAL INSTITUTE OF HEMATOLOGY AND BLOOD
TRANSFUSION FROM 2000 TO 2004
By using FAB classification and more for 306 acute leukemia (AL) patients, the
results show that:
- The rate of AL undifferentiating was 3,9%
- The rate of AL hematopoietic stem cell with CD34+ was: 7,8%
- The rate of AL differentiation was AML was 54,3% .
- The rate of AL differentiation was ALL was 27,7%.
- The rate of mix AL was 6,2%.

These results contributed effectively to pathological study and treatment of
acute myeloid leukemia and acute lymphoblastic leukemia at the National
Institute of Hematology and Blood Transfusion.

Ti liu tham kho

1 Trn Th Minh Hng, Trung Phn: Tnh hnh bnh mu ti Vin
Huyt hc - Truyn mu, Bnh vin Bch mai, K yu cng trnh nghin
cu khoa hc Huyt hc - Truyn mu 1999-2000, Nh xut bn Y hc,
2002: 15-24.
2 Trung Phn, Thi Qu{ v cs, Kt qu bc u thc hin chng trnh
nghin cu nng cao cht lng chn on v iu tr cc bnh mu v
to mu, Y hc Vit nam, 1998: 231, 1-5.
3 Trung Phn: L x mi cp Bnh l t bo ngun to mu, NX Y
hc, 2003.
4 Nguyn Hu Ton, Trng Cng Dun, Nguyn Triu Vn v cs. Gi tr ca
du n mng blast trong phn loi l x mi cp. Y hc Vit nam, 1998;
231, 25-32.
5 Nguyn Anh Tr, Nguyn Hu Ton. T tin leukemia n leukemia cp,
Nh xut bn Y hc. 1995
6 Foon K.A., Gale R.P., et al. Recent advances in the immunologic
classification of leukemia, Seminars in hematology, 1986, 4, 257-283.
7 Hoelzer D. Acute lymphoblastic leukemia: treatment, Hematology,
Singapore, 1996, 276-279.
8 Mauer A.M. Acute lymphocytic leukemia. Williams Hematology, Sixth
edition, McGraw-Hill, Inc.,pp. 1995, 1004-16.


66. M HNH CUNG CP MU TP TRUNG T
NGN HNG MU KHU VC N CC BNH
VIN

PGS. TS. Nguyn Anh Tr, ThS. Trn Ngc Qu

I. M HNH CUNG CP MU
1.1 . Khi qut chung v dch v mu
Mu v ch phm mu l loi thuc c bit s dng trong cp cu v iu
tr bnh. Cho n nay, d loi ngi tin rt xa trong lnh vc khoa hc k
thut nhng vn cha iu ch c cht thay th mu; Bi vy ngun cung cp
mu v ch phm mu vn phi ly t ngi hin mu.
Nhu cu s dng mu trong cp cu v iu tr rt ln, theo WHO th cn phi c
2% dn s ca mt nc cho mu 1 ln/nm p ng nhu cu mu ca quc
gia. S dng mu v ch phm mu ch t hiu qu khi c ch nh ng v p
ng kp thi do vy cn c mu lu tr p ng kp thi cho cp cu, iu tr,
quc phng, an ninh v phng thm ho...
Dch v truyn mu c t chc gm 3 b phn: Vn ng hin mu c ngi
cho mu an ton; Ngn hng mu lm nhim v thu gom, sng lc, iu ch, bo
qun v phn phi mu; Truyn mu lm sng: Ch nh, s dng mu hp l, an
ton.
1.2 . Cng tc truyn mu trn th gii
1.2.1. Lch s cng tc truyn mu:
Lch s truyn mu trong y hc thc s m ra sau khi Karl Landsteiner v
hc tr pht hin ra h nhm mu ABO.
Nm 1913, Reuben Ottenberg nu vn ho hp nhm mu trong truyn
mu v a ra s truyn mu mang tn ng, t y khc phc c tnh
trng t vong do truyn nhm nhm mu.
Nm 1921 cc nc nh Anh, H Lan v Australia thnh lp c nhng
trung tm truyn mu u tin trn th gii. Ti Lin X: nm 1929 F.Rcp
gii thiu cng tc truyn mu qua vic t chc i cp cu trong qun i v
ngh t chc mt i qun cho mu ti trm cp cu qun i. Cui nm 1929,
N.N.Elanxki ngh thnh lp trung tm truyn mu Lningrat. ng cng cp
n vn tng cng i ng ngi cho mu tnh nguyn, ng thi vi vic
lu tr mu ti cc labo chuyn khoa, ri t y chuyn mu v cc c s iu
tr.
Nm 1933, ti Madrit (Ty an Nha) c 39 nhm cng tc truyn mu ti cc
bnh vin khc nhau v nhng ngi cho mu l nhn dn ca thnh ph cho
mu t nguyn. Nm 1939, trn c s rt kinh nghim ti Ty Ban Nha, A.X.
Georgiep (Lin X c) nu ra rng: S hp l nht ca cng tc truyn mu l
xy dng c mt h thng cung cp, lu tr mu tp trung ti mt s trung
tm truyn mu, nhim v ca trung tm ny ngoi vic chun b mu lu tr cn
phi t chc c mt lc lng ng o ngi cho mu ngay ti cc trung tm
v vi s tham gia ca Hi Ch thp .
Nm 1943 J. Loutit, P. Mollison chnh l dung dch chng ng ACD, to iu
kin bo qun lu di mu 4C. n nm 1952 Walter v Murphy m t k thut
ly mu kn bng ti polyvinyl, sau Gibson v cng s pht trin h thng ly
mu bng ti cht do cho php tch huyt tng ra khi mu sau khi lng v
c th bo qun bng ng lnh lu di. l nhng iu kin tt cho mt thi
kz mi trong bo qun, s dng cc thnh phn mu trong y hc.
1.2.2. Truyn mu hin i v m hnh cung cp mu tp trung:
Truyn mu hin nay pht trin v tr thnh chng trnh quc gia ca nhiu
nc trn th gii, cuc cch mng khoa hc k thut a vic sn xut cc
ch phm mu i vo cng nghip ho.
Nhng quan im truyn mu hin i c a ra: Ly ti thiu, s dng ti
a, nh nhn cn g truyn ny, khng cn khng truyn.
Ngun ngi cho mu: Tnh nguyn khng ly tin, c d tr ln p ng c
nhu cu iu tr hng ngy, c d tr phng khi c thm ho, chin tranh...
Nhiu nc gii quyt c vn cho mu khng ly tin, c nhiu ngi
hin mu tnh nguyn khng ly tin. Hin mu tnh nguyn tr thnh trch
nhim v ngha v ca ngi dn:v cc nc tin tin u c ngn hng
mu tp trung.
Truyn mu tng phn, t thn, mu lc bch cu ngy cng pht trin v chim
chnh yu trong truyn mu. Cc thnh phn mu c bo qun trong iu kin
thch hp thit b an ton nn c th lu tr di ngy, an ton cao hn.
An ton truyn mu c quan tm khng ch m bo bng cch ph hp v
mt min dch m l khng truyn cc bnh nhim trng cho ngi nhn bng cc
bin php sng lc. An ton truyn mu tr thnh lut quc gia, lut quc t v
c kim sot cht ch, quan tm c bit, c u t trang thit b, k thut
hin i, phng php p dng c nhy v c hiu cao, cc xt nghim
c tp trung lm cc c s ln, hin i v c cht lng.
An ton truyn mu ch c m bo khi c nhng trung tm truyn mu ln, c
trang thit b hin i v i ng cn b c o to tt. An ton truyn mu
khng ch l m bo an ton ngi cho, ngi nhn v cn b lm cng tc
truyn mu m cn m bo an ton v s lng, cht lng, trong cp cu,
trong iu tr hng ngy v d phng thm ho.
H thng ngn hng mu hoc cc trung tm truyn mu cc nc trn th gii
nhn chung u theo hnh thc X hi ho, ngha l cc t chc x hi phi hp
vi ngnh y t ng ra chu trch nhim t chc, thc hin v m rng chng
trnh truyn mu quc gia. Mt s nc giao cho Hi Ch thp ng ra t
chc thc hin chng trnh truyn mu v cng vi trung tm truyn mu thu
gom, sng lc, iu ch cc ch phm mu v cung cp mu an ton cho cc bnh
vin. in hnh cho hnh thc ny l Australia, B, Phn Lan, c, Nht Bn,
Luxemburg, Hn Quc Mt s nc li ch do cc trung tm truyn mu khu vc
v cc c s y t t chc thc hin nh: Anh, Php, {, Canada, Ireland...
Xu hng tp trung ho ngn hng mu ca cc nc trn th gii hin nay l
gim bt s phn tn cc ngn hng mu nh l v tp trung dn vo nhng trung
tm ln c iu kin thun li trong vic sng lc, iu ch cc ch phm mu
nhm m bo an ton v cht lng hn. C th: Php ang t 60 trung tm
gim xung cn 22 ri 16 trung tm thu gom, sng lc. M giai on trc 1996
c gn 180 trung tm, hin ch cn 6 trung tm lm nhim v sng lc v 32 trung
tm truyn mu m bo cung cp mu trong ton quc. Cc nc: Nht, Hn
Quc, H Lan, Thu in gim bt cc trung tm truyn mu nh cc a
phng tp trung vo cc trung tm ln hn.
II. THC TRNG CUNG CP MU VIT NAM
2.1 . Khi qut:
Vit Nam vi 101 c s truyn mu cp trung ng v cp tnh v 550 c s cp
huyn, t chc c s truyn mu nh, ri rc nm trong h thng cc bnh vin,
trang thit b lc hu, thiu cn b c o to chuyn khoa, t chc thu gom
mu vi s lng t, ngun mu ch yu l t ngi cho mu ly tin, an ton
truyn mu b e do, chi ph cho mt n v mu cao. Vn s dng mu v
ch phm mu ti bnh vin cha hp l v cn thiu an ton: Ch nh v s
dng mu ton phn trong iu tr cn chim t l cao, cc quy trnh truyn mu
lm sng cn cha m bo; cn xy ra tnh trng thiu hoc tha mu mt s
thi im trong nm.
2.2 . u im, nhc im ca cung cp mu phn tn ti Vit Nam:
* u im:
T chc cc c s truyn mu phn tn nm trong ni b cc bnh vin cc
nc ta c th l ph hp trong giai on trc y, khi t nc cn c chin
tranh, kinh t cn cha pht trin, giao thng cha thun li, thng tin lin lc
cn kh khn, ngun ngi cho mu cn t, ch yu l ngi cho mu chuyn
nghip v cha c phong tro hin mu tnh nguyn...
* Nhc im:
T chc cung cp mu theo phng thc t cung t cp trong phm vi hp ca
tng bnh vin Vit Nam c nhiu hn ch:
- Thu gom mu vi s lng t, khng u v th ng.
- Khng ch ng mu v ch phm cho cp cu, iu tr v d phng thm
ho cng nh m bo mu cho an ninh, quc phng.
- Khng iu ch c cc sn phm mu nn ch yu s dng mu ton
phn.
- Chi ph thc t cho n v mu/ch phm mu cao.
- Thiu i ng cn b c kinh nghim, c uy tn thc hin cc dch v
truyn mu v hng dn thy thuc lm sng s dng mu v ch phm
mu.
- Khng p dng c cc k thut hin i sng lc mu.
- Cht lng mu tuz thuc tng bnh vin.
- Khng gp phn thc y s pht trin ca phong tro hin mu nhn
o.
III. S TT YU V CP THIT CN PHI CUNG CP MU TP TRUNG
3.1. Nhng tn ti khi khng t chc cung cp mu tp trung:
- Cng tc vn ng tuyn truyn hin mu: Mi t t chc hin mu ch c
kh nng ly c t ngi dn n ngi tham gia hin mu mt lng tin,
thiu kinh ph tuyn truyn vn ng nn cn tr n phong tro hin mu.
- Kh khn trong u t v o to, hun luyn con ngi; Trong vic xy
dng c s vt cht, mua sm trang thit b p dng nhng phng
php hin i tuyn chn, sng lc, iu ch, lu tr, bo qun v phn
phi mu...
- Trong s dng mu tng phn: Vi s lng mu t s khng th iu ch
c cc sn phm mu nn khng thc hin c truyn mu tng phn
m phi truyn mu ton phn dn n an ton truyn mu khng m
bo.
3.2. Li ch v tnh cp thit ca vic cung cp mu tp trung
- y mnh vic k hoch ho trong truyn mu, ch ng ngun mu phc
v cp cu, iu tr, d phng thm ho v an ninh, quc phng.
- Hin i ho cng tc truyn mu: Truyn mu hin i l mt dy chuyn
cng ngh cn s dng nhiu trang thit b hin i, t tin cho thu gom,
sng lc, iu ch, bo qun vn chuyn mu v cc ch phm mu m vi
qui m ca mt bnh vin cp tnh, huyn khng th p ng c.
- Tit kim nhn lc, vt lc: Khi tp trung ngn hng mu s m bo thu
gom lng mu ln, sn xut c nhiu thnh phn, hiu sut s dng
con ngi v trang thit b cao. ng thi, trung tm ln c th iu phi
c s dng mu ti cc bnh vin, trnh tha thiu cc b, hu mu do
qu hn.
- Gp phn thc y phong tro hin mu nhn o: T chc c nhng
bui hin mu cho nhiu ngi p ng nguyn vng tham gia hin mu,
ng thi tp trung c kinh ph cho cng tc tuyn truyn vn ng.
- M rng truyn mu tng phn, p dng cc bin php iu tr hin i.
Nng cao cht lng mu phc v ngi bnh: m bo p ng c nhu
cu cn g truyn ny, truyn mu c cht lng, an ton.
- m bo s bnh ng ca bnh nhn cc vng ca t nc trong vic
th hng dch v truyn mu, bi v cc bnh nhn d thnh ph ln
hay vng su, vng xa... cng chung mt loi sn phm, mt cht lng.
Vy, truyn mu l mt dch v chi ph cao, c nhng nguyn tc ht sc cht ch
v cng c nhiu ri ro. truyn mu c m bo an ton i hi phi c cc
trung tm truyn mu ln vi i ng cn b c trnh chuyn mn nghip v
cao, trang thit b hin i, m bo nghim ngt cc qui trnh chuyn mn k
thut v ng dng cng ngh thng tin, c hot ng kim tra cht lng hiu
qu.
3.3. Cc quyt nh ca Nh nc lin quan n cung cp mu tp trung:
Trong nhng nm gn y, Nh nc ta c nhiu vn bn v quyt nh
lin quan n cng tc truyn mu, c bit l vn an ton truyn mu:
iu lnh Truyn mu ban hnh theo Quyt nh s: 937/Q-BYT ngy
04/09/1992 ca B trng B Y t l c s php l{ quy nh cc hot ng
truyn mu trong ton quc.
Quyt nh s: 43/Q-TTg ngy 07/04/2000 ca Th tng Chnh ph v
vic vn ng v khuyn khch nhn dn hin mu tnh nguyn.
Quyt nh s: 198/Q-TTg ngy 28/12/2001 ca Th tng Chnh ph v
vic ph duyt Chng trnh An ton truyn mu.
Quyt nh s: 57/Q-TTg ngy 15/01/2002 ca Th tng Chnh ph v
vic u t D n Trung tm truyn mu khu vc.
Thng t lin tch s: 12/TTLT/BTC-BYT ngy 25/02/2003 ca lin tch B
Ti chnh v B Y t hng dn mc gi v ni dung chi cho mt n v mu
t tiu chun.
Quyt nh s: 31/2004/Q-TTg ngy 08/03/2004 ca Th tng Chnh ph
v vic Thnh lp Vin Huyt hc - Truyn mu Trung ng.
Th ca Ch tch nc Trn c Lng gi ng bo, ng ch v chin s
c nc Ku gi hin mu nhn o nhn ngy Ton dn hin mu nhn
o-7/4/2005.
Cc vn bn trn th hin tnh quan trng v cp thit ca vn an ton
truyn mu. Mt trong nhng ni dung quan trng m bo an ton truyn
mu l xy dng cc Trung tm Truyn mu khu vc nhm thc hin cung cp
mu tp trung, p ng nhu cu v s lng mu v cc ch phm mu, nng cao
v cht lng trong dch v truyn mu.
IV. NI DUNG V PHNG PHP TRIN KHAI M HNH CUNG CP MU TP
TRUNG T TRUNG TM TRUYN MU KHU VC CC TNH
4.1. Ni dung ca m hnh cung cp mu t TTTTKV n cc tnh:
a. Trung tm truyn mu khu vc c trch nhim tng bc cung cp mu v
cc sn phm mu c cht lng v an ton cho nhu cu cp cu, iu tr,
d phng cc thm ho; C mu d tr cho nhu cu an ninh, quc phng;
S dng mu v ch phm mu hp l, hiu qu, gp phn lm gim t l
t vong, t l mc bnh; Nghin cu khoa hc, p dng cc tin b cng
ngh trong dch v truyn mu; Tng cng hp tc quc t v lnh vc
truyn mu.
4.1.1. Ni dung M hnh cung cp mu t TTTMKV n cc tnh:
- Cc bnh vin d tr nhu cu mu tng nm, nhn mu v ch phm
theo k hoch ng k{, t chc vn chuyn, lu tr, bo qun ng
qui trnh v s dng mu hp l v an ton cho bnh nhn
- Trung tm truyn mu khu vc lp k hoch cung cp mu cho cc tnh;
chu trch nhim v cht lng mu v ch phm; trang b cc thit b
bo qun; o to cn b truyn mu v bc s, iu dng vin lm
sng trong s dng mu. Trung tm truyn mu tp hp nhu cu mu t
cc bnh vin lp k hoch thu gom.
- Ban ch o vn ng hin mu cc tnh/thnh kt hp vi Trung tm
truyn mu khu vc xy dng k hoch tuyn truyn vn ng v t
chc hin mu nhn o mt cch thng xuyn lin tc trn c s p
ng nhu cu theo k hoch, m bo ngun mu c cht lng an ton
p ng cp cu iu tr v d phng thm ho vi s n v thu gom
mi a phng bng 1,5 n 2 ln s n v m a phng s
dng.
4.1.2. M hnh cung cp mu t TTTMKV n cc tnh:












B Y T
TRUNG TM TRUYN
MU QUC GIA V
KHU VC
TTYT, BV
HUYN,
BV CHUYN
KHOA
BV A KHOA
CC TNH
BV TRC
THUC
B Y T
S Y T
CC TNH






S : M hnh cung cp mu t TTTMKV n cc tnh
* Ch thch:
- B Y t thc hin vic ch o cho TTTM Quc gia v Khu vc, ng thi
tip nhn s bo co ca cc c s .
- Trung tm truyn mu phi hp cht ch vi s Y t cc tnh v cc bnh
vin trc thuc B cung cp mu v ch phm cho cc bnh vin a
khoa tnh v cc bnh vin thuc B.
- Bnh vin a khoa tnh nhn mu t TTTMKV v cung cp cho tt c
cc c s cha bnh trong tnh v c trch nhim bo co v s y t v
TTTNKV.
4.2. Nhng vic cn lm trin khai m hnh cung cp mu t TTTMKV n cc
tnh:
4.2.1 Xy dng cc trung tm truyn mu (Quc gia, Khu vc, Vng), m bo
hin i, hp l v hiu qu, bao gm:
- Tp trung ho ngn hng mu: Xy dng Trung tm truyn mu khu vc
tr thnh mt ngn hng mu ln, chu trch nhim cung cp mu cho cc
bnh vin, cc tnh m Trung tm bao ph. Cc c s truyn mu nh trc
y trong din bao ph ca Trung tm truyn mu khu vc s khng cn t
chc thu gom, sng lc, iu ch cc sn phm mu m ch tp trung vo
pht mu an ton v truyn mu lm sng hp l v hiu qu.
- Xy dng c phong tro hin mu nhn o pht trin bn vng: Thnh
lp Ban ch o Vn ng hin mu cp quc gia v cc cp (tnh, huyn...),
t chc vn ng hin mu mt cch hiu qu, duy tr ngun ngi hin
mu tnh nguyn n nh. Tng bc hon thin qui trnh t chc hin
mu, thu gom mu t cc tnh v trung tm truyn mu khu vc, hon
thin qui trnh chm sc v t vn sc kho ngi hin mu. Xy dng c
ch ti chnh cho cng tc tuyn truyn vn ng hin mu mt cch hp l
v hiu qu; Xy dng quy ch tn vinh ngi hin mu tnh nguyn...
- M rng phm vi cung cp mu ca cc trung tm truyn mu khu vc:
Tng bc hon thin qui trnh cung cp mu t trung tm n cc tnh,
cc bnh vin. Kho st nh gi nhu cu v thc trng s dng mu v cc
ch phm mu ti cc a phng. Nghin cu bin php vn chuyn,
bo qun, phn phi mu v ch phm mt cch kp thi, khoa hc v
thun li.
- u t dy chuyn cng ngh hin i, pht trin cng ngh thng tin:
Trang thit b cho trung tm, vn ng hin mu, vn chuyn v truyn
mu lm sng; ng dng cng ngh thng tin trong qun l ngn hng mu,
qun l v bo co tnh hnh s dng mu, qun l bng m vch...
- Xy dng h thng qun l cht lng: Kim tra cht lng mu v cc sn
phm mu p ng c tiu chun thc hnh sn xut (GMP) mu tt.
4.2.2. Xy dng i ng cn b lm cng tc truyn mu, bao gm:
- Xy dng nh bin ngn hng mu hp l: Hin nay b phn truyn mu
trong bnh vin c nhim v vn ng, thu gom, sng lc v pht mu bnh
vin nn bin ch theo ging bnh. Khi Ngn hng mu thnh lp cn phi
xy dng nh bin ngn hng mu, iu chnh nh bin b phn truyn
mu ti bnh vin cho ph hp.
- o to cn b: o to cn b, nhn vin lm cng tc truyn mu; cn
b, tuyn truyn vin lm cng tc vn ng hin mu; cn b pht mu
lm sng; cc bc s ch nh v s dng mu, ch phm mu hp l, an
ton v hiu qu.
- S dng cn b tt v hiu qu: Tuyn chn v s dng cn b c trnh ,
nng lc. Pht huy ng kh nng, nng lc chuyn mn.
4.2.3. Hon thin h thng vn bn php quy v dch v truyn mu, bao gm:
- Quy nh, quy trnh v truyn mu (do B Y t ph duyt).
- Ngh nh v An ton truyn mu (do Th tng Chnh ph ph duyt).
- Lut v An ton truyn mu (do Quc hi ban hnh).
- C ch ti chnh cho cng tc Tuyn truyn vn ng hin mu.
- Quy ch Tn vinh, khen thng cho cng tc Hin mu nhn o.
4.3. Vai tr, trch nhim ca cc bn lin quan khi thc hin cung cp mu tp
trung t TTTMKV n cc tnh:
4.3.1. Hp ng trch nhim cung cp mu v ngun ngi cho mu:
Hp ng trch nhim v cung cp mu, sn phm mu v hp ng cung cp
ngun ngi cho mu. Trong m bo:
- Trung tm truyn mu khu vc cung cp mu v t chc thu gom, sng lc,
sn xut v phn phi mu.
- Cc tnh cung cp ngun ngi hin mu tnh nguyn, h tr thu gom mu
v thc hin s dng mu an ton.
4.3.2. Vai tr trch nhim ca cc c quan n v:
b. Vai tr v trch nhim ca B Y t:
- Gim st vic thc hin iu lnh truyn mu v vn an ton truyn
mu.
- S kt nh gi hng nm vic thc hin Quyt nh 57 v m hnh cung
cp mu t trung tm n cc bnh vin.
c. Vai tr v trch nhim ca Ban ch o Cuc vn ng hin mu cc tnh:
- T chc tuyn truyn vn ng hin mu nhn o trong nhn dn ca
tnh.
- Ln k hoch t chc hin mu hng nm, thng, qu{, tun.
- Phi hp t chc thu gom mu theo k hoch v ch tiu ra: S ngi
hin mu bng 1,5 n 2 ln s n v mu m tnh nhn t TTTMKV.
d. Vai tr v trch nhim ca S Y t:
- Gim st thc hin hp ng v s dng mu ti cc bnh vin thuc S.
- Phi hp vi Ban ch o trong cung cp y , u n ngi cho mu.
e. Vai tr v trch nhim ca TTTM KV:
- Phi hp vi Ban ch o hin mu cc tnh trong vn ng v thu gom
mu.
- m bo c mu v ch phm cht lng v cung cp theo yu cu.
- Gim st cng tc vn chuyn, lu tr mu v ch phm mu cung cp.
- iu phi lng mu gia cc bnh vin.
- o to cn b truyn mu v s dng mulm sng.
- Nghin cu v trin khai phng php k thut mi trong truyn mu.
f. Vai tr v trch nhim ca bnh vin a khoa tnh:
- Tng hp nhu cu mu v ch phm ca cc bnh vin trong tnh, lp k
hoch s dng mu theo nm, qu{, thng v gi v Trung tm truyn mu
khu vc.
- K hp ng cung cp mu v cc ch phm mu vi trung tm truyn
mu.
- m bo vic vn chuyn, lu tr, phn phi v s dng mu bnh vin.
- Phi hp vi Ban ch o cung cp y , u n ngi hin mu.
g. Vai tr v trch nhim ca bnh vin s dng mu:
- Lp d tr mu v sn phm mu: Hnh nm, hng qu{, thng, tun.
- Ch nh s dng mu v ch phm mu hp l.
- Tng bc xy dng Phng pht mu hin i.
- Thanh ton kinh ph cc n v mu v ch phm mu s dng.
- o co nh kz vic s dng mu v ch phm.
V. NHNG KT QU C U TRIN KHAI M HNH CUNG CP MU TP
TRUNG CA TTTMKV H NI:
5.1. Trc khi trin khai m hnh:
Khu vc H Ni v 4 tnh gm Bc Ninh, H Nam, H Ty, Vnh Ph hin c khong
8 triu dn; 80 bnh vin: 20 bnh vin/vin Trung ng, 17 bnh vin
tnh/thnh/ngnh, 39 bnh vin huyn v 4 bnh vin ngoi cng lp.
Kt qu kho st v h thng truyn mu:
- 13 bnh vin trung ng, tnh/thnh c khoa, b phn truyn mu: t
chc thu gom, sng lc v pht mu thng xuyn v mt s bnh vin
huyn c ly mu cp cu truyn cho ngi bnh. Lng mu thu
gom v s dng hng nm khong 15.000 lt, tuy nhin s lng
cha p ng nhu cu mu v ch phm, hng nm vn cn thiu
mu trong dp h v Tt.
- i ng cn b b thiu v s lng v yu v cht lng.
- Trang thit b, phng tin cho thu gom, sng lc, sn xut, lu tr v
phn phi mu c, cn thiu, cha hin i v khng ng b.
- Truyn mu lm sng: Cha c an an ton truyn mu bnh vin; ch
nh v s dng mu ton phn trong iu tr chim trn 90%; cc quy
trnh truyn mu lm sng cn cha m bo.
- Cha c s iu phi mu gia cc bnh vin khi tnh trng thiu hoc
tha mu tm thi xy ra...
5.2. Kt qu bc u trin khai m hnh TTTM H Ni:
Trung tm truyn mu khu vc H Ni ti Vin Huyt hc - Truyn mu TW c
trch nhim tng bc cung cp mu v cc ch phm mu c cht lng an
ton cho nhu cu cp cu, iu tr, d phng cc thm ho, c mu d tr cho
nhu cu an ninhh, quc phng: S dng mu v cc sn phm mu hp l c hiu
qu. Cho cc bnh vin trn a bn thuc din bao ph: H Ni, H Nam, Bc
Ninh, H Ty v Vnh Ph. Trong thi gian qua, vic trin khai d n Trung tm
truyn mu khu vc thu c mt s kt qu:
5.2.1. Cng tc vn ng hin mu mu:
- Nhn thc ca nhn dn v hin mu nhn o tng cao, trin
khai tt v hin mu tnh nguyn khng ly tin theo Thng t
12/TTLT/BTC-BYT ngy 25/02/2003 ca lin tch B Ti chnh v B
Y t.
- S lng ngi hin mu ngy cng tng, t l ngi hin mu
tnh nguyn tng cao, cht lng mu c nng r rt.
- m rng c a bn v i tng tham gia hin mu.
5.2.2. Cng tc thu gom mu, sng lc mu:
- thu gom c 52.544 n v mu (tng hn nm 2004 l: 16.002 n
v), tng ng vi 14.824,3 lt.
- T l ngi hin mu tnh nguyn l kh cao 55,76%.
- Cht lng mu thu gom c c nng cao, do vic:
+ Sng lc c HV trc i vi ngi hin mu ln u.
+ Sng lc Hemoglobin trc cho mu bng dung dch CuSO4.
+ S lng n v mu 350ml tng cao.
- Sng lc cc bnh nhim trng: 100% s n v mu thu gom u c
sng lc 5 bnh ly truyn theo quy nh l HBV, HCV, HIV, giang mai v
st rt.
5.2.3 Cng tc iu ch, lu tr, phn phi v pht mu:
- iu ch sn phm mu: iu ch hu ht cc ch phm mu
c bn nh: Khi hng cu, khi tiu cu, khi bch cu, huyt
tng v ta lnh yu t VIII Tch cc thnh phn mu bng
my t ng nh Khi tiu cu t 1 ngi cho.
- Lu tr v phn phi mu: TTTMKV k{ hp ng v cung cp
mu cho cc bnh vin thuc din bao ph ca D n v 5 tnh
khc ngoi din bao ph d n. l kt qu ca s quyt tm v
s c gng trong lm vic, k kt nhiu hp ng cung cp mu v
ch phm vi cc tnh.
Bng so snh cc ch s thc hin ca nm 2005 so vi 2004
Ch tiu chuyn mn
Thc hin
2005
(n v)
Thc hin
2004 (n v)
Tmg, gim so vi
nm 2004
S lng n v mu thu
gom
52.544 36.541,8 Tng 143,79%
S lng lt mu thu
gom
14.824,5 9.135,5 Tng 162,27%
T l %NCM tnh nguyn 55,76 32,02 Tng 174,14%
T l %NCM Chuyn
nghip
44,24 67,63 Gim 65,41%
T l %NCM n v
350ml
31,64
21,40 Tng 147,85%
Khi TC tch t 1 ngi
cho
444 0 Tng 444 n v
S lng mu v ch
phm pht
90.287.5 51.551 Tng 175%
S c s Y t cung cp
mu
49 19 Tng 30 n v
S tnh/thnh ph nhn
mu
10 4 Tng 6 tnh
S ni thu gom, phn
phi mu
7 16 Gim 9 ni thu
gom
VI. KT LUN:
Hng triu ngi trn th gii c cu cha bng truyn mu v cng khng
t ngi t vong, khng c cu cha do thiu mu truyn hoc gp ri ro
truyn mu. An ton truyn mu ch c m bo khi c cc trung tm truyn
mu ln vi i ng cn b c trnh chuyn mn nghip v cao, trang thit b
hin i m bo nghim ngt cc qui trnh chuyn mn k thut v ng dng
cng ngh thng tin, c hot ng kim tra cht lng hiu qu m; bo cung
cp mu v ch phm mu y c v s lng v cht lng trong cp cu,
iu tr hng ngy v d phng thm ho.
Hin nay trn th gii h thng truyn mu ca cc nc hu ht t chc theo
hng tp trung ho cc ngn hng mu nh, ri rc thnh nhng ngn hng mu
ln c kh nng t chc thu gom mu, phn phi mu v ch phm mu cho
nhiu bnh vin, nhiu a phng khc nhau. Vit Nam, d n xy dng cc
Trung tm Truyn mu khu vc c Chnh ph ph duyt, theo n sau
nm 2010 chng ta ch cn khong 10 - 12 trung tm truyn mu thay th cho
gn 100 c s truyn mu cp trung ng, tnh.
M hnh Trung tm Truyn mu khu vc c trin khai ti H Ni, Hu,
Thnh ph H Ch Minh v Cn Th. Nhng kt qu thu c trong thi gian va
qua th hin c tnh u vit trong vn p ng nhu cu v s lng mu
v cc ch phm mu, nng cao v cht lng trong dch v truyn mu cng nh
m bo an ton truyn mu, khng nh xu hng tt yu trong s pht trin
ca ngnh truyn mu Vit Nam nhm m bo truyn mu an ton, hiu qu v
tit kim.
TI LIU THAM KHO
1. Trung Phn (2000), An ton truyn mu, Nxb Khoa hc v k thut.
2. Thi Qu{ (1999), Lch s truyn mu, Bi ging sau i hc, trng i hc Y
H Ni.
3. Nguyn Anh Tr (2004), An ton truyn mu v cc bin php m bo
truyn mu c an ton, Mt s chuyn Huyt hc Truyn mu, Nxb Y
hc, tr. 46-60.
4. Bch Quc Tuyn (1986), Truyn mu qu kh, hin ti v tng lai, Hi
tho Vit-Php v Huyt hc-Truyn mu ln th I, tr.10-11.
5. Jean C.E. (2001), WHO strategies for safe blood transfusion, The 11
th
regional
Western Pacific congress international society of blood transfusion, Chinese
journal of blood transfusion (14), pp. 39-42.
6. WHO (1993), Safe blood and blood products. WHO, Programme of AIDS, Mo.1.
7. Gavrilov O.K. (1987), Nhng vn c bn v t chc v nghin cu khoa hc
ca ngnh Truyn mu Maxcva, Ti liu dch ca Nguyn Anh Tr, pp. 4-6;
127-130.
8. Ennio.C Rossi; Loby L. Simon; Gerald S. Moss; Steren A. Goold (1996),
Transfusion in to the next millennium, Principles of transfusion Medicine
William & Wiklins, pp. 2-10.
9. Sang in Kim. MD (2001), Centralized transfusion service in Korea and Word
wide The 11
th
regional Western Pacific congress international society of blood
transfusion, Chinese Journal of blood transfusion, Beijing China, pp. 16-28.
10. Susan R. Hollans (1990), Development of a national blood transfusion sevice
Management of blood transfusion services WHO, pp. 17-26.

67. THC HIN CHIN LC QUC GIA PHNG
CHNG HIV/AIDS TRONG CNG TC AN TON
TRUYN MU NC TA N NM 2010 V
TM NHN 2020.
Nguyn Anh Tr, Nguyn Ch Tuyn

I. M U
Hn mi nm qua, vi s quan tm ca ng, Nh nc, B Y t v s n lc
ca ngnh Huyt hc - Truyn mu, cng tc An ton truyn mu c y
mnh. Tuy nhin vn ny cn nhiu bt cp. An ton truyn mu khng ch
n thun v mt k thut m cn lin quan nhiu n x hi - x hi cung cp
ngun ngi cho mu an ton hay khng? Vic ny cn l thuc vo s hiu bit
ca mi c nhn trong cng ng.
gim tc ng ca i dch HIV/AIDS trong cng ng, m bo An ton truyn
mu i hi phi c Chin lc quc gia vi s tham gia ca cc ngnh, cc cp
v ton x hi. Ngy 17/03/2004 Th tng Chnh ph ban hnh quyt nh s
36/2004/Q-TTg ph duyt chin lc quc gia phng chng HIV/AIDS Vit
Nam v tm nhn 2020 ngy 27/07/2004 B trng B Y t c Quyt nh s
2538/Q - BYT v phn cng xy dng chng trnh hnh ng ca Chin lc
ny - Vn ATTM c a vo chng trnh hnh ng s 5 v s 8.
II.CHNG TRNH AN TON TRUYN MU TRONG CHNG TRNH MC TIU
QUC GIA PHNG CHNG HIV/AIDS N NM 2010 V TM NHN 2020.
A. Tnh hnh dch HIV/AIDS trn th gii v Vit Nam.
1. Trn th gii:
Nhiu nc trn th gii, cuc vn ng ton dn cho mu khng ly tin
ginh thng li. Nm 1948, sau hi ngh ch thp ln th 17 Stockhom -
Thu in cuc vn ng ton dn cho mu khng ly tin c trin khai
khp hnh tinh. Hn 140 nc trn th gii v ang, thc hin mc tiu quc
gia v truyn mu.
Gn y, Trung Quc do tnh hnh nhim HIV/AIDS gia tng, An ton truyn
mu b e do nn thng 1 nm 1998 Chnh ph Trung Quc ban hnh Lut
Hin mu. Trong lut ny nu r trch nhim ca c quan chnh quyn cc cp
trong vic hng dn tuyn truyn v vn ng nhng ngi kho mnh phi c
ngha v cho mu, khi bn thn m au cn mu nhng ngi khc cho mu
cu mnh.
V An ton truyn mu, cc nc tin tin v cc nc trong khu vc p
dng k thut hin i sng lc cc bnh nhim trng qua con ng truyn
mu, do An ton Truyn mu c m bo. Tuy nhin, nguy c ly nhim cc
bnh nhim trng c bit l HIV vn cn rt ln, h lun phi i u vi nguy
c ny nh tnh hnh nhim HIV do truyn mu v cc ch phm mu Php,
Nht Bn, Cng ho lin bang c v gn y l Malaysia c 05 ph n b nhim
HIV do truyn mu, h i Chnh ph phi bi thng 26 triu USD (bo H Ni
mi ngy 23/05/2000) v nhiu quc gia khc nh chu Phi cng xy ra nhiu
trng hp tng t.
Chnh v bc xc ny ngy 07/04/2000 t chc y t th gii (WHO) ly ngy
ny lm ngy "An ton truyn mu ton th gii - an ton truyn mu bt u t
ti, t anh v t chng ta"
2. Vit Nam:
Vi s dn trn 80 triu ngi, nhu cu mu cho iu tr, cp cu phng cc
thm ho rt ln, theo WHO hng nm chng ta cn khong 400.000 lt mu (2%
dn s), hay 1.600.000 n v mu (1 n v = 250ml).
Nm 2003 c nc chng ta mi thu khong 82.000 lt mu (328.000 n v
mu) t 20,3% nhu cu i hi. Trong ch c 36,97 % l ngi cho mu tnh
nguyn (tnh nguyn cn nhn tin bi dng) cn 63% l ngi chuyn i bn
mu. Tim n ca ly nhim HIV cn rt ln v ni no cn c mua v bn mu
th an ton truyn mu vn cn b e do.
Thc trng v An ton truyn mu nc ta vn l vn bc xc hin
nay. Cc k thut sng lc bng huyt thanh cha bo m An ton, ang mc
th s; Nhiu c s truyn mu cn dng k thut ngng kt, kt nhanh xt
nghim sng lc mu (HIV). Trong khi nhiu nc trn th gii s dng kt
HIV hn hp c khng nguyn v khng th (Ag/Ab) v k thut PCR, NAT xt
nghim sng lc mu. Do vy cht lng mu v An ton truyn mu l iu ht
sc bc xc. Tnh trng nhim HIV do truyn mu xy ra, c hng trm
ngi i cho mu nhim HIV c xt nghim sng lc pht hin, nguy c ly
nhim HIV giai on ca s huyt thanh cn rt cao. Truyn mu ton phn l
ch yu (>90% hu ht cc tnh) va lng ph, va khng an ton. H thng
truyn mu lm sng cha c xy dng nn vic theo di v hng dn s
dng mu cn rt lc hu.
Trc tnh hnh ny nu khng c quan tm u t c vt cht, trang
thit b, u t v tr tu mt cch ng mc th nguy c nhim HIV/AIDS v cc
bnh nhim trng qua con ng truyn mu s rt ln.
Bn cnh vic thiu kinh ph u t trang thit b, thiu ng b, s c s
ly mu nc ta cn qu nhiu, c nc c 64 tnh thnh ph (c ti 83 c s
thu gom mu cp tnh), c ti 442 im ly mu cp qun huyn. S phn tn
v manh mn ny ang cn tr vic s dng cc thit b mi v hin i.
T nhng l do trn vic xy dng chng trnh ATTM l mt vn cp bch,
gp phn nng cao cht lung khm cha bnh cho nhn dn; Thc hin nghim
chnh quyt nh ca Th tng chnh ph v chin lc qua phng chng HIV/
AIDS Vit Nam n nm 2010 v tm nhn 2020.
B. Cng tc an ton truyn mu.
1. Tm quan trng.
Nh phn trn nu, An ton truyn mu bao gm.
a/ Ngun ngi cho mu: Tin ti xo b vic mua bn mu. Theo quyt nh s
198/Q - TTg ngy 28/12/2001 phi t 50% cho mu khng ly tin vo nm
2005 v 70% vo nm 2010.
b/ m bo tt cng tc thu gom sng lc mu (ti n v mu) thu gom 100%
n v mu c lm xt nghim HIV ( k c cp cu) v cc xt nghim khc
HBV, HCV, giang mai, st rt. Cc ni c iu kin lm nhng xt nghim khc
nh nhm Rh, khng th bt thng, ALT ...
c/ iu ch cc sn phm mu.
d/ Thc hin truyn mu tng phn, bnh nhn thiu g truyn ny, khng cn
khng truyn - ch nh truyn mu ng.
g/ Pht trin k thut pht mu an ton.
h/ Lu tr, bo qun, phn phi mu v ch phm mu an ton.
2. Mng li truyn mu.
n nm 2010 tin ti c nc ch c 16 trung tm truyn mu khu vc. Hin nay
d n vay vn ngn hng th gii xy dng 4 TTTM khu vc (H Ni, Hu, Bnh
vin Ch Ry, Cn Th). D n ny bao ph 21 tnh thnh ph, phc v 29 triu
dn. Cn li 43 tnh, thanh ph s sp xp li c 12 TTTM khu vc. H thng
truyn mu Vit Nam s tp trung, dn tng bc hin i ho, thc hin tt
chc nng ngn hng mu - m bo an ton truyn mu.
3.i ng cn b.
Chuyn ngnh Huyt hc - Truyn mu trong ton quc s lng cn b ng
o. Tuy nhin nhiu GS, PGS, TS c kinh nghim theo ch v ang dn ngh
cng tc qun l v chuyn mn. Ngnh Huyt hc - Truyn mu phi c k hoch
o to:
- Bc s chuyn khoa Huyt hc - Truyn mu (BS ngn hng mu, BS huyt hc
truyn mu bnh vin).
- K thut vin chuyn khoa Huyt hc - Truyn mu.
- Y t iu dng chuyn khoa Huyt hc - Truyn mu.
Vin Huyt hc - Truyn mu TW c trch nhim bo co lnh o B Cc trng
i hc, trung cp v k thut trong c nc c k hoch o to chuyn khoa
huyt hc truyn mu t nay n nm 2010 v tm nhn 2020 m nhn cng
tc chuyn khoa.
4. Cc hot ng chnh.
- Ch o ngnh: Ch o cng tc huyt hc v lm sng bnh mu.
- T chc v xy dng h thng truyn mu trong ton quc, t tiu chun khu
vc v quc t.
- y mnh cuc vn ng hin mu nhn o thc hin v trin khai tt quyt
nh s 43/2000/Q- TTg ngy 7/4/2000 ca Th tng chnh ph v vic vn
ng khuyn khch nhn dn tham gia hin mu tnh nguyn tng ngun ngi
cho mu an ton, ng thi thc hin, trin khai tt quyt nh s 198/2001/Q -
TTg ngy 28/12/2001 ca Th tng chnh ph n nm 2005 c 50 % v nm
2010 c 70% ngi cho mu tnh nguyn khng ly tin.
Thc hin tt thng t lin tch gia B Y t - B Ti chnh (s 12/2004/TTLT - BYT
- BTC ngy 25/02/2004) v tn vinh ngi cho mu tnh nguyn khng nhn tin.
- Trnh B Y t, Chnh ph, thnh lp Ban ch o vn ng HMN ton quc.
- Php lnh hin mu cu ngi - Trch nhim ca cng dn.
III/ MC TIU CA CHNG TRNH ATTM
1. Mc tiu chung.
Tng bc cung cp mu, sn phm mu c cht lng v an ton cho nhu cu
cp cu, iu tr, d phng cc thm ho, c mu d tr cho nhu cu an ninh,
quc phng.
S dng mu v ch phm mu hp l, hiu qu gp phn lm gim t l t vong,
t l mc bnh, tng cng hp tc quc t v u t quc t.

2. Mc tiu c th.
2.1. T chc v xy dng hp l h thng truyn mu t tiu chun khu vc,
quc t: Nhm tng cng cung cp mu v ch phm mu c cht lng cho
nhu cu cp cu, iu tr, d phng thm ho, c mu d tr cho nhu cu an ninh
v quc phng.
2.2. y mnh vn ng hin mu nhn o tnh nguyn khng ly tin, hp tc
vi Ch thp , thanh nin, sinh vin v cc on th c nhiu ngi cho
mu an ton.
2.3. m bo 100% n v mu (k c cp cu) c xt nghim, sng lc c 5
bnh nhim trng (HIV, HBV, HCV, giang mai, st rt) phn u n nm 2010 cc
c s truyn mu tuyn tnh khng s dng k thut ngng kt ht (Serodia)
trong sng lc HIV. S dng kt hn hp khng nguyn v khng th (Ag/Ab) trong
k thut ELISA sng lc HIV.
2.4. Nng cao cht lng mu v sn phm mu t tiu chun khu vc v quc
t bao gm tiu chun v ngi cho mu, v thu gom mu, sng lc cc bnh
nhim trng, iu ch cc sn phm mu, bo qun, vn chuyn v phn phi
mu v ch phm mu.
2.5. Xy dng h thng truyn mu bnh vin nhm s dng mu, cc sn phm
mu an ton, hiu qu v hp l.
IV. CC GII PHP THC HIN
1. T chc v xy dng hp l h thng truyn mu; o to v o to li i
ng cn b, k thut vin, y t v iu dng m bo c ni dung cng
vic c 3 tuyn: Trung ng, tnh, huyn.
2. X hi ho cng tc vn ng hin mu nhn o tnh nguyn theo quyt nh
43/2000/Q - TTg ngy 7/4/2000 ca Th tng chnh ph tng ngun ngi
cho mu an ton.
3. Tng bc i mi b sung cc trang thit b p ng yu cu pht trin c 3
tuyn: Trung ng, tnh v huyn.
4. Xy dng Ngn hng mu chun ti Vin Huyt hc - Truyn mu TW, 4 Trung
tm truyn mu khu vc v cc thnh ph ln t trin khai ra ton b cc tnh,
thnh trong c nc.
5. Nng cao cht lng t chc v qun l h thng truyn mu trong c nc.
- Sa i v b sung iu lnh Truyn mu (ban hnh 1992) cho ph hp vi tnh
hnh thc t Vit Nam v quc t.
- Xy dng tiu chun ngn hng mu v truyn mu bnh vin c 3 tuyn
Trung ng, tnh, huyn.
- Xy dng h thng kim tra cht lng mu v sn phm mu trong ton
ngnh.
- Tng cng hp tc quc t nng cao cht lng o to, trao i kinh
nghim v nhng thng tin mi chuyn ngnh Huyt hc - Truyn mu.
V. KT LUN
Thc hin chin lc quc gia phng chng HIV/AIDS trong cng tc An ton
truyn mu - m bo 100% cc n v mu v ch phm mu (k c cp cu)
c sng lc HIV trc khi truyn tt c cc tuyn (Trung ng, tnh, huyn).
Tng bc nng cao cht lng xt nghim HIV trong sng lc mu, tng cng
tuyn truyn, vn ng v pht trin bn vng phong tro Hin mu nhn o
tnh nguyn l trch nhim ca mi cn b, nhn vin trong ngnh Huyt hc -
Truyn mu Vit Nam.

SUMMARY
The National strategy on HIV/AIDS Prevention and control in Vietnam till 2010
with A vision to 2020.
(Blood Transfusion safety Project).
The percentage of blood unit which are screened before Tranfusion has increased
every year, from 2000 till now, 100% of blood units and blood products have been
screened. The mobilization of humanitarian blood donation has received due
attention and been stepped up with many humanitarian blood donation
Campaign having been held in all localities. In 2003 alone, the blood Transfusion
system onganized > 500 humanitarian blood donation drives, there by increasing
the percentage of blood donation to 41,75% of total collected blood volume.
Ensuring safe blood Tranfusion is a very great effort of the medical system,
gaining the poeple's confidence and coutributing to maintaining the social
stability.
+ To guide, examine and inspect blood Tranfusion to prevent HIV Transmission. To
strictly implement law provisions on blood Transfusion safety; To formulate and
supplement legal documents on blood Tranfusion safety.
To concentrate joint efforts of the Red cross society, the youth Union and other
branches and services, especially with party organizations, administration at all
levels on conducting propaganda and communication to mobilize non-HIV risk
healthy people to voluntarily donate blood, and consistently maintain the source
of safe blood donors - Donation of safe blood is not only a humanitarian deed but
also a duty of every individual to ward the community.
+ To increase the quality of screening of HIV for blood units and blood products
before being Transfused, provide in time adequate good - quality bio-products for
blood screening in order to ensure 100% of blood units and blood products are
screened for HIV before Transfusion to gradually socialize safe blood transfusion
by calculating fully the unit cost of blood units and blood products.
+ To encourage the increased application of appropriate modern techniques and
prescription of blood transfusion such as: partial blood Transfusion, blood self -
Transfusion, filter of white blood cells... in order to reduce the risk of HIV
infection.
To strictly comply with the rules of blood Transfusion Safety. The prescription of
blood Transfusion should be correctly made to limit total blood Transfusion to are
anemia.
+ To build centralized blood banks (Regional blood banks) using foreign aid and
domestic funding sources, step by step modernize the safety system in blood
transfusion.
+ To provide Knowledge and raise kills for professional staff working in the
Hematology Blood Transfusion system in particular and health worker general on
HIV and blood Transfusion safety.
+ To buil laboratories of national standards for quality control of blood
Transfusion safety including: quality control of bio-products, control of testing
procedures, equipment...



HT





Hin mu cu ngi, mt ngha c cao p.