Cc dung dch

v ch phm mu
thng dng trong hi sc
Bs Phan vn Dng
BV. i Hc Y Dc Tp. HCM

Mc tiu bi ging
Khi nim v nhu cu b th tch tun hon
Gii thiu cc dung dch thng dng
Dung dch pha ch
Dung dch tinh th
Dung dch keo

Ch phm mu

Mu ton phn
Hng cu lng
Huyt tng ti ng lnh
Mu hon t tun hon ngoi c th
Mu hon t h thng lc mu cell saver

Tai bin truyn mu

Khi nim b th tch tun hon

Chn thng, bng, phu thut ln, hi sc bn nng
B th tch tun hon:
vn thit yu n nh ni mi v trnh suy c quan.
m bo huyt ng v khng qu ti tun hon

Chn ch phm mu, cc loi dch truyn vn l :

vn ang cn nhiu tranh ci !!!

A. Cc dung dch thng dng

I. Dung dch tinh th

Dung dch tinh th

DDTT c chia thnh ba nhm:
DD nhc trng : dd Glucose 5%
DD ng trng : dd Lactate Ringer
DD u trng : dd Natri Cloride 3%, 7.5%, 10%

DDTT d dng i qua mng t bo trong huyt

tng, khoang dch ni bo v gian bo.
DDTT ch yu nm khoang gian bo :
Sau khi truyn 1000mL NatriCloride 9 th tch ch tng 180mL
cn phi truyn gp 4-6 ln lng dch mt
Truyn qu nhiu NaCl 9 toan tng Clor mu.
Bn gim p lc thm thu keo ph gian bo.

 Natri Chloride 9
180mL sau khi truyn 1.000mL
375 mL sau khi truyn 2.000mL (Lobo N,Clin Sci 2001;101:173-179)
483 mL sau khi truyn 2.000mL (Reid F, Clin Sci 2003; 104: 17-24)
768 mL sau khi truyn 3.200mL
1.085 mL sau khi truyn 3.500mL

Ringers lactate

18 - 31% th tch
c truyn vo

194 mL sau khi truyn 1.000mL

369 mL sau khi truyn 2.000mL
khong 225 mL sau khi truyn 1.500mL.

Cc dung dch tinh th

Thnh phn cc dd tinh th

II. Dung dch cao phn t

1. Dextran
Dextran 70: sau khi truyn 1.000mL, th tch tng
thm 600 800mL
Dextran 40: ci thin vi tun hon do lm gim kt
dnh hng cu v tiu cu, gim nht ca mu
nguy c cao gy phn ng phn v,
ri lon ng mu,
Mt s trung tm thay dextran bng dd cao phn t
khc

2. Gelatin
1915 s dng rng ri trong th chin th nht
1978 Hoa k khng dng do t l cao phn ng qu mn
Gi trong lng mch gn nh bng lng dch truyn vo
Trng lng phn t thp (35 Kilodalton)
Thi gian bn hu ngn (2 gi) cn truyn lp li
C 3 dng khc nhau :
Gelofundiol: cross-linked gelatine
Haemaccel: urea-linked gelatine
Gelofusine: succinylated gelatine

Tn sut phn ng d ng i vi Dextran v Gelatin 0.3%

HydroxyEthylStarch c xem l an ton nht hin nay

3. HydroxyEthylStarch
HES sn xut t amylopectin
Trng lng phn t (MW):
Cao : > 450 KD
Trung bnh:130 260 KD
Thp : 70 KD

T l thay th phn t (MS) :

Cao : 0.7
Trung bnh : 0.62
Thp : 0.4 v 0.5

T l C2/C6 : yu t quyt nh v dc ng hc

Cc dung dch cao phn t

Dung dch
Huyttngti nglnh

mmol/L
Na+

Cl-

K+

Ca++

168

76

3.2

8.2

Mg++

acetate

Albumin 5%

p sut
tm thu

p sut
keo

mOsm/L

mmHg

300

21

290

19

Dextran (10%) 40/NaCl 9 154

154

310

61

Dextran (6%) 70 / NaCl 9 154

154

310

19

Hetastarch 6% / NaCl 9

154

154

310

31

Hetastarch 10% / NaCl 9

154

154

310

82

Tetraspan 6%

140

118

Gelofusine

154

120

2.5

24

296
274

Thnh phn cc dd cao phn t

B. Mu v cc ch phm t mu

 1628 William Harvey v tun hon mu.

1666 truyn mu ln u tin trn ch Oxford
1818 James Blundell truyn mu ln u tin trn ngi
1937 h thng nhm mu ABO
1940 Landsteiner v Wiener pht hin h Rhesus

1. Mu ton phn
Ch nn dng thnh phn ca mu m bn cn :
Cc ch phm mu
Mt n v mu ton phn cha
450 mL? 250mL?
cht chng ng :
ACD (Acid citric, Citrat natri, Dextrose) 21 ngy
CPD (Citric, Phosphate, Dextrose) 28 ngy
CPDA (Citrate Phosphate Dextrose Adenine) 42 ngy

Mu ton phn (MTP)

Mu ti : < 6 gi, c cc yu t ng mu v tiu cu
Mu TP : > 6 gi
> 24 gi: gim TC v 1 s yu t ng mu khc
> 72 gi : khng cn TC sng, mt hot tnh yu t VIII
u im :
cung cp th tch
ci thin kh nng vn chuyn oxygen.
Bt li :
cha rt t yu t ng mu,
c lng Kali cao, H+, Ammonia,
cha nhiu khng nguyn,
c th qu ti th tch bn ch thiu mu.

2. Hng cu lng
Ly t MTP bng cch rt bt 70 - 80% huyt tng.
HCL gi 4oC/ DD bo dng CPDA d tr c 42 ngy.
Mi v: 125/220 mL, Hct 70% Hb tng 1 g/dL hoc 3% Hct
Sau khi truyn, c 70% HC bnh thng sng sau 24 gi.
HCL khng cha yu t ng mu, sau khi truyn 5 v phi
truyn thm huyt tng ti ng lnh.
HCL lm tng nhanh kh nng vn chuyn oxygen
u im HCL :
gim nguy c qu ti th tch,
gim lng citrate, ammonia v cc acid hu c,
gim nguy c bnh min dch do cha t khng nguyn.

Hng cu lng
Ch nh truyn HCL:
Mt mu cp trong chn thng,
Xut huyt tiu ho hoc tn thng mch mu ln
BN khe mnh nu mt mu:
< 25% th tch mu c th c b hon ton bng DDTT.
> 25% phi truyn HCL v DDTT b th tch v ti oxy.
Trong m: BN thng khng cn truyn mu
Ch nn truyn khi cuc m mt mu nhiu, Hb < 7 g/dL .
Mt mu trong m thng ch cn b th tch bng DDTT
a s bn ch cn truyn HCL + DDTT nu mt mu <2L.

3. Tiu cu
Ly t MTP hay thm tch mu.
Gi c 5ngy 20-24oC, lc lin tc
6 v TC m c = 1 v thm tch mu 250ml cha 400 t
v lm tng TC t 50.000 - 60.000/mL.
TC truyn vo c th hot ng 5 ngy,
Nn truyn TC ng nhm trnh truyn th ng plasma
khng tng hp ABO.
iu ny rt quan trng khi truyn tr em hoc truyn
nhiu TC.
Nn truyn tiu cu t mt ngi cho gim nguy c khng
tiu cu cho.
TC phi c truyn qua mng lc 170

Ch nh truyn tiu cu
Gim TC < 20.000/ mm3 do suy ty.
Gim TC do tiu th:
Tun hon ngoi c th,
ng mu ni mch lan ta,
PT chy mu nhiu v TC< 50.000.

TC trong khong 10.000 - 50.000/ mm 3 c nguy c :

chy mu khi b chn thng hay lm th thut xm ln,
chy mu t nhin hoc sau th thut,
bnh l gan thn gy RL chc nng TC d chy mu t nhin.

TC gim chc nng sau dng thuc khng tiu cu

BN suy gim min dch truyn tiu cu c chiu tia
nga bnh l min dch xy ra do nhim bch cu.

4. Huyt tng ti ng lnh

FFP c tch ra t MTP, c gi ng trong vng 6 gi
sau khi ly v d tr -18oC.
01 v FFP: 200 ml, cha 1 v yu t ng mu/ml v 1-2 mg
fibrinogen/ ml.
FFP phi c truyn theo nguyn tc cng nhm mu.
ha gii nhanh tc dng ca khng vitamine K (Sintrom),
cn 5-8 ml/kg FFP
FFP c truyn trong vng 2 gi sau khi r ng v truyn
qua mng lc 170

FFP Fresh Frozen Plasma

Ch nh truyn HTTL
Chy mu cp km gim ton b yu t ng mu.
Bnh l ng mu do tiu th, gim nng cc y.t ng mu.
BN c gim yu t ng mu bm sinh khi khng c ch
phm chuyn bit truyn (thiu fibrinogen n thun, yu
t VIII hay yu t XIII thng c iu tr bng ta ng).
BN b truyn mu khi lng ln c triu chng ca ri lon
ang chy mu.
BN thiu antithrombine III cn c PT hoc cn iu tr
Heparine
Sau khi truyn, nh gi BN v tnh trng chy mu v chc
nng ng mu.
Khng nn ch nh truyn FFP b tng th tch tun hon

5. Mu hon t tun hon ngoi c th

My tun hon ngoi c th (tim phi nhn to) s dng :
phu thut tim m
phu thut mt s mch mu ln (quai MC)

Mu bn c pha long vi cc dung dch mi to vng

tun hon mi ngoi c th khi mun c lp tim PT.
Sau khi cai my THNCT, mu s c thu hi v s dng li
cho chnh bnh nhn.
Hct thay i tu mi bnh nhn v pha long mu
C cha heparin chng ng

Phi trung ho Heparin vi Protamine sulphate theo t l

10mg sau mi 200mL mu hon
Test nhanh ACT nh gi mc ng mu t an ton?
ACT : activated clotting time

Mu hon t h thng Cell saver

H thng lc hng cu Cell saver c dng trong :
Cc phu thut ln chy mu nhiu
Cc phu thut tim khng dng my tun hon ngoi c th

H thng chun b sn dung dch mi NaCl 9

pha heparine
Mu chy trong phu trng c lin tc ht v h
thng ti cha

Mu hon t h thng Cell saver

Hn hp dch mu c ra v quay ly tm lc
ly hng cu :
Hct >50%
NaCl 9
Heparine
dung dch s c dng li cho chnh bnh nhn
phi trung ho protamine sau khi dng.

6. Kt ta lnh (cryoprecipitate)
KTL l thnh phn protein kt ta do lnh
ly t huyt tng ti 1- 6oC,
d tr ng lnh < -180 trong vng 1 nm.
Mt n v KTL
chng 15 ml
cha 80 n v yu t VIII, yu t XIII, lng ln yu t von
Willebrand
150 mg fibrinogen v fibronectine.
Liu thng dng : 2-4 v /10 kg hay 10-20 ti mi ln.
Khi truyn khi lng ln, nn dng KTL theo nhm mu
ABO, trong vng 6 gi sau khi r ng v qua mng lc 170

Ch nh truyn kt ta lnh
BN gim fibrinogen khi fibrinogen < 100 mg/dL
BN b thiu fibrinogen bm sinh
ng mu ni mch lan ta, c ch nh truyn ta lnh.
BN cn phu thut sm sau khi iu tr thuc tiu si huyt,
Bnh l c gim fibrinogen nhiu.

Bnh Von Willebrand v ang chy mu,

truyn kt ta lnh khi khng c desmopressine (DDVAP)
hoc DDVAP khng hiu qu
khng c yu t VIII m c cha yu t Von Willebrand.

Bn hemophilia A khi khng c yu t VIII m c.

7. Albumine
Albumine chim 50% protein lu hnh v 75% p
lc keo ca huyt tng.
Sn phm albumine c nng 5 - 25% trong dung
dch Natri Chloride 9.
Ch phm c dit virus bng nhit 60 0C
trong 10 gi v khng c kh nng truyn virus
Ch nh truyn albumine :
Duy tr p lc keo.
Gim albumine do suy gan
B th tch cn m bo p lc keo

8. Immunoglobine
Immunoglobine min dch thng c s dng
trong bnh l ni khoa.
Ch nh dng :
Gim min dch nguyn pht hay th pht
nh gim min dch bm sinh,
bnh bch cu lympho mn, ghp ty,
tr em nhim HIV
nga nhim khun tr s sinh thiu thng v nhim
khun Bn nm hi sc.
Bn b ri lon min dch v phn ng vim nh ban xut
huyt gim tiu cu hay hi chng Kawasaki.

9. Antithrombine III (AT III)

AT III l protein trong huyt tng c tnh c ch cc yu t
ng mu nh thrombine hot ha (yu t IIa) v yu t IXa,
Xa, XIa, XIIa.
Thiu AT III c th bm sinh hay mc phi.
Ch phm c dit virus bng nhit 60OC trong 10 gi
AT III c dng rng ri cho bn b thiu AT III bm sinh km
tc mch cp hay nga thuyn tc mch cho bn.
Hin ang dng th nghim AT III nga thuyn tc mch
mu sau m, cp cu sn khoa, sc hay ng mu ni

mch lan ta.

C. Tai bin truyn mu

1. Phn ng tn huyt cp
Tn huyt cp sau truyn mu xy ra do truyn nhm nhm
mu ABO.
Tn huyt xy ra do HC khng tng hp b hy ngay tc
khc bi khng th.

Triu chng:
Bn st, lnh run, au lng, kh th, au ch truyn mu.
Bn b tt HA, chy mu, suy h hp, hoi t ng thn cp.
Nguy him nht l xy ra khi Bn ang c gy m PT,
mt tri gic, khng pht hin c sm cc triu chng.

Phn ng tn huyt cp
X tr:
Ngng truyn mu.
Gi mu v ti mu i xc nh tng hp nhm mu.
B dch, li tiu vi NaCl 9 v furosemide.
Duy tr n nh huyt ng.
XN nh gi tn huyt nh tm Hb t do trong mu, trong nc
tiu, mnh v hng cu, haptoglobine, bilirubine.
Phn ng Coomb trc tip v gin tip phi lm trc v sau khi
truyn mu, cng thc mu, creatinine, chc nng ng mu.

2. Phn ng tn huyt mun

Xy ra 7-10 ngy sau truyn mu do phn ng khng
nguyn-khng th sau truyn mu.
Xt nghim ;
hng cu gim dn
mnh v HC (schistocyte)
test Coomb m tnh trc khi truyn mu tr nn dng tnh.

BN thng khng c triu chng g.

3. St sau truyn mu
Trong khi hoc vi gi sau khi truyn bn st v lnh run.
Do khng nguyn - khng th trong huyt tng, TC hoc
bch cu c truyn cho bn km vi hng cu.
Thng gp bn truyn nhiu ln, sn ph c nhiu con
Phn ng st khng tn huyt thng nh, nhng cng c
th nguy him tnh mng nu bn c tnh trng tim phi khng
tt hay ang bnh nng.
X tr:

Ngng truyn mu.

Loi tr tn huyt bng cch lm li phn ng cho v Coomb.
Loi tr st do nhim khun.
BN c tin cn st sau truyn mu dng paracetamol, meperidine
trc khi truyn nga lnh run hoc truyn mu lc bch cu.

4. Phn ng d ng
Triu chng in hnh: da, m ay, nga, co tht ph
qun, ri lon vn mch v i khi chong phn v.
D ng thng nh. nng ca phn ng d ng khng
ty vo lng mu truyn, c th tip tc truyn mu.
Khi phn ng d ng xy ra,
tm ngng truyn mu,
nh gi tnh trng BNH NHN
dng thuc khng histamine nh diphenhydramine.
Nu BN ci thin vi iu tr, tip tc truyn mu.

Mt s BS cho thuc trc bn c tin cn d ng khi

truyn mu.

5. Nhim khun
Ngy nay nhiu k thut tm sot nhim virus bo m
an ton truyn mu.
Phn ln mu truyn c ly t ngi hin mu t
nguyn an ton hn l mu ly t ngi bn mu.
Mt s ch phm t mu c x l dit virus. Nguy c
nhim khun khi truyn mu thay i ty theo t l bnh
nhim khun ca ly mu.
i khi mu b nhim khun trong lc chun b hay t
ngi cho ang b bnh nhim khun.

6. H thn nhit
H thn nhit xy ra khi BN c truyn mt s
lng ln mu cn lnh.
Thng xy ra khi truyn nhanh 3 n v mu :

HCL d tr 40C,
TC d tr 20-240 C,
FFP d tr -180C.

My lm m mu c th dng nhng khng c >

400C v gy tn huyt.
Cch n gin nht lm m mu l truyn mu
cng vi Natri chloride 9 m (39 - 430 C) va
lm m va pha long mu.

7. Ri lon in gii
Mu d tr c cha citrate lm cht chng ng gy gim
calci mu.
Gim calci mu nng t khi xy ra do qu liu citrate v:

BN c chc nng gan bnh thng s chuyn ha citrate thnh

bicarbonate.
Ngay c khi truyn mu nhiu, cng t khi phi b calci.

Gim kali mu

c th xy ra nu truyn mu nhiu.
citrate c chuyn ha thnh bicarbonate kim mu di
chuyn kali vo t bo.

Tng kali mu

t khi l vn sau truyn mu mc d mu d tr c lng kali

cao,
nhng c th s l vn cho BN suy thn hay s sinh.

D. Truyn mu cp cu

1. Truyn mu cp cu
Tnh hung cp cu: mu O Rh m hoc mu ng nhm
nhng cha lm phn ng cho c th cu mng
nguy c b cc phn ng truyn mu nng.
ch dng trong giai on cp cu, bn sc nng do mt
mu t v khng p ng vi truyn DDTT.
nh nhm mu ABO lm trong 10-15 pht s gip trnh
c phn ln cc bin chng do truyn mu.
Phn ng cho lm trong vng 30-60 pht.
Nu khng c mu cng nhm dng mu O Rh m.
Khi c mu cng nhm th truyn ngay hn ch lng
plasma O c truyn vo (cha khng th anti-A v anti-B).

 Nn dng mu Rh m nu khng lm phn ng

cho ton phn c.
Hng cu lng l ch phm mu duy nht c
dng truyn mu khn.
Huyt tng cha rt nhiu khng th v khng c
vai tr trong chy mu t giai on u.
Ngay khi c HCL ng nhm lm phn ng cho,
cn truyn ngay HCL ny.
Lm phn ng cho v sau s cng kh khn nu
truyn lng ln mu khng lm phn ng cho

2. Truyn mu khi lng ln

TMKLL l truyn 1 lng mu tng ng vi th
tch mu ca bn trong vng 24 gi.
Bin chng: chy mu, ng c citrate, h thn nhit
Chy mu l bin chng thng gp nht do thiu
tiu cu v cc yu t ng mu.
Chy mu thng xy ra khi gim tiu cu kt hp vi ri
lon chc nng tiu cu do bnh gan thn hay ng mu
ni mch lan ta v thiu yu t ng mu.
Thiu yu t ng mu xy ra khi TMKLL v mu d tr
cha t yu t ng mu, c bit l yu t V v VIII.

Truyn mu khi lng ln

Ri lon ng mu cng nng hn khi c h thn
nhit, sc, nhim khun, bnh gan hay ng mu
ni mch lan ta.
Trong PT TM, thng truyn TC v HTTL do bn
thng c truyn mu nhiu v chc nng TC
gim do bnh l hoc dng cc thuc khng TC.
H thn nhit cng l nguy c khi bn c truyn
nhanh cc ch phm mu v vy cn si m mu.

E. K thut truyn mu

1. nh nhm mu-phn ng cho

Mu ngi cho v ngi nhn phi :
nh nhm theo khng nguyn trn b mt hng cu ABO
Rhesus,
tm cc khng th bt thng.

Phn ng cho c lm bng cch trn huyt tng ca

ngi nhn vi hng cu ngi cho xem c hin tng
tn huyt xy ra do hin din ca khng th hay khng.
Trn b mt hng cu c th c khng nguyn A, khng
nguyn B hay AB hay khng c khng nguyn.
Nu trn hng cu khng c khng nguyn A hay B th
plasma c khng th chng khng nguyn .

 Ngi c nhm mu B s c khng th anti-A trong

huyt tng.
Ngi c nhm mu O (hng cu khng c khng
nguyn A v B) s c khng th anti-A v anti-B.
Ngi c nhm mu AB, huyt tng s khng c
khng th anti-A hay anti-B, nn c th nhn mu
ca cc nhm mu khc.
Nhm mu O khng c khng nguyn A hay khng
nguyn B nn c th cho mu cho cc nhm mu
khc.

2. Khng nguyn b mt Rhesus

C (Rhesus dng)
Khng (Rhesus m).
Ngi Rhesus m s to khng th chng Rh khi tip xc
vi mu c Rh dng.
Hin tng ny khng quan trng khi truyn mu ln u, nhng ln
truyn mu sau s b tn huyt do khng th lu hnh.
y l vn c bit ca ngi mang thai.
Khng th anti-Rh l IgG v qua nhau t do. Nu m Rh(-) c khng th
chng Rh, khng th ny truyn qua thai nhi. Nu thai nhi c Rh(+), tn
huyt thai nhi s xy ra.
RHO-immune globuline, khng th chn Rh, nga BN Rh m to khng
th anti-Rh. RHO-immune globuline phi c truyn cho BN nhn
mu Rh dng hay cho m Rh m khi sinh con Rh dng (v c tip
xc mu m - mu con khi sanh).

3. An ton truyn mu

Truyn mu phi xc nh r
tn BN,
nhm mu ca bn
nhm mu ca ti mu.

Kim tra ln cui ti ging bnh trc khi truyn:

kim tra ng thi mu bn v mu s truyn vi huyt
thanh anti-A, anti-B, v anti-AB trn mt tm knh.
Cc phn ng ca mu truyn v mu bn phi ging ht
nhau (c ngng kt hay khng ngng kt).
thy r hin tng ngng kt, ch nn dng mt git
mu nh so vi git huyt thanh.

4. Truyn mu

Kim 16 -18 G nga tn huyt , c th truyn nhanh khi cn.

NaCl 9 : DDTT duy nht tng hp vi hng cu lng.
Mu s b tn huyt nu si m > 400C.
Ngoi tr trng hp khn cp, phi truyn mu chm trong
30ph u tin, giai on m phn ln cc phn ng s xy ra.
Bn khng c bnh l TM c th truyn 1-2 v HCL trong 1-2 gi.
Nhng ngi c nguy c d th tch phi truyn chm 1 n v
trong 3-4 gi.
B lc 170 c dng lc mnh vn tiu cu, fibrine, bch
cu.
Truyn mu nhanh bng cch dng my bm mu bng p lc
300 mmHg.

Xin cm n
v mong c hp tc