Professional Documents
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com 2010
S tay
CN LM SNG
1
Sau Chn on lm sng, nay tip tc vi Bin lun cn lm sng. Theo trnh t: 1) Sinh ha mu 2) Men tim 3) Kh mu ng mch 4) Cng thc mu 5) Pht mu ngoi bin - Ty 12) H hp k.
SINH HA MU
CN thn
ure
l sn phm thoi ha quan trng nht ca protein c thi qua thn. tr s bnh thng (bt): 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. bt: 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..
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. bt: 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.. thanh thi Creatinin (Cl - Cr) (ml/pht) = [(140 - tui) X cn nng (kg)]/ [creatinin/mu (mg%) x 72 ], nu l n x 0,85. Bnh thng: 100 - 120 ml/ pht/ 1,73 m2 da. i n v: umol/l x 0,0113 = mg/dl = mg%.
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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.
2) ure/mu khng phn nh chnh xc chc nng thn v:
1. 2.
3.
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).
3) creatinin/ mu
l cht bin dng ca creatin trong bp tht, ph thuc khi lng bp tht & khng thay i mi ngi. bt: 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 (mg%) -> thanh lc cu thn (ml/pht) 120 cre 2 -> 60 cre 4 -> 30 cre 8 -> 15 cre 24 -> 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).
4) s tng quan Bun - Creatinin/mu: BUN/ Creatinin mu (bt: 10/1)
1. 2. 3. 1. 2. 3.
BUN/ Cre > 10: BUN tng nhiu so vi Cre -> cn nghi ng cc yu t trc thn hoc sau thn lm tng ti hp thu Ure: gim ti mu thn: chong, suy tim, mt nc, mt mu tc nghn sau thn: si, u chn p lng m hp thu nhiu: n nhiu m, XHTH, tng d ha m. -> Trong trng hp Suy thn trc thn: BUN t tng > 100mg% & Cre t khi tng > 3 mg%. BUN/ Cre < 10: BUN tng t so vi Cre. do lng m n vo t: suy dinh dng, x gan tnh trng hoi t c, ly gii c vn cratinin 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.
5) thanh lc cu thn (Clearance: Cl - Cr)
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%). -> kt qu thng nhiu do: khng gi ng nc tiu 24 gi, cn st nc tiu trong bng quang.
tnh GFR theo cng thc MDRD (Modification of Diet in Renal Disease): GFR (ml/ min per 1,73 m2) = 1.86 x [(PCr) (m) - 1.154] x [(age) (m) - 0.203] ( x 0.742: vi 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.
-----------T ng dng lm sng nu c lin quan n: 1) Thiu mu 2) a niu - thiu niu - v niu 3) hi chng ure mu cao 4) sinh l chc nng thn (lin quan gia cp p lc: lc, keo, thy tnh, thm thu) 5) cch ly nc tiu 24 gi.
2. 3. 4.
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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 > 911 (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
@ cp:
CN gan
CN BI TIT: 1) bilirubin 2) phosphatase kim 3) GGT ( Gamma Glutamyl Transferase ) 4) urobilinogen (nc tiu/ 24h). CN TNG HP: 1) albumin huyt thanh 2) Globulin huyt thanh 3) yu t ng mu. HOI T T BO GAN 1) transaminase 2) LDH = LD ( lactate dehydrogenase) 3) St (ferritin huyt thanh). KHC: Cholesterol/ mu.
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Bilirubin
Bilirubin l sn phn chuyn ha ca Hem (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:
- bt: < 17 umol/l ( < 1mg% ): 0,8 - 1,2 mg%. - Vng da khi Bil TP > 2,5 mg%.
Phosphatase kim
hot ng mi trng kim ( pH 8,5 - 9 ). Ngun gc: gan, xng, rut, thn, nhau thai. bt: 20 - 45 U/L. rt nhy pht hin tc mt. tng nh -> 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..
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. bt: 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). bt: 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.
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 / mu tng rt cao. bt:
+ AST (GOT) <= 37 ( 6 - 25 ) + ALT (GPT) <= 40 ( 3 - 30 ) -> n v: U/L - 37oC.
GGT
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. bt: 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..
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. bt: 230 - 460 U/L - 37oC. tng trong: NMCT, nhi mu phi, bnh gan, suy thn cp..
St
Feritin = feric hydroxyd + 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. bt: nam 11 - 27, n 7 - 26 ( n v: umol/l). Sau mn kinh # 7 - 27, ngi gi # 15 - 20. gim trong: thiu mu thiu st, gim d tr.. tng trong: qu ti st, hoi t t bo gan, Thalassemia, nhim trng..
biland lipid
biland lipid (b m) gm cc xt nghim: 1) Cholesterol ton phn 2) Triglycerid 3) HDL - cho v: 4) 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)..
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Cholesterol
Cholesterol l 1 thnh phn ca mt do gan tng hp, c trong hng cu - mng t bo - c.
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 l glycerid ca ng vt 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, TGngoi sinh c vn chuyn bi chylomicron & TG ni sinh c vn chuyn bi VLDL. rut non, TG 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). TG 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. bt: >= 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 ( VeryLow 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. bt: LDL <= 3,4 mmol/l.
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. bt: 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). 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. Trong Hn m do i tho ng, trc iu tr K tng, sau iu tr K gim.
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
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 Clnhp kt hp vi Na+ to thnh NaCl (mui bp). Cl-/mu tng khi nhim toan, gim khi nhim kim chuyn ho. bt: 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. bt: 2,3 - 2,6 mmol/l (4,4 - 5,2 mEq/l). gim trong: thiu vitD, nhc cn gip.. tng trong: dng nhiu vitD, cng cn gip, nhim c gip.. LS xut hin cn tetanie khi Ca++/ mu < 3,5 mEq/l.
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..
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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). bt: 80 - 100%. gim: gim mt s hoc mt yu t ng mu ( Prothrombin, Proconvertin, Proacelerin, yu t Stuart), gim nhiu fibrinogen, xut hin heparin.
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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. bt: 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..
nh lng hormon
T3 ( Triodothyronin )
bt: + 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. bt: + T4 t do: 7 - 21 pmol/l + T4 ton phn: 50 - 130 nmol/l.
HORMON TUYN YN
cn li
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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: bt 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. bt: 5.300 - 12.900 U/L - 37oC. gim: nhim c thuc tr su (cht phosphat hu c..), vim gan, x gan..
AFP = Alpha-Fetoprotein
bt: 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.
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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.
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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 ). bt: 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) CPK l mt enzyme c tm thy ch yu tim, no v c vn. CPK c 3 isoenzymes c cu trc hi khc nhau
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8% trng hp thuyn tc phi Bnh nhn chy thn nhn to bt: 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.
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 .
o o
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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:
1) 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.
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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.
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2. pCO2
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. gi tr: + > 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.
1. pH < 7,35
l trng hp Toan mu. Tip theo xem PaCO2 xc nh l toan h hp or toan chuyn ha: > 45 -> toan h hp < 35 -> toan chuyn ha.
1.
bc 3: xem HCO3 std. C 2 trng hp: PaCO2 > 45: toan h hp. -> xem HCO3 tng bao nhiu vi mi 10 mmHg tng ca PaCO2:
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2.
2. pH > 7,45
l trng hp kim mu. Tip theo xem PaCO2 xc nh l kim h hp hay kim chuyn ha: < 35: kim h hp > 45: kim chuyn ha. bc 3: xem HCO3 std. C 2 trng hp: 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 ) PaCO2 > 45: kim chuyn ha. -> xem PaCO2 tng bao nhiu vi mi 1 mEq tng ca HCO3: tng 0,7 mmHg: kim chuyn ha c b ( 2 s l ca pH = PaCO2 hoc PaCO2 = HCO3 + 15 )
1.
2.
1. 2. o o 3. o o
khng c ri lon: pH, PaCO2, HCO3 std u bnh thng. c ri lon c b : pH: bnh thng PaCO2, HCO3: khng bnh thng. c ri lon kim toan hn hp: pH: bnh thng PaCO2, HCO3: khng bnh thng.
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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.
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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.
o o o o o o
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: Toan chuyn ha -> thay i b tr: pCO2 = 1,5 x HCO3 + ( 8 +/- 2 ). Kim chuyn ha -> TDBT: pCO2 = 0,7 x HCO3 + ( 21 +/- 2 ). Toan h hp cp -> TDBT: /\ (danta) pH = 0,08 x (pCO2 - 40). Toan h hp mn -> TDBT: /\ pH = 0,03 x (pCO2 - 40). Kim h hp cp -> TDBT: /\ pH = 0,08 x (40 - pCO2). 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:
S
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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 kimh 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 kimchuyn 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.
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Anion Gap
o 1. 2. 3.
(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
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CNG THC MU
@ T BO MU NGOI VI
+ Bch cu cng gim trong nhng trng hp nhim c kim loi nng nh ch, arsenic, khisuy ty, nhim mt s virus... gi tr: tng: > 75% ( > 7.000 / mm3 ) gim: < 50% ( < 1.500/ mm3 ). tng:
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+ trong thi k lui bnh ca mt s bnh nhim khun cp tnh. gim: + mt s bnh nhim trng cp tnh + chng mt bch cu ht, sc phn v..
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+ 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. -> Mono & Lym cng tng: + do virus: cm, quai b, si + thng hn.
+ Ngoi ra bch cu ny cn tng cao trong cc bnh l ngoi da nh chm, mn trn da... gi tr: tng: > 500/ mm3 gim: < 25/ 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.
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+ 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.
@ T BO MU NGOI VI
bt:
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+ o trng lng sc t ca hng cu. gi tr: chn on thiu mu + Nam Hb < 13 g/dl + N Hb < 12 g/dl
+ Ph n mang thai & ngi gi Hb < 11 g/dl. lin quan truyn mu (Vin Huyt hc TW):
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< 30% (28%) i vi ngi gi. tng: nc trong t bo, bnh tng hng cu, shock.. gim: thiu mu, xut huyt cp..
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MCH = Mean corpuscular hemoglobin = s lng hemoglobin trung bnh trong mt hng cu
bt: 27 - 32 pg ( pg: picogram, 1 pg = 10 (m)-12 gram ). cng thc: MCH = HGB/ RBC gi tr: < 27: nhc sc > 32: u sc.
MCHC = Mean corpuscular hemoglobin concentration = nng hemoglobin trung bnh trong mt hng cu.
bt: 32 - 36 g/dL. cng thc: MCHC = HGB / HCT x 100 gi tr: < 32: gim sc 32 - 36: ng sc > 36: tng sc.
TM LI
- 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.
@ T BO MU NGOI VI
RDW = Red (cell) Distribution width = phn b hnh thi kch thc hng cu (khong phn b hng cu).
bt: 12 - 15%. c im: + o thay i ca kch thc v hnh dng hng cu -> gi tr cng cao kch thc ca hng cu thay i cng nhiu. + l t l % lch (SD) so vi kch thc trung bnh ca hng cu. ngha: (botruong) -> 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). gi tr: da vo 2 ch s RDW (khong phn b HC) & MCV (th tch TB 1 HC) 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) -> Nhn vo RDW. Nu > 15% do TMTS hoc do TM thiu acid folic. Xem tip MCV: nu MCV < 80 -> TMTS, > 100 -> TM thiu acid folic. -> RDW bnh thng (12 - 15%) & 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 NN). TM gim sn tu l trng hp TM ng sc ng bo, gp trong Suy thn mn.
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+ Suy gim tiu cu v mt s lng hoc cht lng s gy ra bnh sinh chy mu. gi tr: + TC < 100.000: hay c xut huyt + TC < 20.000: xut huyt nng -> t vong.
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S TIN TRIN T BO MU
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phn loi nhm mu da vo s hin din ca Khng nguyn trn mng t bo hng cu. cc KN nhm mu ABO 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%). 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. 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.
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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).
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La chn dch 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
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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.
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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 - 12n 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: 1) bnh XH gim tiu cu MD (ITP) 2) XH gim tiu cu c huyt khi (TTP) 3) 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 )
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2) 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 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). * MCV - MCH -> 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.
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CHC NNG H HP
1.
Theo GOLD, o chc nng h hp l mt phng php nh gi chc nng ca phi bng cch o lng kh bnh nhn c th th ra sau khi ht vo ti a. Ch s ny hin nay tr thnh mt cng c chnh xc v ng tin cy trong vic h tr chn on bnh phi tc nghn mn tnh (COPD).
3.
Ch nh ca Spirometry:
CNHH l cch tt nht pht hin hin tng tc nghn ng dn kh v gip chn on phn bit gia hen v COPD. Cc ch nh o CNHH bao gm: - Xc nh c tc nghn ng dn kh. - Xc nh ch s FEV1/FVC < 70% sau gin ph qun. - nh gi nng ca bnh. - Gip phn bit COPD v hen. - Pht hin COPD cc i tng phi nhim vi yu t nguy c. - Theo di din tin bnh. - nh gi p ng vi iu tr. - Loi tr COPD v trnh iu tr khng thch hp khi CNHH bnh thng.
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3.2. Chn on tc nghn ng dn kh: Tiu chun chn on COPD da vo chc nng h hp l ch s FEV1/FVC thp hn 0.7 sau gin ph qun. nng ca COPD da trn CNHH:
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4.
nh gi CNHH:
4.1. Chc nng h hp bnh thng: ngi bnh thng, ng biu din th tch - thi gian tng nhanh, trn v t nh sau khong 3 4 giy.
Da vo biu ng cong biu din th tch - thi gian trn, ta thy a s kh trong phi s c y ra ngoi ht sau thi gian 1 giy u tin, tng ng vi ch s FEV1/FVC > 70% ngi bnh thng. nhng BN c tc nghn ng dn kh mn tnh, FEV1 s thp hn nhiu. V th, ng biu din trn s khng cn dc nh bnh thng m s dt v ko di hn.
4.2. Test gin ph qun: Cng c c lc gip phn bit COPD v hen ph qun.
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4.4. ng biu din tc th ra - th tch (Flow volume curve): - Bnh thng: ng biu din s tng ln nhanh chng t c tc th ra ti a, sau gim dn u v nhanh cho n khi kh c th ra ht, im ct ca ng biu din v trc honh l FVC.
- Hi chng tc nghn: Trong hi chng tc nghn, ng biu din tng chm hn, khng t c nh ca tc th ti a bnh thng v c dng cong lm ln trn khi gim xung do hin tng tc nghn ng dn kh lm gim th tch kh th ra.
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- Hi chng hn ch: Trong hi chng hn ch, dng ca ng biu din khng thay i nhiu nhng giao im ca ng biu din vi trc honh lch v bn tri, tng ng vi FVC gim.
THE END
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