Cẩm Nang Huyết Học - yhocthuchanh2015

2013
CM NANG
HuYT HC
CUN SCH U TAY CA L VN CNG
Cun sch l tt c nhng g mnh hc tp, tch ly v nghin
cu c trong sut qu trnh hc tp mn Huyt hc. N bao
gm hu ht nhng kin thc thit thc ca mn Huyt hc v
Truyn mu. Hn na , kin thc trong cun sch c vit
di gc ca mt sinh vin nn s tr nn gn gi v d
hiu hn rt nhiu so vi cc Gio s Tin s . Bn hon ton
c th yn tm vi lng kin thc trong cun sch .Bi n
khng ch a ra nhng l thuyt c ng , y m n cn
km theo c gii thch ngha ca tng xt nghim, tng thay
i trong cc trng hp bnh l. Chnh y l ci m mnh
tm c nht cun cm nang ny. Bi ch khi bn hiu bn
mi gii thch c , ch khi bn gii thch c bn mi c
th nh lu c.V ch khi nh lu c bn mi c th hc
tp v lm vic tt c.
L VN CNG
Lp i hc xt nghim 4b i hc k thut y t Hi Dng
Th T, 24 Thang By 2013
CM NANG HUYT HC NG MU
L VN CNG
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Khoa xt nghim
i hc k thut y t Hi Dng
L VN CNG
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Khoa xt nghim
CM NANG
HUYT HC
NG MU
L THUYT NG MU V CC XT NGHIM LIN QUAN
Cun sch u tay ca :
L Vn Cng- i hc k thut y t Hi Dng
Sch ch tng khng bn
KHNG G L KHNG TH
Khi mi chuyn tr nn kh khn , hy t hi bn thn , mnh phi lm g
thay i cc din , mnh phi lm g ci thin tnh hnh.V hy hnh ng
bn nh. ng nn nh bn v ti, bi trn ng i , ch lc vp ng mi bit
mnh ang sai. ng sng trong nhng hoi nim p ca qu kh , m hy
vch ra cho mnh mt tng lai sng sa pha trc.Chc bn v ti thnh cng
trong hc tp v cuc sng
L Vn Cng
L VN CNG
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Khoa xt nghim
L VN CNG
5
Khoa xt nghim
L VN CNG
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Khoa xt nghim
LI M U
Xut phat t nim am m vi mn Huyt hc , v cng mt phn mun khng nh li
kin thc m mnh tip thu c trong sut qua trnh hc tp i hc. Mnh dc ht
thi gian v cng sc t tay vit ln cun Cm nang huyt hc . B cm nang gm
gm 4 cun l 4 phn ca huyt hc : Huyt hc t bo , Huyt hc ng mu , Huyt
hc Min dch v truyn mu , Huyt hc chuyn su v cc vn cn bit.
Cun sach gm tt c nhng g mnh hc tp, tch ly v nghin cu c , trong sut qua
trnh hc tp mn Huyt hc. N bao gm hu ht nhng kin thc thit thc ca mn
Huyt hc v Truyn mu. Hn na , cun sach c vit di gc ca mt sinh vin
nn n s tr nn gn gi v d hiu hn rt nhiu so vi cac Giao s , Tin s .Bn hon
ton c th yn tm vi lng kin thc trong cun sach. Bi n khng ch a ra nhng l
thuyt c ng, y , m n cn km theo c gii thch ngha ca tng xt nghim ,
tng thay i trong cac trng hp bnh l.Chnh y l cai m mnh tm c nht cun
sach ny. Bi ch khi bn hiu bn mi gii thch c , ch khi gii thch c bn mi
nh c th nh lu c. V ch khi nh lu c bn mi hc tp v lm vic tt c.
Bn cnh nhng u im trn th cun sach ny cn c rt nhiu thiu st .Mc d mnh
c gng ht sc r soat v chnh sa , song cng khng th tranh c sai st v cach
trnh by v li chnh t. c bit , y ch l nhng nghin cu nho nh ca bn thn da
vo cc thng tin mnh c sch v nghin cu cc ti liu trn Internet , n cha c
thy c v nhng ngi c uy tn kim chng tnh chnh xc ca vn c cp. V vy
mnh rt mong c bn c v thy c chn thnh ng gp v ni dung ca cun sach,
n tr nn hon ho v tin cy hn. Qua , mnh c th tip thu c nhng kin thc mi
sa cha c nhng hiu bit sai lm trong kin thc cp.
Cun sach ny dnh ring cho L Vn Cng , Lp HXN 4b ,i hc k thut y t Hi
Dng. Nn khng bn Khng mua - Khng cho mn nu khng c s ng ca
mnh. Nu bn c quan tm ti nhng kin thc trong cun sach, mun tm hiu thm
thng tin v c lng ng gp cho cun sach , bn hon ton c th mn mnh c v chp
li nu cn. Mnh b rt nhiu thi gian bn cai may tnh , b nhiu trn bng a
Premier League ca Manchester United v nhng trn cu C1 ny la( i bng con cng
ca bn ang m bn li ang hc th tht l kh chu ht mc, hn na li l nhng
dp cui tun , lc m tt c mi ngi u chi ). c bit N l a con tinh thn ca
mnh, mnh khng mun ai xm phm n. Mnh khng mun cng sc , thi gian , sc
khe ca mnh mang ra quan photo mt cach r mt, mua ban-trao i mt cach min ph
v thoi mai nh bao quyn sach khac.Mong c mi ngi tn trng. Xin cm n!!!!!
Hi Dng , ngy 1 thang 5 nm 2013
L VN CNG
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Khoa xt nghim
L VN CNG
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Khoa xt nghim
MC LC
I-CM MU BAN U
1. Cc yu t tham gia CMB10
2. Cc XN nh gi CMB.12
_ Nghim php dy tht12
_ Thi gian mu chy ( PP Duke )...13
_ XN co cc mu...14
II- NG MU
1. iu ha qu trnh M-Cc yu t tham gia.15
2. Cc giai on ca qu trnh ng mu19
3. Cc XN kho st qu trnh ng mu.24
_ Thi gian mu ng trn lam.24
_ Thi gian mu ng trn ng nghim..25
_ Thi gian Howell26
_ Thi gian APTT.27
_ Thi gian TT...33
_ Bng tm tt cc XN ng mu34
III- TIU SI HUYT

1. Plasminogen v Plasmin39
2. Cht hot ha Plasminogen40
3. Cht c ch qu trnh TSH.42
4. Sn phm thoi ha Fibrin-Cc mnh FDPs.46
5. Cc XN kho st qu trnh tiu si huyt...46
6. Cc xt nghim chuyn su khc
_ Xc nh s c mt cht khng ng ni sinh56
_ Xc nh s c mt cht khng ng ngoi sinh..57
_ Xc nh s c mt cht khng ng ( ni chung )..59
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Khoa xt nghim
_ Xc nh hot tnh yu t III tiu cu.60

_ nh lng yu t XIII.61
_ nh lng yu t M ni sinh VIII ,IX, XI , XII..62
_ nh lng yu t M ngoi sinh VII , X , V..64
_ nh lng Fibrinogen..67
IV- BNH NG MU
1. Hi chng ng mu ri rc lng mch (DIC)..71
2. Hi chng xut huyt gim tiu cu huyt khi (TTP).74
3. Hi chng tan mu Ure huyt cao (HUS).75
4. Tnh trng tng ng-Bnh huyt khi..77
5. ng mu thai nghn...82
6. Bnh Hemophilie ..83
7. Bnh ri lon ng mu mc phi.85
_ Thiu VTM K85
_ Bnh gan.86
_ Bnh h thng Lupus ban (SLE).87
_ Ri lon ng mu sau truyn mu d tr t89
_ Bnh vim thnh mch d ng89
8. Bin lun xt nghim ng mu.90
9. Cc gi tr M cho cuc m an ton. 91
10. Tm hiu c ch v ng dng mt s cht-thuc chng ng
_ Heparin..92
_ Natricitrat..92
_EDTA ( Ethylene diamin tetraacetic acid )..93
_ Wafarin ( thuc c ch VTM K ng ung )94
_ Aspirin.94
11.Bng tr s bnh thng-bt thng ca cc XN ng-cm mu.95
12.Tr s bnh thng ca cc yu t tham gia ng-cm mu v TSH.96
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Khoa xt nghim i hc k thut y t Hi Dng
PHN II- NG MU V CC XT NGHIM LIN QUAN

ng mau gm 3 qua trnh
Cm mau ban u ( CMB )

ng mau ( M )
Tiu si huyt (TSH)
CM MU BAN U
I. 3 YU T
1. Thnh mch
THAM GIA CMB
Ni mch :
_ Cu to : lp n bo , lt ph mt trong ca mch mau
_ Chc nng :
+) Ngn cch dng mu vi t chc khc
+) Chng sinh huyt khi nh heparin sulphat b mt ni mc
+) c ch cc enzyme M nh glycosamino glycan
+) Chng dnh v ngng tp tiu cu nh ADP-ase ging ha ADP
+) Cha thrombomudulin hot ha protein C ( ging ha bt hot Va , VIIIa ) ,
to ra Protein S ( ng yu t protein C , vai tr tng t Pro C )
+) To ra plasminogen khi ng qu trnh TSH
+) SX yu t Willebrand l cht keo sinh hc , gn TC vi Collagen thnh mch
Lp di ni mch
_ Cu to : collagen , Willebrand , Fibrionectin , vi si , si n hi
_ Chc nng : Lp din tch gy ng , hot ha TC v yu t tip xc , khi
lp ni mch b tn thng.
2. Tiu cu
_ Cu to : Mng TC + NSC
+) Mng TC :
Lp kp phospholipid (PL) : ni din ra mt s hot ng M
H thng knh m :gii phng cac ht trong NSC v tng din tch t.xc b mt ca TC
+) NSC : h thng vi ng , vi si , ng dy c ,cac ht : ht c (ADP , Ca2+ ,
serotonin ),ht (PDGF , Ca2+ , Willebrand , Fibrinogen , Fibrionectin ,
Thromboglobulin), thrombosthenin ( protein co ca TC )
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_ Chc nng :
+) Tham gia qu trnh CMB : Nh kh nng dnh- ngng tp , gii phng cac ht
trong NSC.
+) Tham gia qt M : nh yu t 3 PL ca TC cn thit cho s hot ha yu t
VIIa, Xa , Iia.
+) Tham gia giai on co cc mu : nh thrombosthenin trong NSC ca TC
+) Bo v thnh mch : lm non ha TB ni mch , cng c lp ni mch qua yu t
tng trng PDGF
+) p ng vim v thc bo
3. Yu t protein huyt tng : Willebrand , Fibrinogen

Willebrand :
+) Sx t TB ni mch , l cht keo sinh hc gn TC vi collagen thnh mch
+) Kt hp vi yu t VIII , hnh thnh phc hp W-VIII , lu hnh trong mau ,
n nh yu t VIII , bo v yu t VIII do n d b hy trong huyt tng.
Fibrinogen : c tng hp duy nht ti gan , tham gia cng c nt tiu cu nh hnh
thnh si Fibrin khng tan bao quanh nt TC , v l yu t tham gia qua trnh M
II.
CC GIAI ON CMB
1. Co mch
_ Thnh mch tn thngkch thch auco c trn lng mch hp ligim

lng mau mt qua ch tn thngto iu kin hnh thnh nt cm mau
_ ngha : C ch t bo v ca c th , chu tac ng yu t TK-TD .
2. Hnh thnh nt tiu cu

_ Thnh mch tn thnglp ni mch b rachbc l lp di ni mchTC dnh ,
ngng tp v hot ha : thay i hnh dng , gii phng ra cac yu t gip TC dnh thnh
mch , c bit gii phng yu t ADP , Thomboxan A2 hot ha TC xung quanh ,
lm cac TC ngng tp vi nhau ngy cng nhiuTo k hnh thnh nt TC
_ Nt TC mi hnh thnh cn lng lo , d thm , d b dng mau ra tri , v sau c
cng c vng chc , nh hnh thnh si Fibrin khng tan bao bc.
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S CM MU BAN U
( Ngun : http://xetnghiemdakhoa.com )
III.
1.
CC XT NGHIM NH GI CMB
Nghim php dy tht ( sc bn thnh mch )
_ Nguyn tc XN : To 1 ap lc ln mch mau ngn cn dng mau chy v , cac
mch nh v yu s v , HC thoat ra ngoi , to nn cac nt xut huyt . m s nt
xut huyt anh gia sc bn ca thnh mch
_ Mc ch ngha XN :Kho sat qt cm mau ban u (CMB ) , anh gia cht
lng ca thnh mch
_ Nhn nh kt qu :
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+) < 7 nt xut huyt bnh thng

+) >7 nt xut huyt ghi (+) n (++++)
_ Bin lun kt qu : Sc bn mao mch gim khi
+) Tn thng thnh mch : vim thnh mch d ng , c ha cht , .
+) Gim tiu cu ( s lng v / hoc cht lng ) : Suy nhc tiu cu , Leucemia ,
bnh Willebrand .
+ ) Bnh khac : ngi gi , thiu VTM C , .
2. Thi gian mu chy ( Bleeding time-BT ) theo pp Duke

_ Nguyn tc XN : To vt thng vng gia dai tai , o thi gian mau chy t lc to vt
thng n lc mau ngng chy.
_ Mc ch ngha XN : Kho sat qua trnh cm mau ban u , qua anh gia : yu t
thnh mch + tiu cu v 2 yu t Willebrand , Fibrinogen
Mu chy ph thuc
Cht lng thnh mch

S lng tiu cu
Cht lng tiu cu
Yu t Willebrand + Fibrinogen ( SL v CL )
_ Tin hnh :
+ ) Dng c : kim chch , bng , giy thm, ng h
+) Ha cht : Cn 900 ( ete ) bay hi nhanh , khng lm nh hng mch mu xung
quanh v tr chc.
+) Quy trnh:
B1: Sat khun v tr chc i 1-2 cho cn kh
B2: Chch kim vung gc mt phng dai tai( su 2 di 5 ) v bm ng h
B3: Thm mau cho BN , 30s /1 ln , n khi khng thm c bm ng h dng
li ,ghi kt qu lm trn xung.
Ch :
Nu mau chy t hoc khng chy , i 2 , ghi kt qu MC=2

Nu mau chy >6 , i n 10 m vn chy , dt bng cho bnh nhn , ghi kt qu
_ Nhn nh kt qu
Xem video quy trnh ti a ch
+) Bnh thng : 1-4
http://www.youtube.com/watch?v=wmQrqXJCAso
+) Ko di : >6
+) Nghi ng : 4-6 khi phi tin hnh li vi tai kia hoc dng pp Ivy
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( PP Ivy : to vt thng mc trc cng tay , duy tr di p lc 40mmHg , o

thi gian mu chy t lc to vt thng n lc mu ngng chy )
_ Bin lun kt qu : Thi gian mau chy ko di khi
+) Tn thng thnh mch : vim thnh mch d ng, mhim c , thiu Collagen,..
+) Thiu tiu cu ( s lng v / hoc cht lng ) : Suy nhc TC ,KT khng TC
+) Thiu yu t Willebrand , Fibrinogen ;Bnh Willebrand ,suy gan nng
+) iu tr Heparin , dng thuc gim au Aspirin (tham kho c ch bi thi gian Howell)
3. Co cc mu
_ Nguyn tc XN : Mau ly ra khi c th s ng li nh hnh thnh si Fibrin , si
Fibrin m ly cac thnh phn hu hnh ca mau ri co rt li tach khi phn huyt thanh.
_ Mc ch ngha : Kho sat qua trnh CMB , qua anh gia cht lng v s
lng ca tiu cu , Fibrinogen , yu t XIII
Co cc mu ph thuc
S lng v cht lng ca TC

S lng v cht lng ca Fibrinogen
Yu t XIII
Th tch khi HC ( hematocrit )
_ Tin hnh
+) Dng c : B ly mau TM , 2 ng nghim sch trang nc mui sinh l ( to mi
trng ng trng trn thnh ng nghim HC khng v ), bng m , ng h , ni
370
+) Ha cht : Cn 700 , NaCl 9 %0 trang ng nghim
+) Bnh nhn : Ly mau TM
+) Quy trnh :
B1: anh s , ghi tn ng nghim
B2: Ly mau tnh mch khong >2ml bm vo 2 ng nghim trang mui SL
nt cht bng m cho vo ni cach thy sau 4h em kho sat.
_ Nhn nh kt qu:
+ Co cc mau anh gia 4 mc
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Co hon ton :
Co khng hon ton
Cc mau b nat
Cc mau khng co
15
_ Bin lun kt qu: Cc mau khng co , co khng hon ton , cc mau b nat trong
trng hp
+) Gim TC ( SL v /hoc CL ) : Bnh suy nhc TC , KT khng TC , , Leucemia ,..
+) Thiu ht Fibrinogen : Suy gan nng , RL chc nng Fibrinogen
+) Thiu yu t XIII ( xem li chc nng ca yu t XIII )
+) Tng th tch khi HC : a hng cu ( khi HC qu ln ,si Fbrin khng th m ht)
+) iu tr Heparin ( xem gii thch bi APTT )
NG MU
I.
IU HA QU TRNH NG MU
1. Cc yu t hot ha ng mu
Tn yu t
1. Fibrinogen
(I)
2. Prothrombin
(II)
3. Pro-Accelerin
( V)
4. Pro-Convertin
( VII )
5. Yu t VIII
Nhm 1: 12 yu t ng mu huyt tng

Chc nng
_ Fibrinogen sx duy nht ti gan, nng trong mu 2-4 g/l , hot ha
thnh Fibrin bao quanh nt TC , v hnh thnh cc mau ng
_ Do gan tng hp, Prothrombin hot ha thnh Thrombin (IIa)- trung
tm M , hot ng cn VTM K , Ca2+
+) Thrombin gy ngng tp TC rt mnh m rng nt cm mau
+) Thrombin xc tac chuyn Fibrinogen Fibrin
+) Thrombin hot ha V , VIII, XI m rng hot ng M ni sinh
+) Thrombin hot ha yu VIIVIIa m rng hot ng M ngoi
sinh
+) Thrombin hn ch hot ng lan trn ca chnh n bng hot ha
Protein Cc ch M thng qua bt hot yu t Va v VIIIa
+) Thrombin thc y qua trnh TSH thng qua thc y TB ni mch
tng sn xut yu t t-PA tng chuyn Plasminogen Plasmin
_ Do gan sx ,yu t V d b hy trong h/tng lu tr
_ Yu t V l ng yu t ca yu t X , Va cng vi yu t Xa, Ca2+ ,
PL hnh thnh nn phc hp Prothrombinase
_ Do gan sx , cnVTM K v Ca2+ hot ha.
_ Yu t VII , khi ng c/ng M ngoi sinhc/ng ch o
c/th.
_ Do gan sx , yu t VIII d b hy trong huyt tng lu tr , trong mau
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( Chng Hemophili A )
6. Yu t IX
( Chng Hemophili B )
7. Yu t X
(Stuart )
8. Yu t XI
( Rosenthal )
9. Yu t XII
( Hageman )
10. Yu t XIII
11. Yu t PK
( Pre-Kallikrein )
12. Yu t H.M.W.K
kt hp vi yu t Willebrand tng tnh bn vng.

_ Yu t VIII l ng yu t ca yu t IX , cng vi yu t IXa hot
ha yu t X.
_ Do gan sx , hot ng cn VTM K , Ca2+ khi hot ha
_ Yu t IXa cng yu t VIIIa , Ca2+ ,PL hot ha yu t XXa
_ Do gan sx , cn VTM K v Ca2+ hot ha
_ Yu t Xa tac ng ln : V , Ca2+ , PL hnh thnh nn phc
Prothrombinase ct lin kt peptid ca Prothrombin Thrombin
_ Do gan sx , hot ha thnh XIa , khi c mt Ca2+ , XIa hot ha
yu t IXIXa.
_ Do gan sx , yu t XII l yu t t/xc m u con ng M ni sinh.
_ Do gan sx , cng vi Ca2+ , yu t XIII ng vai tr n nh Fibrin t
ha tan Fibrin khng tan.
_ Do gan sx , l yu t tip xc m u con ng M ni sinh
_ Do gan sx , l yu t tip xc m u con ng M ni sinh
1. Yu t thnh mch ( ni mch )

_ Ni mch c nhiu yu t t chc (TF) khi ng con ng M ngoi sinh
_ Lp di ni mch cha collagen , tip xc v hot ha TCkhi ng CMB
_Cha Heparin sulphat tng cng hot ng ca AT III c ch qu trnh M
_ Tac ng ln Thrombomodulin hot ha Protein C c ch M thng qua bt hot y/t Va,VIIa
2. Yu t Tiu cu
_ TC mang cac yu t M xung quanh mnh to nn lp Kh quyn quanh TC
_ TC cha PL mng , khi hot ha tch in m , to iu kin cho yu t M tip xc v gn bam
_ Cht c ch lupus lm kt ta PL tiu cu , ngn IIIIa , gy bin chng huyt khi
3. Yu t t chc (TF)
_ TF c hu ht trong t chc v mch mau, c nhiu trong no v phi , khng c trong TB ni
mch , n to v bc phong ph quanh mch mau nhng li khng tip xc c vi mau do b
ngn cach bi lp ni mch
_ Khi lp ni mch tn thng , TF c gii phng v tip xc vi dng mau , khi ng con
ng ng mau ngoi sinh ( TF gn vi PL TF-phospholipid hot ha yu t VIIVIIa )
4. Yu t Ca2+
_ To iu kin cho yu t ph thuc VTM K ( II , VII , IX , X ) kt hp vi PL hot ha
_ Th hin hot tnh ca yu t XIIIa
_ n nh yu t V , phc h Willebrand-VIIIc
1. Cc yu t c ch ng mu
Nhm 1 : Cc cht c ch Serin protease
1. AT III
_ Sx ti gan , nng trong mau 240 mg/l
( Anti thrombin III )
_ c ch Thrombin , Kallikrein , IXa , Xa , XIa , XIIa
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2. 1- AT
( Alpha 1 Anti trypsin )
3. 2-MG
( Alpha 2-Macro Globulin )
4. HC II
(Heparin confactor II)
5. Cht c ch C1
_ AT III bt hot ch yu Thrombin v yu t Xa , s bt hot ny

cng mnh m khi c mt Heparin do to phc :
AT III Heparin Thrombin
_ AT III khng bt hot yu t VIIa
_ Sx ti gan
_ c ch thrombin , Kallikrein , XIa
_ Sx ti gan
_ c ch Thrombin , Kallikrein
_ Sx ti gan
_ c ch Thrombin
_ Sx ti gan
_ c ch Kallikrein , XIa , XIIa v cac Proteinase b th C1
Nhm 2 : H thng protein C

1. Protein C
_ Sx ti gan , ph thuc VTM K khi tng hp

_ c ch 2 ng yu t Va , VIIIa khi c mt PL- ca TC v Pro-S
Ca2+
_ B c ch bi 1-AT v PCI
2. Protein S
3. Thrombomodulin
_ Sx ti TB ni mc
_ Thrombomodulin cng Thrombin tham gia hot ha protein
Cbt hot 2 ng yu t Va , VIIIa
4. Cht c ch tng hp _ Yu t duy nht c ch yu t VIIa
TFPI
_ TFPI to phc Xa-TFPI-VIIa-TF nn bt hot Xa,VIIa,TF
1. Nhm cc yu t tip xc:

_ Gm 4 yu t yu t XI, XII, prekallikrein v H.M.W.K. tham gia vo giai an khi
ng con ng ng mau ni sinh khi mau tip xc vi lp di ni mc.
_ c im chung l bn vng, n nh tt trong huyt tng lu tr, khng ph thuc
vitamin K khi tng hp v khng ph thuc ion canxi khi hot ha.
2.Nhm cc yu t ph thuc vitamin K (hay nhm prothrombin) :
_ Gm cac yu t II, VII, IX, X. Cac yu t ny u l zymogen (tin men) ca cac serin
protease (men hot ng).
_ c im chung l u ph thuc vitamin K khi tng hp v cn c ion canxi khi hot
ha. Khi lu hnh trong mu bnh thng chng khng c hot tnh enzyme nhng c th b
bin thnh serin protease khi phn ct la chn mt hoc hai dy ni peptid. Cac yu t
trong nhm ny khng b tiu th trong qu trnh ng mu nn chng s c mt trong
huyt thanh (tr yu t II) v chng n nh trong huyt tng lu tr.
_ Khi c th thiu vitamin K th gan ch tng hp ra tin cht ca cac yu t trn, cac tin
cht c hot tnh sinh hc ng mau rt thp v i khi cn c hot tnh c ch ng mau,
c gi chung l PIVKA (proteins induced by vitamin K absence or antagonists).
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3. Nhm fibrinogen:
_ Gm cac yu t I,V, VIII, XIII. Cac yu t ny u chu tc ng qua li ca thrombin.
_ c im chung : b tiu th trong qu trnh ng mu nn khng c mt trong huyt
thanh v nhanh b hy (mt hot tnh trong huyt tng lu tr).
_ Yu t VIII cn c c im khng lu hnh n c trong huyt tng, sau khi tng hp
ra ch trong thi gian ngn (8-12 pht) l chng s gn vi yu t von Willebrand nh
m m bo c tnh n nh ca yu t ny.
Tm tt :
1. Yu t ph thuc VTM K khi tng hp , cn Ca2+ khi hot ha : II , VII , IX , X
2. Yu t km bn trong huyt tng lu tr b mt hot tnh : V , VIII , XIII , TC
3. Yu t khng b tiu th trong qua trnh M : II, VII , IX , X
4. Yu t c Heparin gia tc : AT III ,HC II ( tr 1-AT v cht c ch C1 )
IU HA M CA CHT C CH
M
AT III
TFPI
Xa
VIIa
Va+VIIIa
Thrombin
IXa
XIa
XIIa
Kallikrein
Protein C Protein S
HC2
Cht c ch C1
1-AT
2-MG
Tc gi s : L Vn Cng
L VN CNG
19
II. CC GIAI ON QU TRNH NG MU

Yu t tip xc
(XI , XII , PK , H.M.W.K )
XII
XIIa +PK +Kininogen

XI
XIa + Ca2+
IX
IXa + VIII +Ca2++PL
Thromboplastin+VIIa+Ca2+
Xa
Giai on 1
Giai on 2
Prothrombinase
Prothrombin
(II)
Fibrinogen
V, PL , Ca2+
Thrombin
( Ia )
Fibrin monome
Fibrin ha tan + XIIIa+Ca2+
Giai on 3
L VN CNG
Fibrin khng tan
20
Tc gi s : L Vn Cng
1. Con ng ng mu ni sinh
Giai on 1 : Hnh thnh phc h Prothrombinase ni sinh
Yu t tip xc
(XI, XII , PK , H.M.W.K
)
XIIa ( PK ,Kininogen )
XII
XI
XIa + Ca2+
IXa + VIII +Ca2++PL
IX
IX
Xa
V , PL , Ca2+
Tc gi s : L Vn Cng
Prothrombinase
( Va , Xa , Ca2+ , PL
)
_ Con ng M ni sinh c bt u t vic gn cac yu t tip xc (XII , XI , PK,

Kininogen CPT ) ln b mt TC tch in m .ng thi dng mau tip xc vi si
Collagen khi ng CMBhot ha con ng M ni sinh
_ Bt u l yu t XIIXIIa , yu t XIIa sinh ra kt hp vi yu t PK , Kininogen CPT
hot ha yu t XIXIa . Yu t XIa khi c mt Ca2+ , tip tc hot ha yu t IXIXa .
Yu t IXa kt hp vi ng yu t VIII , Ca2+ v PL , hot ha yu t XXa . Yu t Xa
tac ng ln phc h cac yu t : V , Ca2+ , PL , bin phc h ny thnh Prothrombinase
Prothrombinase gm ( Xa, Va, Ca2+ , PL )
_ B mt tip xc y cn : t chc di ni mc ,TC, thy tinh , Kaolin,Ngi ta
ng dng iu ny lm XN kho sat con ng M ni sinh : thi gian mu ng ,
thi gian Howell, thi gian APTT
L VN CNG
21
Giai on 2 : Hnh thnh Thrombin ni sinh

Prothrombinase
( Va , Xa , Ca2+ , PL
)
Prothrombin (II)
Thrombin (IIa )
_ Prothrombinase hnh thnh , hot ha yu t IIIIa ( Thrombin ) , bng cach ct i 2 lin

kt peptid ca Prothrombin thnh 3 mnh , trong c 1 mnh l Thrombin
_ Thrombin l trung tm ca qu trnh M
+) Thrombin gy ngng tp TC rt mnh tng hot ng CMB
+) Thrombin xc tc chuyn Fibrinogen Fibrin
+) Thrombin hot ha V , VIII, XI m rng hot ng M ni sinh
+) Thrombin hot ha yu VIIVIIa m rng hot ng M ngoi sinh
+) Thrombin hn ch hot ng lan trn ca chnh n bng hot ha Protein Cc ch
M thng qua bt hot yu t Va v VIIIa
+) Thrombin thc y qu trnh TSH thng qua thc y TB ni mnh tng sn xut yu t
t-PA tng chuyn Plasminogen Plasmin
ngng tp TC rt mnh tng hot ng CMB
tng chuyn Plasminogen Plasmin
chuyn Fibrinogen Fibrin
Thrombin
T c ch hot ha Protein C
T khuch ihot ha V , VII, VIII, XI
Tc gi s : L Vn Cng
L VN CNG
22
2. Con ng M ngoi sinh

Giai on 1 : Hnh thnh phc h Prothrombinase ngoi sinh
Thromboplastin m
Thrombin
VIIa + Ca2+
VII
Xa
V , PL , Ca2+
Prothrombinase ngoi sinh
Tc gi s : L Vn Cng
Giai on 2: hnh thnh Thrombin
Prothrombin (II)
Prothrombinase
( Va , Xa , Ca2+ , PL
)
Thrombin (IIa )
_ Khi tn thng thnh mch , c ch M ngoi sinh chim vai tr ch o , do n

hot ha ngay yu t XXa. ( cng hot ha yu t IX khi nng thp )
_ M ngoi sinh c khi ng bng yu t t chc ( TF ) hay Thromboplastin
c gii phng t m , t chc hay mch mau tn thng . Thromboplastin c ai
tnh cao vi yu t VII ( chuyn VIIVIIa) , to phc Thromboplastin-VIIa khi c
mt Ca2+ , PL v ng thi hot ha yu t XXa mt cach nhanh chng
_ Yu t Xa sinh ra , tac ng ln yu tV ( VVa ) cng vi phospholipid v s c
mt ca Ca2+ , chuyn thnh Prothrombinase gm phc : Xa , Va , PL- , Ca2+
_ Prothrombinase hot ha yu t IIIIa ( thrombin) ( c ch xem phn ni sinh )
. Yu t Thrombin sinh ra tip tc hot ha yu t IIa ( fibrin )
_ Ngoi ra , Thrombin cn tham gia CMB bng hot ha mnh TC , tham gia iu
ha M v khuch i chnh n bng hot ha yu t V , VII , VIII, XIII. c ch
chnh n bng hot ha Protein C.
L VN CNG
23
3. Con ng M chung
Thrombin
Fibrinogen
(I)
Fibrin monome
Fibrin polymer ( Fibrin ha tan)

Tc gi s : L Vn Cng
XIIIa
Ca2+
XIII
Fibrin khng tan
_ Thrombin sinh ra , ct 1 lin kt peptid ca Fibrinogen thnh 2 Fibrin monomer

(Fibrin monomer A v B ).Cac Fibrin monomer tri qua qua trnh polymer
haFibrin polymer ha tan ( Tuy nhin vn cn mt s Fibrin monomer A v B
cha kt hp vi nhau , tn ti dng t do )
_ Fibrin monomer ha tan Fibrin khng tan , nh yu t XIIIa v Ca2+. Yu t
XIIIa c hot ha nh Thrombin v c gia tc khi c mt Ca2+
C IM SO SNH
1. Yu t hot ha
2. Tc
3. Yu t tham gia
4. XN kho st
M NI SINH
M NGOI SINH
M CHUNG
_ Yu t tip xc
_ Tiu cu
_ Collagen
_ Thromboplastin m
(TF)
Thrombin ngun gc ni
sinh v ngoi sinh
Chm , din ra vi pht
Nhanh , t=15s nu chn

thng nng
Din ra mnh nh s hip

ng ca c ni v ngoi
sinh
_ Thromboplastin , VII
, X , V , II
IIa , I
_ Thi gian PT
_ nh lng yu t
VII, X, V , II
_ Thi gian TT
_ nh lngFibrinogen
_ Yu t tip xc: XII,

XI , PK , H.M.W.K
_ IX , VIII , V , X ,II
_ Thi gian mau ng (
lam , ng nghim
_ Thi gian Howell
_ Thi gian APTT
_ nh lng cac yu t
VIII,IX, X, XI, XII
L VN CNG
24
III. CC XT NGHIM KHO ST NG MU

1. Thi gian mu ng trn lam
_ Nguyn tc XN : Xac nh thi gian ng ca git mau ton phn da vo s xt hin
ca si Fibrin trong git mau trn lam knh
_ Mc ch ngha : Kho sat con ng M ni sinh , y l XN khng nhy , b nh
hng bi nhiu yu t
_ Tin hnh :
_ Dng c : 2 lam sch , a petri , kim chch , bong , ng h
_ Ha cht : cn 700
_ Bnh nhn : Anh b bnh l M g cha ? Ung thuc Aspirin khng ? iu tr
Heparin khng ? ( ch hi ko mt im , hoc s b nh hng n kt qu XN )
_ Quy trnh :
http://www.youtube.com/watch?v=OQe4K3my6YY
+) B1 : anh s , ghi tn lam knh
+) B2 : sat khun ngn ap tchch nhanh v bm ng hlau git mau u( lau b
m tn thng , do chc ln 1 TC ra nhiu nht , lau i ly cc git tip theo s kho st
u hn )nh mau ln 2 lam knh ( 5-10mm/git) cho lam 2 vo a petri , i trong
3 pht
+) B3 : Sau 3 , kho sat tng lam
Lam 1: nghing 450 ( khng lm v mt thong ) c 30s/450/ 1ln n khi xut hin
si Fibrin ( dung kim chch khu) th kho sat lam 2
Lam 2 lm y ht lam 1, c 30s/450/1ln n khi xut hin si Fibrin ( dung kim chch
khu) th bm ng h dng li . Ghi kt qu lm trn v mc kho st
_ Nhn nh kt qu :
+) Bnh thng : 5-10
+) Ko di : >15
Howell
+) Nghi ng : 10-15 , lm li bng
APTT
Ch : thi gian mu ng < 5 khng c ngha chn on tnh trng Tng ng (T) ,
do n chu nh hng bi nhiu yu t : nhit , mi trng xung quanh , lng mu,.
_ Bin lun kt qu : Thi gian mu ng trn lam ko di trong cc trng hp
+) Bnh nhn ang dng Aspirin , hoc iu tr Heparin
+) Thiu ht yu t M ni sinh , c bit : IX , VIII , XI , trong bnh Hemophili A , B , C
+) C th c khang ng : khng ng lupus , FPDs ,
+) Bnh nhn suy gan nng , bnh hi chng thn h ,
( Gii thch xem thm phn thi gian Howell , APTT , PT )
L VN CNG
25
2. Thi gian M trong ng nghim

_ Nguyn l XN : Cho mau tip xc vi thnh ng nghim khi ng con ng M
ni sinh , o thi gian t lc mau tip xc vi thnh ng nghim n khi mau ng cht
thnh khi
_ Mc ch ngha : Kho sat con ng M ni sinh
_ Tin hnh :
+) Dng c : B ly mau TM , 2 ng nghim sch loi 75 9,5mm trang nc mui
sinh l ( to mi trng ng trng trn thnh ng nghim trnh v HC ) , ng h
, ni 370
+) Bnh nhn : Anh b bnh l M g cha ? Ung thuc Aspirin khng ? iu tr
+) Quy trnh :
B1 : Trang nc mui sinh l , anh s, ghi tn ng nghim
B2 : Ly 2-3ml mau TMbm ng h v bm vo thnh ng nghim chia u 2
ngem 2 ng trong ni 370 trong 3 Xem video quy trnh ti a ch
http://www.youtube.com/watch?v=mXnGS1or5v
B3 :Sau 3 kho sat tng ng
U
ng 1 : nghing 450 ( khng lm v mt thong )c 30s/450/1 lnMau ng cht
thnh khi tip tc kho sat ng 2 , y ht ng 1
ng 2 : lm y ht ng 1 Mau ng cht thnh khi bm ng h dng lighi
kt qu lm trn n mc kho sat.
_ Nhn nh kt qu
+) Bnh thng : 5-12
+) Ko di : > 15
Howell
+) Nghi ng : 12-15 , lm li bng
APTT
Ch : thi gian mu ng < 5 khng c ngha chn on tnh trng Tng ng (T)
Nhn xt : Thi gian mu ng trong ng nghim c nhiu u im hn M trn lam
do c thc hin 370C gn iu kin c th nht , mt khc n khng chu nhiu nh
hng bi mi trng xung quanh (bi , hi nc ) v do c chia bng bm nn lng
mu l chnh xc hn . Tuy nhin nhc im ca pp l dng mu ton phn.
_ Bin lun kt qu : Thi gian mu ng trn ng nghim ko di khi
Bnh nhn ung Aspirin , iu tr Heparin
Thiu ht yu t M ni sinh : XII , XI , PK , H.M.W.K , IX, VIII , X
C th c khang ng : cht khang ng lupus , FPDs,
Bnh nhn suy gan nng ,
Hi chng thn h,
ng 1
L VN CNG
ng 2
26
3. Thi gian Howell ( thi gian phc hi Ca2+ )

_ Nguyn tc XN : Mau ton phn c chng ng bng Natricitrat 3,8% em
ly tm ly huyt tng giu tiu cuthm 1 lng ti u Ca2+. o thi gian t lc
phc hi Canci n khi huyt tng ng cht thnh khi.
_ Mc ch ngha : Kho sat con ng M ni sinh , anh gia giai on hot ha
yu t XXa
SL v CL Tiu cu ( yu t 3 phospholipid )
Thi gian Howell ph thuc:
Yu t VIII, IX, X ( XII, XI ,PK, H.M.W.K )
_ Tin hnh :
+) Dng c : B ly mau TM , 2 ng nghim sch loi 75 9,5mm, pipet , ng h,
ni 370
+) Ha cht : Dung dch CaCl2 0,025M ( pha t CaCl2 0,1M=100g CaCl2 ha tan
trong 1000ml nc ct , ly CaCl2 0,1M pha vi nc ct t l 1:3CaCl2 0,025M )
+) Bnh nhn : : Anh b bnh l M g cha ? Ung thuc Aspirin khng ? iu tr
+) Quy trnh:
B1: Ly >2ml mau TMcho vo l Natricitrat ti vch 2em ly tm 1000vng/10
B2: anh s, ghi tn ng nghimHt 0,2ml huyt tng cho vo 2 ng 0,2ml/1 ng
em 2 ng huyt tng v ng CaCl2 370 / 3
B3: Sau 3 kho sat tng ng :
ng 1 : Thm 0,2ml CaCl2 v bm ng hlc ngang n 9s( trn u) yn
trong 1nghing 450130 nghing 450 c 15s /nghing 450/1lnn khi
huyt tng ng cht thnh khibm ng h dng liT1 lm trn v mc kho
st.
ng 2 : lm y ht ng 1 n khi huyt ng chtbm ng h dng liT2 lm
trn v mc kho st
_Nhn nh kt qu :
http://www.youtube.com/watch?v=6Rlvw2OwksU
Bnh thng : Howelltb = 130-230
Ko di > 60s so vi chng
Ch : Thi gian Howell ngn hn bnh thng khng phn nh c tnh trng
tng ng.
Nhn xt : Thi gian Howell c u im hn M trong ng nghim l dng huyt
tng giu tiu cu , loi b i HC , BC. V dng huyt tng giu TC nn khi
thi gian Howell ko di , khng th xc nh c do bt thng v yu t M
hay do TC y chnh l nhc im ca pp , tuy nhin n l XN thng xuyn
theo di iu tr Heparin.
_ Bin lun kt qu : Thi gian Howell ko di trong trng hp
Thiu ht yu t : IX , VIII , X
L VN CNG
27
Thiu ht yu t TC ( SL v/hoc CL ) :KT khng TC , Suy ty , Leucemia,

Bnh nhn ung Aspirin , iu tr Heparin
C th c khang ng : cht chng ng lupus , mnh FDPs ,.
Bnh Hemophili A , B ; Bnh suy gan nng ; Hi chng thn h
Gii thch 1 s trng hp lm thi gian Howell ko di

Bnh nhn ung Aspirin : c ch ngng tp TC mnh v tn ti sut i sng ca
TCTC khng tng hp ra cac men mi c nanh hng n CMB , v
M. C ch tc ng ca Aspirin nh sau:Aspirin c ch men cyclo-oxygenase
Ngn cn hnh thnh Thomboxan A2Nh c ch s ngng tp TC
iu tr Heparin : :Heparin l thuc chng ng ng tim ,n tc ng ln yu t
IIa(thrombin),Xa lm b.i c.trc yu t IIa ,Xa(to phc Xa-AT III-IIa-heparin
Mt tac dng yu t IIa , Xa. ng thi n gia tc hot ng cho cac yu t c ch
M t nhin khac nh AT III , HC II . c bit l AT III ( tc ng tng gp 20003000 ln khi c mt heparin ) .
Bnh h thng lupus ban , c khng ng lupus ban : Khang ng Lupus ban
bn cht l cac IgG , IgM . Cac khang th ny lm kt ta PL ca TCc ch s
hot ha ca cac yu t cn phospholipid nh II , X.
Bnh suy gan gim tng hp yu t M
Hi chng thn h lm mt yu t M qua nc tiu ,.
Bnh Hemophili : Hemophili l bnh DT gen ln trn NST gii tnh X , bnh DT
cho . Bnh do thiu bm sinh yu t VIII ( hemophili A ) , yu t IX (hemophili B).
Trong Hemophili A hay gp hn chim 80-85% trng hp
4. Thi gian APTT (Thi gian Thromboplastin hot ha tng phn , thi
gian Cephalin-Kaolin)
_Nguyn l XN : Mau ton phn c chng ng bng Natricitrat 3,8% em ly
tm ly huyt tng ngho tiu cuthm Kaolin thng nht hot yu t tip xc
thm Cephalin thay yu t 3 phospholipid ca TCthm lng ti u Ca2+. o thi
gian t lc phc hi Ca2+ n khi huyt tng bt u ng ( xut hin mng ng )
_ Mc ch ngha : Thi gian APTT kho sat con ng M ni sinh , giai on
hot ha yu t XXa , khng ph thuc yu t 3- phospholipid ca TC , nn n l
xt nghim ti u nht nh gi M ni sinh
Thi gian APTT ch ph thuc yu t IX , VIII
L VN CNG
28
_ Tin hnh :
+) Dng c : b ly mau TM , 2 ng nghim sch loi 75 9,5mm , pipet , ng h ,
ni 370
+) Ha cht : Actin-FS ( np xanh ), dung dch CaCl2 0,025 M
+) Quy trnh :
B1: Ly mau TMcho vo ng NatriCitrat 3,8% ti vch 2em ly tm
2000vng/10 ly huyt tng ngho TC
B2 : anh s ghi tn ng nghim
B3 : Ht 0,1ml huyt tng vo 2 ng nghim : 0,1ml/ngem 2 ng huyt
tng v ng dd CaCl2 vo ni cach thy.
B4 : Hot ha tng phn
Thm vo mi ng 0,1ml ACTIN FSlc uc 15s/lc u/3
B5 : Phc hi Canci : kho sat tng ng
ng 1 : Thm 0,1ml CaCl2 v bm ng hlc ngang n 9sa ngang tm mt
lc v quan sathuyt tng xut hin mng ngbm ng h dng liT1 ghi kt
qu c phn tch tc.
ng 2: Lm y ht ng 1 huyt tng xut hin mng ngbm ng h dng
liT2 ghi kt qu c phn tch tc. Xem video quy trnh ti a ch
http://www.youtube.com/watch?v=V9dCV1dkZtU
_Nhn nh kt qu
Bnh thng : APTTtb = 30-40s
APTTbnh/chng=0,9-1,15
* Ko di : > 1,2
Bnh l >20s so vi chng
_ Bin lun kt qu : APTT ko di trong cc trng hp sau
Thiu yu t VIII , IX , X : bnh Hemphili A , B
C khang ng lu hnh : iu tr heparin , chng ng dng lupus , mnh FDPs,.
Bnh suy gan nng , Bnh Hi chng thn h ,.
Gii thch 1 s trng hp lm thi gian APTT ko di
iu tr Heparin :Heparin l cht chng ng ng tim ,n tc ng ln yu
t thrombin (IIa) ,Xa lm b.i c.trc yu t IIa ,Xa do to phc Xa-AT III-IIaheparin Mt tac dng yu t IIa , Xa. ng thi n gia tc hot ng cho
cac yu t c ch M t nhin khac nh AT III , HC II . c bit l AT III (
tc ng tng gp 2000-3000 ln khi c mt heparin ) .
L VN CNG
29
Bnh h thng lupus ban , c khng ng lupus ban : Khang ng Lupus

ban bn cht l cac IgG , IgM . Cac khang th ny lm kt ta PL ca
TCc ch s hot ha ca cac yu t cn PL nh II , X.
Bnh suy gan gim tng hp yu t M
Bnh hi chng thn h lm mt yu t M qua nc tiu ,.
Ha cht ACTIN FS lm xt nghim thi gian APTT
ng 1
L VN CNG
ng 2
30
5. Thi gian PT (thi gian Prothrombin , thi gian Quick , t l

prothrombin)
_Nguyn l XN : Mau ton phn c chng ng bng NatriCitrat 3,8% em ly tm
ly huyt tng ngho tiu cuthm 1 lng ti u hn hp Thromboplastin v CaCl2.
o thi gian t lc thm ha cht n khi huyt tng bt u ng .
_ Mc ch ngha : Kho sat con ng M ngoi sinh , qua nh gi cc yu t
VII, X, V, II. y l xt nghim kh nhy nh gi M ngoi sinh.
_Tin hnh:
+) Dng c : B ly mau TM , 2 ng nghim loi 75 9,5mm, pipet , ng h , ni
cach thy 370
+) Ha cht :
T sn xut t c th : Pha c th vi nc mui sinh l (dung dch m) theo t l c
50mg c th + 1ml NaCl 90/00 ngoay u lin tc trong 30
Thm 1ml CaCl2 0,025M ( t l 1:1 vi NaCl 90/00 ) lnght dch trong
pha trn lm XN
Mua t nh sn xut : L Thromborel ( np vng )
+) Quy trnh :
B1: Ly mau TMcho vo l Natricitrat ti vch 2em ly tm 2000vng/10
ly huyt tng ngho tiu cu
B3 : Ht 0,1ml huyt tng cho vo mi ng : 0,1ml/ng em 2 ng huyt
tng v ng ha cht 370C / 3.
B4 : Sau 3 , kho sat tng ng :
ng 1: Thm 0,2ml ha cht v bm ng h lc ngang n 9sa ngang tm mt
lc v quan sat n khi huyt tng bt u ngbm ng h dng li T1 gi
nguyn n phn tch tc
ng 2: Lm y ht ng 1 n khi huyt tng bt u ngbm ng h dng li
T2 gi nguyn n phn tch tc
_ Nhn nh kt qu
Bnh thng :PTtb = 11-14s
* T l Prothrombin = 70-140%
Ko di : >2s so vi chng
* Gim < 60% (cng gim t.gian cng ko di )
ng 1
ng 2
PTbnh/chng=0,9-1,15
L VN CNG
31
Ko di : > 1,15
_ Bin lun kt qu : Thi gian PT ko di trong cc trng hp sau
Thiu ht yu t M ngoi sinh : VII , X , V , II
Thiu VTM K : iu tr ngoi tiu ha , dng khng sinh ko di , thiu bm sinh tr
s sinh,.
Dng thuc chng ng ng ung khang VTM K l dn xut ca Coumarin :
Wafarin ,.
C th c khang ng : iu tr heparin , khng ng dng lupus , FDPs,.
Bnh DIC , Bnh gan , Hi chng thn h ,
_ Lu : Xt nghim thi gian PT ph thuc nhiu vo ha cht thromboplastin ( v
nhiu hang sn xut khc nhau v t nhiu ngun : c th , phi , c ln,.). V vy
WHO a ra ch s INR-ch s bnh thng ha quc t ( International
normalized ratio =INR ) , cho mi xt nghim theo cng thc

= (
)

ISI- ch s nhy cm quc t ( Internation Sensitivity Index =ISI )
Ch s INR c dng theo di bnh nhn s dng thuc chng ng khng VTM K
an ton nn duy tr INR=2-4 . Nu <2 nguy c huyt khi , cn >4 nguy c xut
huyt.
Gii thch mt s trng hp khin thi gian PT ko di :
Thuc chng ng ng ung l dn xut ca Coumarin , n cnh tranh vi VTM K
trong c thc ch hot ng ca cac yu t M ph thuc VTM K nh l : II , VII ,
IX , X , Protein C , Protein S . C ch tac ng nh sau ( theo TS- Nguyn Anh Tr ):
Thuc c tc dng c ch epoxyd reductasec, t lm tng t s oxyd / VTM K.
Lng oxyd nhiu s cnh tranh vi VTM K1 , vng cm thVTM K1 b gim hiu
lc.
iu tr Heparin :Heparin l cht chng ng ng tim ,n tc ng ln yu t
IIa,Xa lm bin i cu trc yu t IIa ,Xa(to phc Xa-AT III-IIa-heparin )Mt tac
dng yu t IIa , Xa. ng thi n gia tc hot ng cho cac yu t c ch M t
nhin khac nh AT III , HC II . c bit l AT III ( tc ng tng gp 2000-3000 ln
khi c mt heparin ) .
L VN CNG
32
Bnh h thng lupus ban , c khng ng lupus ban : Khang ng Lupus ban
bn cht l cac IgG , IgM . Cac khang th ny lm kt ta PL ca TCc ch s hot
ha ca cac yu t cn PL nh II , X.
Mnh FDPs sn phm ca qu trnh tiu si Fibrin / Fibrinogen : Sn phm thoai ha
Fibrinogen/Fibrin l cac mnh X, Y , E , D ( s cp k phn TSH ).Cac mnh ny c
tac dng c ch ngng tp TC ( nh hng ti CMB v yu t ph thuc
phospholipid TC ). Ngoi ra mnh X, Y c ch s polymer ha ca
FibrinmonomeFibrinpolyme ( mnh E , D tc ng yu hn ). c bit cac mnh E ,
D tng hot ha PlasminogenPlasmin ( tng tiu Fibrinogen/Fibrin ) , thng qua vic
tng hiu lc cac cht hot ha Plasminogen : t-PA , Tcu-PA .,,,,
Bnh gan: Gan l c quan tng hp hu ht cac yu t tham gia qua trnh ng-Cm
mau .Trong bnh suy ganchc nng gan gimKh nng tng hp cac yu t M
gimri lon qua trnh M. Trong bnh vim gan tc mtKh nng to dch mt
gim , cng vi s tc mtDch mt khng/gim xung ta trng nh tng ha
lipid , to iu kin hp thu VTM K tan trong dunh hng n cac yu t ph
thuc VTM K.
Hi chng thn h : Gin mng lc cu thn , cng vi s km tai hp thu cac cht cn
thit ng thn Lm mt nhiu cac yu t M.
Ha cht lm xt nghim thi gian PT
L VN CNG
33
6. Thi gian TT
_ Nguyn l XN : Mau ton phn c chng ng bng NatriCitrat 3,8% em ly tm
ly huyt tng ngho TCthm 1 lng ti u ha cht Thrombino thi gian t
lc thm ha cht n khi huyt tng bt u ng.
_ Mc ch ngha : Kho sat con ng M chung , anh gia Fibrinogen , giai on
u chuyn FibrinogenFibrin , nh Thrombin
Thrombin
Fibrinogen
(I)
Fibrin monome
Fibrin polymer ( Fibrin ha tan)
_ Tin hnh
+) Dng c : B ly mau TM , 2 ng nghim sch , pipet , ng h , ni cach thy
+) Ha cht : L Thrombin ( 25 v/ml)
+) Bnh nhn : : Anh b bnh l M g cha ? Ung thuc Aspirin khng ? iu tr
+) Quy trnh :
B1: Ly mau TM >2mlcho vo l NatriCitrat ti vch 2em ly tm 2000vng/10 ly
huyt tng ngho TC
http://www.youtube.com/watch?v=SgzTJAucbb8
B2: anh s ghi tn ng nghim
B3: Ht 0,1ml huyt tng v 0,1ml NaCl 9o/oo ( n nh pH cho Thrombin v n l 1
enzym, c th thay bng dung dch m) cho vo 2 ng nghim (0,1ml huyt tng+0,1ml
NaCl 9o/oo) / 1 ngem 2 ng huyt tng 370/3
B4: Sau 3 kho sat tng ng
ng 1: Thm 0,1ml ha cht v bm ng hlc ngang n 9sa ngang tm mt
lc v quan sathuyt tng bt u ngbm ng h dng liT1 gi nguyn c
phn tch tc.
ng 2: lm y ht ng 1huyt tng bt u ngbm ng h dng liT2 gi
nguyn c phn tch tc.
L VN CNG
34
_ Nhn nh kt qu :
Bnh thng : TTtb=15-20s
TTbnh/chng=0,85-1,15
Ko di >1,15
_ Bin lun kt qu : thi gian TT ko di trong cc trng hp sau

Thiu ht yu t Fibrinogen : <1g/l , gim tng hp hoc tng s dng ( DIC )
C th c cht khang Thronbin : heparin , mnh FDPs ( c ch xem bi PT )
Bnh nhn suy gan nng ( c ch xem bi PT )
L VN CNG
35
BNG TM TT CC XT NGHIM CM-NG MU
Tn XN
S lng
2
1.BT (MC)
ngha
Kho sat qua trnh cm mau
ban u , qua anh gia :
yu t thnh mch + tiu cu
v yu t Willebrand ,
Fibrinogen
Mu chy ph thuc
Cht lng thnh mch
S lng tiu cu
Cht lng tiu cu
Thiu yu t
Willebrand+Fibrinogen
Gi tr bnh thng / bt
thng
MC=1-4
+) Bnh thng :
+) Ko di : >6
+) Nghi ng : 4-6 khi phi
tin hnh li vi tai kia hoc
dng pp Ivy
Kho sat qua trnh CMB

, qua anh gia cht
lng v s lng ca tiu Co cc mu nh gi 4 mc
cu , Fibrinogen , yu t
Co hon ton :
XIII
HT 50-65% HC<5mm
Co cc mu ph thuc
S lng v cht lng ca
TC
S lng v cht lng ca
Fibrinogen
Yu t XIII
Th tch khi HC(hematocrit )
2.Co cc
mu
Co khng hon ton
HT <40%HC>5mm
Cc mau b nat :nhiu HC t
do
Cc mau khng co
khng c cc ng
+) Bnh thng : M=5-
10
+)Ko di : >15
+) Nghi ng : 10-15 , lm li
bng
APTT , Howell
3.M trn
lam
L VN CNG
Kho sat con ng M

ni sinh
Ch : thi gian mu ng < 5

khng c ngha chn on tnh
trng Tng ng (T) , do n
chu nh hng bi nhiu yu t
: nhit , mi trng xung
quanh , lng mu,.
36
+) Bnh thng :
M = 5-12
+)Ko di >15
+) Nghi ng : 12-15
lm li bng Howell , APTT
Ch : thi gian mu ng < 5
khng c ngha chn on tnh
trng Tng ng (T)
4.M trn
ng
Kho sat con ng M ni

sinh
Nhn xt : Thi gian mu ng

trong ng nghim c nhiu u
im hn M trn lam do c
thc hin 370C gn iu kin c
th nht , mt khc n khng
chu nhiu nh hng bi mi
trng xung quanh (bi , hi
nc ) v do c chia bng
bm nn lng mu l chnh
xc hn . Tuy nhin nhc im
ca pp l dng mu ton phn.
Bnh thng :
Howelltb = 130-230
5.Howell
Ch : Thi gian Howell ngn

Kho sat con ng M ni sinh hn bnh thng khng phn nh
, anh gia giai on hot ha yu c tnh trng tng ng.
t XXa
Nhn xt : Thi gian Howell c u
Thi gian Howell ph thuc:
im hn M trong ng nghim l
+)Yu t VIII, IX, X ( XII, XI
dng huyt tng giu tiu cu ,
,PK, H.M.W.K )
loi b i HC , BC. V dng huyt
+) SL v CL Tiu cu ( yu t 3
tng giu TC nn khi thi gian
phospholipid )
Howell ko di , khng th xc
nh c do bt thng v yu t
M hay do TC y chnh l
nhc im ca pp , tuy nhin n
l XN thng xuyn theo di iu
tr Heparin.
Thi gian APTT kho sat con
ng M ni sinh , giai on
hot ha yu t XXa , khng
ph thuc yu t 3- phospholipid
ca TC , nn n l xt nghim ti
u nht nh gi M ni sinh
6.APTT
Thi gian APTT ch ph thuc

yu t IX , VIII
L VN CNG
Bnh thng :
APTTtb = 30-40s
Bnh l >20s so vi chng
APTTbnh/chng=0,9-1,15
Ko di : > 1,2
37
Bnh thng :
PTtb = 11-14s
Kho sat con ng M

ngoi sinh , qua nh gi
T l Prothrombin = 70-140%
cc yu t VII, X, V, II. y l Gim < 60% (cng gim t.gian
xt nghim kh nhy nh gi cng ko di )
M ngoi sinh
7.PT
PTbnh/chng=0,9-1,15
Ko di : > 1,15
Kho sat con ng M

chung , anh gia Fibrinogen ,
giai on u chuyn
FibrinogenFibrin , nh
Thrombin
8.TT
TT ph thuc : nng
Fibrinogen trong mu , cht
lng Thrombin
L VN CNG
Bnh thng :
TTtb=15-20s
TTbnh/chng=0,851,15
Ko di >1,15
38
TIU SI HUYT
1. Qua trnh M to ra cc mau ng cm mauTuy nhin , nu cc mau ng ny c
tn ti mi trong lng mch s gy nn nguy c tc mch ngn nga u xy ra ,
trong c th c c ch Tiu si huyt lm tan cc mau ng sau khi tn thng
lnh mnh.
2. Tiu si huyt (TSH) c s tham gia ca yu t plasminogen trong mau , n khng gy
tac ng TSH, m cn phi c cac cht hot ha t-PA , Tcu-Pa , chuyn thnh Plasmin ,
gy ra tac ng tan cc mau cha si Fibrin/ Fibrinogen.
3.Tuy nhin , nu hot ng TSH lan trn c th dn ti bin chng chy mau , do , cn
c cac yu t c ch qua trnh TSH. Cac cht c ch TSH y gm 2 nhm
Nhm 1l : c ch s hot ha PlasminogenPlasmin , thng qua bt hot yu t hot
ha Plasminogen l t-PA , Tcu-PA
Nhm 2 gm : Cac cht khang PlasminLm mt tac dng tiu cc mau ca Plasmin
_ Sn phm ca qua trnh TSH , li tham gia iu ha M mc khac nhau. ( s trnh
by r phn sn phm TSH )
L VN CNG
39
I.
CHT THAM GIA TIU SI HUYT
A - Plasminogen v Plasmin
TN
C IM
VAI TR
_Bn cht l chui Euglobulin
gm 791aa
_ Sn xut ti gan , c mt trong huyt
tng , TB BC on trung tnh , mng TC
,b mt TB ni mc, dch bao khp.
_ Nng trong mau : 0,13-0.2 g/l
1.Plasminogen
_ Plasminogen tng trong 1 s bnh :
Nhim trng , phn ng vim , thai nghn
Gim trong bnh gan , iu tr chng
ng ,.
_ Plasminogen khng bn vng vi nhit
v pH trung tnh , b mt hot tnh 560C
_ L tin t khng hot
ng ca Plasmin.
_ V vy , nu cha c s
xut hin ca Fibrin th tac
ng tiu si huyt cha
xy ra.
_ Plasmin ch hnh thnh khi
_ Do ngun gc hnh thnh t
2.Plasmin
trong c th c cc mau
ng , vi s c mt ca si
Fibrin. Ch bnh thng
trong c th khng c
plasmin.
plasminogen , nn v cu to , trnh t sp
xp aa , tnh KN ging plasminogen
_ Plasmin c ph tac dng
_ Plasmin hot ng pH trung tnh
rng , n khng ch phn
hy Fibrin/Fibrinogen , m
cn phn hy c yu t :
v-WF , V , VIII , XIIIa ,......
L VN CNG
40
II. CHT HOT HA PLASMINOGEN

_ Plasminogen mun phat huy tac dng phi c hot ha , hnh thnh nn Plasmin.
C rt nhiu cht hot ha Plasminogen , c bit quan trng y l 2 cht t-PA , v
Tcu-PA ( Urokiase )
TN
C IM
VAI TR
_t-PA ch hot ha PlasminogenPlasmin
khi c s xut hin ca Fibrin.

_ t-PA sn xut ch yu TB ni
1.
mc , 1 t c sx t TB cnh
biu m , Mu TC , BC mono,...
.
_ t-PA hot ha Plasminogen
cc i pH kim
t-PA
_ Urokiase c sn xut bi TB
2. Tcu-PA
(Urokiase)
thn di dng tin cht ProUrokiase v c o thi qua

nc tiu.
_ Pro-UrokiaseUrokiase , nh
s tac ng ca Plasmin
Kallikrein , XIIa
L VN CNG
_Tac dng lm tiu Fibrin ca t-PA rt

mnh :do t-PA v Plasminogen cng c
gn trc tip ln si Fibrin, v tr lysin.
_ Tac dng trn cng xy ra vi
Fibrinogen nhng t hn nhiu , do v tr
gn trn Fibrinogen b che khut.
_ Urokiase ( Tcu-PA) hot ha
plasminogenplasmin , bng cach ct i 1

lin kt peptid : tc ng ny xy ra d c
hay khng s xut hin ca Fibrin
iu ny cho thy , Tcu-PA tiu
Fibrinogen nhiu hn tiu Fibrin.
41
S phi hp tc ng ca t-PA v Tcu-PA , trong hot ha PlasminogenPlasmin

TB ni mch
Fibrin
(ccng)
TB thn
Pro-Urokiase (Scu-PA)
t-PA
Urokiase ( Tcu-PA)
Plasminogen
Plasmin
Tc gi s : TS- Nguyn Anh Tr
Sn phm thoai ha FDPs
MT S CHT C TC DNG HOT HA PLASMINOGEN KHC :

1. Staphylokiase (SPK)
_ Staphylokiase l 1 men do T cu vng ( S.aureus ) tit ra trong qua trnh sng ,
N to phc SPK-plasminogen , qua chuyn plasminogenplasmin. Phc ny s
b bt hot bi 2-antiplasmin ( 2-AP)
_Ngc vi Staphylokiase , TCV c men Coagulase , hot ha hnh thnh si Fibrin
bao quanh VKbo v VK trc tn cng ca TB , BC on ,.
2. Streptokiase (SK) ( c thm trong Vi sinh 2 )
_ Streptokiase l 1 men do Lin cu ( Streptococus) tit ra trong qua trnh sng.
_ Steptokiase cng to phc vi plasminogen SK-plasminogen,qua chuyn
plasminogenplasmin
3. Bat-PA
_Bat-PA c nc bt loi di ht mau , n cng l cht hot ha plasminogen
4. Yu t Kallikrein v XIIa
_ Khi c mt Kininogen CPT , n hot ha Pre-KallikreinKallikrein. Cht ny c
tac dng chuy Pro-UrokiaseUrokiase . Yu t XIIa cng c tac dng nh vy
5. Cc cht hot ha khng c hot tnh men v s t hot ha ca Plasminogen
_ Cc cht Clorofom , dn xut benzene , ure ,. Thc y chuyn plasminogen
thnh plasmin thng qua vic gii phng plasminogen khi cht c ch.
_ Plasminogen cng c th t hot ha thnh Plasmin 200C v pH=7,8
_ Trypsin v Plasmin cng c kh nng hot ha Plasminogen
L VN CNG
42
III. CC CHT C CH QU TRNH TIU SI HUYT

A. Cht c ch hot ha
Plasminogen
B. Cht khng Plasmin
1.2-Antiplasmin (2-AP )
_ 2-AP c tng hp t gan , c ch trc tip
PAI-1 : c ch t-PA v tcu-PA
plasmin , v c ch c cht hot ha plasminogen
,bng cch to phc bt hot , c
(t-PA , tcu-PA )nhng chm
kh hic ch hot ha
_ 2-AP gn c nh vo v tr hot ng ca
plasminogen
plasmin v c ch v tr hot ng , lin kt ny
_Nng trong huyt tng :
lc u c th hi c , nhng v sau th khng
1-100ng/ml
hi phc
_ PAI-1 tng trong PNCT , ngi bo
_Ngoi ra, nh tac ng ca yu t XIIIa , 2-AP
ph , T , vim-nhim khun
lin kt trc tip vi chui Fibrin , t hn ch s
c nh Plasminogen vo Fibrin
2.Antithrombin III ( AT III)
PAI-2 : c ch t-PA hot ha ,
_AT III l cht c ph tac dng rng , ngoi c ch
c bit l Tcu-PA
hot ng yu t M , n cn l cht khang
_ PAI-2 : tng ch yu khi c thai ,
plasmin. Bng cach to phc vi plasminmt tac
LXM th M4 , M5, khi u,..
dng ca plasmin
3. 1-Antitrypsin (1-AT)
_ Nh ni phn II5 , Trypsin cng l cht c kh nng hot ha plasminogen.
_ 1-Antitrypsin cng ging AT III l cht c ph tac dng rng ngoi c ch hot ng
yu t M , n cn l cht khang plasmin lm mt tac dng ca Trypsin bng cach ct i
1 lin kt peptid
4. Cht c ch C1
_ Quay tr li vi phn II2 , Pro-UrokiaseUrokiase , nh s tc ng ca Plasmin, Kallikrein ,
XIIa.
_ Nh vy , cht c ch C1 c ch TSH bng cach ngn khng cho
Pro-Urokiase---------Urokiase hay cac cht hot ha plasminogen ph thuc h t/xc ni

chung
5. 2-Macroglobulin (2-MG) cng l 1cht khang Plasmin
S IU HA QU TRNH TIU SI HUYT

L VN CNG
43
TB ni mch
Fibrin
(ccng)
TB thn
Pro-Urokiase (Scu-PA)
t-PA
Urokiase ( Tcu-PA)
Plasminogen
Plasmin
Sn phm thoai
ha FDPs
3.1-Antitrypsin (1-AT)
4.Cht c ch C1
5. 2-Macroglobulin (2-MG)
PAI-1
PAI-2
Tc gi s : L Vn Cng ci bin
L VN CNG
44
NHC LI S NG MU
Yu t tip xc
(XI , XII , PK , H.M.W.K )
XII
XIIa +PK +Kininogen

XI
XIa + Ca2+
IX
IXa + VIII +Ca2++PL
Thromboplastin+VIIa+Ca2+
Xa
Giai on 1
Giai on 2
Prothrombinase
Prothrombin
(II)
Fibrinogen
V, PL , Ca2+
Thrombin
( Ia )
Fibrin monome
Fibrin ha tan + XIIIa+Ca2+

Tc gi s : L Vn Cng
Giai on 3
L VN CNG
Fibrin khng tan
45
NHC LI IU HA M CA CHT
C CH M
AT III
TFPI
Xa
VIIa
Va+VIIIa
Thrombin
IXa
XIa
XIIa
Kallikrein
Protein C Protein S
HC2
Cht c ch C1
1-AT
2-MG
Tc gi s : L Vn Cng
L VN CNG
46
IV. SN PHM CA THOI HA FIBRIN-MNH FDPs

1. Di tac ng tiu si Fibrin ca plasmin , sn phm ca qua trnh l cac mnh
FPDs ( Fibrin degradation products )
2. FPDs ch yu gm c 4 mnh ( chui ) : mnh X , mnh Y , mnh E , mnh D.
Trong mnh X-Y xut hin sm trong qua trnh thoai ha , mnh E-D xut
hin mun hn , khong sau 24h tac ng ca plasmin ln Fibrin.
3. Hiu lc sinh hc ca cc mnh FDPs ln qu trnh ng-cm mu
Cac mnh FDPschng ngng tp TCkim sot CMB v M , ngoi ra ha
hng ng BC monocyte.
Cac mnh X-Yc ch qu trnh polymer ha ca cc Fibrin monomerhn ch
qu trnh M ( Cc mnh E-D cng c tc ng ny nhng yu hn nhiu )
Cac mnh E-Dtng hiu lc ca cc cht hot ha plasminogen ( t-PA , tcu-PA ,
Kallikrein , XIIa,. )tng qu trnh TSH.
4. Hiu lc sinh hc ca cac mnh FDPs v c bn l c li cho c th , v chng
tham gia v h thng iu ha ng-cm mau v TSH , hn ch ti a qua trnh
tha , khng c li
_ Tuy nhin , trong mt s iu kin , th n l ngi n gy nn bin chng
bnh l huyt khi xut huyt.
V. CC XT NGHIM KHO ST QU TRNH TSH

1. Thi gian tiu euglobulin ( Nghim php Von-Kaulla )
_ Nguyn l XN : Huyt tng giu TC c pha long vi nc ct v acid
ha nhm lm ta yu t Fibrinogen v cc yu t hot ha TSH ( t-Pa ,
plasminogen hot ha ) , ng thi loi b cc yu t c ch TSH ( cht c ch
TSH , yu t VII t b ta). Sau ha tan ta vi nc mui sinh l , ri lm
ng tr li (nh Howell ).o thi gian t khi ng ti khi tan hon ton.
_ Mc ch ngha : anh gia mc hot ng ca h thng tiu si huyt
y l XN cn thit :
Theo di iu tr tiu huyt khi.
Chn on tnh trng tiu Fibrin tin pht v th pht , pht hin tnh trng tiu
Fibrin tim tang ( trong x gan , trc khi m tim )
L VN CNG
47
_ Tin hnh :
+) Dng c : ng nghim , pipet , ng h , ni cach thy
+) Ha cht :A.acetic 2% ,
m Michaelis pH=7,35 ( empha long t l 1:4 vi NaCl 0,9%)
NaCl 0,9%
CaCl2 0,1M
+) Bnh nhn : Khng c dng thuc chng ng . Hi (Anh b bnh l M
g cha ? Ung thuc Aspirin khng ? iu tr Heparin khng ? ( ch hi ko
mt im , hoc s b nh hng n kt qu XN )
+)Quy trnh :
B1: Ly >2ml mau TMcho vo l Natricitrat 3,8% ti vch 2em ly tm
1500vng/10 ly huyt tng giu tiu cu.
B3: Ht 0,3ml huyt tng thm 3ml nc ctthm 1 git A.acetic 2% ,
kim tra c pH=5,2
B4: em ly tm 3000vng/15gn b phn trong (yu t c ch TSH) + gi li
phn trong ( yu t hot ha TSH)Dng giy thm, thm kh thnh ng (
loi b hon ton phn yu t c ch c th bm vo ng )
B5: Thm 0,3ml m Michaelis pH=7,35 ( pha )Dng que anh tan
tathm 1git CaCl2 0,1Mem vo ni 370C ch ngGhi thi im
ng v theo di thi gian tan hon ton , bng cch 15 nhc ng xem 1 ln.
_ Nhn nh kt qu : Thi gian tan tiu euglobulin bnh thng >60
<15 TSH cp
15-30TSH nng
30-45TSH va
45-60TSH nh
_ Bin lun kt qu : Khi cc ng euglobulin khng hnh thnh
Do k thut :
Thm A.acetic khng : pH khong 5,2 th vic to ta fibrinogen l tt nht. Nu
pH ln s khng to ta hoc ta rt t, ngc li nu pH nh hn 5,2 s ta c cac
cht c ch tiu si huyt hoc thm ch pha hng c cu trc cac cht (v pH thp qua
m)
Thm ng nghim khng kh ( yu t c ch vn bm vo thnh ngc ch yu t
hot ha TSH thi gian tan ko di gi to do gim hnh thnh plasmin.
Do bnh l :
H thng hot ha Plasminogen qua mnhng n u tan n y
L VN CNG
48
Bnh l DICtiu th ht yu t M , yu t tiu Fibrinkhng th hnh thnh cc

ng hoc c ng nhng khng tan.
_ Cch phn bit hot ha Plasminogen qu mnh v tiu th ht
Thm 1 git huyt tng bnh thng vo dung dch euglobulin ri
thm Ca2+. Tin hnh nh KT , kt qu thu c :
+) C ng c nhng sau tan ngay tiu Fibrin qu mnh
+) C ng nhng >60khng tantiu th ht yu t hot ha
3000vng/15
300ml huyt tng

3000ml nc ct
1 git A.acetic 2%
m
Michaelis
pH=7,35
300ml
1 git Ca2+
2. Nghim php ru (ethanol) v Nghim php Protamin

vo nisulphat
370C
L VN CNG
49
_ Nguyn l XN: Thrombin tac ng ln Fibrinogen cac Fibrinmonomer ri tri qua

qua trnh polymer ha thnh Fibrin . Mt t Fibrinmonomer khng c polymer ha s
to thnh phc ha tan vi Fibrinogen v cc mnh FDPsPhc ny s c phat hin
nh Ethanol / Protamin sulphat do b gel ha.
_ Mc ch ngha : Nghim phap ru (ethanol) v Nghim phap Protamin sulphat
dng tnh chng t trong mu mau XN c phc hp ha tan l bng chng ca tnh
trng ng mau ri rac lng mch DIC. y l xt nghim chn oam DIC , tuy nhin
trng hp m tnh khng c ngha loi tr DIC.
_ Tin hnh :
+) Dng c : ng nghim , pipet , ni cach thy , may ly tm
+) Ha cht : Ethanol 50% , Protamin sulphat 1%
Chng(+): thm 0,1ml thrombin (0,2 v NIH/ml) vo 0,9ml huyt tng citrate
370/30si Fibrin s hnh thnhem quay ly tm phat hin r hn.
+) Bnh nhn : Khng c dng thuc chng ng . Hi (Anh b bnh l M g cha ?
Ung thuc Aspirin khng ? iu tr Heparin khng ? ( ch hi ko mt im , hoc s b
nh hng n kt qu XN )
+)Quy trnh nghim php ethanol
B1:Ly mau TM >2mlcho vo l Natricitrat 3,8% ti vch 2em ly tm 1000vng/10
ly huyt tng giu TC.
B2: anh s , ghi tn ng chng , ng th
B3: Ht 0,45 ml huyt tng giu TCthm 0,15ml Ethanol 50% y nt kn
370C/40 ly ng ra xem c gel ( ng ) kt qu (+) .
+) Quy trnh nghim php Protamin sulphat
Ht 1ml huyt tng giu TC cho vo 2 ng chng/ng th thm vo mi ng
0,05ml protamin sulphatt trong ni cach thy 3 Kt qu (+) khi c gel.
+) Nhn nh kt qu :
_ C gel (+) Bnh nhn c tnh trng DIC
_ Khng gel (-) Phi hp vi cc XN khc , cha loi tr DIC
Ch : Khng nn pha t cn 70 , cn 90 thnh cn 50 v s khng chnh xac. Do pha
nhiu ln gy ra sai s. Nn s dng cn tuyt i pha. Nu pha thp hn 50 th khng
to gel. Ln hn 50 s kt ta fibrinogen. Do o ngi ta thy 50 l tt nht.
L VN CNG
50
3. nh lng D-Dimer trong huyt tng

_ Sn phm thoai ha Fibrin (FDPs) gm 4 mnh X-Y-E-D .
Sn phm thoai ha cui cng l D-D ( D-Dimer) . Nh vy
D-Dimer xut hin khi hnh thnh cc mu ng v cc mu
ng t tiu bi plasmin.
_Nguyn l XN :Dng ht latex gn KT n dng chng li
Fibrin D-dimerqua nh lng Fibrin D-dimer c trong
huyt tng.
_Nng bnh thng: Fibrin D-dimer = < 200 mg/l
_ Mc ch ngha : y l xt nghim c gia tr chn
oan huyt khi hay khng , tc mch do huyt khi hay do
nguyn nhn khac
D-dimer bnh thng : loi tr s hin din ca huyt khi trong c th
D-dimer tng cao : gp trong DIC , tuy nhin 1 sinh l bnh thng cng gp , nn
n khng c hiu chn oan cho bnh no c , cm lm thm cac XN khac.
Dng c ha cht :
B kit xt nghim D-dmimer gm :
+) Latex Reagent : hn dch latex gn KT , KN D-dimer
+) D-dimer hiu chun
+) Dung dch m pha long
+) Chng m , chng dng
+) Tm card thc hin phn ngBan nh lng bng tay
Tin hnh
_ Ly mau TM chng ng Natricitrat 3.8% ly tm 2500 vng/15 ly huyt
tng ngho TC
_ Ban nh lng ( lm bng tay )
+) Trong vng trn trn tm card lm xt nghim , thm 20l huyt tng cn kim
tra ( khng pha long )
+) Trong vng trn khac trn card , thm 20 l chng dng
+) Trong vng trn khac trn card , thm 20 l chng m
+) Thm vo mi vng trn 20 l Latex Reagent nghing v trn trong 3
+) Kim tra ngng kt , so sanh vi chng dng v chng m anh gia kt qu.
+) Trng hp dng tnh , ban nh lng bng cach pha long huyt tng cn
kim tra theo t l 1/2, 1/ 4, 1/8, 1/6
L VN CNG
51
Mu kim tra
nguyn Pha 1/2
(-)
(+)
(-)
(+)
(+)
(+)
(+)
(+)
(+)
(+)
(+)
Pha 1/4
(-)
(-)
(+)
(+)
(+)
Pha 1/8
(-)
(-)
(-)
(+)
(+)
Pha 1/6
(-)
(-)
(-)
(-)
(+)
Nng g/ml
<0.05
0.5
1
2
4
8
<1
<2
<4
<8
Bin lun kt qu :
_ D-dimer tng trong : tng tiu Fibrin , DIC , tiu si huyt tin phat , huyt khi , ph
n c thai , do can thip hoc chn thng D-Dimer cng tng
_ D-dimer bnh thng loi tr c nghi ng tc mch do huyt khi.
4. nh lng sn phm thoi ha Fibrin ( nh lng FDPs )

- FDP c mt nhanh chng trong mu c hai tr-ng hp: tiu si huyt ton th v tiu si
huyt cc b kt hp vi s lng ng fibrin trong lng mch (c ng mu trong lng
mch).
- Trong mu ng-i bnh th-ng c th c FDP d-i dng vt, l kt qu ca tiu si
huyt sinh l. FDP cao hn trong thi k kinh nguyt, c bit ng-i rong kinh. FDP cng
tng ng-i x gan, tc mch, nhi mu phi v trong bnh nhn ghp thn. bnh nhn
ghp thn, tng FDP trong n-c tiu l biu hin ca tnh trng thi ghp.
- FDP cn tr phn ng Thrombin -Fibrinogen, lm ko di thi gian thrombin huyt t-ng.
Huyt thanh c FDP s lm tng nhanh s kt t ca tiu cu.
- Ph-ng php min dch l ph-ng php nhy nht xc nh FDP.
_ FDP vn c tnh KN ging FibrinogenNn khi cho 1 lng huyt thanh MD khang
Fibrinogen , FDPs s kt ta ( do hnh thnh phc KN-KT ). Hin nay hay dng k thut c
ch ngng kt HC ( ngoi pp ny ra cn nhiu pp khc )
4.1 nh l-ng FDP bng ph-ng php ng-ng kt latex
Nguyn l
Khi trn huyt thanh hoc n-c tiu vi dch treo c ht latex gn khng th c hiu
chng FDP, nu c hin t-ng ng-ng kt, ngha l trong huyt thanh hoc n-c tiu c FDP.
Ph-ng php bn nh l-ng -c tin hnh bng cch pha long mu xt nghim cc
nng khc nhau.
L VN CNG
52
Thuc th, ho cht

Dng thrombo-wellcotest kit (Wellcome reagents LTD. Beckenham, Kent)
Tin hnh k thut
- Tch huyt thanh:
+ Ly 2ml mu vo mt ng nghim chuyn dng cho xt nghim FDP (c cha
thrombin v cht c ch tiu m mu ng nhanh v ngn nga tiu si huyt invitro).
+ ng mu vo thng cch thu 37C cho n khi cc mu bt u co, quay ly tm
tch ly huyt thanh lm xt nghim.
- Thc hin phn ng:
+ Pha long huyt thanh 1/5, 1/20 vi m glycin c trong b kit.
+ Ly mt git hn dch mi pha long ca huyt thanh nh vo phin knh vi
mt git dch treo latex. Lc phin knh nh nhng cho n khi nhn thy ng-ng t bng mt
th-ng (thi gian khng qu 2 pht).
- Nu cht xt nghim l n-c tiu cng lm t-ng t nh- huyt thanh: cho 2 ml n-c tiu
vo ng chuyn dng, t vo thng cch thu 37C khong 30 pht, sau lc n-c tiu
qua giy lc hnh a (Whatman GF/B). Thc hin phn ng vi n-c tiu khng pha long
v pha long 1/5.
Kt qu
- Huyt thanh: nu ng-ng kt pha long 1/5 th l-ng FDP trong huyt thanh khng
qu 10 g/ml, nu ng-ng kt pha long 1/20 th l-ng FDP trong huyt thanh khng
qu 40 g/ml.
- N-c tiu: Nu ng-ng t n-c tiu khng pha long th FDP khng qu 2 g / ml, Nu
pha long 1 /5 th FDP c trong n-c tiu nguyn khng pha long khng qu 10 mg /
ml
- Kt qu ca ph-ng php dng latex t-ng t vi ph-ng php dng hng cu x l bng
acid tanic nh-ng n cho kt qu nhanh v tin cho nhng phng xt nghim khng lm
th-ng xuyn.
L VN CNG
53
4.2 : nh l-ng FDP da vo ph-ng php min dch c ch ng-ng kt hng cu

Nguyn l FDP c tnh khng nguyn, s phn ng vi khng th khng fibrinigen ng-i.
Khi cho vo huyt thanh c FDP, khng th khng fibrinogen ng-i s b trung ho v do
gim kh nng ng-ng kt hng cu -c gn fibrinogen (c ch ng-ng kt hng cu)
Chun b thuc th, ho cht v dng c
a. Thuc th:
- Dung dch m pH 7,2
- KH2PO4 0,15 M
23,9 ml
- Na2HPO4 0,15 M
76 ml
- NaCl 0,85 %
100 ml
- Dung dch m phosphat citrat pH 6,4

- 0,35 th tch Na2HPO4 0,15 M
- 0,65 th tch KH2PO4
0,25 M
- 1 th tch Natri citrat
0,1 M
a. Huyt thanh ng-i bnh th-ng v huyt thanh bnh:

- Ly 3 ml mu khng chng ng vo ng nghim c sn 10 mg cht c ch: acid amino
caproic (hoc cht c ch Kuniet).
- thng cch thu 370C trong 3 gi.
- Quay ly tm 3000 vng/pht trong 10 pht, tch ly huyt thanh.
b. Huyt t-ng chng:
- Trn huyt t-ng citrat ca nhng ng-i bnh th-ng cng nhm hng cu h ABO.
- Ly tm mnh 3000-5000 vng/pht trong 20 pht. nh l-ng fibrinogen trong huyt
t-ng .
L VN CNG
54
c. Huyt thanh chng fibrinogen ng-i:

- Tim fibrinogen ng-i cho th to khng th. Khi c hiu gi cao t yu cu th ly mu
th khng chng ng thu huyt thanh, kim tra bng in di min dch v hiu gi khng
th tr-c khi l-u tr.
d. Hng cu ng-i nhm O hoc hng cu cu
- Ly 20ml mu, chng ng bng 3 ml ACD hoc citrat, mu l-u tr 2 ngy tr-c khi
cm nhim.
- X l hng cu vi acid tanic 1/200.000:
+ Ra hng cu 7 ln bng m pH 7,2.
+ Pha hng cu 5% trong m pH 7,2
+ X l vi acid tanic: 1 th tch hng cu 5 % vi 1 th tch acid tanic 1/200.000.
nhit phng (c th trong gii hn 22- 37 C ) trong 20 pht.
- Ra hng cu 3 ln bng m pH 7,2 v cui cng pha thnh hng cu 5 % trong m.
e. Dng c vi ng-ng kt, khay nha nhiu hng l.
Tin hnh k thut
a. Hiu gi khng th :
- Cm nhim hng cu
+ Hng cu 5% tip xc vi huyt t-ng ng-i pha long 1/250 trong dung dch m pH
7,2.
+ Hng cu 5% tip xc vi huyt thanh pha long 1/250
(1 th tch hng cu, 1 th tch huyt t-ng hoc huyt thanh pha long 1/250 37 0C
trong 30 pht).
+ Ra hng cu 3 ln ri pha li 5%.
- Chn nng khng huyt thanh
+ Pha long khng huyt thanh bng dung dch m pH 7,2 c cha 1% gelatin trn hai
hng l.
+ Hng l 1 s c thm hng cu 5% tip xc vi huyt t-ng pha 1/250
L VN CNG
55
+ Hng l 2 c thm hng cu tip xc vi huyt thanh pha 1/250

+ nhit phng, sau 1-2 gi c ng-ng kt
+ Nng khng huyt thanh -c dng l nng ln hn 2 pha long so vi pha
long cui cng cn ng-ng kt.
b. nh l-ng FDP :
- Pha long huyt t-ng chun (Pool -c nh l-ng fibrinogen) trong m pH 7,2 c 1
% gelatin vi nng : 1/30, 1/90, 1/270, 1/540(Vi cc mu kim tra v huyt thanh
bnh th-ng (c cht c ch) th pha 1/3, 1/9, 1/27...)
- Cho 0,05 ml huyt thanh hiu gi chn vo mi l 10-30 pht 4C, thm vo mi
l 0,05 ml hng cu 5% cm nhim nhit phng 2 h.
Kt qu
- Chng d-ng l hng c huyt t-ng chun.
- Chng m l hng c huyt thanh ng-i bnh th-ng.
- Mc ng-ng kt pha long ca mu cn kim tra -c so snh vi huyt t-ng
chun.
Th d; huyt t-ng chun c cha 300mg/l, fibrinogen c ch ng-ng kt 1/600 th mi
pha long s l:
300 1000 1
100
= 0,5g/ml.
6000
Nu c ch ng-ng kt xy ra 1/80 ca hng mu cn kim tra th trong mu s c

0,5g/ml 80/1 =40g/mlFDP.
Bnh th-ng FPDs trong huyt thanh c t 0-5g/ml.
Nguyn nhn sai lm
- Nng acid tanic khng thch hp x l hng cu
- Khng huyt thanh khng m bo cht l-ng.
L VN CNG
56
5. Xc nh s c mt cc cht khng ng ng ni sinh

_ Nguyn l
Thi gian mt xt nghim ng mau ko di do: thiu ht mt hay nhiu yu t M
hoc s c mt ca cht khng ng lu hnh.
Pht hin khng ng lu hnh da vo kh nng b ca cc yu t ng mu.
Thi gian ng ca hn hp 1 th tch huyt tng bnh thng v 1 th tch huyt
tng ca bnh nhn thiu ht 1 hay nhiu yu t ng mau s gn bng thi gian
ng ca huyt tng bnh thng.
Trai li, thi gian ng ca hn hp 1 th tch huyt tng bnh thng v 1 th tch
huyt tng ca bnh nhn c cht khang ng lu hnh s ko di gn bng thi gian
ng ca huyt tng bnh nhn.
_ Chun b
+) Dng c:ng nghim, pipet, ni cach thy, may ly tm
+) Ha cht:
- Natri citrat 3,8%
- Cephalin Kaolin
- CaCl2 M/40
- Huyt tng chng
+) Bnh nhn: Khng s dng cac thuc chng ng.
+) Tin hnh
- Ly mau, chng ng bng natricitrat 3,8% theo t l 1/10
- Ly tm tach huyt tng ngho tiu cu
- Pha hn hp huyt tng chng v huyt tng bnh theo t l 1:1
- Chun b 3 ng nghim, anh s 1,2,3
- ng 1 cho 0,1 ml hn hp huyt tng bnh nhn v huyt tng chng
- ng 2 cho 0,1 ml huyt tng chng
- ng 3 cho 0,1 ml huyt tng bnh nhn
- Thm vo mi ng 0.1 ml Cephalin Kaolin 37oC/ 3 pht.
- Thm 0,1 ml CaCl2 M/40 vo ng 1, bm ng h. Lc ti 9s, quan sat mng ng v
ghi kt qu.
- Kho sat ng 2 v 3 tng t. Ghi kt qu.
+) Kt qu:
Khi thy kt qu thi gian ng ca mu huyt tng hn hp chng v bnh gn vi
thi gian ng ca huyt tng bnh chng t s c mt ca cac cht khang ng lu
hnh.
L VN CNG
57
Ch s Rosner:
(+) ( )
( )
_ Nhn nh kt qu:
< 12 khang ng ni sinh (-)

12 15 khang ng ni sinh nghi ng.
> 15 Khang ng ni sinh (+)
C cac cht khang ng cac yu t: VIII, IX, XI, XII
Cc cht khng ng ni sinh bao gm:

+ Antithrombin III (AT III): khang XIIa, XIa, IXa, Kallinkrein ...
+ 1 Antitypsin: kallikrein, XIa
+ Cht c ch C1: kallikrein, XII, XIa
+ Protein C, Protein S: VIIIa
+ Khang th khang yu t VIII
+ Khang th khang yu t IX
+ Cht c ch trong bnh Lupus ban : gy ta phospholipid
Ngoi ra cn mt s yu t khac nh: nexin protease 1, 2 Macroglobulin
_ Cc yu t nh hng kt qu xt nghim:
+) Cht lng cephalin kaolin
+) Huyt tng chng tp hp ca t hn 10 ngi.
6.1
Xt nghim xc nh s c mt ca cc cht khng ng ngoi sinh
Nguyn l
Thi gian mt xt nghim ng mau ngoi sinh ko di do: hoc thiu ht mt hay nhiu
yu t ng mau hoc s c mt ca cht khang ng lu hnh.
Nguyn l phat hin khang ng lu hnh ngoi sinh da vo kh nng b ca cac yu t
ng mau. Thi gian ng ca hn hp 1 th tch huyt tng bnh thng v 1 th tch
huyt tng ca bnh nhn thiu ht 1 hay nhiu yu t ng mau s gn bng thi gian
ng ca huyt tng bnh thng. Trai li, thi gian ng ca hn hp 1 th tch huyt
tng bnh thng v 1 th tch huyt tng ca bnh nhn c cht khang ng lu hnh s
ko di gn bng thi gian ng ca huyt tng bnh nhn.
Dng c:
- ng nghim, pipet, ni cach thy, may ly tm
L VN CNG
58
Ha cht:
- Natri citrat 3,8%
- Thromboplastin
- CaCl2 M/40
- Huyt tng chng
Bnh nhn:
- Khng s dng cac thuc chng ng.
Tin hnh
- Ly mau, chng ng bng natricitrat 3,8% theo t l 1/10
- Ly tm tach huyt tng ngho tiu cu
- Pha hn hp huyt tng chng v huyt tng bnh theo t l 1:1
- Chun b 3 ng nghim, anh s 1,2,3
- ng 1 cho 0,1 ml hn hp huyt tng bnh nhn v huyt tng chng
- ng 2 cho 0,1 ml huyt tng chng
- ng 3 cho 0,1 ml huyt tng bnh nhn
- Pha hn hp thromboplastin : CaCl2 M/40 theo t l 1:1.
- Thm 0,2 ml hn hp thromboplastin calci vo ng 1, bm ng h. Lc ti 9s, quan sat
mng ng v ghi kt qu.
- Kho sat ng 2 v 3 tng t. Ghi kt qu.
Kt qu:
Khi thy kt qu thi gian ng ca mu huyt tng hn hp chng v bnh gn vi thi
gian ng ca huyt tng bnh chng t s c mt ca cac cht khang ng lu hnh.
(+) ( )
Ch s Rosner:

( )
anh gia kt qu:
< 12: khang ng ngoi sinh (-)
12 15: khang ng ngoi sinh nghi ng.
> 15: Khang ng ngoi sinh (+)
- C cac cht khang ng cac yu t: II, V, VII, X
Cc cht khng ng ngoi sinh bao gm:
+ Antithrombin III (AT III): Xa, Thrombin...
+ 1 Antitypsin: thrombin
+ 2 Macroglobulin: thrombin
+ Protein C, Protein S: thoai ha yu t V -> gian tip kim soat Xa v thrombin
L VN CNG
59
+ Nexin protease 1
+ TFPI (tissue factor pathway inhibitor Cht c ch con ng yu t t chc)
+ Cht c ch trong bnh Lupus ban : gy ta phospholipid-> ng hng s chuyn
prothrombin(II) thnh thrombin(IIa). ng thi cnh tranh gy nh hng ti s hot ng
ca yu t X.
Cc yu t nh hng kt qu xt nghim:
- Cht lng thromboplastin
- Huyt tng chng tp hp ca t hn 10 ngi.
- Huyt tng qua 4 gi.
6.2
Xt nghim xc nh s c mt ca cc cht khng ng ( ni chung )
_ Nguyn l
Thi gian mt xt nghim ng mu ko di do: hoc thiu ht mt hay nhiu yu t
ng mu hoc s c mt ca cht khng ng l-u hnh. Nguyn l pht hin khng
ng l-u hnh da vo kh nng b ca cc yu t ng mu. Thi gian ng ca hn
hp 1 th tch huyt t-ng bnh th-ng v 1 th tch huyt t-ng ca bnh nhn thiu ht
1 hay nhiu yu t ng mu s gn bng thi gian ng ca huyt t-ng bnh th-ng.
Tri li, thi gian ng ca hn hp 1 th tch huyt t-ng bnh th-ng v 1 th tch
huyt t-ng ca bnh nhn c cht khng ng l-u hnh s ko di gn bng thi gian
ng ca huyt tng bnh nhn.
_ Dng c, thuc th, ho cht
- Bnh cch thu 37oC.
- ng nghim 75x9,5mm.
- ng h bm giy.
- Huyt t-ng chng.
- Tu theo loi xt nghim cn tin hnh (thi gian prothrombin hay thi gian kaolincephalin hot ho v.v) m chun b thuc th.
_ Tin hnh k thut
- Ly mu tch huyt t-ng: nh- xt nghim thi gian Howell
- Tin hnh xt nghim ng thi vi 3 mu huyt t-ng trong cng iu kin:
+ Mu huyt t-ng chng.
+ Mu huyt t-ng bnh.
+ Mu huyt t-ng hn hp chng v bnh theo t l 1/1.
- Ghi thi gian ng ca c 3 mu.
Trong mt s tr-ng hp, tin hnh li xt nghim vi c 3 mu sau khi 2 gi bnh cch
thu 37oC.
_ Kt qu
Thi gian ng ca mu huyt t-ng hn hp chng v bnh t l 1/1 ko di gn vi thi
gian ng ca huyt t-ng bnh chng t s c mt ca khng ng l-u hnh. Cn tin hnh
xc nh bn cht ca khng ng l-u hnh ny.
L VN CNG
60
Thi gian
Cephalin
Kaolin
Ko di
Bnh th-ng
Ko di
Ko di
Thi gian
Prothrombin
Bnh th-ng
Ko di
Ko di
Ko di
Thi gian
Thrombin
Bnh th-ng
Bnh th-ng
Bnh th-ng
Ko di
Cht khng ng l-u hnh chng:
XII, IX, XI, VIII

VIIa- thromboplastin t 61hoc.
X, V, II
Thrombin
7.Xc nh hot tnh yu t III ca Tiu cu.

_ Nguyn l: Hot tnh yu t 3 tiu cu xc nh bng s khc nhau ca thi gian -c
phc hi Calci ca huyt t-ng sau khi -c hot ha bi Kaolin tr-c v sau khi loi b
tiu cu. Bn nh l-ng -c nh gi qua -ng biu din thi gian ng ca huyt t-ng
bnh th-ng vi s l-ng tiu cu 50G/L , 25G/L 12,5G/L
Thuc th, ho cht
- Mu chng ng bng citrat natri3,8% t l 1/10 trong ng nghim nha hoc thy tinh
trng silicon. Quay li tm c huyt t-ng giu tiu cu v ngho tiu cu.
- Dng huyt t-ng ngho tiu cu pha long huyt t-ng giu tiu cu, c 50 109 v
12,5 109/ l, c th dng pool huyt t-ng ngho tiu cu ca ng-i bnh th-ng nh-ng
lu.
- Dng pool huyt t-ng ngho tiu cu bnh th-ng pha huyt t-ng giu tiu cu c s
l-ng tiu cu 50 109, 25 109 v 12,5 109/ l.
- CaCl M/ 40
- Kaolin 5mg/ml hoc celit 15mg/ml.
- m Michalis pH 7,3
Tin hnh k thut
- Trong cc ng nghim cha 0,1ml huyt t-ng c cha s l-ng tiu cu khc nhau: 50
109, 25 109 v 12,5 109/ l v ngho tiu cu chng, 50 109, 25 109 ; v ngho tiu cu
bnh.
- t vo thng cch thy 370C,cho thm 0,1 ml hn dch Kaolin 5mg/ml hay celit
15mg/ml lc u. ng 2 pht sau cho thm 0,1 ml CaCl M/ 40 bm ng h theo di thi
gian ng.
Kt qu
L VN CNG
61
- S khc nhau gia thi gian ng ca ng huyt t-ng giu v ngho tiu cu ni ln hot
tnh yu t 3 tiu cu.
- Qua thi gian ng ca cc ng huyt t-ng chng ta v -ng thng chun trn giy bn
Logarit vi trc tung l thi gian ng, trc honh l cc nng tiu cu (50 109/l t-ng
-ng 100%, 25 109 /l t-ng -ng 50%...).T th ny tnh -c hot tnh yu t 3 tiu
cu ca bnh nhn qua thi gian ng.
Nguyn nhn sai lm
- Mu ly lu qu 3 gi mi lm xt nghim.
- Pha long tiu cu khng chnh xc.
8. nh lng yu t XIII
Nguyn l
Yu t XIII -c hot ho trong qu trnh ng mu nh Ion calci v thrombin. Yu t
XIII hot ho lm n nh cc fibrin.
Khi c yu t XIII cc fibrin s khng ho tan trong dung dch ure 5 mol/l, cn cc
fibrin -c to t huyt t-ng thiu yu t XIII s b tan.
Thuc th, ho cht
- Huyt t-ng Citrat ca bnh v ca chng.
- CaCl2 M/40
- Ure 5 mol/l (300 g/l)
Tin hnh k thut
- Chun b 2 ng nghim thu tinh 75 x12 mm
- Cho 0,2 ml huyt t-ng chng hoc bnh vo mi ng
- Cho thm 0,2 ml CaCl2 M/40 vo tng ng
- thng cch thu 370C trong 30 pht, sau thm 3 ml dung dch ur 5 mol/l.
- Lc cc ng trong dung dch ur. ng nghim nhit phng qua m v kim tra
cc ng vo hm sau.
Kt qu
- Nu yu t XIII c trong huyt t-ng th cc ng vn cn.
- Ph-ng php ny th-ng ch dng chn on thiu yu t XIII bm sinh v nhng
tr-ng hp yu t XIII < 1%
- L-u :
- bit kh nng lm tan cc fibrrin ca dung dch ur, ng-i ta tin hnh lm xt nghim
L VN CNG
62
vi ng chng d-ng nh- sau: trong ng nghim cho 0,2 ml huyt t-ng citrat, 0,2ml
thrombin, sau cho dung dch ure nh- trn. Cc ng s tan trong ure v yu t XIII khng
hot ho do thiu Ca++.
- C th thay dung dch ur 5 mol /l bng acid monochloracetic 2%.
9.nh l-ng cc yu t da trn XN APTT (Yu t VIII, IX, XI v XII)

Nguyn l
Thi gian thromboplastin tng phn ca huyt t-ng ng-i hay huyt t-ng b
khng c mt trong cc yu t VIII, IX, XI v XII s b ko di. Thi gian ny s -c iu
chnh khi b sung huyt t-ng c yu t thiu ht . Mc iu chnh ph thuc nng
yu t thiu ht trong huyt t-ng b sung. Da vo , ng-i ta pha long huyt t-ng cn
xt nghim ra cc nng khc nhau v trn vi huyt t-ng khng c yu t cn kho st
(huyt t-ng th) theo di mc iu chnh v tnh ra nng yu t ng mu .
y chng ti m t ph-ng php nh l-ng yu t VIII C mt th cn ph-ng
php nh l-ng cc yu t IX, XI, XII cng t-ng t.
1. nh l-ng yu t VIII C
Dng c, ho cht
- Huyt t-ng th: l huyt t-ng khng c yu t VIII C, c th dng loi ng kh bn
sn, c th dng huyt t-ng ca bnh nhn hemophilia A c hot tnh yu t VIII C d-i
1% hoc c thi gian sinh thromboplastin tng phn hot ho trn 150 giy v khng c
khng th khng yu t VIII C.
- Cephalin: c th dng loi ng kh bn sn hoc t sn xut ti phng th nghim.
- CaCl2 M/40.
- Kaolin: 5 g/l trong m.
- Huyt t-ng chng: c th dng pool huyt t-ng ca ng-i bnh th-ng, c th dng
huyt t-ng bit tr-c hot tnh yu t VIII C.
Quy trnh k thut
- Ly mu bnh nhn tch huyt t-ng nh- xt nghim thi gian Howell.
- Pha long huyt t-ng
+ Pha long huyt t-ng chng theo t l: 1/10, 1/20, 1/40, 1/80 trong m Michaelis pH
7,3.
+ Pha long huyt t-ng bnh nhn theo t l 1/10 (nu bnh phm l mu yu t VIII
c c th cn pha long hn).
- Tin hnh xt nghim:
L VN CNG
63
+ Xy dng th chun: trong mt dy ng nghim:

. Mi ng cho 0,1 ml huyt t-ng chng mi nng pha long,
. 0,1 ml huyt t-ng th (khng c yu t VIII C),
. 0,1 ml hn dch cephalin-kaolin
bnh cch thu 370C trong 2 pht.
Sau thm 0,1 ml CaCl M/40 .
Bm ng h, theo di thi gian ng.
Da vo thi gian ng cc pha long, ta dng mt th trong trc tung l thi
gian ng ca cc pha long, trc honh l hot tnh ca yu t VIII C. th s l mt
-ng thng.
+ Xt nghim mu kim tra: cc b-c tin hnh nh- i vi huyt t-ng chng.
Da vo th ta tnh -c nng yu t VIII C.
- Hot tnh yu t VIIIC ca ng-i bnh th-ng l 50 -200%.
Nguyn nhn sai lm
- Huyt t-ng th ch-a ng tiu chun (cn hot tnh VIII C trn1%)
- Kt qu thi gian ng ca cc nng pha long huyt t-ng chng khng chnh xc nn
th khng phi l 1 -ng thng.
- Mt s nguyn nhn chung: dng c lm xt nghim khng sch, ly bnh phm khng
chun.
L-u : ngoi s dng huyt t-ng chng, ng-i ta cn dng huyt t-ng chun kim
tra, quy trnh ging nh- i vi huyt t-ng chng v th l mt -ng thng song song
vi -ng thng ca huyt t-ng chng.
2. nh l-ng cc yu t khc.
Cc b-c tin hnh t-ng t nh l-ng yu t VIII C, y ch trnh by cch chun
b huyt t-ng th:
nh l-ng yu t IX
- Huyt thanh khng c yu t IX:
+ Ly 3 ml mu bnh nhn b bnh Hemophili B cho vo ng nghim nh
+ Cho thm vo 3 git thromboplastin pha long 1/10 trong dung dch NaCl 9 %0 hoc
dung dch m Michelis pH 7,3
+ ng thng cch thu 370C trong 4 gi cho cc mu co hon ton, quay ly tm tch
huyt thanh.
nh l-ng yu t XI
- Huyt t-ng khng c yu t XI:
+ Ly mu chng ng bng citrat
L VN CNG
64
+ Ly tm mnh tch ly huyt t-ng ngho tiu cu

+ Hot ho yu t XII bng Celit
+ bnh cch thu 370 C trong 6 gi tiu th ht yu t XI.
+ Th li thi gian APTT, ch s dng lm huyt t-ng th khi thi gian APTT t 150 giy
tr ln.
L-u :
Mu ca bnh nhn Hemophilia dng sn xut thuc th phi khng c khng th
khng yu t ( IX, XI ).
10.nh l-ng cc yu t da trn XN PT (prothrombin, yu t V, VII & X)

Nguyn l chung
- Thi gian prothrombin ca huyt t-ng biu hin nng cc yu t V, VII, X,
fibrinogen v prothrombin. Mun nh l-ng mt trong cc yu t, ng-i ta theo di thi
gian thrombin ca huyt t-ng vi thuc th c d- cc yu t khc.
- Thuc th l cc mu ng kh ca huyt t-ng ng-i khng c prothrombin hoc
yu t V hoc yu t VII -c bn sn. Nhng sn phm ny cha hot tnh yu t cn nh
l-ng khng qu 1% nh-ng c cc yu t khc cn thit cho xt nghim thi gian
prothrombin.
- nh l-ng da trn s so snh mc iu chnh thi gian prothrombin ca huyt
t-ng thiu ht yu t bit sau khi thm vo cc nng pha long ca huyt t-ng bnh
v sau khi thm vo cc nng pha long ca huyt t-ng chng.
- Thi gian prothrombin -c nh gi bng cch dng thromboplastine t c vi CaCl2.
nh l-ng yu t II, V, VII
Thuc th, ho cht
- Huyt t-ng thiu ht yu t nh kim tra.
- m mui barbitone
- Thromboplastine t c th hoc c ng-i.
- CaCl2 M / 40 ( 0,025 mol/l ).
- Huyt t-ng chng.
Tin hnh k thut
- Pha long huyt t-ng chng v huyt t-ng cn kim tra 3 nng : 1/10, 1/50, 1/100
trong m.
- Ly 3 ng nghim, trong mi ng cho:
+ 0,1 ml huyt t-ng chng pha cc nng trn
+ 0,1 ml huyt t-ng khng c yu t kim tra (II hoc V hoc VII)
L VN CNG
65
+ 0,1 ml thromboplastin
- vo bnh cch thu 30 giy,
- Sau thm vo mi ng 0,1 ml CaCl2, bm ng h theo di thi gian ng.
- K -ng biu din gia thi gian ng vi pha long trn giy logarit kp.
- Tip tc lm nh- th vi huyt t-ng bnh ri c kt qu trn th.
Ghi ch: c th chun b cc huyt t-ng thiu cc yu t nh- sau:
- Huyt t-ng khng c yu t V c th -c chun b bng cch ly huyt t-ng oxalat
370C trong 3 ngy trong iu kin v trng (mu chng ng t l 9:1 vi oxalat natri 14
g/l), bo qun -20 0C.
- Huyt t-ng khng c yu t VII c th chun b t huyt t-ng bnh nhn dng Warfarin
sau 48 gi hoc huyt t-ng ca mt loi ch c thiu ht yu t VII bm sinh.
- Nc rn Viper i Loan (oxyuranus scutellatus) c kh nng trc tip bin prothrombin
thnh thrombin trong s vng mt ca nhng yu t ng mu bit no . V th c th
dng n nh- mt thuc th c hiu nh l-ng yu t II mt th.
- Bch Quc Tuyn v cng s sn xut thuc th nh l-ng yu t II t huyt thanh
oxalat ho v huyt t-ng ht vi t l 1:2
- Thuc th nh l-ng yu t VII -c sn xut t huyt t-ng cu chng ng bng
wintrobe, ht bng bt silicagen G hoc trn mng lc aming 20 %.
L VN CNG
66
11.nh l-ng yu t X
Nguyn l
- Thay th thromboplastin trong thi gian Quick bng nc rn h mang Russell pha long
ta s c thi gian ng di hn. Nc rn hot ho rt mnh yu t X m khng cn s tham
gia ca yu t VII.
- nh l-ng yu t X, ng-i ta dng mt thuc th l huyt t-ng b lc qua than
hot. Thuc th ny thiu ht c hai yu t VII & X. Nh-ng nu thay thromboplastin bng
nc rn Russell xt ghim thi gian prothrombin, yu t VII thiu ht s khng nh
h-ng n kt qu.
- So snh thi gian prothrombin vi nc rn Russell ca thuc th nh yu t X ca huyt
t-ng chng v bnh bit nng yu t X ca bnh nhn.
Thuc th, ho cht
- Huyt t-ng b lc amiang ( khng c yu t X )
- Dung dch nc rn Russell 1/150000 pha vi Cephalin.
- Cephalin pha vi m mui pH 7,4 c nng thch hp.
- Huyt t-ng Citrat ca chng v bnh.
- CaCl2 m//40.
- ng nghim, pipet, thng cch thu, ng h bm giy.
Tin hnh k thut
- Pha long huyt t-ng chng v bnh 1/10, 1/100, 1/1000 trong m mui pH 7,4.
- Cho vo mi ng nghim 0,1 ml huyt t-ng b khng c yu t X, 0,1 ml huyt t-ng
chng v bnh pha long cc nng v 0,1 ml thuc th gm nc rn vi cephalin.
- vo thng cch thu.
- Sau ng 30 giy cho thm 0,1 ml CaCl2 M/40, bm ng h theo di thi gian ng.
Lm mi ng ca mi nng lp li 2 ln.
Kt qu
- Thi gian ng ca cc nng huyt t-ng chng s -c v thnh -ng thng trn
giy logarit kp.
- Hot tnh yu t X ca bnh c th c trn th theo kt qu thi gian ng ca ng
c huyt t-ng bnh pha long 1/10.
Nguyn nhn sai lm
L VN CNG
67
(ca nh l-ng cc yu t da trn c s thi gian prothrombin)

- Ngoi nhng nguyn nhn chung nh- ly bnh phm khng chnh xc, dng c khng
sch, y cn ch n cht l-ng ca thuc th: nu trong cn nhiu yu t m ta
cn loi tr, kt qu s khng chnh xc.
12.Ph-ng php xc nh Fibrinogen

nh l-ng nhanh
Nguyn l
Sau khi thm thrombin vo huyt t-ng th huyt t-ng s b ng. Thi gian ng ph
thuc hm l-ng fibrinogen trong huyt t-ng. Da vo , ng-i ta cho d- thrombin
nh gi nng fibrinogen.
Thuc th, ho cht
- Thrombin: dung dch thrombin 250 n v NIH trong 1 ml NaCl 0,9%
- m Barbitone pH 7,4: Tr-c khi dng pha vi NaCl 0,9% theo t l 1:1
- Fibrinogen 0,4g/l: Fibrinogen ng-i 40 mg/100 ml m barbitone
Tin hnh k thut
- Ly mu, tch huyt t-ng: t-ng t tch huyt t-ng trong xt nghim thi gian
Howell.
- Pha dung dch fibrinogen c nng 0,1; 0,2; 0,3 g/l trong dung dch m.
Chun b 4 ng nghim, cho vo b m 37 0C .
- Cho vo mi ng 0,2 ml dung dch fibrinogene theo cc nng pha.
- Thm vo 0,2 ml dung dch thrombine, bm ng h theo di thi gian ng (va
lc trn va theo di ng). V -ng thng chun ca thi gian ng v nng
fibrinogen trn giy logarit kp.
- Pha long 1/10 huyt t-ng bnh nhn trong m Barbitone v tin hnh xt
nghim nh- trn.
Kt qu
Thi gian ng -c i chiu trn -ng thng chun. Sau nhn vi 10 c l-ng
fibrinogen trong huyt t-ng bnh nhn. Nu thi gian ng khng nm trong gii hn
-ng thng chun th cn pha mu xt nghim c nng khc cho thch hp (c hay
long hn 1/10 ) v nhn theo t l pha long mi ny.
L VN CNG
68
Bn nh l-ng
Nguyn l
Cc nng pha long ca huyt t-ng bnh th-ng v mu xt nghim -c lm ng
bng thrombin. So snh hin t-ng ng nhng nng pha long khc nhau tnh t l
fibrinogen trong mu xt nghim.
Cc xt nghim -c thc hin vi dung dch pha long: (a) trong n-c mui, (b) trong
n-c mui c cha Epsilon aminocaproic acid (EACA) ngn nga tiu si huyt v (c)
trong n-c mui c cha protamin sulphat ngn nga tc dng c ch ca sn phm thoi
ho fibrinogen v fibrin nu c. Trong nhng tr-ng hp cp cu ch nhng nng pha
long vi n-c mui c th cho nhng thng tin cn thit.
Thuc th, ho cht
- Huyt t-ng citrat ca bnh nhn v ng-i bnh th-ng.
- Thrombin: pha 50 n v NIH trong 2 ml dung dch NaCl 9 0/00 ngay tr-c khi
dng.
- EACA: 1 mg/ ml dung dch NaCl 9 0/00
Tin hnh k thut
- Chun b 3 b, mi b 7 ng nghim xt nghim huyt t-ng bnh th-ng v 3
b khc t-ng t xt nghim huyt t-ng bnh nhn.
- Mi ng ca b th nht cho 0,5 ml n-c mui.
- Mi ng ca b th hai cho 0,5 ml EACA pha trong n-c mui.
- Trong ng mt ca b th ba cho 0,5 ml protamin sulphat pha trong n-c mui v
6 ng cn li cho 0,5 ml n-c mui.
- Thm 0,5 ml huyt t-ng bnh th-ng hoc mu xt nghim vo ng u ca mi
b, trn u v chuyn 0,5 ml sang ng 2 v tip tc t-ng t sang ng 3, 4...nh- vy ta
s c nng huyt t-ng t 1/2 n 1/128.
- Thm 0,1 ml thrombin vo mi ng v trn u.
- t cc ng vo bnh cch thu 370C v yn 15 pht, sau kim tra xem c
fibrin hay khng (c ng hay khng) ?
L VN CNG
69
Kt qu
- Bnh th-ng fibrin s c trong tt c cc nng pha long huyt t-ng t 1 n
1/128. Trong gim fibrinogen nng th khng thy cc ng bt k nng no, nu
gim nh th s c cc ng fibrin 1 - 3 ng u.
- Nu thy cc ng cc ng c EACA pha long hn so vi ng ch c n-c mui
th chng t tiu si huyt nng.
- Nu thy cc ng ng c protamin sulphat nng pha long cao hn so vi
ng ch c n-c mui l c sn phm thoi ho fibrinogen v fibrin trong huyt t-ng.
- Cc ng nghim ca b huyt t-ng bnh th-ng dng lm chng d-ng.
L VN CNG
70
L VN CNG
71
BNH NG MU
I.
HI CHNG NG MU RI RC LNG MCH
1. nh ngha
_ DIC l bnh l ng mau tiu th , c trng bi s hot ha qua mc cac yu t
Mto ra nhiu cc huyt khi nh ri rac lng mch . S tng hot ng qua trnh
M tng hot ha qua trnh tiu cc mau ng. C 2 qua trnh dn n tiu th qua mc
cac yu t M v TC. Hu qu ri lon ng mau gm chy mu v huyt khi.
2. Nguyn nhn v c ch bnh sinh ca tng nhm bnh hay gp

Nguyn nhn
C ch
1. Nhim khun
_ VK tit ra ni c t:
Khi ng M ni sinh : hot ha trc tip yu t XII v gian
tip yu t XII , qua hot ha yu t tip xc PK.
Khi ng M ngoi sinh : bc l yu t TF trn mng TB
monocyte v TB ni mc.
c ch qt TSH: c ch TB ni mc gim sn xut yu t hot
ha plasminogen t-PA , ng thi tng gii phng yu t c
ch plasminogen PAI-1 , PAI-2
2. Bnh l sn khoa
_ Rau bong non ,thai
lu
_ Tc mch nc i
Rau thai , thai non cha nhiu yu t TF , nc i cha nhiu

yu t X hot ha M ngoi sinh
Chy mau trong Rau bong non l mt yu t M v TC
Cac bnh l ny lm tn tng TB ni mch din rng dn n

3. Bnh l mch mu
Hot ha M ni sinh
_ U mch , phng mch
Tng lng ng Fibrin
vim mch
Tng hin tng dnh v kt tp TC
_ Tim , no , phi , c quan khi tn thng gii phng nhiu yu
4. Chn thng ngoi t TFhot ha M ngoi sinh
khoa ( tim , no , phi) _ ng thi , vi cac chn thng ny dn chy mau , lm mt
cac yu t M , TC,
L VN CNG
72
3.Cc xt nghim nh gi tnh trng DIC

A. Cc xt nghim cm mu ban u
Tn xt nghim- gi tr bnh thng
Nguyn nhn thay i kt qu
_ PLT gim < 100G/L do tng tiu th
1. m s lng tiu cu
Bnh thng : 150-400 G/L
_BT ko di >6 do tiu th qua mc hoc
mt nhiu do chy mau
B. Cc xt nghim ng mu
_ APTT > 1.2 hoc ko di >20s so vi
1. APTT
Bnh thng: 0.9-1.15 (30-40s)
chng
_ APTT ko di do tiu th qua mc cac
yu t M ni sinh. Tuy nhin giai on
u DIC l s tng ng , APTT c th rt
ngn.
_ PT > 1.15 hoc PT ko di >2s so vi
2. PT
Bnh thng : 0.9-1.15
chng hoc t l Prothrombin < 60%
(11-14s hay t l prothrombin 70-140 % ) _ PT ko di do tng tiu th yu t M
ngoi sinh. c bit DIC bnh gan , va
tng tiu th va gim sn xut .
_TT > 1.15 hoc TT ko di >5s so vi
3. TT
Bnh thng : 0.85-1.15 ( 15-20s )
chng
_ TT ko di do tng tiu th Fibrinogen ,
ng thi tng thoai ha Fibrinogen th
phat.
_Fibrinogen < 1g/l do tng tiu th trong qt
4. nh lng Fibrinogen
Bnh thng : 2-4g/l
M v tng thoai ha trong qt TSH
5. nh lng yu t hot ha V,VIII , Gim nng trong DIC do tng tiu th
XIII v yu t c ch AT III , pro C/S trong qt M.
C. Cc xt nghim tiu si huyt
<15 TSH cp
1. Thi gian tiu euglobulin
( Nghim php Von-Kaulla )
15-30TSH nng
_ Bnh thng >90
30-45TSH va
45-60TSH nh
_ Do tng qua trnh TSHtng yu t hot
ha plasminogenplasmin
_Do tiu th qua mcgim Fibrinogen
2. Thi gian mu chy (BT)
Bnh thng : 1-4
L VN CNG
73
2. nh lng FDPs
(Nghim php ethanol )
_ Bnh thng : <10 g/ml hoc (-)
3. nh lng D-dimer
_ Bnh thng < 200mg/l hoc (-)
_ FDPs (+) c gia tr chn oan DIC

_ FDPs (-) cha d iu kin loi b kh
nng DIC
_ D-dimer bnh thng : loi tr huyt khi
trong DIC
_ D-dimer (+) / cao >200mg/l: cha th
khng nh c DIC , cn lm phi hp
vi cac XN khac.
4. Chn on phn bit

_ng mu do pha long : Sau khi truyn mau lu gi t, thy c hin tng thiu
ht cac yu t chng ng nhng khng c cc phc hp phn gii ho tan ca
fibrinogen, do vy FDP khng tng.
_ ng mu trong sn xut suy gan nng : C th kt hp vi ng mau tiu th.
Thy gim nng fibrinogen v cac yu t II, V, VII, IX, khng c gim tiu cu,
khng c phc hp phn gii ho tan ca fibrinogen do vy FDP khng tng.
5. Biu hin lm sng ca DIC

_ 2 triu chng in hnh ca DIC l : Hi chng huyt khi v Hi chng chy mu th
pht
Hi chng huyt khi : nhi mau tim , no , thn , phi ,.
Hi chng chy mu : L hu qu ca huyt khi , do s dng qua mc cac yu t M
v tiu cugim TC , gim Fibrinogen , gim yu t M khac ,
_ Chy mau di da-nim mc
_ Chy mau vt thng c t trc chy mau nhiu , ko di
L VN CNG
74
II.
HI CHNG XUT HUYT GIM TIU CU

HUYT KHI ( TTP)
1. nh ngha
_ TTP l bnh xut huyt gim tiu cu min dch , thng gp ph n tr , bnh c
trng bi tnh trng xut huyt do gim nng s lng tiu cu (<50G/L)tn thng
TB ni m thnh mchthc y qua trnh ng-cm mauHu qu l bnh nhn c
c HC xut huyt v HC huyt khi th pht.
2. C ch bnh sinh
_ Do tnh trng nhim trng , hoc iu tr ha cht a vo c th , y l cac cht l
i vi c th (KN) , kch thch c th sinh KT tng ng .
Trong huyt thanh bnh nhn c KT chng li TC , KT ny bam ln b mt mng tiu
cu , lm bin i cu trc mng tiu cu. Khi tiu cu i qua h lin vng ni m s b
bt gi v thc bo , hoc b tiu hy khi c mt b th.
_
3. Lm sng ( Tam chng TTP )

_ Xut huyt : do gim nng SLTCgim sc bn thnh mchHC d thoat ra ngoi
_ Thiu mu : do s lu thng ca HC b cn tr bi nt tiu cuthiu mau tan mau.
_ Ri lon thn kinh :
4. Cc xt nghim chn on TTP

A. CC XN NG-CM MU
1.Cm mau ban u
_ m s lng TC : <50G/L
_ Nghim phap dy tht (++++)
_Thi gian mau chy : ko di >6
_ XN co cc mau : cc mu khng co/co khng hon ton
2.ng mau
APTT , PT , TT: bnh thng (XN phn bit TTP/DIC)

B. CC XN MIN DCH
1.XN tm KT chng li TC
2.Nghim phap Coombs tiu cu
3.o i sng TC (8-12 ngy ): rt ngn ch cn vi gi
C. TY
1. S lng MTC : tng
L VN CNG
75
III. HI CHNG TAN MU URE HUYT CAO (HUS)

1. nh ngha
_ HUS l mt bnh l tan mau him gp , bnh thng gp tr em, sau bnh tiu chy
do E.coli , VK ng rut khac,.HUS v c bn ging vi TTP: bnh nhn c c
HC xut huyt v HC huyt khi th pht.. Mun phn bit HUS vi TTP phi da vo :
chc chn c suy thn v t c RLTK.
2. C ch bnh sinh ca HUS

_C ch tan mu HUS: Do ngoi c t ca E.Coli lm tn thng TB ni mch ca
mch mau hnh thnh nt tc TC gy cn tr , chn p s lu hnh ca HC trong
cac mch mau nh , lm HC b pha v.
_C ch Ure mu cao HUS :Tan mau HUS tng qua trnh thoai ha Hb--> sn
phm thoai gm nhn Hem v Globin . Globin c bn cht l chui aa chng s tip tc
c thoai ha to thnh NH3 , cui cng c gan kh c bng cach chuyn thnh
Ure . Cng vi tnh trng suy thn ( do thiu mu cc b ti thn ) , lm thn km o thi
Ure tng Ure trong mau.
_C ch huyt khi HUS: khi nhim E.Coli , vi khun tit ra ngoi c t ( tm hiu
thm E.Coli ti cun Vi sinh 2 TS-Trn Quang Cnh trang 201 ) ngoi c t ny gy
hoi t rutvo mau gy tn thng TB ni mchthc y qua trnh ng-cm mau.
3. Lm sng (Tam chng HUS)

_Xut huyt :xut huyt tiu ha do ngoi c t ca E.Coli. Cng tnh trng gim TC
do tng tiu th , lm sc bn thnh mch gim ( c li vai tr ca TC vi sc bn
mch mu ).
_Thiu mu tan mu : c KT pha hy HC hng lot
_Suy thn : do thiu mau cc b ti thn
4. Cc xt nghim chn on HUS

A. CC XN NG-CM MU
1.Cm mau ban u
_ m s lng TC : <100G/L ( gim nh hn TTP )

_ Nghim phap dy tht (+++)
_Thi gian mau chy : ko di >6
_ XN co cc mau : cc mu khng co/co khng hon ton
2.ng mau
L VN CNG
APTT , PT , TT: bnh thng (XN phn bit HUS v TTP/DIC)

76
B. CC XT NGHIM HA SINH
Tn XN
Thay i trong HUS
Gii thch kt qu
1.LDH
LDH tng > 480U/L _ LDH c mt trong bo tng ca mi TB.
(200-480U/L)
HUS do tan HC nn gii phng ra nhiu LDH
2.Ure mau
Ure tng cao > 7,5
_ Ure tng t l vi mc tan huyt ( xem c
(2,5-7,5mmol/l) mmol/l
ch phn trn)
3.Creatinin mau Creatinin tng cao
_ Creatinin c to ra c, ch yu t
60-120mol/l
creatinphosphat v creatin c. Creatinin theo
53-110mol/l
mau qua thn, c thn lc v bi tit ra nc
tiu.
_ Suy thn lm gim o thi Creatinin dn ti tng
cao trong mau. y l ch s vng nh gi tnh
trng suy thn
5. 5 tiu chun chn on HUS

1.Thiu mau tan mau
2.Gim tiu cu ( gim nh hn TTP )
3. LDH huyt thanh tng
4.Cac xt nghim M bnh thng
5. Khng c bt thng v thnh kinh
L VN CNG
77
TNG NG V HUYT KHI

I. C CH IU HA NG MU
1. Cc cht c ch M t nhin
Nhm 1 : Cc cht c ch Serin protease

1. AT III
( Anti thrombin III )
2. 1- AT
( Alpha 1 Anti trypsin )

3.
2-MG
( Alpha 2-MacroGlobulin )
4. HC II
(Heparin confactor II)

5. Cht c ch C1
_ Sx ti gan , nng trong mau 240 mg/l

_ c ch Thrombin , Kallikrein , IXa , Xa , XIa , XIIa
_ AT III bt hot ch yu Thrombin v yu t Xa , s bt hot ny
cng mnh m khi c mt Heparin do to phc :
AT III Heparin Thrombin
_ AT III khng bt hot yu t VIIa
_ Sx ti gan
_ c ch thrombin , Kallikrein , Xia
_ Sx ti gan
_ c ch Thrombin , Kallikrein
_ Sx ti gan
_ c ch Thrombin
_ Sx ti gan
_ c ch Kallikrein , XIa , XIIa v cac Proteinase b th C1
Nhm 2 : H thng protein C

1. Protein C (PC)
2. Protein S (PS)
3. Thrombomodulin
4. Cht c ch tng hp TFPI

_ c ch 2 ng yu t Va , VIIIa khi c mt PL- TC v Pro-S +Ca2+
_ B c ch bi 1-AT v PCI
_ Sx ti TB ni mc
_ Thrombomodulin cng Thrombin tham gia hot ha protein
Cbt hot 2 ng yu t Va , VIIIa
_ Yu t duy nht c ch yu t VIIa
_ TFPI to phc Xa-TFPI-VIIa-TF nn bt hot Xa,VIIa,TF
_ Trong cac cht c ch M t nhin , quan trng hn c l 3 yu t AT III , PC v PS.

Khi thiu cc yu t c M ny , cng vi tng yu t hot ha MM lan trn nguy
c tng ng-huyt khi.
L VN CNG
78
2. H thng hot ha tiu si huyt

_ Qua trnh M to ra cc mau ng , nh h thng tiu si huyt , lm tan cc mau
ng sau khi vt thng lnh mnhm bo cho dng mau lu thng bnh thng.
_H thng tiu si huyt gm : plasminogen l tin men ca plasmin cht gy tac ng
TSH chnh. Nhng mun plasminogenplasmin , phi c h thng hot ha plasminogen ,
v t-PA v tcu-PA l 2 cht chnh.
_ Bn cnh , h tiu si huyt c iu ha bi cac cht c ch hot ha
plasminogen ( PAI-1 , PAI-2 ) v cht khang plasmin ( 1-AP , 2-AT , AT III , 2-MG )
_ Khi gim cc yu t hot ha TSH v tng cc yu t c ch TSH cng gy nn nguy
c tng ng-huyt khi.
CC CHT HOT HA PLASMINOGEN
TN
C IM
VAI TR
_t-PA ch hot ha
_ t-PA sn xut ch yu TB
1. t-PA
PlasminogenPlasmin khi c s xut

hin ca Fibrin.
ni mc , 1 t c sx t TB
cnh biu m , Mu TC , BC
mono,...
_Tac dng lm tiu Fibrin ca t-PA

rt mnh :do t-PA v Plasminogen cng
c gn trc tip ln si Fibrin, v tr
_ t-PA hot ha Plasminogen lysin.
cc i pH kim
_ Tac dng trn cng xy ra vi
Fibrinogen nhng t hn nhiu , do v tr
gn trn Fibrinogen b che khut.
_ Urokiase c sn xut bi
2. Tcu-PA
TB thn di dng tin cht

Pro-Urokiase v c o thi
qua nc tiu.
(Urokiase)
_ Pro-UrokiaseUrokiase ,
nh s tac ng ca Plasmin
Kallikrein , XIIa
L VN CNG
_ Urokiase ( Tcu-PA) hot ha
plasminogenplasmin , bng cach ct i

1 lin kt peptid : tc ng ny xy ra d
c hay khng s xut hin ca Fibrin
iu ny cho thy , Tcu-PA tiu

Fibrinogen nhiu hn tiu Fibrin.
79
A. Cht c ch hot ha
Plasminogen
B.
Cht khng Plasmin
PAI-1 : c ch t-PA v tcuPA ,bng cch to phc bt hot , c

kh hic ch hot ha
plasminogen
_Nng trong huyt tng :1100ng/ml
_ PAI-1 tng trong PNCT , ngi
bo ph , T , vim-nhim khun
PAI-2 : c ch t-PA hot

ha , c bit l Tcu-PA
_ PAI-2 : tng ch yu khi c thai ,
LXM th M4 , M5, khi u,..
3.
_ 2-AP c tng hp t gan , c ch trc tip

plasmin , v c ch c cht hot ha plasminogen
(t-PA , tcu-PA )nhng chm
_ 2-AP gn c nh vo v tr hot ng ca
plasmin v c ch v tr hot ng , lin kt ny
lc u c th hi c , nhng v sau th khng
hi phc
_Ngoi ra, nh tac ng ca yu t XIIIa , 2-AP
lin kt trc tip vi chui Fibrin , t hn ch s
c nh Plasminogen vo Fibrin
_AT III l cht c ph tac dng rng , ngoi c
ch hot ng yu t M , n cn l cht khang
plasmin. Bng cach to phc vi plasminmt tac
dng ca plasmin
1-Antitrypsin (1-AT)
_ Nh ni phn II5 , Trypsin cng l cht c kh nng hot ha plasminogen.

_ 1-Antitrypsin cng ging AT III l cht c ph tac dng rng ngoi c ch hot ng
yu t M , n cn l cht khang plasmin lm mt tac dng ca Trypsin bng cach ct i
1 lin kt peptid
4.
Cht c ch C1
_ Quay tr li vi phn II2 , Pro-UrokiaseUrokiase , nh s tc ng ca Plasmin, Kallikrein ,

XIIa.
_ Nh vy , cht c ch C1 c ch TSH bng cach ngn khng cho
Pro-Urokiase---------Urokiase hay cac cht hot ha plasminogen ph thuc h t/xc

ni chung
5.
2-Macroglobulin (2-MG) cng l 1cht khang Plasmin
L VN CNG
80
II. TNH TRNG TNG NG

1. nh ngha
_ Tng ng (T) l tnh trng M thun li , c khuynh hng gy huyt khi nhng
cha xy ra huyt khi thc s.
2. Nguyn nhn
T tin pht ( di truyn)
T th pht ( mc phi )
_ Thiu ht yu t c ch M: AT II , PC, _ T mc phi ch l iu kin thun li

PS (do bt thng gen tri/NST thng ). hnh thnh huyt khi:
_Thiu yu t hot haTSH( plasminogen V d : thai nghn, bo ph, tiu ng,
t-PA , tcu-PA )v tng yu t c ch TSH nhim trng, ung th , XVM,..
( PAI-1 , PAI-2, 1-AP )
_Bt thng cu trc Fibrinogen : Fibrin
sinh ra khng chu tc ng ca plasmin.
3. Xt nghim nh gi tnh trng tng ng

_ Tiu cu tng : S lng/cht lng tiu cu tng
_Yu t M tng : Fibrinogen tng , VII , XII ,...Yu t c ch M gim (AT III ,
PC PS gim ).
_ APTT , PT , TT rt ngn : do tng cac yu t M.
_ Khi lng v qunh ca mu tng.
III. BNH HUYT KHI

c im so
snh
1. C ch
2. Lm sng
HUYT KHI TNH

MCH
HUYT KHI NG MCH
Tam chng Virchow:

+) Tn thng thnh TM
+) tr tun hon
+) Mt thng bng ng mu
Hai nguyn nhn HK M
_ HKTM nng chi di : thng

km theo vim nhim
_HKTM su chi di: bin chng
Tc mch phi
_Tc mch phi : nguy him nht
ca HKTM
_ Tc mch vnhnhi mau c tim

_Tc mch no nhi mau no
_Tc mch mc treohoi t rut
_Tc mch ngoi vi chi dihoi t
bn chn
L VN CNG
+) Tn thng thnh M hay gp ti

ni c XVM
+)Tng ng (him gp) : gim yu t
c ch M , gim yu t hot ha TSH
81
3.Cu trc HK
Huyt khi : hnh thnh

khi dng mau chy chm , cac
si Fibrin bao bc TB mau
Huyt khi trng: hnh thnh t ni

TB ni mch tn thng , tiu cu n
dnh v ngng tpnt cm mau
_ Thnh phn : Fibrin+HC
_ Thnh phn : Tiu cu
Huyt khi hn hp : khi phat l HK trng vi tp ch yu l TCKhi

lng M hp dng mau chy chmFibrin lng ng bao bc nt
cm mau v HCHK , vi tp ch yu Fibrin v HC
4.XN chn
on HK
_ Bnh nhn HKTM thng

xut pht t T tin pht
_ Bnh nhn HKM thng do T

th pht : XVM , bo ph , T
1.CMB-M
1.CMB-M
_ S lng TC tng
_ S lng TC tng
_ Thi gian mau chy rt ngn
_ Thi gian mau chy rt ngn
_APTT , PT , TT rt ngn
_APTT , PT , TT rt ngn
2.nh lng yu t M
2.nh lng yu t M
_ Fibrinogen tng
_ Fibrinogen , VII , VIII ,IX tng
_AT III , PC , PS gim

3.TSH
3.TSH
_ nh lng D-dimer :
_ nh lng D-dimer :
D-dimer bnh thng/(-)
D-dimer bnh thng/(-)
tr nguyn nhn tc
mch do HK
loi
D-dimer tng/(+)
D-dimer tng/(+)
khng th loi tr tc mch

do HK , cn lm thm cc XN
khc
khng th loi tr tc mch do HK ,

cn lm thm cc XN khc
loi
L VN CNG
tr nguyn nhn tc mch do
HK
5.Tm cht khng ng lupus
82
NG MU THAI NGHN
I. THI K C THAI
_ Gim s lng tiu cu < 150G/L do b pha long
_ Tng yu t hot ha M ( VIII , yu t Willebrand, VII, X , Fibrinogen )
_ Gim yu t c ch M : AT III gim nh , PC tng nh , c bit PS gim nhiu.
_ Gim kh nng TSH
S tng yu t hot ha yu t M gim yu t c ch M-Gim kh nng
tiu si huyt Tnh trng tng ng
II. THI K HU SN
_ S lng TC tr v bnh thng sau 24h
_ Tt c cac yu t M tr v bnh thng sau 3-6 tun
III. CC BNH L M C TH GP THAI PH

_ Bnh Von-Willebrand : do gim s lng TC thi k mang thai
_ Bnh xut huyt gim TC min dch : gim TCMD phi hp gim TC thai nghn ,
gim TC trong bnh lupus ban .
_ Hi chng DIC do thai cht lu : thai nhi giu yu t t chc TFhot ha mnh
M ngoi sinh tng tiu th qua mc thiu yu t M , TC cc bchy mau.
_ Rau bong non : rau thai cng giu yu t TF , ngoi ra bong rau non gy chy mau
lm mt yu t M
L VN CNG
83
BNH HEMOPHILIE
1. nh ngha
_ Hemophilie l bnh di truyn do gen ln nm trn nhim sc th gii tnh X , bnh ch
biu hin nam gii mang gen bnh hoc n gii th ng hp ( trng hp ny kh sng
ti tui trng thnh )
_ Bnh xy ra do thiu ht yu t VIII ( Hemophilie A ) , thiu ht yu t IX (Hemophilie
B) , thiu ht yu t XI (hemophilie C). Trong hay gp nht Hemophilie A chim 85%,
Hemophilie B chim 15% . Hemophilie C him gp, tnh trng nh , bnh gp c nam v
n, do n di truyn gen tri nm trn NST thng.
_ Bnh biu hin c trng bi tnh trng xut huyt , t mau c-khp ( ni chu p lc
ln ) , tai phat nhiu ln gy bin chng teo c , cng khp , dn n tn ph sut i.
2. Di truyn ph h
B bnh thng M gen bnh 50% gen bnh : 50% bnh
XY XaX XaX : XX : XaY : XY
B bnh M bnh thng 100% gen bnh : 100% bnh thng
XaY XX XaX : XaX : XY : XY
B bnh M gen bnh 50% bnh : 50% gen bnh
50% bnh : 50% bnh thng
XaY XaX XaXa , XaX , XaY , XY
3. Phn Hemophilie da vo nng yu t VIII , IX bnh thng 50-200%

_ Th nng : < 1% chy mau t nhin ( 60%)
_ Th trung bnh : 1-5% chy mau sau chn thng nh ( 22%)
_ Th nh : 5-30% ch chy mau sau chn thng nng (17.5%)
_ Ph n mang gen bnh : 20-50% bnh biu hin nh.
4. Lm sng c trng bi tnh trng xut huyt vi 4 c im ni bt:

+) Xut huyt thng bt u lc nh 1-5t
+) Xut huyt xy ra sau va chm nh , khng c xut huyt t nhin
+) Xut huyt xy ra tng t , tai phat nhiu ln ti v tr chy mau trc
+) Hnh thai xut huyt ch yu t mau c-khp , mng xut huyt v bc mau di da
L VN CNG
84
5. Cc xt nghim ng cm mu chn on Hemophilie

_ Bnh Hemophilie do thiu ht yu t VIII , IX , XI thuc con ng M ni sinh , nn ch
c cc XN kho st con ng M ni sinh ko di , cn cc XN kho st CMB , M
ngoi sinh , M chung vn bnh thng.
Kho sat M ni sinh ko di:
_ Thi gian mau ng ko di ( 5-12 ) > 15
_ Thi gian Howell ko di ( 130-230 ) >330
_ Thi gian APTT ko di ( 30-40s ) > 60s hoc APTTbnh/chng > 1.2 ( 0.9-1.15 )
nh lng nng yu t VIII , IX < 30% c gi tr chn on xc nh Hemophilie
Kho sat CMB bnh thng
_ m SLHC bnh thng : 150-400 G/L
_ Thi gian mau chy bnh thng : 1-4
Kho sat M ngoi sinh v M chung bnh thng : PT , TT bnh thng
_ Thi gian PT bnh thng 11-14s hoc PTbnh/ chng = 0.9-1.15
_ Thi gian TT bnh thng 15-20s hoc TTbnh/chng = 0.85-1.15
L VN CNG
85
RI LON NG MU MC PHI
_ Thiu vitamin K
_ Bnh gan
_ Bnh lupus ban
_ Ri lon ng mau sau truyn mau lu tr t
_ Vim thnh mch d ng
I. THIU VTM K
1. Nguyn nhn C ch bnh sinh
_ C ch bnh sinh : VTM K cn thit cho s tng hp yu t II , VII , IX , X , PC ,
PSThiu VTM K dn n cac yu trn c tng hp ra nhng khng c kh nng
hot ha.
_ Nguyn nhn :
+) Gim hp thu ( vim gan tc mt , tc rut , suy gan ) : Dch mt c gan to ra ,
xung ta trng trong qua trnh tiu ha. Dch mt c vai tr nh tng ha lipid , to
iu kin hp thu cac VTM tan trong du , trong c VTM K Vim gan tc mt lm
bi tit mt xung ta trnggim hp thu mgim hp thu VTM KRLM
+) Gim tng hp ( iu tr khang sinh ko di ) : Mt s VK ng rut c kh nng
tng hp VTM K cho c th dung KS ko ditiu dit h VK nygim tng hp
VTM K cho c thRLM.
+) Bm sinh tr s sinh : Do kh nng to mt ca gan cha y , h VK ng
rut cha phong ph tim b sung VTM K cho tr.
2. Cc xt nghim ng-cm mu nh gi RLM trong thiu VTM K

_ Bnh sinh do thiu VTM K m VTM K ch nh hng n cc yu t II , VII , IX , X,
PC , PS .Trong c yu t VII , X , II tham gia M ngoi sinh. V vy cc XN nh
lng yu t II , VII , IX , X s thy gim , ng mu ngoi sinh ko di ( PT ko di )
Gim yu t II , VII , IX , X
Thi gian PT ko di
Thi gian APTT bnh thng/ hoc ko di ( gim nng yu t X )
Thi gian TT bnh thng
SLTC bnh thng , BT bnh thng
L VN CNG
86
II. BNH GAN

1. C ch bnh sinh
_ Gan l c quan duy nht to ra dch mt xung ta trng trong qua trnh tiu ha ,
nh tng ha lipipid , to iu kin hp thu VTM K tan trong du Bnh gan lm
qua trnh tng hp dch mt gim Gim tiu ha mGim hp thu VTM KRLM
_ Gan l c quan tng hp hu ht cac yu t thuc h thng M v h thng
TSHBnh gan lm gim tng hp cac yu t thuc 2 h nyRLM.
_Gan cn l ni thanh thi cac yu t M hot hahn ch s M lan
trnBnh gan lm chc nng suy gimThng dn ti tnh trng DIC.
2. Cc xt nghim ng-cm mu v TSH nh gi RLM trong bnh gan

_ Do gan l c quan tng hp hu ht cc yu t M , nn trong bnh gan tt c cc XN
ng-cm mu u thay i , ring XN TSH pht hin tnh trng bnh nhn DIC do
gan.
Cm mu ban u
_ S lng tiu cu gim <100G/L : do tnh trng xut huyt lm mt TC
_ Thi gian mau chy ko di > 6 : do gim SLTC , Fibrinogen
ng mu
_ Thi gian APTT , PT , TT ko di
_ nh lng Fibrinogen <1 g/l (bnh thng 2-4 g/l )
Tiu si huyt nh pht hin tnh trng DIC do bnh gan
_ Nghim phap Von-Kaulla ( Thi gian tiu euglobulin) < 60 ( bnh thng >60)
_ Nghim phap Ethanol (+) c gia tr chn oan DIC
_ nh lng FDPs > 10 g/ml ( bnh thng < 10 g/ml )
L VN CNG
87
III. BNH LUPUS BAN H THNG (SLE)

1. C ch bnh sinh ( S ni k trong phn Huyt min dch )
_ Bnh lupus l bnh t min do c th t sinh ra khang th chng li cac c quan ca
chnh mnh.
_ C ch bnh sinh : Bnh lupus sinh ra cac KT IgG, IgM .Cac KT ny lm ta yu t
phospholipid ( yu t 3 ca TC ) c ch cac yu t ph thuc phospholipid khi hot
ha : II , VII , IX , Xkhng tng hp c Prothrombinase ( cht chng ng lupus
cn c tn l Anti-prothrombinase )RLM
2. Cc xt nghim ng-cm mu v cc XN chn on khc

_ Cm mu ban u : SLTC gim <100G/L , thi gian mau chy ko di > 6
( do cht chng ng lupus lm gim S lng va cht lng ca TC )
_ ng mu : APTT, PT , TT ko di ( do cc yu t II , VII , IX , X b bt hot )
_ XN huyt thanh giang mai ( phn ng BW ) : BW (+) gi
_ XN tm cht khng ng lupus : anti-Prothrombinase (+)
Phn ng kt hp b th BW pht hin anti-cardiolipin antibodies ( KT khng
Cardiolipin )
Cardiolipin l mt thnh phn quan trng ca mng trong ty th, cn thit cho cac chc
nng ti u ca nhiu enzym c lin quan n chuyn ha nng lng ca ty th.
Cardiolipin cng l mt khang nguyn ca Treponema-Giang mai ( c thm Vi sinh 2
trang 251 ca TS- Trn Quang Cnh)
Cac khng th khng cardiolipin c trong hi chng khang phospholipid ( bnh lupus
ban ) BW (+) gi
BW l mt xt nghim phc tp ( ti liu no cng cp nh vy )
L VN CNG
88
L VN CNG
89
IV. RI LON NG MU SAU TRUYN MU LU

TR T
_ C ch : Mau lu tr cng lu th cac yu t TC , yu t V , VIII , XIII gim cng nhiu.
Do khi truyn mau d tr vi khi lng ln c th gy bin chng chy mau cp sau
truyn mau.
_ Sau truyn mu thng
+) gim tiu cu (SL v CL )
+) Yu t M b mt , tiu th , pha long hoc gim sn xut
Tnh trng thiu ht.
Nu bnh nhn truyn >10n v mau d tr , c biu hin suy gim cm mau , th
cn phi truyn mau ti.
V. BNH VIM THNH MCH D NG

1. C ch bnh sinh
_ Vim thnh mch d ng l 1 loi bnh min dch do d nguyn gy ra , bnh biu hin
bng cac nt ban xut huyt di da-nim mc , hoc c xut huyt ni tng
_ C ch bnh sinh: D nguyn xm nhp c th , kch thch c th sinh KT chng li . Phc
hp KN-KT lng ng ti lp TB ni mc . Cng vi s kt hp ca b th v s gii phng
ra cac sn phm trung gian trong phn ng vim tng tnh thm thnh mch+ tn thng
lp TB ni mc tnh trng xut huyt.
L VN CNG
90
BIN LUN XN NG MU
Bnh l c th
Cc xt nghim vng 2
_ Gim cht lng TC : suy nhc TC ,

KT khang TC..
_ Thiu yu t XIII
_ Tn thng thnh mch : Gin mch ,
vim thnh mch d ng ,
_ Tnh trng M bnh thng :va p ,..
_ Thiu yu t : VIII , IX , X , XI , XII , PK
, Kininogen CPT
_ Bnh von-Willebrand ( yu t i cng
yu t VIII)
_ C th c khng ng : khang c hiu
yu t M , khang ng ni sinh khang
phospholipid ( lupus ban )
_Bnh gan
_ Thiu yu t VII , X , V , II
_ Thiu VTM K : do iu tr ngoi TH ,
iu tr khang sinh
_ Thuc chng ng ng ung : khang
VTM K dx coumarin
_ C th c khng ng : khang c hiu
yu t M , khang ng ngoi sinh khang
prothrombinase
_Bnh gan
_ Thiu yu t VII, X , V , II
_ Thiu VTM K: do iu tr ngoi TH ,
iu tr khang sinh
_ Thuc chng ng ng ung khang
VTM K , dx coumarin
_ Bnh gan
_ Thi gian mau chy , o

ngng tp tiu cu vi ADP ,
Ristosetin ,
_ nh lng yu t XIII , XN co
cc mau
_ Nghim phap dy tht
APTT PTT TT TC
1
_ Xut huyt gim TC
_ Truyn mu d tr t (Mau d tr mt
nhiu yu t TC , VIII , XIII.Fibrinogen
bnh thng.)
_ Suy gim chc nng gan
_ ang s dng heparin

_ Thiu Fibrinogen
_ Tng tiu Fibrin
_ Bnh gan
_ Bnh DIC
_ Bnh gan cp km DIC
L VN CNG
_ nh lng yu t VIII , IX , XI
, XII
_ nh lng yu t VIII
_ Tm cht khang ng lupus
_ Xn anh gia chc nng gan
_ nh lng yu t VII , X , V ,
II
_ Kim tra iu tr : ngoi tiu
ha , iu tr KS
_ Dng s dng thuc chng
ng , ri kim tra li
_ Tm cht khang ng
_Xn anh gia chc nng gan
_ nh lng yu t X , V , II
_ Kim tra li iu tr : ngoi tiu
ha , thuc KS
_ Dng s dng thuc chng
ng, kim tra li
_Xn anh gia chc nng gan
_ Ngng s dng heparin , kim
tra li.
_ nh lng yu t Fibrinogen
_ nh lng FDPs
_ XN chc nng gan
_ Tm nguyn nhn gim TC :
+) Ty
+) Tm KT khang TC
_ Truyn mau ti nu > 10v
_ XN anh gia chc nng gan
_ Nghim phap Von-Kaulla
_Nghim phap Ethanol
_ nh lng FDPs
91
CC GI TR AN TON V NG MU CHO
CUC M AN TON
1.
2.
3.
4.
5.
6.
S lng tiu cu : 150-400 G/L

Thi gian mau chy theo pp Ivy <8 ( pp Duke 1-4)
APTTbnh/chng = 0.9-1.15 ( 1,2 - 1,3)
PTbnh/chng = 0.9 1.15 + t l Prothrombin >70% + INR <1.2
TT bnh/chng =0.85-1.15 (1.2 - 1.3 )
Fibrinogen = 2-4 g/l
L VN CNG
92
TM HIU MT S THUC-CHT
CHNG NG V C CH TC DNG
TRONG XN V IU TR
I. Heparin
_ Heparin tc ng ln ch yu ln con ng M ni sinh : tc ng ln yu t thrombin
(IIa) ,Xa lm b.i c.trc yu t IIa ,Xa to phc Xa-AT III-IIa-heparin Mt tac dng
yu t IIa , Xa.
_ Phc hp sinh ra giac Heparin-AT III cn gia tc hot ng cho cc yu t c ch M
t nhin v tng phn hy thrombin ( Tc ngca AT III tng gp 2000-3000 ln khi c
mt heparin ) .
_ Heparin c th gn n mc bo ha vi cac protein huyt tng , TB ni mc ,
Monocyte.
_ Thi gian ban hy ca Heparin l 30-150 pht
_ Trong iu tr chng ng : Heparin c s dng theo ng tim . Khi vo mau ,

nng Heparin s cc i sau 4-6h sau tim ( v vy , nu bnh nhn ang tr Heparin XN
ng mu s b nh hng trong vng 6h sau khi tim ).
_ Ch :iu tr nhiu Heparin cng lm gim SLTC
_ Trong phng xt nghim : ng heparin ( mu en ) thng
c s dng cho cac XN ha sinh , khng dng cho cac XN
huyt hc v n c ch khng hi phc con ng M ni sinh ( thrombin v yu t X)
nn khng dng cho cc XN M v lm thay i hnh dng TB mu ( do mui LitiHeparin )
II. Natricitrat
_ Natricitrat to phc c hi phc vi Ca2+ , lm gim Ca2+ trong mau , Ca2+ l yu t cn
thit cho s hot ha ca yu t : VII , X , V , II cac yu t ny khng c hot
haM b c ch.
L VN CNG
93
_ Trong truyn mu : Mau d tr truyn cho bnh nhn thng s dng Natricitrat t l
3-4 gam/0.5ml mau . Khi vo c th nng b pha long nn khng gy chy mau ,
nhng c th gy c natricitrat nu truyn mau d tr nhiu ln.
_ Trong xt nghim : Natricitrat ph hp cho cac XN huyt hc M , v n ch c ch tm
thi qua trnh ng mau , khi phc hi Ca2+ , qua trnh li din ra bnh thng .
+) Ch : T l chng ng y l 1mu : 9 chng ng , nu dng sai t l XN s b
nh hng do :
Nu ly lng mau nhiu hn quy nh th s lm mau b ng (c th ch l ng
dy) v nh vy kt qu XN tt nhin s sai (rt ngn thi gian ng).
Nu ly mau t hn th s lm d lng Natri. V vy khi lm XN (phc hi li
Canxi) th lng Natri d s c ch 1 phn lng Canxi cho vo (m lng Canxi cho vo
l c nh) do vy s lm gim nng Canxi t lm thay i thi gian ng (thng l
ko di hn). Nh vy kt qu s khng chnh xac.
* V vy vi Xn ng mu phi ly ng t l quy nh, nu ly sai phi ly li.
_ Natricitrat khng dng cho cc cc XN ha sinh v lm thay i kt qu cc XN do:
+) Gim gi to Ca2+ - Tng gi to Na+
+) c ch ALP , ALT
+) Thay i kt qu nh lng Phosphate
III. EDTA ( Ethylene diamin tetraacetic acid )

_ EDTA l cht chng ng thng s dng trong phng xt nghim
_ EDTA: dng trong xt nghim t bo mu ngoi vi, huyt , mu lng, nh nhm mu,
hng cu li, HBA1C
Gi n nh hnh dng TB trong thi gian di do gi nng dung dch ng trng
Xt nghim HbA1C o lng glycohemoglobin trong hng cu do phi ly c
hng cu nguyn vn. V vy nn ly bng chng ng EDTA. Ngoi ra c may o HbA1c
bng mau mao mch nn khng cn chng ng (may ca nhn). Cn nu dng cac chng
ng khac th khng tt nhng khng c ngha l khng dng c. Ch cn tranh lm v
hng cu
_ Mt s trng hp khng dng EDTA v c ch :
1. Khng dng EDTA cho xt nghim ng mu v: EDTA l 1 loi Hp cht
hu c, c thnh phn Na. khi dng EDTA cho xt nghim ny s hnh thnh tng
tac gng km gp mt Ca trong mau lm nh hng ti c con ng ni sinh v
ngoi sinh.
L VN CNG
94
2. Khng dng EDTA chi xt nghim sinh ha v : EDTA lm nh hng ti

kt qu in gii : tng gi to Na+- K+ do c trong thnh phn EDTA , gim gi to
Ca2+ , Fe2+ do to phc vi Ca2+ , Fe2+ .
IV. CC THUC CHNG NG NG UNG

1. Dn xut ca Coumarin - WAFARIN
_Cac thuc chng ng ng ung l cac cht khang VTM K , thng l cac thuc dn
xut ca Coumarin ( Wafarin )
_ Thuc c ch s hot ng ca VTM K Qua c ch cac yu t ph thuc VTM K
khi hot ha: II , VII , IX , X , PC , PS Cac yu t ny c tng hp nhng khng c
kh nng hot ha
_ C ch c ch VTM K din ra nh sau : Thuc c ch enzyme epoxyd reductase , t
lm tng t s oxyd/vitamin K . Lng oxyd nhiu s cnh tranh vi VTM K vng th
cm lm VTM K b gim hiu lc.
_ Thuc c hp thu qua ng ung , vo mau gn rt cht vi protein huyt tng , ch

c dng t do mi hot ng. Thuc b phn hy bi enzyme microsom gan.
_ Thi gian ban hy l 36-48h .
_ Ch :
+) Wafarin tc ng ch yu ln con ng M ngoi sinh nn XN thi gian PT s b nh
hng nu bnh nhn s dng chng ng ng ung trong 48h .
+) Wafarin l mt trong nhng tc nhn gy qui thai , thuc c th gy d dng h TK , ri
lon thnh gic,Thuc chng ch nh cho ph n c thai.
V. ASPIRIN
_ Aspirin v cac thuc chng vim khng steroid (NSAID ) c tac dng chng kt tp tiu
cu , bng cach c ch TC gii phng ra yu t Thomboxan A2 v ADP .
_ C th nh sau : Aspirin c ch men cyclo-oxygenase ngn cn hnh thnh Thomboxan
A2nh c ch s ngng tp TC
L VN CNG
95
BNG CC CH S BNH THNG

CA CC XT NGHIM NG MU
Tn- gi tr bnh thng
1. m s lng tiu cu
PLT=150-400 G/L
2. Thi gian mau chy theo pp Duke (BT)
BT=1-4
3. Co cc mau
Bnh thng : Co hon ton
4. Thi gian mau ng trn ng nghim
Mng = 5-12
5. Thi gian Howell
Howell = 130 230
6. Thi gian APTT
APTT(s)= 30-40s
APTTbnh/chng=0.9-1.15
7. Thi gian PT
PT(s)= 11-14s
PTbnh/chng= 0.9-1.15
T l prothrombin = 70-140%
8. Thi gian TT
TT (s) = 15-20s
TTbnh/chng= 0.85-1.15
9. Thi gian tiu cc ng
Bnh thng > 90
_ Nghim phap Von-Kaulla > 60
10.Nghim phap Ethanol

Bnh thng (-)
11.nh lng FDPs ( < 10 g/ml )
FDPs=0-5 g/ml
12.nh lng Fibrinogen
Fibrinogen = 2-4 g/l
L VN CNG
Gi tr bt thng
>450 G/L
< 100 G/L
>6
_ Cc mau khng co
_ Cc mau co khng hon ton
_ Cc mau b nat
> 15
> 60s so vi chng
( > 330)
> 8s ko di ( >48s )
> 20s bnh l ( >60s )
> 1.2
> 2s so vi chng ( >16s )
> 1.15
< 60% ( ko di )
> 5s so vi chng ( >25s )
> 1.15
<15 TSH cp
15-30TSH nng
30-45TSH va
45-60TSH nh
(+)
> 10 g/ml
< 1 g/l
96
Tr s bnh thng ca cc yu t tham gia qu trnh

ng mu v tiu si huyt
Tn yu t
1. SLTC
2. V-WF-Ag
3. Fibrinogen
4. Prothrombin (II)
5. V
6. VII
7. VIII
8. IX
9. X
10.XI
11.XII
12.XIII
13.Pre-Kallikrein
14.Kininogen CPT
15.PAI-1
16.PAI-2
17.AT III
18.Protein C
19.Protein S
20.Plasminogen
21.2-AP
22. HC II
23.t-PA
24.scu-PA
Gia tr bnh thng

150-400 G/L
500-2000 U/L
2-4 g/l
100-150 mg/l
5-10 mg/l
10 mg/l
< 0.1 mg/l
0,1 mg/l
7.5 mg/l
12 mg/l
4 mg/l
25 mg /l
3 mg/l
25 mg/l
0.05 mg/l
< 0.05 mg/l
80-120%
70-140%
60-140%
80-120%
70 mg/l
55-145 %
0.005 mg/l
0.008 mg/l
THE END
L VN CNG
97
L VN CNG
98
MC LC
I-CM MU BAN U
3. Cc yu t tham gia CMB10
4. Cc XN nh gi CMB.12
_ Nghim php dy tht12
_ Thi gian mu chy ( PP Duke )...13
_ XN co cc mu...14
II- NG MU
4. iu ha qu trnh M-Cc yu t tham gia.15
5. Cc giai on ca qu trnh ng mu19
6. Cc XN kho st qu trnh ng mu.24
_ Thi gian mu ng trn lam.24
_ Thi gian mu ng trn ng nghim..25
_ Thi gian Howell26
_ Thi gian APTT.27
_ Thi gian TT...33
_ Bng tm tt cc XN ng mu34
III- TIU SI HUYT

7. Plasminogen v Plasmin39
8. Cht hot ha Plasminogen40
9. Cht c ch qu trnh TSH.42
10.Sn phm thoi ha Fibrin-Cc mnh FDPs.46
11.Cc XN kho st qu trnh tiu si huyt...46
12.Cc xt nghim chuyn su khc
_ Xc nh s c mt cht khng ng ni sinh56
_ Xc nh s c mt cht khng ng ngoi sinh..57
_ Xc nh s c mt cht khng ng ( ni chung )..59
L VN CNG
99
_ Xc nh hot tnh yu t III tiu cu.60

_ nh lng yu t XIII.61
_ nh lng yu t M ni sinh VIII ,IX, XI , XII..62
_ nh lng yu t M ngoi sinh VII , X , V..64
_ nh lng Fibrinogen..67
IV- BNH NG MU
13.Hi chng ng mu ri rc lng mch (DIC)..71
14.Hi chng xut huyt gim tiu cu huyt khi (TTP).74
15.Hi chng tan mu Ure huyt cao (HUS).75
16.Tnh trng tng ng-Bnh huyt khi..77
17.ng mu thai nghn...82
18.Bnh Hemophilie ..83
19.Bnh ri lon ng mu mc phi.85
_ Thiu VTM K85
_ Bnh gan.86
_ Bnh h thng Lupus ban (SLE).87
_ Ri lon ng mu sau truyn mu d tr t89
_ Bnh vim thnh mch d ng89
20.Bin lun xt nghim ng mu.90
21.Cc gi tr M cho cuc m an ton. 91
22. Tm hiu c ch v ng dng mt s cht-thuc chng ng
_ Heparin..92
_ Natricitrat..92
_EDTA ( Ethylene diamin tetraacetic acid )..93
_ Wafarin ( thuc c ch VTM K ng ung )94
_ Aspirin.94
23.Bng tr s bnh thng-bt thng ca cc XN ng-cm mu.95
24.Tr s bnh thng ca cc yu t tham gia ng-cm mu v TSH.96
L VN CNG
100

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Cẩm Nang Huyết Học - yhocthuchanh2015

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2013

III- TIU SI HUYT

_ Xc nh hot tnh yu t III tiu cu.60

PHN II- NG MU V CC XT NGHIM LIN QUAN

Cm mau ban u ( CMB )

THAM GIA CMB

3. Yu t protein huyt tng : Willebrand , Fibrinogen

_ Thnh mch tn thngkch thch auco c trn lng mch hp ligim

2. Hnh thnh nt tiu cu

+) < 7 nt xut huyt bnh thng

2. Thi gian mu chy ( Bleeding time-BT ) theo pp Duke

Cht lng thnh mch

Nu mau chy t hoc khng chy , i 2 , ghi kt qu MC=2

( PP Ivy : to vt thng mc trc cng tay , duy tr di p lc 40mmHg , o

S lng v cht lng ca TC

Nhm 1: 12 yu t ng mu huyt tng

kt hp vi yu t Willebrand tng tnh bn vng.

1. Yu t thnh mch ( ni mch )

_ AT III bt hot ch yu Thrombin v yu t Xa , s bt hot ny

Nhm 2 : H thng protein C

_ Sx ti gan , ph thuc VTM K khi tng hp

1. Nhm cc yu t tip xc:

II. CC GIAI ON QU TRNH NG MU

XIIa +PK +Kininogen

IXa + VIII +Ca2++PL

Fibrin ha tan + XIIIa+Ca2+

Fibrin khng tan

_ Con ng M ni sinh c bt u t vic gn cac yu t tip xc (XII , XI , PK,

Giai on 2 : Hnh thnh Thrombin ni sinh

_ Prothrombinase hnh thnh , hot ha yu t IIIIa ( Thrombin ) , bng cach ct i 2 lin

tng chuyn Plasminogen Plasmin

chuyn Fibrinogen Fibrin

T khuch ihot ha V , VII, VIII, XI

2. Con ng M ngoi sinh

Prothrombinase ngoi sinh

Giai on 2: hnh thnh Thrombin

_ Khi tn thng thnh mch , c ch M ngoi sinh chim vai tr ch o , do n

Fibrin polymer ( Fibrin ha tan)

Fibrin khng tan

_ Thrombin sinh ra , ct 1 lin kt peptid ca Fibrinogen thnh 2 Fibrin monomer

Chm , din ra vi pht

Nhanh , t=15s nu chn

Din ra mnh nh s hip

_ Yu t tip xc: XII,

III. CC XT NGHIM KHO ST NG MU

( Gii thch xem thm phn thi gian Howell , APTT , PT )

2. Thi gian M trong ng nghim

3. Thi gian Howell ( thi gian phc hi Ca2+ )

Thiu ht yu t TC ( SL v/hoc CL ) :KT khng TC , Suy ty , Leucemia,

Gii thch 1 s trng hp lm thi gian Howell ko di

Bnh h thng lupus ban , c khng ng lupus ban : Khang ng Lupus

5. Thi gian PT (thi gian Prothrombin , thi gian Quick , t l

Ha cht lm xt nghim thi gian PT

Fibrin polymer ( Fibrin ha tan)

_ Bin lun kt qu : thi gian TT ko di trong cc trng hp sau

BNG TM TT CC XT NGHIM CM-NG MU

Kho sat qua trnh CMB

Co khng hon ton

+) Bnh thng : M=5-

Kho sat con ng M

Ch : thi gian mu ng < 5

Kho sat con ng M ni

Nhn xt : Thi gian mu ng