A - CNG THC MU Cng thc mu c 17 ch s, theo trnh t c ca my: 1) WBC = white blood cell = bch cu 2) NEU: NEUTROPHIL = a nhn

trung tnh 3) LYM: LYMPHOCYTE = Bch cu Lympho 4) MONO: MONOCYTE = Mono bo 5) EOS: EOSINOPHIL = a nhn i toan 6) BASO: BASOPHIL = a nhn i kim 7) RBC = Red Blood Cell = hng cu 8) HGB = Hb = Hemoglobin = huyt sc t 9) HCT = Hematocrit = dung tch hng cu 10) MCV = Mean corpuscular volume = th tch trung bnh mt hng cu 11) MCH = Mean corpuscular hemoglobin = s lng hemoglobin trung bnh trong mt hng cu 12) MCHC = Mean corpuscular hemoglobin concentration = nng hemoglobin trung bnh trong mt hng cu 13) RDW = Red (cell) Distribution width = phn b hnh thi kch thc hng cu (khong phn b hng cu) 14) PLT = platelet = Tiu cu 15) MPV = Mean platelet volume = Th tch trung bnh tiu cu 16) PCT = Plateletcrit = Th tch khi tiu cu 17) PDW = Platelet distribution width = Di phn b kch thc TC. Ngoi ra, c th ngh lm thm b 3 xt nghim chc nng ng cm mu: 1) TP (Prothrombin content) = t l Prothrombin ( ~ TQ = Quick Time) 2) aPTT (activative Partial Thromboplastin Time) = thi gian Thromboplastin tng phn (~ TCK = cephalin - kaolin time). 3) Fibrinogen. phn bit cc cp bnh: Schoenlein Henoch & Suy nhc tiu cu, Hemophilia & Willebrand cn lm thm TS (Saignement time) = thi gian mu chy. nh gi trng thi & kh nng sinh HC ca ty xng, nht l trong Suy ty, xem mc sn xut hng cu mau hay chm & ty xng p ng ra sao trc s thiu mu => cn lm Hng cu li. Xt nghim ny cn gip cng c cho hng chn on TM tn huyt cng nh phn bit cc nguyn nhn thiu mu: TM c tnh (khng sn xut hng cu) hay TM hng cu hnh lim, Thalassemia (HC b hy: TM tn huyt). Vi case bnh c hng iu tr truyn mu (XHTH, BCC, TM nng..): xc nh nhm mu l iu bt buc. Ch nh truyn khi: Hb < 7 g/dl (huyt hc) hoc Hct < 20 % vi ngi tr, < 25% vi ngi gi (tiu ho).

1/ DNG HNG CU RBC (Red Blood Cell): S lng hng cu - l s lng hng cu c trong mt n v mu (thng l lt hay mm) Tng: + C c mu (mt nc, nn nhiu, i ngoi), a hng cu thc (bnh Vaquez). + Bnh gy ri lon tun hon tim, phi (bnh tim bm sinh, hp M phi, COPD..), thiu oxy.. Gim: thiu mu, suy tu, thp khp cp, gi, mang thai.. HGB hay Hb (Hemoglobin): Nng hemoglobin trong mu (n v tnh bng g/l hay g/dl), o hm lng hemoglobin trong mu. Hemoglobin, hay haemoglobin, huyt sc t - l mt protein phc tp cha phn t st c kh nng thu nhp, lu gi v phng thch xy trong c th ng vt hu nh v mt s ng vt khc. Thut ng hemoglobin l s kt hp ca heme v globin, cho thy rng mi n v con ca hemoglobin l mt protein cu trc hnh cu vi nhm heme (hay haem) nh km; mi nhm heme cha mt phn t st, v n m nhim cho vic gn kt vi xy. Cc loi hemoglobin chung nht u cha bn n v con, mi n v km theo mt nhm heme. Nng hemoglobin trong bo tng ca hng cu c th ln n 34 g/dL t bo. l nng ti a khng lm ri lon chc nng to hemoglobin trong hng cu. ngi khe mnh bnh thng, nng hemoglobin trong hng cu lun gn mc ti a ny. Tuy nhin, khi chc nng to hemoglobin b suy yu, nng ny tt gim ng k, c th lm th tch hng cu gim theo. Lin quan truyn mu (Vin Huyt hc TW): + Trn 10 g/dl: thiu mu nh, khng cn truyn mu. + T 8-10 g/dl: thiu mu va, cn nhc nhu cu truyn mu. + T 6-8 g/dl: thiu mu nng, cn truyn mu. + Di 6 g/dl: cn truyn mu cp cu. => < 7g: cn truyn mu/XHTH. t bin v gen vi hemoglobin dn ti mt nhm cc bnh di truyn gi l hemoglobinopathies, trong ph bin nht l bnh t bo hnh lim (sickle-cell disease) v thalassemia. Gi tr bnh thng ca hemoglobin ty thuc vo tui tc v gii tnh (i vi ngi trng thnh). Gi tr bnh thng ca hemoglobin l: S sinh: 7 - 22 g/dl 1 tun tui: 15 - 20 g/dl 1 thng tui: 11 - 15 g/dl Tr em: 11 - 13 g/dl Ngi trng thnh: o Nam: 14 - 18 g/dl o N: 12 - 16 g/dl Sau tui trung nin: o Nam: 12.4 - 14.9 g/dl o N: 11.7 - 13.8 g/dl Tt c nhng gi tr trn c th thay i cht t ty thuc vo phng xt nghim. Mt s phng xt nghim khng tch nhng ngi trng thnh v nhng ngi sau tui trung nin ra thnh 1 nhm khc nhau.

Hct (Hematocrit): dung tch hng cu - y l t l phn trm gia khi hng cu & mu ton phn hay l phn trm th tch ca mu m cc t bo mu (ch yu l hng cu) chim. Bc s u tin lu tm n ch s ny trc so vi RBC v ch s ny khng ph thuc vo th tch nc c th (mc thiu nc), thng thng Hct/3 = HGB. Ch tiu ny c gi tr trong vic nh gi v theo di cc tnh trng mt mu cp: thiu mu do xut huyt tiu ha, gin v tnh mch thc qundo hin tng b tr ca c th mu c huy ng t cc c quan d tr mu nh lch, h tnh mch su nn gi tr huyt sc t thay i chm hn so vi lng mu mt. Tng: nc trong t bo, bnh tng hng cu, shock.. Nu > 55%: nguy c tai bin mch mu no (stroke) Gim: thiu mu (25% i vi ngi trng thnh v 28% i vi ngi gi), xut huyt cp nu < 20% i vi ngi trng thnh v < 30% i vi ngi gi th phi thc hin truyn mu. MCV(Mean Corpuscular Volume): th tch trung bnh hng cu, n v thng dng l femtolit (1 fl = 10-15lit), c tnh bng cng thc: MCV = Hct/s hng cu. Gi tr MCV cho php phn bit cc loi thiu mu sau: Thiu mu hng cu nh: khi MCV < 90 fl Thiu mu hng cu bnh: khi 90 fl < MCV < 100 fl Thiu mu hng cu i: khi MCV > 100 fl MCHC (Mean Corpuscular Hemoglobin Concentration): nng hemoglobin trung bnh trong mt hng cu, n v thng dng l (g/dl hay g/l) c tnh theo cng thc: MCHC = Hb/Hct. MCHC cho php phn bit thiu mu Thiu mu ng sc: khi MCHC trong gi tr bnh thng Thiu mu nhc sc: khi MCHC < 33g/l MCH (Mean Corpuscular Hemoglobin): s lng hemoglobin trung bnh trong mt hng cu, n v thng dng l picogram (1 pg = 10-12g) c tnh theo cng thc: MCH = Hb/RBC RDW (Red cell Distribution Width): o thay i ca kch thc v hnh dng hng cu. Gi tr ny cng cao c ngha l kch thc ca hng cu thay i cng nhiu. Gi tr bnh thng nm trong khong t 11-15. Ch s ny cng ln th hin rng cc hng cu c kch thc chnh nhau cng ln gin tip cho thy c c hng cu non v hng cu trng thnh mu ngoi vi hoc c th ton hng cu trng thnh nhng kch thc li to nh khc nhau (cc loi thiu mu hng cu to, nh). Da vo 2 ch s RDW & MCV phn bit gia: + Thiu mu thiu st, Thiu mu do thiu acid folic, Thiu mu bt sn tu (khi LS hng n nhng bnh ny) c th: - Nu RDW > 15% => do TMTS hoc do TM thiu acid folic. Kt hp MCV KL: nu MCV<80 => TMTS, nu MCV > 100 => TM thiu acid folic. - Nu RDW bnh thng (12 - 15%) v MCV > 100 => TM bt sn tu. Mt cht phn bit: Bt sn l hin tng khng hnh thnh y mt c quan. Gim sn l c quan hnh thnh nhng ch c hnh dng v cu trc tng t nhng khng hon chnh. TM bt sn tu l trng hp tu xng mt kh nng sn sinh cc t bo mu, nguyn nhn thng do bnh t min (khng r nguyn nhn). TM gim sn tu l trng hp TM ng sc ng bo, gp trong suy thn mn.

+ Thalassemia, Bnh v gan, Thiu mu do tan mu min dch & Bnh suy ty xng (khi LS hng n nhng bnh ny) Nu RDW bnh thng & MCV > 100 => bnh suy ty xng. Nu RDW > 15% : c th TM do tan mu MD, bnh v gan hoc Thalassemia. Kt hp MCV KL: nu MCV < 80 => Thalassemia (d RDW cao hoc bnh thng), nu MCV > 100 => TM do tan mu MD, nu MCV bnh thng (80 - 100) => bnh v gan. RET % (% Reticulocyte) Hng cu li (Hng cu mng): l HC tr va trng thnh t Nguyn HC i toan trong qu trnh sinh HC, l dng chuyn tip gia HC non trong ty xng & HC trng thnh ngoi vi. Hng cu li l giai on bit ha v trng thnh cui cng ca hng cu trong ty xng trc khi vo dng mu tun hon. i sng: 24 - 48 gi. Nguyn bo hng cu tch lu dn hemoglobin cho n khi thnh HCL, HCL mt nhn (mng li cc cu trc a kim) v i vo mu thnh hng cu. Tn gi hng cu li l do khi c nhum (bng mt s phng php nht nh) v quan st di knh hin vi, ngi ta thy mt cu trc dng li trong bo tng ca loi t bo ny. Xc nh t l % HC li cho php nh gi trng thi & kh nng sinh HC ca ty xng => phn nh mc sn xut hng cu mau hay chm, cho bit ty xng p ng ra sao trc s thiu mu. Ch s bnh thng: 0,2 - 2%. Nu reticulocyte count ( tnh ra t % reticulocyte ) thp, s cho ta thy ty xng bnh, khng sn xut cc hng cu; ngc li, khi tr s ny cao, ta bit ang c s tht thot hng cu qu mc (nh chy mu ng tiu ha, chy mu ng sinh dc...), hoc ang c hin tng tan huyt, hy hoi hng cu bt thng trong c th (v truyn sai mu, v dng thuc...). Tng: Hng cu li tng c v s lng ln t l phn trm khi c s tng sn xut hng cu chng hn trong hi chng thiu mu huyt tn hay trong bnh thiu mu hng cu hnh lim. Gim: suy tu, ha tr liu, thiu mu c tnh.. Tm li, cc tr s ca dng hng cu cho nhng thng tin v tnh trng hng cu ca mu ngi c lm xt nghim, tt nhin khng y , gi bnh l thiu mu v nguyn nhn gy thiu mu. Thng thng, cc bc s da vo nng hemoglobin chn on v nh gi mc thiu mu, v da theo nh ngha sau: Thiu mu khi nng Hb thp hn: 13 g/dl (130 g/l) nam gii, 12 g/dl (120 g/l) n gii v 11 g/dl (110 g/l) ngi ln tui - Thiu mu hng cu nh, nhc sc l do bt thng cht lng tng hp huyt sc t gy lon sn hng cu. - Thiu mu hng cu to l do bt thng cung cp cc cht sn xut ti to hng cu. - Thiu mu hng cu bnh thng bnh sc: nu thiu mu khng hi phc l do bt thng ty xng. Nu thiu mu c hi phc c th do mt mu chy mu ngoi vi.

2/ DNG BCH CU WBC: l s lng bch cu c trong mt n v mu. Gi tr bnh thng ca thng s ny l 4000-10000 bch cu/mm (trung bnh khong 7000 bch cu/mm mu; Tng: nhim trng, nhim c, vim, mt mu nhiu, sau n no, sau hot ng (v vy khng nn ly mu th lc ny). S lng bch cu tng cao trong cc bnh nhim khun cp tnh, v c bit cao trong cc bnh bch huyt cp hoc mn tnh (ung th mu - leucemie). WBC> 10.000 => tng tht s Gim: do thuc, st rt, thng hn, bnh do virus: vim phi khng in hnh, thy u, cm.. WBC < 5.000 => gim c th hi phc; WBC< 4.000 => gim, kh nng hi phc thp: c bnh l..) Cng thc bch cu: l t l phn trm cc loi bch cu trong mu. S thay i t l ny cho nhiu ngha quan trng. Cn tnh ra s lng tuyt i ca mi loi (v c khi t l phn trm gim nhng s lng tuyt i li bnh thng nu tng s bch cu tng - hay ngc li) NEUTROPHIL: Bch cu trung tnh, l nhng t bo trng thnh trong mu tun hon v c mt chc nng quan trng l thc bo, chng s tn cng v ph hy cc loi vi khun, virus ngay trong mu tun hon khi cc sinh vt ny va xm nhp c th. V vy bch cu a nhn trung tnh tng trong cc trng hp nhim trng cp. i khi trong trng hp nhim trng qu nng nh nhim trng huyt hoc bnh nhn suy kit, tr s sinh, lng bch cu ny gim xung. Nu gim qu thp th tnh trng bnh nhn rt nguy him v sc chng c vi khun gy bnh gim st nghim trng. Bch cu cng gim trong nhng trng hp nhim c kim loi nng nh ch, arsenic, khi suy ty, nhim mt s virus... Tng > 75% ( > 7.000 / mm3 ): + cc bnh nhim khun cp tnh: vim phi, vim ti mt.. + Cc qu trnh sinh m: apxe, nht.. + Nhi mu c tim, Nhi mu phi + Cc bnh gy nghn mch + Bnh Hogdkin, bnh bch cu + Sau ba n, vn ng mnh ( tng t - tm thi ). Gim < 50% ( < 1.500/ mm3 ): + Nhim trng ti cp + Cc bnh do virus trong thi k ton pht: cm, si, thy u.. + St rt + Cc bnh c lch to gy cng lch, Hogdkin + Thiu B12 c tnh ( bnh Biermer ) + Nhim c thuc, ha cht + Sc phn v + Gim sn hay suy ty xng + Bch cu cp, Bch cu kinh th lympho. EOSINOPHIL: Bch cu a nhn i toan, kh nng thc bo ca loi ny yu, nn khng ng vai tr quan trng trong cc bnh nhim khun thng thng. Bch cu ny tng cao trong cc trng hp nhim k sinh trng, v bch cu ny tn cng c k sinh trng v gii phng ra nhiu cht git k sinh trng. Ngoi ra bch cu ny cn tng cao trong cc bnh l ngoi da nh chm, mn trn da...

Tng: > 500/ mm3 * Tng nh & thong qua: + Thi k lui bnh ca mt s bnh nhim khun, nht l sau khi iu tr khng sinh + Khi iu tr hng cu thiu mu bng cc tinh cht gan. * Tng cao & lin tc: + Cc bnh giun sn + Cc trng thi d ng: hen, chm, mn nga, bnh l huyt thanh, hi chng Loeffler + Leucemie ty th bch cu a nhn i toan, bnh Hogdkin + Bnh cht to keo + Sau th thut ct b lch + Sau chiu tia X. Gim: < 25/ mm3. + Suy ty b tn thng hon ton + Nhim khun cp tnh, qu trnh sinh m cp tnh + Hi chng Cushing, trng thi sc iu tr bng Corticoide. BASOPHIL: Bch cu a nhn i kim, ng vai tr quan trng trong mt s phn ng d ng. Tng: + Bnh Leucmie mn tnh: cng tng - tin lng cng tt + Bnh tng hng cu Vaquez + Sau tim huyt thanh hay cc cht albumin + Trong vi trng thi do thiu mu tan mu, BC a nhn i kim tng 2 - 3%. Gim: + Ty xng b tn thng hon ton + D ng. MONOCYTE: Mono bo, l dng cha trng thnh ca i thc bo trong mu v vy cha c kh nng thc bo. i thc bo l nhng t bo c vai tr bo v bng cch thc bo, kh nng ny ca n mnh hn ca bch cu a nhn trung tnh. Chng s phn b n cc m ca c th, tn ti ti hng thng, hng nm cho n khi c huy ng i lm cc chc nng bo v. V vy mono bo s tng trong cc bnh nhim khun mn tnh nh lao, vim vi trng mn... Tng: + Bnh do virus: cm, quai b, vim gan + Thi k lui bnh ca mt s bnh nhim khun: vim ni tm mc bn cp (Osler), lao.. + St rt + Bnh cht to keo + Chng mt BC ht do nhim c d ng + Mt s bnh c tnh: K ng tiu ho, bnh Hogdkin, u tu, bch cu cp dng mono. LYMPHOCYTE: Lympho bo: y l nhng t bo c kh nng min dch ca c th, chng c th tr thnh nhng t bo "nh" sau khi tip xc vi tc nhn gy bnh v tn ti lu di cho n khi tip xc ln na vi cng tc nhn y, khi y chng s gy ra nhng phn ng min dch mnh m, nhanh v ko di hn so vi ln u. Lympho bo tng trong ung th mu, nhim khun mu, nhim lao, nhim virus nh ho g, si... Gim trong thng hn nng, st pht ban... Tng > 30% ( > 4.000/ mm3 ): + Bch cu cp th lympho + Nhim khun mn tnh: lao, thp khp.. + cc bnh do virus: si, ho g, vim gan siu vi..

+ trong thi k lui bnh ca mt s bnh nhim khun cp tnh. Gim: < 15% ( < 1.000/ mm3 ). + mt s bnh nhim trng cp tnh + chng mt bch cu ht, sc phn v.. + bnh Hogdkin, nht l trong giai on sau + Bch cu cp (tr th lympho) + cc bnh t min, to keo + iu tr thuc c ch min dch, ha cht tr K.. Nu Mono & Lym cng tng: + do virus: cm, quai b, si + thng hn.

3/ DNG TIU CU PLC/PLT (Platelet Cell): S lng tiu cu - cho bit s lng tiu cu c trong mt n v mu. S lng tiu cu bnh thng l 150.000-400.000 tiu cu/mm mu. + Tiu cu c i sng 8-12 ngy. i mi sau 4 ngy. + L nhng mnh v hnh a mng, khng nhn, t t bo cht ca nhng t bo megakaryocyte c tm thy trong ty xng. + Bnh thng tiu cu tri t do theo dng mu. Khi mch mu b t, nhng si colagen di lp biu m b bc l v tiu cu s kt dnh t li ch mch t (do thnh mch mt in m khng y tiu cu na). Tip , nhng tiu cu ang lu thng s n kt t vo v ko theo s kt t ca lp tiu cu th 3, th 4... cho n khi hnh thnh nt tiu cu (cn gi inh cm mu Hayem) bt kn ch tn thng. + Tiu cu c vai tr quan trng trong qu trnh ng cm mu, v vy Suy gim tiu cu v mt s lng hoc cht lng s gy ra bnh sinh chy mu. Khi s lng tiu cu gim di 100.000/mm hay c xut huyt, di 100.000/mm xut huyt nng => t vong Tng tiu cu (>500.000/mm): + Hi chng tng sinh ty, thiu mu thiu st, sau ct lch, tng do phn ng sau mt s bnh l: ung th di cn ty xng, u thn, u gan + Tng tiu cu gi to: do my m nhm thnh TC bi: - Mnh hng cu v hoc hng cu kch thc qu nh (MCV < 65 fl). - Mu mu ln bi bn. - My ni t khng tt gy hin tng nhiu nn cc xung in nh s c my ghi nhn l cc tiu cu. Gim: + Gim sn xut (suy ty xng, bnh mu c tnh ln t, ung th di cn ty xng, xut huyt gim tiu cu min dch/ITP), tng tiu th (xut huyt gim tiu cu, ri lon ng mu tiu th). + a s cc trng hp tng s dng tiu cu dn n hot ha tiu cu, mt s c lin quan n huyt tc. Vi nhim v to ra vn cc mu (Clot), TC tch t pha trn mng thnh mt khi cng bao quanh vnh ng mch, gy ra chng huyt khi (Thrombus), huyt khi tch t lu ngy s dy lm bt ng knh ca ng mch v lm tc nghn hon ton. Bao gm: - Thiu mu gim tiu cu do hy tiu cu/TTP - Hi chng tn huyt - tng ur huyt/HUS - Tiu hemoglobin cc im v m/PNH - ng mu ni mch lan ta/DIC - Gim tiu cu do heparin/HIT. + Gim tiu cu gi to c th gp do: - Tiu cu tng kt dnh: ly mu qu lu lm hot ha tiu cu, ly mu vo ng thy tinh lm tiu cu kt dnh do thnh ng lm hot ha v kt dnh tiu cu. - Tiu cu tp trung xung quanh bch cu MPV (Mean Platelet Volume): Th tch trung bnh tiu cu, cng c tnh bng n v femtolit, gi tr bnh thng t 7,5-11,5 fl PCT (Plateletcrit): Th tch khi tiu cu, gi tr bnh thng t 1,6 -3,6 % PDW (Platelet Distribution Width): di phn b kch thc TC, gi tr bnh thng t 11 -15% Cc ch s tiu cu khi cao hn bnh thng th d b ng mu (tc mch) v khi thp hn bnh thng th d chy mu.

Cc gi tr bnh thng ca hng cu Gi tr bnh thng Hng cu RBC hay HC /l) (10 Hemoglobin - Hb (g/l) Hematocrit - Hct (%) MCV (fl) MCH (pg) MCHC (g/dl) Cc gi tr bnh thng ca bch cu Cc loi bch cu Gi tr tuyt i (trong 1mm) T l phn trm a nhn trung tnh - NEUTROPHIL 1700 7000 60 - 66% a nhn i toan - EOSINOPHIL 50 500 2 - 11% a nhn i kim - BASOPHIL 10 50 O.5 - 1% Mono bo - MONOCYTE 100 1000 2 - 2.5% Bch cu Lymph - LYMPHOCYTE 1000 4000 20 - 25% (Tham kho trong sch Lm Sng Huyt Hc - PGS Trn Vn B - NXB Y Hc Tp. HCM 1999) N gii 3.87 - 4.91 117.5 - 113.9 34 - 44 92.57 - 98.29 30.65 - 32.80 33.04 - 35 Nam gii 4.18 - 5.42 132.0 - 153.6 37 - 48 92.54 - 98.52 31.25 - 33.7 32.99 - 34.79

CCH C CNG THC MU Khi c cng thc mu nhn ngay vo cc ch s nh sau: 1) CH TIU BCH CU CTBC b c WBC - NEU - LYM - MONO - EOS - BASO: mi s liu c ngha ring. + WBC: l s lng BC, nhn ch s ny bit tng lng. bit tng thnh phn tng hay gim cn tnh ch s tuyt i (% x WBC) ( v c khi t l phn trm gim nhng s lng tuyt i li bnh thng nu tng s bch cu tng - hay ngc li). BC c nhim v chng vim, dit khun nn khi s lng gim < 4000 phn nh tnh trng d vim nhim. Tuy nhin, khi BC tng qu cao ( > 50.000 ) vi nhiu t bo non u dng (blast) khng chc nng cng phn nh mc nhim trng nng, LS thng gp Bch cu cp. Tip cn BN: - Nu nhim trng ti i ti li, t (nhim trng ni bt) khm c gan lch hch to cn ngh n bnh bch cu. Ty th c hi chng u hoc ch lch to, hch lch to. Phn bit l BCC, BCK hay BCK chuyn cp da vo CLS (CTM). - Nu xut huyt nhiu ch (chy mu mi, chy mu rng, chy mu d dy..) trn nn thiu mu nh (xut huyt ni bt) cn ngh n XH gim tiu cu. Tm sot nguyn nhn (nhim trng, nhim c, thuc..) khng tm c hng ti ITP (XH gim tiu cu do MD). - Nu thiu mu nng (BN xanh xao, da nim trng bch..) d truyn mu cng khng ci thin km theo xut huyt nhim trng (thiu mu ni bt) hng ti Suy ty thc s. Chn on phn bit vi Suy ty tiu hao (BCC) da vo Ty . + NEU: l BC a nhn trung tnh. Nhim v chng vim - dit khun & x l m tn thng. V chim t l cao ( 60 - 66% ) nn vai tr Neu thng i din cho vai tr BC ni chung. NEU tng > 7.000 phn nh qu trnh vim nhim, nu khm nghe ran n ngh ti vim phi, nu c vng da (km st - gan to) ngh ti nhim trng ng mt, nu c hch to ri rc ton thn ngh ti Hogdkin, nu c nhim trng t ti i ti li ngh ti BCC, nu lm xt nghim sau ba n hay vn ng mnh & ch tng nh: tng NEU sinh l. NEU gim < 1.500 phn nh tnh trng bnh nng, c th bnh bch cu, suy ty, Hogdkin, mt nhim trng nhim c ti cp, hoc c th l st rt (do Mui Anopheles) vi rt run - st cao v m hi. Neu l 1 trong 3 t bo c ngun gc t Nguyn ty bo ( 2 loi cn li l Baso & Eos ). Lym c ngun gc t nguyn bo lympho. Nguyn ty bo & Nguyn bo lympho l 2 nhnh trc thuc dng bch huyt bo, v hin din khp ni trong c th (hch bch huyt, gan, l lch, dc ng rut - h hp) nn mt nhiu thi gian huy ng, b li hiu qu trong vic dit khun. Dng cn li l Ty bo c cc nhnh: TC + HC + BC mono vi chc nng hng ro chng vim nhim tip xc u tin vi vi khun. + LYM: BC lympho l nhng t bo c kh nng min dch (lympho B sn sinh khng th, lympho T iu khin h min nhim, c th dit virus & t bo ung th). LYM tng > 4.000 c th l BCC th lympho (vi WBC tng, 15% trng hp tng > 100.000), cng c th l Lao (nu c ho khc m c), hoc Vim gan siu vi.. Trong cn phn bit gia BCC dng lympho & BCK th lympho, lc ny phi da vo Pht mu ngoi bin & Ty .

+ MONO: l dng cha trng thnh ca i thc bo, phn b n cc m ca c th ch c huy ng i lm cc chc nng bo v. Khi MONO tng phn nh trng hp nhim khun mn (BCC dng mono, lao..), khi MONO & LYM cng tng: hng ti Thng hn. + EOS: tng ( > 500 ) trong trng hp nhim k sinh trng v gii phng ra nhiu cht git k sinh trng. Nu tng cao lin tc hng ti bnh giun sn, nu tng nh thong qua c th do iu tr khng sinh. + BASO: ng vai tr quan trng trong mt s phn ng d ng, c bit Leucmie mn tnh BASO cng tng tin lng cng tt. (bt 10 - 50/ mm3). => Tm li, CTBC phn nh tnh trng vim nhim. BC c v von l 'lnh nh vim nhim' bo v cho c th, i qun BC c nhiu thnh phn, phn ra 2 dng chnh: dng Ty bo c MONO, cn li thuc dng Bch huyt bo (NEU - LYM - EOS - BASO). Dng Ty bo tuy l hng ro chng vim nhng kh nng khng nhiu, MONO l dng cha trng thnh ca i thc bo, khi tng phn nh nhim trng mn. NEU - LYM - EOS - BASO l i ng dit khun chng vim hiu qu vi tng u th ring. NEU & LYM l 2 thnh phn thng c quan tm trn LS. NEU (thc bo) tng phn nh tnh trng vim nhim, NEU gim phn nh tnh trng bnh nng. LYM (min dch) tng phn nh tnh trng nhim virus & km EOS tng ngh do k sinh trng, tng lin tc cn soi phn tm giun, tng nh thong qua r li khng sinh dng. Cui cng, BASO - thnh phn t nht trong i ng Bch cu (chim 0,5 - 1%), BASO gim lin quan d ng, cn tng khng nhiu lo ngi. Kinh nghim lm sng: + LYM & MONO tng trong bnh l mn, MONO bnh thng gi bnh l cp + Nhim trng cp: EOS lun gim + C s hin din ca nguyn ty bo: l bnh bch cu. 2) CH TIU HGB => xc nh TM, Hb < 13 (nam), < 12 (n), < 11 (n mang thai, ngi gi) kt lun TM. TM cn tm nguyn nhn: do gim sinh, do mt mu hay do tan mu. Do gim sinh c 2 nhm: + TM do thiu nguyn liu (st, acid folic, vit B12, protein) - trong nhm ny TMTS chim t l cao + TM do ty (gim sn - bt sn): suy ty thc s (bm sinh mc phi), suy ty tiu hao (bch cu cp) l 2 trng hp thng gp LS. Cn chn on phn bit: Suy ty tiu hao (Bch cu cp) & Suy ty thc s + Suy ty & Xut huyt gim tiu cu khng r nguyn nhn. => xc nh thiu mu ch yu da vo Hb v ch s ny phn nh chnh xc tnh trng khi mu trong c th. Hb o trng lng sc t ca HC, cn Hct (o th tch HC) ph thuc vo lng dch - truyn dch lm gim Hct; RBC (s lng HC) khng gip nhiu trong TM v c trng hp RBC cao nhng cht lng khng t tham gia vn chuyn oxy (bnh a HC) vn khng cung cp oxy m cho c th. => RBC c ch trong trng hp phn bit gia Thalassemia & TM thiu st. c 2 u TM hng cu nh nhng trong trng hp Thalassemia th RBC > 5 triu, cn TMTS RBC < 5 triu (bs.NTMai). (RBC bt # 5 triu, < 3,5 triu = thiu mu).

-> Hb x 3 = Hct. Nhn Hb c th d on Hct, khi Hb # 20 g/dl c nguy c TBMMN. -> Hb < 7 g/dl: ch nh truyn mu. Ty bnh chn phm mu truyn: + XHTH: truyn HC lng, 1 n v (250ml) nng Hb ln 1g/dl, ty mc tiu cn nng bao nhiu g truyn by nhiu n v. Tc : XL git/pht. Lm phn ng cho trc truyn. Mc ch: khi phc vn chuyn oxy. + XH gim tiu cu: truyn TC m c, 1 n v (150ml) nng TC ln 30.000, nhng truyn TC khng nhm nng TC m phng chy mu & iu tr nguyn nhn. Ty cn nng bao nhiu kg truyn by nhiu n v: 0,1 n v/ kg. Tc : C git/ pht (x ti a). + XH do ri lon ng mu (thiu vit K, x gan, K gan..): truyn Huyt tng ti ng lnh. BN nng bao nhiu kg truyn by nhiu n v: 12 - 15 ml/kg, 1 n v ~ 250ml. Tc : XL git/pht. Mc ch: iu tr & d phng cc ri lon ng mu do thiu ht 1 hoc nhiu yu t ng mu. + Bch cu cp, BC kinh: truyn HC lng (khi WBC < 100 ngn). + Suy ty: nu khng chy mu truyn HC lng, nu c chy mu truyn Tiu cu m c. + Tn huyt do min dch: truyn HC ra. Cch tnh n v - tc tng t HC lng. Mc ch: khi phc vn chuyn oxy & trnh a yu t l vo c th. + Thalassemie: truyn mu nh k - truyn HC lng - nng Hb ln # 10 g/dl. + Hemophilia: truyn ta lnh. Cch tnh n v - tc tng t HC lng. Mc ch: khi phc thnh phn ang thiu (yu t VIII). Xem MCV MCH Nu c thiu mu nhn ngay 2 ch s ny. Xc nh TM l HC nh hay to, nhc sc hay u sc. C 2 u l ch s v HC: MCV l th tch trung bnh, cho bit HC to - nh; MCH l s lng hemoglobin trung bnh, cho bit HC nhc - u sc. MCV bt 80 - 100 fl, < 80 l nh, > 100 l to, > 140 l khng l. MCH bt 27 - 32 pg, < 27 l nhc sc, > 32 l u sc. Nhn nh: + Thiu mu hng cu nh, nhc sc l do bt thng cht lng tng hp huyt sc t gy lon sn hng cu. + Thiu mu hng cu to l do bt thng cung cp cc cht sn xut ti to hng cu. + Thiu mu hng cu bnh thng bnh sc: nu thiu mu khng hi phc l do bt thng ty xng. Nu thiu mu c hi phc c th do mt mu chy mu ngoi vi. Khm lm sng bnh thiu mu: Thiu mu mn: 1. BN ny c thiu mu khng? - hi: chng mt tai hoa mt? th nhanh? hi hp nh trng ngc? (thiu mu gy thiu oxy cc m) - khm: da nim, nu rng, li, lng bn tay chn - CLS: da vo Hb: trung bnh 7 - 9, nng < 7, rt nng < 4; ring nh th phn ra: nam > 9 -13, n > 9 - 12, n mang thai > 9-11 (n v g/dl). 2. TM mn hay cp? - hi: thi gian xut hin xanh xao - khm: m thi thiu mu tim, kh nng chu ng (nu Hb < 7g/dl nhng tnh to i li c chng t BN thch nghi vi thiu mu t t, din ra nhiu ngy -> chu ng c ), mch HA (thng n nh khi TM mn, mnh nhanh HA thp/tt khi TM cp mc trung bnh hoc nng). 3. nh gi mc TM?

- hi: mt khi gng sc? -> nh, khi lm vic nh? -> TB, khng t lm v sinh c nhn c? -> nng - khm: da nim trng bch, i li kh khn cn ngi gip , nhp tim nhanh, th nhanh nng. Thiu mu cp: Lng mu mt Triu chng Nh ( 1) =<10% th tch mu Gim ti mu c quan ngoi bin, tnh, hi mt Trung bnh ( 2) <30% th tch mu Gim ti mu c quan trung ng. Mt mi, nim nht, da xanh, chng mt, m hi, tiu t. 100 -120 l/p 80 90 mmHg 20% - 30% 2 - 3 M/L Nng () >30% th tch mu Gim ti mu c quan trung ng, khng cn chu ng c, ht hong, lo u, li b, vt v, th nhanh, v niu >120 l/p <80mmHg, HA kp <20% < 3 M/L

Mch HATT Hct RBC

90 -100 l/p >90mmHg >=30% >= 3 M/L

B XT NGHIM SINH HA 1/ CHC NNG THN URE L sn phm thoi ha quan trng nht ca protein c thi qua thn. Tr s bnh thng: 2.5 - 7.5 mmol/l => BUN (Blood Urea Nitrogen) = ure (mg) x 28/60; i n v: mmol/l x 6 = mg/dl. Tng: bnh thn, n nhiu m, st, nhim trng, tc nghn ng tiu.. Gim: n t m, bnh gan nng, suy kit..

BUN L nit ca ure trong mu. Tr s bnh thng: 4,6 - 23,3 mg/dl. => Bun = mmol/l x 6 x 28/60 = mmol/l x 2,8 (mg/dl). Tng: suy thn, suy tim, n nhiu m, st, nhim trng.. Gim: n t m, bnh gan nng..

Acid Uric = Urat L sn phm chuyn ha ca base purin (Adenin, Guanin) ca ADN & ARN, thi ch yu qua nc tiu. Tr s bnh thng: nam 180 - 420, n 150 - 360 (n v: umol/l). Tng: - Nguyn pht: do sn xut tng, do bi xut gim (t pht) -> lin quan cc men: bnh Lesh - Nyhan, Von Gierke.. - Th pht: do sn xut tng (u ty, bnh vy nn..), do bi xut gim (suy thn, dng thuc, x va ng mch..). - Bnh Gout (thng phong): tng acid uric/ mu c th km nt tophi khp & si urat thn. Gim: bnh Wilson, thng tn t bo gan. Creatinin L sn phm o thi ca thoi ha creatin phosphat c, lng to thnh ph thuc khi lng c, c lc qua cu thn & thi ra nc tiu; cng l thnh phn m n nh nht khng ph thuc vo ch n -> c gi tr xc nh chc nng cu thn. Tr s bnh thng: nam 62 - 120, n 53 - 100 (n v: umol/l). Tng: bnh thn, suy tim, tiu ng, tng huyt p v cn, NMCT cp.. Gim: c thai, sn git..

Clearance: Cl Cr thanh lc cu thn/ thanh thi Creatinin. H s thanh thi mt cht l th tch huyt tng lc sch cht trong 1 pht. C nhiu cch tnh Cl - Cr: + Da vo cre/ mu & nc tiu: ly nc tiu 24 gi, o th tch nc tiu & lng cre bi tit trong 24 gi -> C = ( U x V ) / P vi: U l cre/ NT (mg%), V l th tch nc tiu (ml/pht), P l nng cre/ mu (mg%)

Cch ny kt qu thng nhiu do: khng gi ng nc tiu 24 gi, cn st nc tiu trong bng quang. Cch ly nc tiu 24 gi: 7h: BN tiu ra ngoi, nhng ln tiu sau cho n 7h hm sau (k c khi tm, i tin) th tiu vo bnh, bnh trc c ra sch. V bo tn nc tiu trnh ln men amoniac lm h hi cc t bo, bin cht hay ngn cn s pht trin ca tp trng: cn cho vo trong bnh phenol - 1 git cho 30ml nc tiu. + Cng thc Corkroft - Gault: da theo cn nng & tui: (Cl - Cr) (ml/pht) = [(140 - tui) x cn nng (kg)]/ [creatinin/mu (mg%) x 72 i vi nam v 0,85 i vi n], tr s bnh thng: 100 - 120 ml/ pht/ 1,73 m2 da. i n v: umol/l x 0,0113 = mg/dl = mg%. Khng nn p dng cng thc ny nu mp qu hoc ph nhiu, v: ch ng khi ly c cn nng trc khi ph (tc l cn nng chnh xc ca bnh nhn) v cng khng ng khi bnh nhn bo ph. + Tnh GFR theo cng thc MDRD (Modification of Diet in Renal Disease): GFR (ml/ min per 1,73 m2) = [(PCr)^ - 1.154] x [(age)^ - 0.203] x 1.86 nam v 0.742 n Ch cc yu t nh hng n GFR: + S co gin tiu M cu thn: Gin tiu M vo lm tng dng mu n thn -> tng lc & ngc li: co tiu M vo lm gim dng mu n thn -> gim lc. Co tiu M ra lm tng p lc thm thu cu thn -> tng lc & ngc li: gin tiu M ra lm gim p lc thu thu cu thn -> gim lc. + p sut M tng gy tng p sut thy tnh mao mch cu thn -> tng lc. + p sut keo ca protein huyt tng gim gy gim mc lc & ngc li: p sut keo ca protein huyt tng tng gy tng mc lc. + p sut thy tnh nang Bownman tng kh tc ng thn, niu qun hoc ph thn -> gim lc. + Lin quan cc p lc nh hng n GFR: PL = PC - ( Pk + Pn). Trong : PL l p lc lc, PC l p sut ti mao mch cu thn, Pk l p lc keo ca mu trong mao mch cu thn, Pn l p lc thy tnh ca nang Bownman. Da vo Cl - Cr (C) phn suy thn mn theo giai on: I -> C = 60 - 41 -> Cre/mu < 130 -> LS: bnh thng. II -> C = 40 - 21 -> Cre/mu = 130 - 299 -> LS: thiu mu nh. IIIa -> C = 20 - 11 -> Cre/mu = 300 - 499 -> LS: triu chng tiu ha + thiu mu va. IIIb -> C = 10 - 5 -> Cre/mu = 500 - 900 -> LS: thiu mu nng + hi chng ure mu cao. IV -> C < 5 -> Cre/mu > 900 -> LS: tiu t.

Ure/mu khng phn nh chnh xc chc nng thn v: Ure ch tng khi chc nng thn gim # 60%. S bi tit ure cn ty thuc s bi tit nc tiu: + Lng nc tiu gim (do thiu nc) + p lc nang Bownman tng (tc nghn ng tiu). => 2 yu t trn lm tng ti hp thu ure => tng ure/mu. S bi tit ure ph thuc lng m hp thu: + n nhiu m, xut huyt tiu ha + D ha m tng (nhim trng, corticoid, tetracylin).

Creatinin/ mu L cht bin dng ca creatin trong bp tht, ph thuc khi lng bp tht & khng thay i mi ngi. Tr s bnh thng: 0,8 - 1,5 mg% (cho c 2 phi). Creatinin phn nh trung thc chc nng thn hn Ure v khng ph thuc cc yu t khc; ch tng khi chc nng thn gim 50% & tng gp i khi lc cu thn gim xung cn mt na => do tr s creatinin/ mu gip ta c on c chc nng thn cn li: cre 1/2/4/8/24 (mg%) => thanh lc cu thn (ml/pht) 120/60/30/15/5 i vi BN gy, suy kit: c th tr s Creatinin trong gii hn bnh thng mc d suy gim chc nng thn ng k (v c teo => bin dng creatin km => to t creatinin/mu). S tng quan Bun - Creatinin/mu: BUN/Creatinin mu (Tr s bnh thng: 10/1) BUN/ Cre > 10: BUN tng nhiu so vi Creatinin mu => cn nghi ng cc yu t trc thn hoc sau thn lm tng ti hp thu Ure: 1. Gim ti mu thn: chong, suy tim, mt nc, mt mu 2. Tc nghn sau thn: si, u chn p 3. Lng m hp thu nhiu: n nhiu m, XHTH, tng d ha m. Trong trng hp Suy thn trc thn: BUN t tng > 100mg% & Creatinin mu t khi tng > 3 mg%. BUN/ Cre < 10: BUN tng t so vi Creatinin mu. 1. Do lng m n vo t: suy dinh dng, x gan 2. Tnh trng hoi t c, ly gii c vn 3. Cratinin mu tng gi to do ung mt s thuc: Vit C, khng sinh.. BUN/ Cre # 10 : s gia tng ng thi c 2 tr s ny vi t l duy tr 10/1 chng t c tn thng thc th ti nhu m thn. Mt s chn on lm sng c lin quan n cc tr s trn Niu: + a niu: > 3 lit/ 24h + thiu niu: < 0,5 lit/24h + v niu: < 100ml/ 24h + tiu m: > 2 ln/ m, nhiu m lin tip + tiu gt: lt nht, tiu but = au + b tiu: mun tiu m khng tiu c - Cu bang quang (+). Hi chng ure mu cao: + C nng: RLTH (bun nn - nn - chn n), cm gic (yu - lnh - mt - nga). + Thc th: Nhn: da vng ti (do t urochrom) - l ln hn m - thay i tm thn (do lit dy thn kinh: bnh thn kinh do ure mu cao); xut huyt - vi ha hoi t m mm. Ngi: hi th c mi amoniac. Nghe: ting c mng ngoi tim (c th km trn dch mng tim).

2/ CHC NNG GAN CN BI TIT: Bilirubin Bilirubin l sn phn chuyn ha ca Heme (nhm ngoi ca Hemoglobin): Bil t do c to thnh lch & h thng vng ni m, n c chuyn ti gan to thnh Bil lin hp. Bil lin hp theo ng mt xung rut. Bil t do = Bil gin tip, Bil lin hp = Bil trc tip. Bil ton phn = Bil gin tip + Bil trc tip. i n v: umol/l x 0,0585 = mg%. Bil ton phn: - Tr s bnh thng: < 17 umol/l ( < 1mg% ): 0,8 - 1,2 mg%. - Vng da khi Bil TP > 2,5 mg%. Bil trc tip ( lin hp ): chim # 10% - Tr s bnh thng: < 4,3 umol/l ( < 0,25 mg%) - Bil trc tip hnh thnh trong gan nh Glucuronyl Transgerase - Cu to ha hc: lin hp vi acid glucuronic - V tr chuyn ha: sau gan - Tnh tan: tan trong nc - Tnh c: khng c - Phn ng nh lng: trc tip. Bil gin tip ( t do ): chim # 90% - Tr s bnh thng: < 12,7 umol/l ( < 0,74 mg%) - Bil gin tip cha qua gan, khng thi qua thn, mt (t) - Cu to ha hc: khng lin hp - V tr chuyn ho: trc gan - Tnh tan: khng tan trong nc, tan trong lipid, dung mi hu c - Tnh c: c - Phn ng nh lng: gin tip. Tng Bil TP + Bil TD: vng da tiu huyt (thiu mu tan huyt, st rt, sau truyn mu khc loi..) Tng Bil TP + Bil TT: tc mt trong gan ( vim gan, x gan..), tc mt ngoi gan ( do si, K, hch to).

Phosphatase kim Hot ng mi trng kim ( pH 8,5 - 9 ). Ngun gc: gan, xng, rut, thn, nhau thai. Tr s bnh thng: 20 - 45 U/L. Rt nhy pht hin tc mt. Tng nh n va (2 ln): vim gan, x gan, di cn hoc thm nhim. Tng cao (> 3 ln): do tc mt ngoi gan. Gim: nhc gip, thiu vitamin C. GGT (Gamma Glutamyl Transferase) Rt nhy nh gi chc nng bi tit ca gan. GGT c ch yu : gan - thn, t hn : tuyn tin lit - c tim - lch.

GGT gip pht hin nhiu bnh nhu m gan: tng sm & gi mc cao khi tn thng t bo vn cn. Nng GGT/ mu cao 12 - 24 gi sau ung nhiu ru, v vn cn cao 2 - 3 tun sau khi thi ung ru => dng kim sot vic cai ru. Tr s bnh thng: nam 11 - 50, n 7 - 32, gi hi cao hn ngi ln. Chung: < 30 . n v: U/L - 37oC. Tng trong: suy thn, NMCT, i tho ng, nghin ru..

Urobilinogen (nc tiu/ 24h). CN TNG HP: Albumin L protein chim hn mt na protein huyt tng, c tng hp bi gan, c vai tr quan trng trong chnh p & s duy tr dch trong lng mch mu. S gim Albumin huyt tng khin dch trong mch thot ra m gy ph. Tr s bnh thng: 35 - 50 g/L 52 - 68% protein ton phn. Gim trong: x gan mn tnh (> 3 tun), suy dinh dng, mt albumin qua ng tiu (HCTH), mt albumin qua ng tiu ha (hi chng km hp thu). Tng: thng khng tng, nu c do: mt nc, nn nhiu, tiu chy nng.

Globulin Cu to khng thun nht. Do h vng ni m - gan - lch - hch to nn. Gm: globulin a1 (anpha1), a2 (anpha2), b (beta), y (gamma). Tr s bnh thng: 24 - 38 g/L. Tng trong: Vim gan t min ( tng IgG ), x gan tc mt nguyn pht ( tng IgM ), x gan do ru ( tng IgA ). Gim: thiu mu tan huyt, vng da nng. t s A/G: bnh thng 60/40 # 1,5, khi < 1 => bnh gan mn tnh.

Yu t ng mu HOI T T BO GAN Transaminase L enzym chuyn nhm amin (aminotransferase). Ph bin l 2 loi: + ALT (alanine aminotransferase) hay GPT (glutamat - pyruvat transaminase) + AST (aspartate aminotransferase) hay GOT (glutamat - oxaloacetat transaminase). AST: c trong bo tng, ty th c tim, gan - xng - thn - no - ty. ALT: c trong bo tng t bo gan. ALT & AST trong mu thp, nhng khi c s hoi t t bo (Vim gan, Nhi mu c tim..) => ALT & AST trong mu tng rt cao. Tr s bnh thng: + AST (GOT) <= 37 ( 6 - 25 ) n v: U/L - 37oC. + ALT (GPT) <= 40 ( 3 - 30 ) n v: U/L - 37oC. Transaminase tng hu ht trong cc bnh l v gan: + Tng cao ( > 3000 U/L ) => hoi t t bo gan do Vim gan cp hoc mn, Vim gan do thuc, c cht..

+ Tng va ( 100 - 300 U/L ): vim gan do ru (ch yu tng AST). + Tng nh ( 50 - 99 U/L ): vim gan cp hoc mn mc nh, c bnh l gan mn khc. T s De Ritis: AST/ALT = GOT/GPT = 1 - 1,3: < 1 : trong hoi t t bo gan cp > 1,3: tn thng gan mn -> x gan, nghin ru, NMCT > 2: vim gan do ru. LDH LDH l 1 enzym ni bo c trong hu ht cc t bo ang chuyn ha. Hm lng cao : tim - c xng - gan - thn - no - hng cu. LDH/ mu = LDH ton phn. Trong Nhi mu c tim, LDH tng rt cao sau 24h n 10 - 15 ngy, nng tng t l vi tn thng. Tr s bnh thng: 230 - 460 U/L - 37oC. Tng trong: NMCT, nhi mu phi, bnh gan, suy thn cp..

St Feritin = ferric hydroxide + apoferitin (protein). Feritin l protein d tr st, c sn xut : gan - lch - ty xng. Nng feritin lin quan n lng st d tr cc m. 100g huyt sc t tng ng 0,335g st. Tr s bnh thng: nam 11 - 27, n 7 26, sau mn kinh # 7 - 27, ngi gi # 15 20 (n v: umol/l). Gim trong: thiu mu thiu st, gim d tr. Tng trong: qu ti st, hoi t t bo gan, Thalassemia, nhim trng...

KHC: BILAND LIPID (b m) gm cc xt nghim: Cholesterol ton phn, Triglycerid, HDL cho, LDL cho, l nhm xt nghim nh gi nguy c x va ng mch. Thng c ch nh trong cc bnh: Tng huyt p, i tho ng, Hi chng thn h, Tng acid uric mu (Gout).. Cholesterol Cholesterol l 1 thnh phn ca mt do gan tng hp, c trong hng cu - mng t bo - c. Khong 70% cholesterol c ester ha (kt hp vi acid bo, 30% di dng t do trong mu (huyt tng). Trong xt nghim, 2 dng ny thng c o chung vi nhau gi l Cholesterol ton phn. Choles Ton phn = choles T do + Choles Ester. Gan l c quan chnh to Cholesterol & gan cng l c quan duy nht ester ha Cholesterol. Cholesterol chuyn ha thnh acid mt & mui mt (cn cho s tiu ha m), thnh cc hormon steroid ( v thng thn - bung trng - tinh hon). Tng cholesterol huyt c th gy ra nhng mng lng ng M vnh => NMCT. Cholesterol huyt tng ln theo tui c nam & n cho n 60 tui. Trc 50 tui, choles nam > n, sau 50 tui, choles n > nam. Tr s bnh thng: 3,9 - 5,2 mmol/L. i n v: mmol/l x 387 = mg/dl . Tng: x va M, vng da tc mt, tiu ng, tng huyt p.. Gim: cng gip, hi chng Cushing..

 V XVM & bnh mch vnh, cn ch : + Mong mun: < 200 mg/dL ( < 5,2 mmol/L ) + Nguy c va: 200 - 240 mg/dL ( # 5 - 6 mmol/L) + Nguy c cao: > 240 mg/dL ( > 6 mmol/L ).

Triglycerid L ester ca glycerol vi 3 acid bo, c vn chuyn trong mu di dng lipoprotein. ngi, trong t chc m d tr nhng acid bo thng l: acid palmitic, acid oleic. Triglycerid c trong du thc vt & m ng vt. M ng vt l glycerid c nhiu acid bo no, v du thc vt l glycerid cha nhiu acid bo khng no. Triglycerid c 2 ngun gc: ngoi sinh (thc n) & ni sinh (do gan tng hp). Trong huyt tng, Triglycerid ngoi sinh c vn chuyn bi chylomicron & Triglycerid ni sinh c vn chuyn bi VLDL. rut non, Triglycerid b thy phn bi lipase thnh glycerol & acid bo. Acid bo c hp thu phn ln qua h bch huyt & cui cng ti dng mu di dng ht m (chylomicron). Triglycerid gy ra huyt tng c nh sa sau ba n m (bin mt sau 6 gi, v c gan a vo VLDL, LDL, HDL chuyn n cc m, nht l m m). BT: 0,46 - 1,88 mmol/l. i n v: mmol/l x 87,5 = mg/dL -> bt: 40 - 165 mg/dL. Thay i sinh l: gim khi hot ng th lc mnh. Tng trong: ht thuc, ung ru, tui 50 - 60, sau n.. Tng trong: XVDM, nhi mu c tim, tiu ng nng, thiu mu c tnh, x gan, vim tu, vim gan.. Gim trong: suy kit.

HDL - cho HDL l lipoprotein t trng cao ( High Density Lipoproteins ), c tng hp gan & rut di dng hnh a sau chuyn thnh hnh cu trong huyt tng. choles huyt tng c vn chuyn trong HDL : # 25%. HDL vn chuyn ngc cholesterol d tha t t bo ngoi bin v gan gan oxy ha & o thi ra ngoi theo ng rut. Qu trnh ny gip cho t bo ngoi bin khi b ng lipid, chng li hin tng sinh x va -> HDL c gi l yu t chng x va. Tr s bnh thng: >= 0,9 mmol/l. Tng: gim nguy c XVDM & bnh mch vnh. Gim: XVDM, bnh mch vnh, bo ph, ht thuc l, tng Triglycerid huyt, km tp luyn.

LDL - cho LDL l lipoprotein t trng thp ( Low Density Lipoproteins ), VLDL l lipoprotein t trng rt thp ( Very Low Density Lipoproteins ) -> c gi l nhng LP gy x va. Qu trnh to LDL: lipid tng hp gan c a vo mu trong thnh phn ca VLDL, u tin l VLDL1. Trong mu: VLDL1 -> VLDL2 -> IDL -> LDL. Khong 20% tiu phn VLDL bin thnh LDL. LDL c gan hay bt c t bo no khc ca

c th nm bt nh cc th th c hiu (th th LDL). Sau khi c nm bt, LDL tng trng - dinh dng - chuyn ha nh c ch ni m bo qua trung gian th th. Nobel Y hc 1985 (Goldstein & Brown): khi c bt thng th th LDL: khng c kh nng nm bt LDL lu hnh, khng c kh nng ni m bo qua trung gian th th n cc h c o v vo trong bo tng => hu qu l nng LDL lu hnh tng, lng ng di lp ni mc => dn n X va ng mch. LDL (mmol/l) = Choles - (TG/2,2) - HDL. Tr s bnh thng: LDL <= 3,4 mmol/l. Tng: tng nguy c XVDM & bnh mch vnh. 3/ ION cc ion ha tr I: 1 mEq/l = 1 mmol/l, ha tr II: 2 mEq/l = 1 mmol/l. K+ L cht in gii ca dch ni bo. K - huyt thanh c khong dao ng hp: tim c th ngng p khi K - hthanh < 2,5 mEq/l hoc > 7 mEq/l. Khi c s phn hy m: K ri t bo vo dch ngoi bo (dch k & huyt tng). 80 - 90% K ca c th c thi qua thn. S thi qu nhiu K s dn n h K/mu. Nu thn tit < 600ml nc tiu/ ngy th K s tch li trong dch lng mch -> K - huyt thanh tng. S cn li thi qua ng phn & m hi ( # 10 mEq/ngy ). c th khng d tr K, thn thi trung bnh 40 mEq/l/ngy ngay c khi s nhp K thp. Nhu cu K: 3 - 4 g/ngy. K ton c th: 30 mEq/l, cation ch yu ca khu vc ni bo, ch c 2% khu vc ngoi bo. iu ha K trong mu: thn - pH/mu - nng Insulin/mu - Aldosteron. Tr s bnh thng: 3,5 - 5 mEq/l. Nguyn nhn gim: 1) mt qua ng tiu ho: tiu chy - i ma - dng thuc x, d rut - d mt - d thng ng dn tiu rut, ht d dy, kim mu. 2) mt qua ng tiu: do dng li tiu - khng sinh ( Carbenicilline, Amphotericine, Amioglycosides ) - corticoides lng nhiu, li tiu thm thu - toan huyt do nguyn nhn ng thn - cng Aldosteron, hi chng Fanconi - hi chng Bartter. 3) K+ cho vo khng : vi lng K hng ngy < 10 - 20 mEq trong 1 - tun a n H K/mu. 4) K+ t ngoi bo vo ni bo: do kim ha mi trng ngoi bo hoc dng Glucose u trng + Insulin. Nguyn nhn tng: K/mu > 5,5 mEq/l v nng > 6,5 mEq/l => cn tr dn truyn thn kinh (Acetylcholine) => lit c, gim phn x gn xng, ph t bo, nhp chm, ngng tim (rung tht or v tm thu). 1) Gim bi tit qua ng thn: suy thn cp - suy thn mn, hi chng Addison hi chng gim Renin _ Aldosterone, li tiu khng mt K, bnh thn tc nghn. 2) Ti phn phi K t dch ni bo ra ngoi bo trong trng hp: 1. toan huyt, 2. qu liu Digitalis, thiu Insulin, gia tng nhanh chng thm thu dch ngoi bo (do dng nhiu Glucose u trng, Manitol). 3) Lng K gia tng t ngun ngoi sinh: ung - truyn K, truyn mu - truyn PNC K+ liu cao ( 1 triu PNC cha 1,7 mEq K ).

4) K ni sinh gia tng do hy hoi cc m ( tn huyt, ly gii c vn, i phu, XHTH, chn thng do chn p). 5) Trong Hn m do i tho ng, trc iu tr K tng, sau iu tr K gim. 6) Tng kali gi: 1. K phng thch t cc mu mu b ng c tng bch cu, tng tiu cu; 2. dung huyt cc mu mu; 3. t dy tht mch qu lu. Na+ Na+ l cation chnh ca dch ngoi bo, c tc dng gi nc. Khi c tha Na+ trong dch ngoi bo th nc c ti hp thu nhiu thn Chc nng Na+: dn truyn xung ng TK - c, tham gia hot ng enzym, iu ha thng bng acid - base ( kt hp vi ion Cl- & ion HCO3- ). Nhng thay i ca Na+ thng i i vi Cl-. Nguyn nhn gim: 1) Mt mui: suy thng thn (Addison), suy thn, m hi nhiu, dng Li tiu. 2) Do pha long: + iu tr bng ADH or kch thch tit ADH + Hi chng bi tit ADH khng thch hp do carcinoma phi, do stress, do cc bnh l no + Suy tim huyt, x gan, hi chng thn h + Do dng nhiu nhng cht c nng thm thu (Glucose u trng, Manitol..) 3) Gim th tch dch ngoi bo: i ma, tiu chy, dng li tiu, li tiu thm thu, Addison. Nguyn nhn tng: 1) Tng Na+ huyt vi p lc thm thu do mt nc - mt mui, ch yu l mt nc -> thng gp: hn m tng thm thu do tiu ng. 2) Gia tng dch ngoi bo u trng (do truyn Sorbitol u trng). 3) Gim dch ngoi bo mt nc nhc trng, b khng ng hoc dng dung dch u trng. 4) Ri lon chc nng di i trong U no. 5) Gi mui trong bnh l: suy tim, suy thn, x gan. Tr s bnh thng: 135 - 145 mEq/l. Gim < 135, gim nng < 120. Tng > 145, nng > 160.

ClCl- l anion chnh ca Dch ngoi bo, ng vai tr quan trng trong duy tr thng bng nc, thm (cng vi Na+) & thng bng acid - base. Kt hp vi H+ to HCl dch v. Cnh tranh vi HCO3- i vi Na+ ( duy tr thng bng kim toan). Phn ln Cl- nhp kt hp vi Na+ to thnh NaCl (mui bp). Cl-/mu tng khi nhim toan, gim khi nhim kim chuyn ho. Tr s bnh thng: 98 - 106 mmol/l. Gim do: n nht, mt nc cp gy nhim kim chuyn ho, nn ko di (hp mn v), dng thuc li tiu, tiu chy, vim i trng, vim d dy rut.. Tng trong: n mn, toan chuyn ho, suy thn cp, shock phn v, hn m tng p lc thm thu..

Ca++ Khong 99% lng Ca ca c th xng - rng (ch yu di dng mui phosphat)

Ca - huyt thanh c 3 dng: phc hp khuch tn c _ CaR, Ca ion ha _ Ca+ +, v Ca gn vi protein _ Ca - Prot. Ca++ khuch tn c, nng tng khi nhim toan & gim khi nhim kim. Tr s bnh thng: 2,3 - 2,6 mmol/l (4,4 - 5,2 mEq/l). Gim trong: thiu vit D, nhc cn gip.. Tng trong: dng nhiu vit D, cng cn gip, nhim c gip.. LS xut hin cn tetanie khi Ca++/ mu < 3,5 mEq/l.

4/ GLUCOSE V LIN QUAN Glucose L monosacarid c 6C, c cht chuyn ha chnh ca glucid. C ngun gc t thc n cha glucid ( tinh bt, sacarose, lactose..), c d tr di dng glycogen gan - c - xng. Glucose huyt = glycemie => LS thng dng ng/ huyt tng ( v kt qu khng ty thuc vo dung tch hng cu & gn vi tr s trong m gian bo) Cc yu t nh hng n Glucose - huyt: + Lm tng: adrenalin, glucagon, hormon gip trng, hormon tng trng, glucorcorticoid.. + Lm gim: insulin.. + Yu t gy bin thin sinh hc: alcol, n nhiu glucid, thuc (morphin, atropin..), thuc m, lnh, kch thch thn kinh.. Nhng yu t trn gip duy tr nng glucose huyt n nh & glucose khng ra nc tiu. Khi glucose huyt vt qu ngng thn ( 1,6 - 2 g/L ) ( 160 - 180mg%) th glucose xut hin nc tiu. i n v: mmol/l x 18 = mg% = mg/dl ; mg/dl / 1000 x 10 = mg/dl /100 = g/ L Tr s bnh thng: 3,9 - 6,4 mmol/l ~ 80 - 120 mg%. Tr s bnh thng trong ng huyt tng: 70 - 120mg% - cao hn tr s bnh thng trong mu ton phn 10 - 15%: 60 - 110mg%. (v huyt tng khng cn t bo mu nn lng ng trong mt n v th tch ln). ng mu ton phn c dng trong trng hp khn cp: BN t theo di bng Glucometer. Tng: tiu ng, Basedow, suy gan, vim thn cp, sau truyn Glucose, chn thng s no.. Gim: hn m h ng huyt, dng Insulin qu liu, suy gan nng, x gan, nghin ru.. ng huyt c th ly TM, mao mch, hoc o trong khong gian bo. LS dng ng huyt/mao mch, thng c thc hin lc BN bng i. BN i tho ng thng c xt nghim ng huyt vo 5h sng ( chnh liu Insulin bui chiu) & 5h chiu ( chnh liu Insulin bui sng).

HbA1c ( huyt sc t A1c kt hp vi glucose) do phn ng Ketoamin (gia Glucose & nhm amin ca 2 chui beta ca phn t huyt sc t). c 3 loi: HbA1 - (a,b,c) gp thnh HbA1. HbA1c chim 4 - 6,5% tng s huyt sc t, 70% HbA1.

HBA1c thng tng trong trng hp tng ng huyt mn tnh ( phn ng Glycosylat ha khng o ngc c & huyt sc t glycosylat ha tn ti theo i sng hng cu: trung bnh 120 ngy). L tiu ch tt gip nh gi s n nh ng mu trn BN T. Gi tr: 5 - 6,5% ( < 7% ) trn BN T: cho bit BN c kim sot ng mu tt trong thi gian 3 thng trc . Nu > 8%: khng c kim sot tt. Nu BN tng ng huyt c iu tr tch cc, ng huyt n nh nhanh th HbA1c gim sm nht sau 4 tun. Theo UKPD: gim 1% HbA1c s gim 20% bin chng mun do T. Cc yu t nh hng n kt qu o: 1) mt mu cp/mn 2) tn huyt 3) suy thn mn 4) mt s bnh v huyt sc t.

Ceton huyt thanh & nc tiu Th ceton gm: acid beta hydroxybutyric, acid aceto - acetic, aceton. Dng vin acetest o ceton trong huyt thanh & nc tiu: nu vin thuc i t mu trng sang mu hoa c: (+). C gi tr bn nh lng. 5/ CHC NNG NG CM MU TP (Prothrombin content) L t l Prothrombin ( ~ TQ = Quick Time ). Kho st ng ng mu ngoi sinh (7) & ng chung (10, 2, 1, 5, Antithrombin). Tr s bnh thng: 80 - 100%. Gim: gim mt s hoc mt yu t ng mu ( Prothrombin, Proconvertin, Proacelerin, yu t Stuart), gim nhiu fibrinogen, xut hin heparin. aPTT ( activative Partial Thromboplastin Time ) L thi gian Thromboplastin tng phn ( ~ TCK = cephalin - kaolin time ). Kho st ng ng mu ni sinh (12, 11, 9, 8, Fletcher, Fitzgeraid) & ng chung ( 10, 5, 2, 1, Antithrombin). Tr s bnh thng: 30 - 45s. Tng: gim fibrinogen huyt, tiu fibrin, bnh a chy mu.. Fibrinogen L 1 protein huyt tng c tng hp gan, b phn ct bi thrombin thnh nhng si fibrin cn cho s to thnh cc mu ng. Thiu ht Fibrinogen gy ra chy mu. Fibrinogen huyt ch yu do gan to ra. Nng Fibri - huyt tng thp c th do s ng mu ni mch ri rc do chn thng nng hoc bin chng sn khoa. Tr s bnh thng: 0,2 - 0,4 g/dL. Tng: nhim trng, tng bch cu, thp khp cp.. Gim: bnh gan nng (x gan, ng c phospho), lao phi, BCC, ng mu ni mch ri rc..

6/ NH LNG HORMON HORMON TUYN GIP Gm: T3, T4 => vn chuyn trong mu ch yu di dng kt hp vi protein, dng t do rt t. Lm tng tc ly calci ra khi xng ( cng gip ko di s lm mt calci xng ) => tng Ca/mu. T3, T4 tng: cng gip, bu gip c (bnh Graves - Basedow).. T3, T4 gim: suy thy trc tuyn yn, nhc gip..

T3 ( Triodothyronin ) Tr s bnh thng: + T3 t do = FT3: 5,3 - 9,2 pmol/l + T3 ton phn = T3: 1,5 - 3,1 nmol/l. Bu c n thun: T3, T4 bnh thng. T4 (tetraiodothyronin) = thyroxin L hormon chnh ca gip trng. Tr s bnh thng: + T4 t do: 7 - 21 pmol/l + T4 ton phn: 50 - 130 nmol/l. HORMON TUYN YN TSH ( Thyroid Stimulating Hormon ) L hormon kch thch tuyn gip ( = kch t gip ), do tuyn yn trc ch tit. Tr s bnh thng: <= 10 mU/L . Gim: suy thy trc tuyn yn, cng gip (nhim c gip - Basedow - Cn bo gip) Tng: suy gip ngoi vi, tng nh trong bu c khuch tn.. 7/ KHC CRP ( C reactive protein = Protein C phn ng ) L protein to ta vi polysacarid ca ph cu khun C, thuc loi globulin. Khng c ngi bnh thng, xut hin trong huyt tng BN b bnh c vim nhim => ngha xt nghim: kho st tnh trng vim. 6 - 10h sau vim cp & h hi m, t nh trong vng 48 - 72h. l xt nghim dng theo di cc pha vim cp ca vim khp dng thp & st thp khp. ng thi tin on nguy c bnh tim mch & nh gi s p ng ca c th vi thuc Statin. Tng trong nhim vi trng, khng tng trong nhim virus. Tr s bnh thng: < 10 mg/L. Tng: nhim trng, k sinh trng, thp khp cp, lupus ..

INR (International Normalized Ratio = t s bnh thng ha quc t) ngha xt nghim: nh gi hiu qu s dng ca warfarin v cc thuc khng ng ung ( Sintrom..) Ty bnh, mc tiu INR khc nhau: van ng mch ch c hc cn INR t 2 3 trong khi van 2 l c hc cn INR t 2,5 3,5. Nu INR khng t ti ngng mc tiu th s d b cc mu ng lm kt van, nu cao qu mc tiu th d b chy mu (nng nht l chy mu no). Amylase L enzym thy phn tinh bt thnh maltose & glucose. Ngun gc: ch yu tuyn ty - tuyn nc bt, cn c gan - rut non - tinh hon - vi Fallope. Amylase huyt: Tr s bnh thng 86 - 268 U/L. Tng: bnh ty (vim ty cp, vim ty mn). Ngoi ra: thng rut - tc rut, vim ti mt - nhim trng ng mt, vim rut tha, nhi mu mc treo, thai ngoi t cung v, vim tuyn mang tai, suy thn, K phi.. Vim ty cp m Amylase/mu khng tng: 1) Vim ty cp tr 2) Bnh tng Triglyceride i km 3) Vim ty cp/ Vim ty mn. Do xt nghim ny cn c h tr bi siu m bng (thy c ty ph n hoi t ng thi chn on phn bit vi cc nguyn nhn gy tng Amylase mu khc) & chc d dch mng bng (dch mng phi) di siu m - nh lng men ty trong dch. (vim ty cp: > 20.000 UI/ml).

Cholinesterase L enzyme phn ly Acetylcholin tip din thn kinh & ch ni thn kinh - c. C 2 loi: + Acetylcholinesterase: l choli tht, c trong hng cu & m thn kinh. + Pseudocholinesterase: l choli huyt thanh. Tr s bnh thng: 5.300 - 12.900 U/L - 37oC. Gim: nhim c thuc tr su (cht phosphat hu c..), vim gan, x gan.. AFP = Alpha-Fetoprotein Tr s bnh thng: 10 - 20 ng/ml. K tc tng nhanh gy tng AFP - gm nhng bnh: 1. K gan 2. K tinh hon 3. K bung trng. Gi tr: + Vim gan cp, 3 thng cui thai k: tng # 60 ng/ml. + Vim gan mn: tng > 100 => c kh nng K ha trong 5 nm lin tip. Tng > 200: kh nng K giai on hin ti. + K nguyn pht: tng > 1.000. Lng Alpha-fetoprotein o bng cch xt nghim mu. Alpha-fetoprotein (AFP) l mt ch im ung th thng tng t 60% n 70% bnh nhn ung th t bo gan (hepatocellular carcinoma= HCC).

Bnh thng, AFP mc < 10 ng/ml, nhng thng tng n mc gii hn (10 n 100 ng) nhng bnh nhn vim gan mn. Tuy nhin, tt c nhng bnh nhn c tr s AFP tng cao u nn c tm sot HCC (bng siu m bng, CT scan hoc MRI) c bit khi AFP tng hn so vi tr s cn bn cc xt nghim lm trc y. Theo kinh nghim, khi tr s AFP tng ln u n th chn on HCC hu nh chc chn. chuyn bit ca AFP rt cao nu tr s vt qua 400 ng/ml. Cc carcinom qui (teratocarcinoma) khng bit ho v carcinom t bo phi thai (embryonal cell carcinoma) ca tinh hon hay bung trng c th cho kt qu dng tnh gi, nn chng cn phi c a vo phn chn on phn bit tng AFP. Thi gian tr s AFP tng gp i l t 60 n 90 ngy. Do , nn kim tra AFP mi 3 n 4 thng tm sot HCC cc bnh nhn x gan c nguy c cao (vim gan C, vim gan B, v bnh mu nhim st hemochromatosis).

PH LC 1. Glucose; HbA1C: Chn on bnh i tho ng, theo di iu tr bnh nhn b i tho ng; h ng huyt. 2. Cholesterol; Triglycerid; HDL-C; LDL-C: Bnh tng Lipid mu, nguy c va x ng mch, tng huyt p nhi mu c tim, thn h nhim m, gan nhim m 3. Ure; Creatinin; Ure nc tiu 24 gi; Creatinin nc tiu 24 gi: Bnh l v thn: Thiu nng thn, vim cu thn cp, mn, suy thn 4. Protein ton phn; Albumin; in di protein: au tu xng, suy nhc c th, gan, vim thn, suy thn 5. Acid uric: Bnh Gout (thng phong), bnh thn. 6. Bilirubin ton phn; Bilirubin trc tip; Bilirubin gin tip: Cc trng hp vng da do: tan huyt, vim gan, tc mt 7. LDH; CK-MB: Nhi mu c tim 8. SGOT (ALAT); SGPT (ASAT); g GT (Gama GT): Cc bnh v gan: vim gan cp, mn, tn thng nhu m gan (vim gan siu vi trng, vim gan do ung ru) 9. ALP (Phosphataza kim): Ri lon chuyn ho xng, ci xng, nhuyn xng, tc ng mt, ung th tin lit tuyn 10. Amylase: Vim ty cp, mn, quai b, vim tuyn nc bt 11. in gii (Na+, K+, CL-, Ca+): Cc ri lon in gii trong bnh thn, tim mch, co git, mt nc bnh h canxi mu 12. Fibrinogen: Bnh ri lon ng mu, gan, khp Di y l bng lit k thng dng ti cc phng th nghim c. Ha cht Thn v khong cht Sodium (Natrium) Potassium (Kalium) Chloride Bicarbonate n v mmol/L mmol/L mmol/L mmol/L Nng bnh thng 136 - 145 3,5 - 5,5 96 - 108 20 - 32

Urea Creatinine Uric acid Calcium, ton phn Calcium, chnh Phosphate Magnesium Gan Bilirubin, ton phn Gamma GT ALP ALT AST Protein, ton phn Albumin Globulins M trong mu Triglyceride Cholesterol HDL-Cholesterol LDL-Cholesterol T l Chol/HDL

mmol/L mmol/L mmol/L mmol/L mmol/L mmol/L mmol/L umol/L U/L U/L U/L U/L g/L g/L g/L mmol/L mmol/L mmol/L mmol/L

< 8,0 0,04 - 0,11 0,12 - 0,40 2,10 - 2,60 2,10 - 2,60 0,8 - 1,4 0,7 - 1,0 < 21 < 35 < 120 < 35 < 35 60 - 80 35 - 50 23 - 35 Rec <1.9 Rec < 5,5 0,9 - 2,4 < 3,5 < 4,4

C - MEN TIM

L nhm xt nghim khng th thiu i vi cc trng hp Nhi mu c tim. Cc men thng lm: Troponin I, CK - MB.

Troponin I Troponin l protein si c ca c vn. Gm 3 bn n v: 1) Troponin I: c ch actomyosin ATPase 2) Tropnonin T: gn phc hp Troponin vi Tropomyosin 3) Troponin C: c 4 v tr gn calci. Troponin Troponin tng cng cao, t sut cng cao Cn t nht hai ln o vi ln sau cng cch t nht 6 gi sau cn au ngc loi tr nhi mu c tim Sau nhi mu c tim cp, troponin c th tng hn 10 ngy nn khng th dng nh gi au ngc sau nhi mu. Troponin I c tnh nhy v c hiu chn on nhi mu c tim chu phu Troponin khng c hiu 100% cho nhi mu c tim cp Trng hp dng tnh gi: C th do gn kt khng c hiu gia khng th trong thuc th vi troponin trong mu c ngun gc khng t tim (circulating troponin of non-cardiac origin) Suy thn: troponin l ch im tim tt bnh nhn chy thn nhn to nhng khng hu ch bnh nhn suy thn mn khng c chy thn nhn to Yu t dng thp (RF) cng c th lm kt qu c troponin I dng tnh. Troponin I: c nhy - chuyn bit cao. c im: + L cht nh du tim c chc chn cho chn on hn CK - MB. ( Tuy CK - MB tng c chuyn bit i vi c tim b hoi t > 95% nhng i khi ch s ny c cao lin tc => khng ng hc; nguyn nhn do phn ng cho gia CK - MB vi CK - BB) + Gip chn on chnh xc NMCT BN hu phu (CK - MB c tng sau chn thng c) Tr s bnh thng: 0,5 - 2 ng/mL ( < 0,1 - 0,2 ng/mL ), > 2 : chn on chc chn. ng hc: khi tng 3 - 12h, nh 24 - 48h, v bnh thng 5 - 14 ngy. CK - MB CPK ( Creatin Phosphat Kinase ), gi gn l CK ( Creatin Kinase ) : l enzym chuyn phosphat t ATP sang creatin. C nhiu : tim - c xng, t no. CK c 2 bn n v l M (muscle: c) & B (brain: no), c 3 isoenzym l: 1) CK - BB ( CK1 ): c nhiu no 2) CK - MB ( CK2 ): c nhiu tim 3) CK - MM ( CK3 ): c nhiu c. CK - MB l isoenzym ca CK, c s dng trong chn on NMCT v c nhiu tim - c hiu cho tn thng c tim khi o 24 - 36h sau au ngc. CPK (Creatine phosphokinase) cng cn c gi l CK (Creatine kinase), l mt enzyme c tm thy ch yu tim, no v c vn. CPK c 3 isoenzymes c cu trc hi khc nhau CPK-1 (cn gi l CPK-BB, CK-BB) tp trung ch yu no v phi CPK-2 (cn gi l CPK-MB, CK-MB) tm thy ch yu tim

CPK-3 (cn gi l CPK-MM, CK-MM) tm thy ch yu c vn

+ Do CK tng khng c ngha chn on nhi mu c tim v n khng c hiu cho tn thng ti tim m c th do nhng tn thng ti c vn, no, phi + CK-MB c tnh c hiu cho tn thng ti tim hn CK v c xem l mt trong nhng ch im ca hoi t c tim + CK-MB hn 5% CK c ngha dng tnh cho nhi mu c tim. Nu CK-MB tng m CK bnh thng cng c ngha l bnh nhn c nguy c nhi mu c tim cao. + CK-MB c th dng tnh gi trong 8% trng hp thuyn tc phi Bnh nhn chy thn nhn to Tr s bnh thng: CK - MB <= 24 U/L - 37oC. ng hc: khi tng 3 - 12h, nh 24h, v bnh thng 48 - 72h. (+) gi do: - gim thanh thi CK MB - phn ng cho vi CK - BB. => Nu BN n tr qu thi gian nh & thi gian ht ca CK - MB (qu 10 ngy): lc ny phi da vo men LDH, Troponin. LDH ( = LD = Lactate Dehydrogenase ) LDH l enzym ni bo c trong hu ht cc t bo ang chuyn ha, hm lng cao : tim - c xng - gan - thn - no - hng cu. L men tng mun trong NMCT cp, nhy nhng khng c hiu. Ngoi NMCT, LDH cn tng trong: tn huyt, bnh bch cu, bnh thn.. LDH/mu = LDH ton phn. Khi in di, tch bit c 5 isoenzym: LDH1, LDH2, LDH3, LDH4, LDH5 => nu thy LDH tng, lm thm ng v LDH1 (c trong c tim) c hiu hn & t s LDH1/LDH2 > 1 -> NMCT. Tr s bnh thng: 230 - 460 U/L - 37oC. ng hc LDH: khi tng 12h, nh 24 - 48h, v bnh thng 10 - 14 ngy. Kt hp Troponin & CK - MB u tng trong trng hp: 1) Vim c tim, vim mng ngoi tim 2) ng dp tim, phu thut tim 3) Kh rung lin tip. Troponin I vt tri hn CK - MB v 2 mt: 1) nhy, chuyn bit cao. 2) Tng sm 3 gi sau khi pht au, nh 24 - 48h, mi 5 - 14 ngy sau mi tr v bnh thng. Vi vic duy tr s nh du lu nht nh th, Troponin bao gm u im (sm) ca Myoglobin, CK - MB & u im (mun) ca LDH. Troponin I u th hn CK - MB trong mt s hon cnh: + Cn chn on phn bit NMCT khng ST chnh ln vi au tht ngc khng n nh. (CDTNKOD khng th lm tng Troponin nhng i khi c CK - MB (tim) tng do giao thoa vi s tng CK - BB (no). + Cn pht hin NMCT cp BN hu phu (m CK - MB c th tng do vt m c bp). + Cn khng nh NMCT cp nhng ngi b hy hoi c nhiu ( CK - MB cng tng ) nh: vim a c, lon dng c, suy thn mn; hoc Bn Xut huyt no, Nhi mu no

- c hy hoi m no ( CK - BB tng & c s tng giao thoa CK - MB); hoc BN ang K ph qun - phi, K tuyn tin lit, nhi mu rut. Tuy nhin, khi cn phn nh NMCT vi chn thng tim, phu tim, vim c tim, vim mng ngoi tim, sc in kh rung tht lin tip: CK - MB & Troponin u tng (v l du n t bo c tim b hy) nn u th c 2 nh nhau. S dng men tim cn cho trng hp c 1 tiu chun ri cn 1 tiu chun na: + Mi m, gi, DTD -> o ECG c du NMCT -> dng men tim chn on xc nh. + au ngc kiu NMCT nhng ECG ch c du hiu block nhnh hay BN t my to nhp => che lp ECG => lm men tim. Cc trng hp: phnh vch tht, au tht ngc khng n nh => ch cn ECG theo di l .

D - KH MU NG MCH Ch nh KMDM: 1) Suy h hp mi nguyn nhn: ti phi hay ngoi phi 2) Suy tun hon, chong, nhim trng mu (SEPSIS) 3) Suy thn & bnh l ng thn 4) Bnh ni tit: i tho ng nhim toan ceton, bnh v thng thn, suy gip 5) Hn m, ng c 6) Bnh tiu ha: i, tiu chy, d ti mt or rut non, ty tng 7) Cc ri lon in gii: tng gim K mu, Chlor mu 8) Theo di iu tr: oxy liu php, th my, nui n qua ng tnh mch, lc thn, truyn dch or truyn mu lng ln, iu tr li tiu.. => tm li: suy h hp - suy thn - i tho ng - ri lon in gii - hn m ng c, th oxy - lc thn - truyn dch/ mu lng nhiu.. Cc ch s cn quan tm chn on Ri lon kim toan: pH, PaCO2, HCO3 std (= standard bicarbonate = HCO3 chun). Cc trng hp thng gp: Toan h hp trong bnh COPD Toan h hp trong ARDS Toan chuyn ha trong sc nhim trng Toan chuyn ha trong hn m nhim ceton / tiu ng. Ri lon toan kim hn hp: Toan chuyn ha + toan h hp: ngng tim ngng th, ph phi cp nng, nhim c. 2) Toan chuyn ha + kim h hp: ng c Salicylate, SEPSIS, suy gan nng. 3) Toan chuyn ha + kim chuyn ha: suy thn/ i nhiu, nhim toan ceton/ i nhiu. 4) Kim chuyn ha + toan h hp: COPD/ i nhiu, dng nhiu li tiu. 5) Kim chuyn ha + kim h hp: suy gan nng/ i nhiu. ---------------------1. pH Cho bit trng thi thng bng kim toan (< 7,35: toan, > 7,45: kim). pH toan cng vi PaO2 gim l du hiu thiu oxy m. Khi PaCO2 tng m pH bnh thng l tnh trng ng CO2 mn, cn pH gim l cp. gi tr: 7,3 - 7,5: ri lon toan kim nh -> ch cn iu tr nguyn nhn. 7,1 - 7,3: toan mu nng mt b. 7,5 - 7,6: kim mu nng mt b. < 7,1 or > 7,6: nguy him tnh mng. < 6,9 or > 7,7: t vong nhanh chng. Da vo bnh cnh xem xt mc nguy him. Vi tnh hung: + pH = 7,2: c th cha c triu chng bi s chu ng tt ca BN COPD trong khi l trng hp nguy him tnh mng i vi BN suy h hp cp. + pH < 7: c th c BN b ng kinh khi ln cn nhng him khi cn gii quyt v pH s nhanh chng v bnh thng sau khi iu tr chm dt cn co git. [H]+: l 1 trong 3 ch s trong phng trnh Henderson -> tnh [H]+ kim tra kt qu kh mu (v my o thng ch o pH & PaCO2 => sau tnh HCO3) ng
1)

thi gip tnh nng HCO3 cn thit iu chnh pH mu trong iu tr. Tnh [H]+ da vo pH. Tng quan: + Nu nng [H]+ tng th pH gim, nng [H]+ gim th pH tng: t l nghch. (v pH l log m ca nng [H]+ ) + Nu pH tng hay gim 0,1 th nng [H]+ gim hay tng thm 20%. + Cn nh 2 cp: pH = 4,0 -> [H]+ = 40 , pH = 7,0 -> [H]+ = 100. (n v [H]+: nEq/l) => phng trnh Henderson: [H]+ = 24 x ( PaCO2 / HCO3 ). 2. pCO2 Tr s bnh thng: 35 - 45 mmHg (40 +/- 5). L phn p carbon dioxide trong mu (p sut phn ca kh CO2 thng bng vi mu). Trong mu: M => PaCO2, TM => PvCO2. PaCO2 c iu chnh bi phi -> l thnh phn h hp ca thng bng kim toan. ngha: phn nh trc tip mc thng kh ph nang c ph hp vi tc chuyn ha ca c th khng => dng trong LS nh gi thng kh ph nang. Khng i theo tui. (c th) gim khi i tng gia tng thng kh (do lo lng, ln cao > 2.500m). PaCO2 nh hng n pH theo phng trnh: CO2 + H2O <=> H2CO3 <=> HCO3- + H+ => PaCO2 tng: s chuyn hng phng trnh qua phi: toan h hp. => PaCO2 gim: s chuyn hng phng trnh qua tri: kim h hp. Tr s: + > 45 => gim thng kh ph nang => mc thng kh thp hn nhu cu thi CO2 ca c th => nguyn nhn: 1.gim thng kh ph nang, 2.bt xng gia thng kh v ti mu. + < 35 => tng thng kh ph nang => mc thng kh cao hn nhu cu thi CO2 ca c th. => nguyn nhn: 1.gim PaO2, 2.gim pH, 3. h thn kinh b kch thch, 4. cho th my qu ng. Chn on suy h hp nh PaCO2: suy h hp cp nu pH gim, mn nu pH bnh thng.

3. HCO3 std ( HCO3 chun - standard bicarbonate) Tr s bnh thng: 21 - 26 mmol/L. l nng Bicarbonate trong mu ng mch (HCO3- khi PaCO2 = 40mmHg, bo ha vi oxy v 37oC). HCO3 c iu chnh bi thn, l thnh phn chuyn ha ca thng bng kim toan. CCH C KH MU NG MCH c KMDM qua 3 bc xc nh toan kim: Bc 1: xem Ph Bc 2: xem PaCO2 Bc 3: xem HCO3 std. C 3 tnh hung:

Tnh hung 1: pH < 7,35

L trng hp Toan mu. Tip theo xem PaCO2 xc nh l toan h hp or toan chuyn ha: PaCO2> 45 => toan h hp, PaCO2 < 35 => toan chuyn ha. Bc 3: xem HCO3 std. C 2 trng hp: 1. PaCO2 > 45: toan h hp. => xem HCO3 tng bao nhiu vi mi 10 mmHg tng ca PaCO2: + tng 1 - 1,2: toan h hp cp ( pH gim 0,07 ) + tng 3 - 4: toan h hp mn ( pH gim 0,03 ) + tng 1,2 - 3: toan h hp cp trn nn mn ( pH 0,03 - 0,07 ) 2. PaCO2 < 35: toan chuyn ha. => xem PaCO2 gim bao nhiu vi mi 1 mEq gim ca HCO3, nu gim 1 - 1,2 mmHg => toan chuyn ha c b (2 s l ca pH = PaCO2 hoc PaCO2 = (1,5 x HCO3) + 8, hoc PaCO2 = HCO3 + 15)

Tnh hung 2: pH > 7,45 L trng hp kim mu. Tip theo xem PaCO2 xc nh l kim h hp hay kim chuyn ha: PaCO2< 35: kim h hp, PaCO2> 45: kim chuyn ha. Bc 3: xem HCO3 std. C 2 trng hp: 1. PaCO2 < 35: kim h hp. => xem HCO3 gim bao nhiu vi mi 10 mmHg gim ca PaCO2: + Gim 2 - 2,5: kim h hp cp ( pH tng 0,08 ) + Gim 5: kim h hp mn ( pH tng 0,03 ) 2. PaCO2 > 45: kim chuyn ha => xem PaCO2 tng bao nhiu vi mi 1 mEq tng ca HCO3, nu tng 0,7 mmHg => kim chuyn ha c b ( 2 s l ca pH = PaCO2 hoc PaCO2 = HCO3 + 15 ) Tnh hung 3: 7,35 < pH < 7,45 c 3 kh nng: 1. Khng c ri lon: pH, PaCO2, HCO3 std u bnh thng. 2. C ri lon c b : o pH: bnh thng o PaCO2, HCO3: khng bnh thng. 3. C ri lon kim toan hn hp: o pH: bnh thng o PaCO2, HCO3: khng bnh thng. P DNG 5 QUY LUT C KMDM Lut 1 Ri lon toan kim chuyn ha nguyn pht nu: pH bt thng & pH, PCO2 thay i cng chiu. Nhim toan chuyn ha: pH < 7,35 & PCO2 < 35. Nhim kim chuyn ha: pH > 7,45 & PCO2 > 45.

Lut 2 Ri lon toan kim h hp km theo nu:

PaCO2 o c > PaCO2 d on: toan h hp. PaCO2 o c < PaCO2 d on: kim h hp.

Lut 3 Ri lon toan kim h hp nguyn pht khi: PaCO2 bt thng & pH, PCO2 thay i ngc chiu. Toan h hp: PCO2 > 45 & pH < 7,35. Kim h hp: PCO2 < 35 & pH > 7,45.

Lut 4 S thay i pH mong i (tnh theo phng trnh) quyt nh: ri lon h hp cp/mn? C ri lon toan kim do chuyn ha km theo? Cc ri lon nguyn pht: o Toan chuyn ha => thay i b tr: pCO2 = 1,5 x HCO3 + ( 8 +/- 2 ). o Kim chuyn ha => TDBT: pCO2 = 0,7 x HCO3 + ( 21 +/- 2 ). o Toan h hp cp => TDBT: /\ (danta) pH = 0,08 x (pCO2 - 40). o Toan h hp mn => TDBT: /\ pH = 0,03 x (pCO2 - 40). o Kim h hp cp => TDBT: /\ pH = 0,08 x (40 - pCO2). o Kim h hp mn => TDBT: /\ pH = 0,03 x (40 - pCO2).

Gi tr: < 0,003 => mn, > 0,008 => cp (ri lon toan kim do chuyn ha). B khi < 0,003 & b 1 phn khi 0,003 < /\ < 0,008.

Lut 5. Ri lon toan kim hn hp: pCO2 bt thng, pH bnh thng pH bt thng, pCO2 bnh thng. P DNG @1 pH < 7,35: nhim toan. PaCO2 gim hoc bnh thng: toan chuyn ha nguyn pht. Da vo quy lut 2 xc nh toan kim h hp kt hp? PaCO2 tng: toan h hp nguyn pht. Da vo quy lut 4 bit ri lon cp/ mn & c ri lon toan kim chuyn ha kt hp?

@2 pH > 7,45: nhim kim. PaCO2 bnh thng hoc cao: kim chuyn ha nguyn pht. Da vo quy lut 2 bit ri lon toan kim h hp kt hp? PaCO2 thp: kim h hp l nguyn pht. Da vo quy lut 4 bit cp/mn & c ri lon toan kim chuyn ha kt hp?

@3

pH bnh thng: 7,35 - 7,45. PaCO2 cao -> toan h hp & kim chuyn ha hn hp. PaCO2 thp -> kim h hp & toan chuyn ha hn hp. PaCO2 bnh thng: c th l toan chuyn ha ng thi c kim chuyn ha.

Anion Gap (khong trng anion) AG = Na+ - ( Cl - + HCO3- ) = 12 +/- 4 mEq/l. AG cho bit toan chuyn ha l do tch t acid hay do mt HCO3-: AG tng -> tch t acid hu c (acid lactic, keto acid) hoc suy thn khng thi acid c. Gp trong: suy thn cp, tiu ng, suy dinh dng, chong (nhim trng, tim, gim th tch), ng c thuc, ru. AG bnh thng -> toan chuyn ha mt HCO3- , thng km gim K+ mu. Gp trong: tiu chy, iu tr bng Diamox, toan huyt ng thn.

E NHM MU 1/ Phn loi nhm mu da vo s hin din ca Khng nguyn trn mng t bo hng cu. Cc KN nhm mu A, B, O l mucopolysaccharide. Da vo s c mt hay khng c mt ca cc KN A & B trn mng HC, Landsteiner phn thnh 4 nhm mu: A, B, AB, O: + A: c KN A trn mng HC, Khng th Anti - B trong huyt thanh. + B: c KN B trn mng HC, KT Anti - A trong huyt thanh. + AB: c KN A & B trn mng HC, khng c Anti - A & Anti - B trong huyt thanh. + O: khng c KN A & B trn mng HC, c KT Anti - A & Anti - B trong huyt thanh. T l nhm mu ngi VN: O (48%) -> B (28%) -> A (20%) -> AB (4%). 2/ H Rhesus: + Quy c: hng cu c cha yu t Rh -> Rh+, ngc li => Rh-. VD: Nhm mu A+ => nhm mu A & Rh+. + Yu t Rh l 1 h thng gm 13 khng nguyn trong quan trng nht l yu t D. + Cc khng th h Rh khng c sn trong mu, ch xut hin khi c s tip xc vi KN => v vy, khng th h Rh c gi l KT min dch. + Trong cc khng th ca h Rh, anti D l KT quan trng nht. Anti D l 1 loi IgG. + nhng phn ng do yu t Rh thng xy ra trong 2 trng hp: 1) ngi c mu Rh- nhn nhiu ln lin tc mu Rh+ 2) m c nhm mu Rh- nhiu ln mang thai c mu Rh+ + gi tr: - Nu truyn mu ca ngi c Rh+ cho ngi c Rh- th s xy ra ngng kt v mu ca ngi Rh- s sn sinh ra mt loi khng th c bit chng Rh+. - Khng th chng Rh+ khng c sn trong huyt tng nh alpha v beta ca mu m ch c hnh thnh nhng ngi Rh- sau khi nhn c nhiu ln 1 lng mu Rh+. Khng th pht trin chm, khong 2 - 3 thng sau khi nhn mu Rh+ mi phn ng. Khi c to ra th tnh min dch s c tn ti nhiu nm. - Do , nu 1 ngi Rh- cha h tip xc vi mu Rh+ th vic truyn mu s khng gy 1 phn ng tc thi no. Tuy nhin nu ln sau h li c truyn mu Rh+ c th xy ra tai bin nghim trng nh h thng ABO. Mt cht phn bit: @ KT t nhin: - ngun gc: khng qua qu trnh min dch r rng - khng th: IgM - iu kin hot ng: 4 - 20oC ( 0 - 37oC ) - c im: 1) khng qua nhau thai 2) gy ngng kt & hy dit HC 3) tiu huyt trm trng trong lng mch. @ KT min dch: - ngun gc: c qu trnh min dch r rng - khng th: IgG - iu kin hot ng: 37Oc - c im: 1) qua nhau thai

2) khng gy ngng kt nhit lnh & phng th nghim 3) ch bm ln b mt HC. 3/ Nhm mu Bombay (Oh): + L nhm mu khng c khng nguyn H trn HC, nhng c khng th chng H trong huyt thanh gy tan mu vi hiu gi cao. V vy, huyt thanh ny c th lm ngng kt vi cc hng cu ca tt c cc nhm mu trong h ABO, tr hng cu ca ngi c cng nhm mu Bombay. + Phn bit vi nhm mu O nguy him: l nhm mu O c nng anti A & anti B cao, do va c Anti A, Anti B t nhin, va c Anti A & Anti B min dch. 4/ ngha ca xc nh nhm mu: l c s quyt nh cho truyn mu. 5/ Nguyn tc truyn mu: * Th 1: Khng cho KN & KT tng ng gp nhau trong mu ngi nhn => phi truyn mu cng nhm. * Th 2: Khi c mu cng nhm, c th cho truyn khc nhm theo nguyn tc: KN trn mng HC ngi cho khng b ngng kt bi KT tng ng trong huyt tng ngi nhn. T y c th gii thch c v tnh cht ca nhm mu: + Nhm mu O: khng c KN trn mng HC nn khng b KT trong huyt tng ngi nhn lm ngng kt. Do nhm O c th truyn cho c 3 nhm. + Nhm mu AB: khng c KT trong huyt tng nn khng th ngng kt bt k HC ngi cho no. Do nhm AB c th nhn mu ca c 3 nhm. + Nhm mu A: c KT Anti B trong huyt thanh nn c th b ngng kt bi KN trn HC ngi cho. Do nhm A ch c th nhn t nhm mu O l nhm mu khng c KN trn HC. + Nhm mu B: gii thch tng t. + Mi nhm mu u c th nhn mu cng nhm (tt nht): v bo m KN & KT tng ng khng gp nhau trong mu ngi nhn. + Cu hi t ra: KT trong huyt tng ngi cho c gy ngng kt HC ngi nhn khng? => Trong thc t, kh nng ny khng xy ra v KT c truyn vo vi lng rt nh nn b pha long ngay trong mu ngi nhn, khng ngng kt HC. Ngoi ra KT cn b trung ha bi nhng KN c trong cc t bo & cc dch c th. + Tai bin: - VD1: ngi c mu nhm A th ch c th tip nhn c mu t ngi nhm A v nhm O/Rhesus m tnh. Nu nhn mu t nhng nhm khc th s gy ra cc phn ng d ng, c th gy t vong v cc yu t A, B, AB, O, Rh l nhng antigen (khng nguyn) s lm cho c th to ra cc khng th (antibody) chng li cc nhm mu khc v hu hoi cc nhm mu khc ny gy ra nhng kch xc rt nguy him. - VD2: Nu thai nhi tha hng Rhesus dng tnh (= khng nguyn D) ca ngi cha, th c th gp nguy him. Do s trao i mu gia ngi m v thai nhi qua l nhau (placenta), ngi m sn xut cc khng th chng li khng nguyn D (= anti-D antibody). Cc khng th ny xuyn qua l nhau v c th ph hy cc hng huyt cu ca thai nhi, do thai nhi b thiu mu v c khi cht trong bng m.

F - TRUYN MU Trong trng hp cn truyn mu, cn cn nhc la chn: truyn loi no? truyn bao nhiu? tc truyn? nhng phn ng ph no c th xy ra - hng x tr? Nhng trng hp thng gp:

1) XHTH: Truyn loi no? Do mt mu ton phn + yu t ng mu + HC + huyt tng, v vy tt nht cho truyn mu ton phn ti - cn yu t ng mu & TC, tuy nhin mu thng tr sn nhit 4 - 6o nn 2 thnh phn va nu khng c ng thi mu ton phn d tai bin, v vy thc t ty trng hp: truyn HC lng km dung dch NaCl 9 o/oo (t nguy him hn). * Quan im hin nay v mu ton phn: 1. Trong mu ton phn d c cc thnh phn nhng nhng thnh phn ny vi iu kin bo qun khc nhau: + Hng cu lng, mu ton phn d tr 4 oC trong vng 35 ngy. + Tiu cu m c bo qun 220C - 240C v lc nh lin tc v ch bo qun trong vng 5 ngy. + Huyt tng ng lnh, kt ta lnh d tr : -18 oC trong 12 thng; - 40 oC trong 2 nm; -65 oC trong 7 nm. Do vy thng khng cn khi truyn. Vi trng hp thiu yu t ng mu (Hemophilia, Rosenthal..): do trong c th ngi ch c 30% nhm yu t tham gia vo qu trnh ng mu, v vy vn cn > 50% tr sn cho qu trnh ng cm mu; khi truyn HC lng vn . 2. Truyn mu ton phn s a mt s thnh phn khng mong mun vo c th: huyt tng tha s gy tnh trng qu ti tun hon, hoc bch cu l loi t bo gy phn ng khng mong mun. 3. Truyn mu ton phn c nguy c nhn nhiu mm bnh: vim gan siu vi B, C, HIV, HTLV, Giang mai, St rt.. * Quan im hin nay v truyn mu: thiu g truyn . + Thiu ht hng cu => truyn hng cu lng + Bnh a chy mu => truyn kt ta lnh giu yu t VIII (hoc huyt tng ti ng lnh nu khng c kt ta lnh) + Thiu ht tiu cu => truyn tiu cu m c * Trong trng hp cn khi phc khi lng tun hon: truyn HC lng bn cnh b dch. + Nu 2 ng truyn ng thi: dung dch duy nht c truyn vi ch phm mu l NaCl 9 o/oo. + C cc loi: dch tinh th, dch keo. - Dch tinh th: Nc mui ng trng 0,9% (NaCl 9 o/oo) l dch truyn tt nht, ngoi ra c th dng dung dch Ringer Lactat. - Dch keo: dung dch Albumin 5% v 25%, plasma, 10% Dextran-40 v 6% Dextran-70 => c khuynh hng li trong mu gi dng nhng Protein huyt tng duy tr hoc lm tng p lc keo, p lc thm thu ca mu. Truyn bao nhiu? C 1 n v HC lng (250ml) nng nng Hb ln thm 1 g/dl hoc tng Hct ln thm 3%. Ty gi tr c th so vi mc tiu (nng Hb > 10 g/dl & Hct > 30%) quyt nh s n v truyn.

VD: BN Hb 7 g/dl, Hct 21% -> cn truyn 3 n v HC lng. Tc truyn? HC lng 1000ml/ 3 - 4 gi -> # XL git/ pht. Cng thc tnh: T (gi) = V/( s git x 3) => p dng cho mi phm mu & dch truyn. VD: chn phm mu 450ml truyn, gi nh tc XL g/p => T = 450 / (40x3) = 3,75h: tha iu kin. Phn ng ph c th xy ra? -> XHTH l trng hp mt mu cp, thc t sau truyn lng Hb & Hct c nng ln khng lun tng ng theo t l: 1 n v HCL - 1 g/dl Hb - 3% Hct. Trng hp cp cu c th truyn > 6 n v m bo huyt ng cho BN. Khi truyn mu ton phn khc nhm > 6 n v, Lng khng th truyn vo c th cao c th gy phn ng truyn mu. Hng x tr: lm phn ng cho trc cho mi n v mu & hn ch truyn mu ton phn khc nhm. Cch lm phn ng cho: - phn ng cho chnh (khoa xt nghim): HC ngi cho + huyt thanh ngi nhn -> ngng kt? - nu c khng truyn (v tng k). - phn ng cho ph (bnh phng): HC ngi nhn (chch mu mao mch nh th ng) + huyt thanh ngi cho (t bch mu) => ngng kt? - nu khng c truyn. Vi nt v truyn dch - truyn mu/ XHTH: X tr theo cc mc

XHTH mc trung bnh: Tr li khi lng tun hon mt bng dung dch ng trng, u tin dd mn, c th dng LR. Khng c dng cc dung dch u trng v tng nht ca mu => lm chm tc tun hon => toan mu d xy ra sc. Khng dng cc thuc vn mch. X tr XHTH mc III - IV: Tr li th tch khi lng tun hon: bng dch ng trng v mu. Truyn n khi M, HA n nh (HA 90mmHg), ht thiu oxy no, Hct > 20%, Hng cu > 2 triu. T l truyn 2/3 dch ng trng v 1/3 mu. VD: Mt 1200ml = 2/3 dch (800ml) + 1/3 mu (2 n v). Nu b/n cn chy mu, tip tc truyn dch nc s ra gian bo => ph nc. Lc khng dng dd ng trng na m phi dng dd cao phn t ko nc vo: Huyt tng, Albumine, Dextrane, Gelatine.

LIU PHP DCH

Cc loi dch truyn: Theo T chc y t th gii 2001, dung dch tinh th v dung dch keo c ch nh trong mi trng hp chy mu cp khi phc th tch mu trc khi truyn mu, bi v: Khng th c mu ngay truyn. Vn cn mt lng O2 d tn ti m t bo mc d Hb gim.

C ch huy ng hng lot phn ng p ng b tr duy tr cung cp O2 n

m. Khi c ch b tr c s dng, truyn dch thay th s lm tng cung lng tim do vn m bo cung cp O2 mc d nng Hb gim. Truyn dch thay th lm pha long mu v cc thnh phn mu => gim nht ca mu => ci thin lu lng mao mch v cung lng tim => tng cng cung cp O2 ti m.

La chn dch Loi dch Mu Huyt tng Gelatin Albumin Dextran 40 NaCl 0,9% Lactate R Glucose 5% Ni khuych tn Trong lng mch Trong lng mch Mch mu Mch mu Mch mu Ngoi t bo Ngoi t bo Ngoi t bo Th tch phc hi 1/1 1/1 1/1 3-4/1 2/1 1/10 Protein 70 70 200 Bn hy 30-35 ngy 30-35 ngy 4-5 gi 21 ngy 6-8 gi 8 gi

a.Dch keo (Plasma, Albumin, HAES, Gelatin, Destran): gi p lc keo huyt tng v lu trong lng mch (thi gian na i sng l 3-6g). b.Dch tinh th (NaCl 0,9%, Ringer lactate): T1/2 trung bnh l 20-30 pht, cn bng v khuych tn khp ton b khoang ngoi t bo. Mt s im c nht tr: Dch tinh th c truyn lng c tc dng bng dch keo trong vic khi phc th tch tun hon. B th tch tun hon bng dch tinh th, cn lng gp 3-4 ln so vi dch keo. Hu ht cc b/n thiu dch ngoi t bo => thiu dch trong lng mch (th tch tun hon). Truyn nhanh v nhiu dch tinh th (> 4-5 lt) thng km ph t chc. Truyn mu v cc thnh phn ca mu Vn chuyn xy ti t chc ph thuc rt nhiu vo cung lng tim v Hb mu, khi Hb gim th c th b tr bng tng lu lng tim. Vn chuyn xy ti t chc gim nu thiu mu bnh nhn khng th tng c lu lng tim. Hb > 10gr/dl hoc Hct > 30% th khng truyn mu. Hb < 7gr/dl hoc Hct < 21% th truyn mu. Tuy nhin cn ph thuc vo thi gian thiu mu (thiu mu t t bnh nhn c th chu ng c). Khi huyt ng n nh, xem xt truyn mu: *Bnh nhn khe: gi Hct > 18%. *Bnh nhn c bnh h thng cn b tt: gi Hct > 24%. *Bnh nhn tim mch hoc bnh phi c triu chng: gi Hct > 30%. Truyn mu thch hp: truyn mu tng phn *Bnh nhn b mt mu cp: b th tch l ch yu, cn hng cu vn chuyn xy do khng truyn hng cu lm tng th tch.

*Hng cu lng: ci thin kh nng vn chuyn xy. Ch nh: duy tr Hb 7 10 g/dl, khi lng: 1 2 n v. * Truyn mu ton phn: Ch nh: +Truyn dch khng p ng +Mt khi lng mu ln ( III tr ln) + ni khng lm c hng cu lng. + Khi lng: 2 4 n v, khng nn truyn khi lng ln mu ton phn d tr. Truyn mu khi lng ln l truyn mt lng mu d tr tng ng lng mu mt hoc ln hn th tch mu ca bnh nhn trong thi gian < 24 gi. *Truyn mt khi lng ln mu ton phn d tr c th gy mt s bin chng sau: 1. Nhim toan 2. Tng kali mu 3. Nhim c citrate v h calci 4. H thn nhit 5. Gim fibrinogen v cc yu t ng mu (c bit V v VIII), plasma ng lnh t0 < -200C, cc yu t ng mu vn tn ti. 6. Gim tiu cu (tiu cu gim rt nhanh, sau 48 gi khng cn tiu cu). 7. DIC (Disseminated Intravascular Coagulation): DIC l s hot ho ca h thng ng mu v h thng tiu Fibrin lm tiu th nhiu yu t ng mu v tiu cu. 8. Vi ngng kt: do cc nhm mu ph s to nn cc vi ngng kt dn n DIC. 9. Gim 2, 3 diphosphoglycerate (2, 3 DPG). M 2,3DPG gip cho s gii phng O2 ca Hb. Cng thc tnh th tch mu mt V mu mt = 2 V mu bnh thng x (Hb bnh thng Hb hin ti)/ (Hb bnh thng + Hb hin ti) * Bnh nhn khng ri lon ng mu: 1/3 th tch mu mt c thay th bng dung dch tinh th (Lactale, nc mui sinh l). 2/3 dung dch keo (Dextran, Albumin) B/n c ri lon ng mu hay Hemophie B 1/3 mu mt = dung dch tinh th theo t l 1:3 1/3 mu mt = dung dch keo t l 1:1 1/3 mu mt = huyt tng t l 1:1 B/n c gim tiu cu: b th tch + truyn tiu cu Tiu cu < 20G/l: truyn 1-2 kt tiu cu (1 kt = 7 khi, v c th lm tng s lng tiu cu t 35-50 G/l) Tiu cu 20-50G/l: truyn 1 kt tiu cu.
B/n Hemophilie A: b th tch + yu t VIII Truyn yu t VIII: theo cng thc. yu t VIII cn truyn = VIII cn t VIII ban u x V hin ti

2) XH gim tiu cu: Truyn loi no?

Thiu TC truyn TC m c. - TC m c l khi TC c iu ch t nhiu n v mu ton phn (thng 4 - 12 n v) hoc t tch TC trc tip ca 1 ngi cho. - 4 ch tiu ca 1 pool khi TC iu ch t 4 n v mu ton phn (250ml/v): 1) th tch: 130 +/- 20ml 2) s lng TC: >= 130.000/ cm3 3) s lng BC cn li: <= 120/ mm3 4) s lng HC cn li: <= 2.200/ mm3. Lu khi truyn TC: + Cn nhc iu tr, khi cn thit mi truyn: - Bnh cnh st - nhim trng - C hi chng xut huyt nng - iu tr xut huyt BN suy ty hoc BN K ang c iu tr ha cht.. - Truyn nhm mc ch phng chy mu & iu tr nguyn nhn gim s lng cht lng TC. iu tr d phng vi mc ch duy tr s TC > 20.000/ cm3. + Sau truyn cho hiu qu km: c th do nguyn nhn min dch hoc khng min dch: - MD: do ng min dch vi KN ca TC hoc KN HLA, hoc do t min dch gp trong bnh XH gim TC min dch. - Khng MD: gan lch to, s dng ha cht, ri lon ng cm mu tng tiu th TC. + Mt s trng hp gim s lng - cht lng TC nhng chng ch nh truyn TC: - Bnh XH gim tiu cu MD (ITP) - XH gim tiu cu c huyt khi (TTP) - Hi chng tan mu & tng ure mu (HUS). + Thi gian sng ca TC: 9 - 10 ngy. Tuy nhin, khi truyn vo c th, i sng TC gim st do: - Khng th chng TC trong mu ngi nhn - khng ha hp nhm HC ABO. + TC phi c truyn trong 6 gi sau khi gn lc.( <= 24 gi). Truyn bao nhiu? 1 n v TC m c ( 150ml ) nng TC ln 10 - 30.000. Lng truyn da vo cn nng BN: 0,1 n v/ kg. VD: BN 50kg -> cn truyn 5 n v TC. Tc truyn? 1 n v truyn trong # 1/2 - 1 gi, gi nh truyn vi tc C git/ pht. T (gi) = V / (s git x 3) = 150 / (100 x 3) = 1/2 gi: tha iu kin. (thc t LS thy x kha truyn tc ti a). Phn ng ph c th xy ra: + Hiu qu km do nguyn nhn MD - khng MD dn ti TC gim st i sng, c trng hp ch tn ti vi pht trong c th ngi nhn => tc dng phng chy mu khng t. Thng do bt ng min dch h HLA. HLA = Human Leucocyte Antigen. Trong truyn mu: cc BC & TC mang khng nguyn HLA. Do , truyn cc huyt phm c cha cc t bo ny c th gy d min dch. - X tr: ch nh truyn khi TC my. TC my l khi TC tch t 1 ngi cho bng my tch t bo. 1 khi TC my ~ 4 n v TC thng.

- Tham kho thm: nh gi hiu qu sau truyn da vo CCI ( Corrected Count Increment ): CCI = P1 - Po/ BSA x n P1 = s lng TC sau truyn ( G/l ; G = 10(m) 9 ) (trong 1 gi). Bnh thng TC = 150 - 400 G/l . Po = s lng TC trc truyn ( G/l ) BSA = din tch da c th tha nhn n: s lng TC c truyn ( 10(m) 11 ) => Khi CCI >= 5.000: truyn c kt qu. 3) XH do thiu vit K, bnh gan mn (x gan, K gan..): Truyn loi no? + Thiu yu t ng mu truyn Huyt tng ti ng lnh (nu khng c kt ta lnh). + Qu trnh: huyt tng ti c tch ra t mu ti ton phn ngay trong 6 - 8 gi u sau khi ly mu, sau c ng lnh & bo qun nhit -30oC n -20oC. + Huyt tng ti c nng yu t V, VIII mc bnh thng trong khi huyt tng bo qun c nng yu t V, VIII gim thp. + 3 ch tiu ca mt pool huyt tng (iu ch t 2 n v mu ton phn loi 250ml/dv): - Th tch: 250 +/- 20ml - Yu t VIII: >= 0,7 UI - Protein ton phn: >= 50g. + Thnh phn HTT: albumin, immunoglobulin, cc yu t ng mu. Lc b cc yu t ng mu ta c huyt thanh. Ch nh truyn: iu tr & d phng cc ri lon ng mu do thiu ht 1 hoc nhiu yu t ng mu. + Thiu ht yu t ng mu: VIII, IX, XI (Hemophilia) & thc t lm sng khng c dung dch c c cc yu t ny. + Thiu ht ng thi nhiu yu t ng mu gy chy mu: ng mu ri rc trong lng mch, XH gim tiu cu huyt khi, bnh gan.. + Thiu ht cc yu t ng mu khng gy chy mu nhng cn can thip phu thut. + ang iu tr thuc chng ng thuc nhm vitamin K xut hin bin chng chy mu. Khng truyn khi: + Huyt tng khng cn yu t VIII & yu t V. + C th iu tr hiu qu hn bng vitamin K, ta ng lnh yu t VIII. + Dng vi mc ch chng tnh trng gim th tch tun hon ( trong khi c th nng bng dch tinh th - dch keo ). Truyn bao nhiu? Liu khi u 12 - 15 ml/kg. VD: BN 50kg -> 15 x 50 = 750ml ~ 3 n v HTTDL. i vi bnh Xut huyt gim TC huyt khi, lng HTTDL cn truyn c th ln ti 3l /24 gi. Tc truyn? Tng t Hng cu lng -> # XL git/pht. Phn ng ph c th xy ra?

Truyn s lng ln ( > 10 n v/ 24 gi) gy ri lon ng cm mu. X tr: khi truyn mu > 200ml, c mi n v mu cho thm 10ml Sodium Bicarbonate 3,75%. 4) TMTS: BN Thiu mu thiu st khng cn thit phi truyn mu, ch truyn khi TM nng (Hb < 7 g/dl) - truyn HC lng (nh nu trong trng hp XHTH). Quan trng nht phi tm nguyn nhn & gii quyt nguyn nhn, km theo b st bng ng ung. B Fe: + Sulfat Fe 20 mg/kg/j, chia 2 - 3 ln, ung gia cc ba n ( 100mg sulfat Fe cho 20mg Fe ). + Gluconat Fe: 40 mg/kg/j, chia 2 - 3 ln, ung gia cc ba n ( 100mg Gluconat Fe c 11mg Fe ). Thi gian iu tr: 8 - 12 tun ( khi Hb tr v bnh thng ). Cho thm vitamin C d hp thu. Khi khng dng ng ung c, cho Inferon 50mg/ml tim bp.

@ Cc trng hp cn li: 5) Thalassemie: TM tn huyt do nguyn nhn ti HC (bnh v Hemoglobin). * Truyn mu nh k. * S dng hng cu lng hoc hng cu ra. * Nng Hb ln # 10 g/dl. 6) Bch cu cp: bch cu > 100.000, HC - TC gim; BC kinh: BC > 100.000, HC - TC bnh thng. Khng c truyn mu ngay cho BN khi s lng BC qu cao & ton l BC non c kch thc ln, d gy tc mch. Trc nht phi s dng thuc gim bch cu, sau khi BC gim xung < 100 K/uL s ch nh truyn mu. Truyn HC lng. 7) Suy ty: gim 3 dng. Nu khng chy mu truyn HC lng, nu c chy mu truyn Tiu cu m c, nu c ri lon ng mu truyn Huyt tng ti ng lnh. 8) Hemophilia: xut huyt do ri lon qu trnh ng mu (Ri lon sinh Thromboplastin) thiu yu t VIII, IX. V vy tt nht truyn kt ta lnh (yu t VIII), nu khng c truyn huyt tng ti ng lnh. * V ta lnh: + L ch phm c iu ch t nhiu n v huyt tng ti ng lnh c cha liu lng cao yu t VIII ( yu t chng Hemophilia A). Ch phm cn cha liu lng cao Fibrinogen. + iu kin bo qun: - 35oC. + Hn dng: 2 nm. + Ch nh: iu tr & d phng chy mu do thiu ht yu t ng mu bm sinh (Hemophilia A, Von Willebrand..) hoc phi hp trong mt s bnh l khc (ng mu ni mch ri rc..) iu tr thiu ht Fibrinogen bm sinh & mc phi. + Lu : yu t VIII sau khi truyn ch tn ti thi gian ngn trong c th BN (na i sng # 8 12h). Hemophilia A l bnh di truyn bm sinh nn cn iu tr sut i, do cn cn nhc ch nh truyn da vo: tui ca BN

Mc nng ca bnh Nguy c chy mu trc mt Nguy c tim tng do s dng nhiu ch phm mu S sn c ca cc loi ch phm S c hoc khng c mt ca khng th chng yu t VIII Tnh trng di chng..

9) Tn huyt do min dch: ng khng th gy tan mu s sinh; do bt ng nhm mu m con h ABO, Rh; TM tan mu t min ( khng th IgG hay IgM ); lin quan vi thuc (Penicillin, Methyldopa.. ) => truyn HC ra ( HC lng ra sch 3 ln vi NaCl 9 o/oo) trnh a yu t l vo c th. * V HC ra: + L khi HC c ra nhiu ln bng dung dch mui ng trng nhm loi b hu ht huyt tng, sau b sung dung dch mui pha long. + iu kin bo qun: 4oC. + Hn dng: trong 24 gi. + Ch nh: TM tan mu MD c hot ha b th Ch nh hp l trong TM mn c tin s truyn mu d ng vi cc thnh phn huyt tng. + IgA l thnh phn c th thiu ht bm sinh gp mt s ngi khi c tip xc vi thnh phn thuc, dch truyn c ln IgA => c th sinh khng th chng IgA. Cc KT ny thng gy phn ng d ng (shock phn v) khi truyn mu c cha IgA. Truyn khi HC ra c th trnh c tai bin ny.