Cẩm Nang Huyết Học_yhocthuchanh2015

CM NANG

HuYT HC CUN SCH U TAY CA L VN CNG Cun sch l tt c nhng g mnh hc tp, tch ly v nghin

cu c trong sut qu trnh hc tp mn Huyt hc. N bao

gm hu ht nhng kin thc thit thc ca mn Huyt hc v

Truyn mu. Hn na , kin thc trong cun sch c vit

di gc ca mt sinh vin nn s tr nn gn gi v d

hiu hn rt nhiu so vi cc Gio s Tin s . Bn hon ton

c th yn tm vi lng kin thc trong cun sch .Bi n

khng ch a ra nhng l thuyt c ng , y m n cn

km theo c gii thch ngha ca tng xt nghim, tng thay

i trong cc trng hp bnh l. Chnh y l ci m mnh

tm c nht cun cm nang ny. Bi ch khi bn hiu bn

mi gii thch c , ch khi bn gii thch c bn mi c

th nh lu c.V ch khi nh lu c bn mi c th hc

tp v lm vic tt c.

2013

L VN CNG Lp i hc xt nghim 4b i hc k thut y t Hi Dng

Th T, 24 Thang By 2013

CM NANG HUYT HC NG MU

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L VN CNG Khoa xt nghim i hc k thut y t Hi Dng


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CM NANG

HUYT HC

NG MU L THUYT NG MU V CC XT NGHIM LIN QUAN

Cun sch u tay ca :

L Vn Cng- i hc k thut y t Hi Dng

Sch ch tng khng bn

KHNG G L KHNG TH

Khi mi chuyn tr nn kh khn , hy t hi bn thn , mnh phi lm g

thay i cc din , mnh phi lm g ci thin tnh hnh.V hy hnh ng

bn nh. ng nn nh bn v ti, bi trn ng i , ch lc vp ng mi bit

mnh ang sai. ng sng trong nhng hoi nim p ca qu kh , m hy

vch ra cho mnh mt tng lai sng sa pha trc.Chc bn v ti thnh cng

trong hc tp v cuc sng

L Vn Cng


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LI M U

Xut phat t nim am m vi mn Huyt hc , v cng mt phn mun khng nh li

kin thc m mnh tip thu c trong sut qua trnh hc tp i hc. Mnh dc ht

thi gian v cng sc t tay vit ln cun Cm nang huyt hc . B cm nang gm

gm 4 cun l 4 phn ca huyt hc : Huyt hc t bo , Huyt hc ng mu , Huyt

hc Min dch v truyn mu , Huyt hc chuyn su v cc vn cn bit.

Cun sach gm tt c nhng g mnh hc tp, tch ly v nghin cu c , trong sut qua

trnh hc tp mn Huyt hc. N bao gm hu ht nhng kin thc thit thc ca mn

Huyt hc v Truyn mu. Hn na , cun sach c vit di gc ca mt sinh vin

nn n s tr nn gn gi v d hiu hn rt nhiu so vi cac Giao s , Tin s .Bn hon

ton c th yn tm vi lng kin thc trong cun sach. Bi n khng ch a ra nhng l

thuyt c ng, y , m n cn km theo c gii thch ngha ca tng xt nghim ,

tng thay i trong cac trng hp bnh l.Chnh y l cai m mnh tm c nht cun

sach ny. Bi ch khi bn hiu bn mi gii thch c , ch khi gii thch c bn mi

nh c th nh lu c. V ch khi nh lu c bn mi hc tp v lm vic tt c.

Bn cnh nhng u im trn th cun sach ny cn c rt nhiu thiu st .Mc d mnh

c gng ht sc r soat v chnh sa , song cng khng th tranh c sai st v cach

trnh by v li chnh t. c bit , y ch l nhng nghin cu nho nh ca bn thn da

vo cc thng tin mnh c sch v nghin cu cc ti liu trn Internet , n cha c

thy c v nhng ngi c uy tn kim chng tnh chnh xc ca vn c cp. V vy

mnh rt mong c bn c v thy c chn thnh ng gp v ni dung ca cun sach,

n tr nn hon ho v tin cy hn. Qua , mnh c th tip thu c nhng kin thc mi

sa cha c nhng hiu bit sai lm trong kin thc cp.

Cun sach ny dnh ring cho L Vn Cng , Lp HXN 4b ,i hc k thut y t Hi

Dng. Nn khng bn Khng mua - Khng cho mn nu khng c s ng ca

mnh. Nu bn c quan tm ti nhng kin thc trong cun sach, mun tm hiu thm

thng tin v c lng ng gp cho cun sach , bn hon ton c th mn mnh c v chp

li nu cn. Mnh b rt nhiu thi gian bn cai may tnh , b nhiu trn bng a

Premier League ca Manchester United v nhng trn cu C1 ny la( i bng con cng

ca bn ang m bn li ang hc th tht l kh chu ht mc, hn na li l nhng

dp cui tun , lc m tt c mi ngi u chi ). c bit N l a con tinh thn ca

mnh, mnh khng mun ai xm phm n. Mnh khng mun cng sc , thi gian , sc

khe ca mnh mang ra quan photo mt cach r mt, mua ban-trao i mt cach min ph

v thoi mai nh bao quyn sach khac.Mong c mi ngi tn trng. Xin cm n!!!!!

Hi Dng , ngy 1 thang 5 nm 2013


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MC LC

I-CM MU BAN U

1. Cc yu t tham gia CMB10

2. Cc XN nh gi CMB.12

_ Nghim php dy tht12

_ Thi gian mu chy ( PP Duke )...13

_ XN co cc mu...14

II- NG MU

1. iu ha qu trnh M-Cc yu t tham gia.15

2. Cc giai on ca qu trnh ng mu19

3. Cc XN kho st qu trnh ng mu.24

_ Thi gian mu ng trn lam.24

_ Thi gian mu ng trn ng nghim..25

_ Thi gian Howell26

_ Thi gian APTT.27

_ Thi gian TT...33

_ Bng tm tt cc XN ng mu34

III- TIU SI HUYT

1. Plasminogen v Plasmin39

2. Cht hot ha Plasminogen40

3. Cht c ch qu trnh TSH.42

4. Sn phm thoi ha Fibrin-Cc mnh FDPs.46

5. Cc XN kho st qu trnh tiu si huyt...46

6. Cc xt nghim chuyn su khc

_ Xc nh s c mt cht khng ng ni sinh56

_ Xc nh s c mt cht khng ng ngoi sinh..57

_ Xc nh s c mt cht khng ng ( ni chung )..59


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

_ nh lng yu t XIII.61

_ nh lng yu t M ni sinh VIII ,IX, XI , XII..62

_ nh lng yu t M ngoi sinh VII , X , V..64

_ nh lng Fibrinogen..67

IV- BNH NG MU

1. Hi chng ng mu ri rc lng mch (DIC)..71

2. Hi chng xut huyt gim tiu cu huyt khi (TTP).74

3. Hi chng tan mu Ure huyt cao (HUS).75

4. Tnh trng tng ng-Bnh huyt khi..77

5. ng mu thai nghn...82

6. Bnh Hemophilie ..83

7. Bnh ri lon ng mu mc phi.85

_ Thiu VTM K85

_ Bnh gan.86

_ Bnh h thng Lupus ban (SLE).87

_ Ri lon ng mu sau truyn mu d tr t89

_ Bnh vim thnh mch d ng89

8. Bin lun xt nghim ng mu.90

9. Cc gi tr M cho cuc m an ton. 91

10. Tm hiu c ch v ng dng mt s cht-thuc chng ng

_ Heparin..92

_ Natricitrat..92

_EDTA ( Ethylene diamin tetraacetic acid )..93

_ Wafarin ( thuc c ch VTM K ng ung )94

_ Aspirin.94

11. Bng tr s bnh thng-bt thng ca cc XN ng-cm mu.95

12. Tr s bnh thng ca cc yu t tham gia ng-cm mu v TSH.96


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PHN II- NG MU V CC XT NGHIM LIN QUAN

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

ng mau ( M )

Tiu si huyt (TSH)

CM MU BAN U I. 3 YU T THAM GIA CMB

1. Thnh mch

Ni mch :

_ Cu to : lp n bo , lt ph mt trong ca mch mau

_ Chc nng :

+) Ngn cch dng mu vi t chc khc

+) Chng sinh huyt khi nh heparin sulphat b mt ni mc

+) c ch cc enzyme M nh glycosamino glycan

+) Chng dnh v ngng tp tiu cu nh ADP-ase ging ha ADP

+) Cha thrombomudulin hot ha protein C ( ging ha bt hot Va , VIIIa ) ,

to ra Protein S ( ng yu t protein C , vai tr tng t Pro C )

+) To ra plasminogen khi ng qu trnh TSH

+) SX yu t Willebrand l cht keo sinh hc , gn TC vi Collagen thnh mch

Lp di ni mch

_ Cu to : collagen , Willebrand , Fibrionectin , vi si , si n hi

_ Chc nng : Lp din tch gy ng , hot ha TC v yu t tip xc , khi

lp ni mch b tn thng.

2. Tiu cu

_ Cu to : Mng TC + NSC

+) Mng TC :

Lp kp phospholipid (PL) : ni din ra mt s hot ng M

H thng knh m :gii phng cac ht trong NSC v tng din tch t.xc b mt ca TC

+) NSC : h thng vi ng , vi si , ng dy c ,cac ht : ht c (ADP , Ca2+ ,

serotonin ),ht (PDGF , Ca2+ , Willebrand , Fibrinogen , Fibrionectin ,

Thromboglobulin), thrombosthenin ( protein co ca TC )


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_ Chc nng :

+) Tham gia qu trnh CMB : Nh kh nng dnh- ngng tp , gii phng cac ht

trong NSC.

+) Tham gia qt M : nh yu t 3 PL ca TC cn thit cho s hot ha yu t

VIIa, Xa , Iia.

+) Tham gia giai on co cc mu : nh thrombosthenin trong NSC ca TC

+) Bo v thnh mch : lm non ha TB ni mch , cng c lp ni mch qua yu t

tng trng PDGF

+) p ng vim v thc bo

3. Yu t protein huyt tng : Willebrand , Fibrinogen

Willebrand :

+) Sx t TB ni mch , l cht keo sinh hc gn TC vi collagen thnh mch

+) Kt hp vi yu t VIII , hnh thnh phc hp W-VIII , lu hnh trong mau ,

n nh yu t VIII , bo v yu t VIII do n d b hy trong huyt tng.

Fibrinogen : c tng hp duy nht ti gan , tham gia cng c nt tiu cu nh hnh

thnh si Fibrin khng tan bao quanh nt TC , v l yu t tham gia qua trnh M

II. CC GIAI ON CMB 1. Co mch _ Thnh mch tn thngkch thch auco c trn lng mch hp ligim

lng mau mt qua ch tn thngto iu kin hnh thnh nt cm mau

_ ngha : C ch t bo v ca c th , chu tac ng yu t TK-TD .

2. Hnh thnh nt tiu cu

_ Thnh mch tn thnglp ni mch b rachbc l lp di ni mchTC dnh ,

ngng tp v hot ha : thay i hnh dng , gii phng ra cac yu t gip TC dnh thnh

mch , c bit gii phng yu t ADP , Thomboxan A2 hot ha TC xung quanh ,

lm cac TC ngng tp vi nhau ngy cng nhiuTo k hnh thnh nt TC

_ Nt TC mi hnh thnh cn lng lo , d thm , d b dng mau ra tri , v sau c

cng c vng chc , nh hnh thnh si Fibrin khng tan bao bc.


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S CM MU BAN U

( Ngun : http://xetnghiemdakhoa.com )

III. CC XT NGHIM NH GI CMB 1. Nghim php dy tht ( sc bn thnh mch )

_ Nguyn tc XN : To 1 ap lc ln mch mau ngn cn dng mau chy v , cac

mch nh v yu s v , HC thoat ra ngoi , to nn cac nt xut huyt . m s nt

xut huyt anh gia sc bn ca thnh mch

_ Mc ch ngha XN :Kho sat qt cm mau ban u (CMB ) , anh gia cht

lng ca thnh mch

_ Nhn nh kt qu :
http://xetnghiemdakhoa.com/


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+) < 7 nt xut huyt bnh thng

+) >7 nt xut huyt ghi (+) n (++++)

_ Bin lun kt qu : Sc bn mao mch gim khi

+) Tn thng thnh mch : vim thnh mch d ng , c ha cht , .

+) Gim tiu cu ( s lng v / hoc cht lng ) : Suy nhc tiu cu , Leucemia ,

bnh Willebrand .

+ ) Bnh khac : ngi gi , thiu VTM C , .

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

_ Nguyn tc XN : To vt thng vng gia dai tai , o thi gian mau chy t lc to vt

thng n lc mau ngng chy.

_ Mc ch ngha XN : Kho sat qua trnh cm mau ban u , qua anh gia : yu t

thnh mch + tiu cu v 2 yu t Willebrand , Fibrinogen

Mu chy ph thuc Cht lng thnh mch

S lng tiu cu

Cht lng tiu cu

Yu t Willebrand + Fibrinogen ( SL v CL )

_ Tin hnh :

+ ) Dng c : kim chch , bng , giy thm, ng h

+) Ha cht : Cn 900 ( ete ) bay hi nhanh , khng lm nh hng mch mu xung

quanh v tr chc.

+) Quy trnh:

B1: Sat khun v tr chc i 1-2 cho cn kh

B2: Chch kim vung gc mt phng dai tai( su 2 di 5 ) v bm ng h

B3: Thm mau cho BN , 30s /1 ln , n khi khng thm c bm ng h dng

li ,ghi kt qu lm trn xung.

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

Nu mau chy >6 , i n 10 m vn chy , dt bng cho bnh nhn , ghi kt qu

_ Nhn nh kt qu

+) Bnh thng : 1-4

+) Ko di : >6

+) Nghi ng : 4-6 khi phi tin hnh li vi tai kia hoc dng pp Ivy

Xem video quy trnh ti a ch

http://www.youtube.com/watch?v=wmQrqXJCAso


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

thi gian mu chy t lc to vt thng n lc mu ngng chy )

_ Bin lun kt qu : Thi gian mau chy ko di khi

+) Tn thng thnh mch : vim thnh mch d ng, mhim c , thiu Collagen,..

+) Thiu tiu cu ( s lng v / hoc cht lng ) : Suy nhc TC ,KT khng TC

+) Thiu yu t Willebrand , Fibrinogen ;Bnh Willebrand ,suy gan nng

+) iu tr Heparin , dng thuc gim au Aspirin (tham kho c ch bi thi gian Howell)

3. Co cc mu

_ Nguyn tc XN : Mau ly ra khi c th s ng li nh hnh thnh si Fibrin , si

Fibrin m ly cac thnh phn hu hnh ca mau ri co rt li tach khi phn huyt thanh.

_ Mc ch ngha : Kho sat qua trnh CMB , qua anh gia cht lng v s

lng ca tiu cu , Fibrinogen , yu t XIII

Co cc mu ph thuc S lng v cht lng ca TC

S lng v cht lng ca Fibrinogen

Yu t XIII

Th tch khi HC ( hematocrit )

_ Tin hnh

+) Dng c : B ly mau TM , 2 ng nghim sch trang nc mui sinh l ( to mi

trng ng trng trn thnh ng nghim HC khng v ), bng m , ng h , ni

370

+) Ha cht : Cn 700 , NaCl 9 %0 trang ng nghim

+) Bnh nhn : Ly mau TM

+) Quy trnh :

B1: anh s , ghi tn ng nghim

B2: Ly mau tnh mch khong >2ml bm vo 2 ng nghim trang mui SL

nt cht bng m cho vo ni cach thy sau 4h em kho sat.

_ Nhn nh kt qu:

+ Co cc mau anh gia 4 mc Co hon ton :

Co khng hon ton

Cc mau b nat

Cc mau khng co


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_ Bin lun kt qu: Cc mau khng co , co khng hon ton , cc mau b nat trong

trng hp

+) Gim TC ( SL v /hoc CL ) : Bnh suy nhc TC , KT khng TC , , Leucemia ,..

+) Thiu ht Fibrinogen : Suy gan nng , RL chc nng Fibrinogen

+) Thiu yu t XIII ( xem li chc nng ca yu t XIII )

+) Tng th tch khi HC : a hng cu ( khi HC qu ln ,si Fbrin khng th m ht)

+) iu tr Heparin ( xem gii thch bi APTT )

NG MU

I. IU HA QU TRNH NG MU

1. Cc yu t hot ha ng mu

Nhm 1: 12 yu t ng mu huyt tng

Tn yu t Chc nng

1. Fibrinogen

(I)

_ Fibrinogen sx duy nht ti gan, nng trong mu 2-4 g/l , hot ha

thnh Fibrin bao quanh nt TC , v hnh thnh cc mau ng

2. Prothrombin

(II)

_ Do gan tng hp, Prothrombin hot ha thnh Thrombin (IIa)- trung

tm M , hot ng cn VTM K , Ca2+

+) Thrombin gy ngng tp TC rt mnh m rng nt cm mau

+) Thrombin xc tac chuyn Fibrinogen Fibrin

+) Thrombin hot ha V , VIII, XI m rng hot ng M ni sinh

+) Thrombin hot ha yu VIIVIIa m rng hot ng M ngoi

sinh

+) Thrombin hn ch hot ng lan trn ca chnh n bng hot ha

Protein Cc ch M thng qua bt hot yu t Va v VIIIa

+) Thrombin thc y qua trnh TSH thng qua thc y TB ni mch

tng sn xut yu t t-PA tng chuyn Plasminogen Plasmin

3. Pro-Accelerin

( V)

_ Do gan sx ,yu t V d b hy trong h/tng lu tr

_ Yu t V l ng yu t ca yu t X , Va cng vi yu t Xa, Ca2+ ,

PL hnh thnh nn phc hp Prothrombinase

4. Pro-Convertin

( VII )

_ Do gan sx , cnVTM K v Ca2+ hot ha.

_ Yu t VII , khi ng c/ng M ngoi sinhc/ng ch o

c/th.

5. Yu t VIII _ Do gan sx , yu t VIII d b hy trong huyt tng lu tr , trong mau


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( Chng Hemophili A ) kt hp vi yu t Willebrand tng tnh bn vng.

_ Yu t VIII l ng yu t ca yu t IX , cng vi yu t IXa hot

ha yu t X.

6. Yu t IX

( Chng Hemophili B )

_ Do gan sx , hot ng cn VTM K , Ca2+ khi hot ha

_ Yu t IXa cng yu t VIIIa , Ca2+ ,PL hot ha yu t XXa

7. Yu t X

(Stuart )

_ Do gan sx , cn VTM K v Ca2+ hot ha

_ Yu t Xa tac ng ln : V , Ca2+ , PL hnh thnh nn phc

Prothrombinase ct lin kt peptid ca Prothrombin Thrombin

8. Yu t XI

( Rosenthal )

_ Do gan sx , hot ha thnh XIa , khi c mt Ca2+ , XIa hot ha

yu t IXIXa.

9. Yu t XII

( Hageman )

_ Do gan sx , yu t XII l yu t t/xc m u con ng M ni sinh.

10. Yu t XIII _ Do gan sx , cng vi Ca2+ , yu t XIII ng vai tr n nh Fibrin t

ha tan Fibrin khng tan.

11. Yu t PK

( Pre-Kallikrein )

_ Do gan sx , l yu t tip xc m u con ng M ni sinh

12. Yu t H.M.W.K _ Do gan sx , l yu t tip xc m u con ng M ni sinh

1. Yu t thnh mch ( ni mch ) _ Ni mch c nhiu yu t t chc (TF) khi ng con ng M ngoi sinh

_ Lp di ni mch cha collagen , tip xc v hot ha TCkhi ng CMB

_Cha Heparin sulphat tng cng hot ng ca AT III c ch qu trnh M

_ Tac ng ln Thrombomodulin hot ha Protein C c ch M thng qua bt hot y/t Va,VIIa

2. Yu t Tiu cu _ TC mang cac yu t M xung quanh mnh to nn lp Kh quyn quanh TC

_ TC cha PL mng , khi hot ha tch in m , to iu kin cho yu t M tip xc v gn bam

_ Cht c ch lupus lm kt ta PL tiu cu , ngn IIIIa , gy bin chng huyt khi

3. Yu t t chc (TF) _ TF c hu ht trong t chc v mch mau, c nhiu trong no v phi , khng c trong TB ni

mch , n to v bc phong ph quanh mch mau nhng li khng tip xc c vi mau do b

ngn cach bi lp ni mch

_ Khi lp ni mch tn thng , TF c gii phng v tip xc vi dng mau , khi ng con

ng ng mau ngoi sinh ( TF gn vi PL TF-phospholipid hot ha yu t VIIVIIa )

4. Yu t Ca2+ _ To iu kin cho yu t ph thuc VTM K ( II , VII , IX , X ) kt hp vi PL hot ha

_ Th hin hot tnh ca yu t XIIIa

_ n nh yu t V , phc h Willebrand-VIIIc

1. Cc yu t c ch ng mu

Nhm 1 : Cc cht c ch Serin protease

1. AT III

( Anti thrombin III )

_ Sx ti gan , nng trong mau 240 mg/l

_ c ch Thrombin , Kallikrein , IXa , Xa , XIa , XIIa


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

cng mnh m khi c mt Heparin do to phc :

AT III Heparin Thrombin

_ AT III khng bt hot yu t VIIa

2. 1- AT

( Alpha 1 Anti trypsin )

_ Sx ti gan

_ c ch thrombin , Kallikrein , XIa

3. 2-MG

( Alpha 2-Macro Globulin )

_ Sx ti gan

_ c ch Thrombin , Kallikrein

4. HC II

(Heparin confactor II)

_ Sx ti gan

_ c ch Thrombin

5. Cht c ch C1 _ Sx ti gan

_ c ch Kallikrein , XIa , XIIa v cac Proteinase b th C1

Nhm 2 : H thng protein C

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

_ c ch 2 ng yu t Va , VIIIa khi c mt PL- ca TC v Pro-S

Ca2+

_ B c ch bi 1-AT v PCI

2. Protein S _ Sx ti gan , ph thuc VTM K khi tng hp

3. Thrombomodulin _ Sx ti TB ni mc

_ Thrombomodulin cng Thrombin tham gia hot ha protein

Cbt hot 2 ng yu t Va , VIIIa

4. Cht c ch tng hp TFPI

_ Yu t duy nht c ch yu t VIIa

_ TFPI to phc Xa-TFPI-VIIa-TF nn bt hot Xa,VIIa,TF

1. Nhm cc yu t tip xc: _ Gm 4 yu t yu t XI, XII, prekallikrein v H.M.W.K. tham gia vo giai an khi

ng con ng ng mau ni sinh khi mau tip xc vi lp di ni mc.

_ c im chung l bn vng, n nh tt trong huyt tng lu tr, khng ph thuc

vitamin K khi tng hp v khng ph thuc ion canxi khi hot ha.

2.Nhm cc yu t ph thuc vitamin K (hay nhm prothrombin) : _ Gm cac yu t II, VII, IX, X. Cac yu t ny u l zymogen (tin men) ca cac serin

protease (men hot ng).

_ c im chung l u ph thuc vitamin K khi tng hp v cn c ion canxi khi hot

ha. Khi lu hnh trong mu bnh thng chng khng c hot tnh enzyme nhng c th b

bin thnh serin protease khi phn ct la chn mt hoc hai dy ni peptid. Cac yu t

trong nhm ny khng b tiu th trong qu trnh ng mu nn chng s c mt trong

huyt thanh (tr yu t II) v chng n nh trong huyt tng lu tr.

_ Khi c th thiu vitamin K th gan ch tng hp ra tin cht ca cac yu t trn, cac tin

cht c hot tnh sinh hc ng mau rt thp v i khi cn c hot tnh c ch ng mau,

c gi chung l PIVKA (proteins induced by vitamin K absence or antagonists).


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3. Nhm fibrinogen: _ Gm cac yu t I,V, VIII, XIII. Cac yu t ny u chu tc ng qua li ca thrombin.

_ c im chung : b tiu th trong qu trnh ng mu nn khng c mt trong huyt

thanh v nhanh b hy (mt hot tnh trong huyt tng lu tr).

_ Yu t VIII cn c c im khng lu hnh n c trong huyt tng, sau khi tng hp

ra ch trong thi gian ngn (8-12 pht) l chng s gn vi yu t von Willebrand nh

m m bo c tnh n nh ca yu t ny. Tm tt :

1. Yu t ph thuc VTM K khi tng hp , cn Ca2+ khi hot ha : II , VII , IX , X

2. Yu t km bn trong huyt tng lu tr b mt hot tnh : V , VIII , XIII , TC

3. Yu t khng b tiu th trong qua trnh M : II, VII , IX , X

4. Yu t c Heparin gia tc : AT III ,HC II ( tr 1-AT v cht c ch C1 )

IU HA M CA CHT C CH

M AT III

Thrombin

Kallikrein

IXa

Xa

XIa XIIa

VIIa

1-AT 2-MG

HC2

Cht c ch C1

TFPI

Va+VIIIa

Protein C Protein S

Tc gi s : L Vn Cng


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II. CC GIAI ON QU TRNH NG MU

XII

Tc gi s : L Vn Cng

X

XII XIIa +PK +Kininogen

XI XIa + Ca2+

IXa + VIII +Ca2++PL

Yu t tip xc

(XI , XII , PK , H.M.W.K )

V, PL , Ca2+ Prothrombinase

Prothrombin

(II)

Thrombin

( Ia )

Fibrinogen Fibrin monome

Fibrin ha tan + XIIIa+Ca2+

Fibrin khng tan

IX

Xa Thromboplastin+VIIa+Ca2+

Giai on 1

Giai on 2

Giai on 3


21


1. Con ng ng mu ni sinh

Giai on 1 : Hnh thnh phc h Prothrombinase ni sinh

XII

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

Kininogen CPT ) ln b mt TC tch in m .ng thi dng mau tip xc vi si

Collagen khi ng CMBhot ha con ng M ni sinh

_ Bt u l yu t XIIXIIa , yu t XIIa sinh ra kt hp vi yu t PK , Kininogen CPT

hot ha yu t XIXIa . Yu t XIa khi c mt Ca2+ , tip tc hot ha yu t IXIXa .

Yu t IXa kt hp vi ng yu t VIII , Ca2+ v PL , hot ha yu t XXa . Yu t Xa

tac ng ln phc h cac yu t : V , Ca2+ , PL , bin phc h ny thnh Prothrombinase

Prothrombinase gm ( Xa, Va, Ca2+ , PL )

_ B mt tip xc y cn : t chc di ni mc ,TC, thy tinh , Kaolin,Ngi ta

ng dng iu ny lm XN kho sat con ng M ni sinh : thi gian mu ng ,

thi gian Howell, thi gian APTT

IX

V , PL , Ca2+

Prothrombinase

( Va , Xa , Ca2+ , PL

)

Yu t tip xc

(XI, XII , PK , H.M.W.K

)

XII XIIa ( PK ,Kininogen )

XI XIa + Ca2+

IXa + VIII +Ca2++PL

IX Xa

Tc gi s : L Vn Cng


22


Giai on 2 : Hnh thnh Thrombin ni sinh

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

kt peptid ca Prothrombin thnh 3 mnh , trong c 1 mnh l Thrombin

_ Thrombin l trung tm ca qu trnh M

+) Thrombin gy ngng tp TC rt mnh tng hot ng CMB

+) Thrombin xc tc chuyn Fibrinogen Fibrin

+) Thrombin hot ha V , VIII, XI m rng hot ng M ni sinh

+) Thrombin hot ha yu VIIVIIa m rng hot ng M ngoi sinh

+) Thrombin hn ch hot ng lan trn ca chnh n bng hot ha Protein Cc ch

M thng qua bt hot yu t Va v VIIIa

+) Thrombin thc y qu trnh TSH thng qua thc y TB ni mnh tng sn xut yu t

t-PA tng chuyn Plasminogen Plasmin

ngng tp TC rt mnh tng hot ng CMB

chuyn Fibrinogen Fibrin

T khuch ihot ha V , VII, VIII, XI

T c ch hot ha Protein C

tng chuyn Plasminogen Plasmin

Thrombin

Tc gi s : L Vn Cng

Prothrombinase

( Va , Xa , Ca2+ , PL

)

Thrombin (IIa ) Prothrombin (II)


23


2. Con ng M ngoi sinh

Giai on 1 : Hnh thnh phc h Prothrombinase ngoi sinh

Giai on 2: hnh thnh Thrombin

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

hot ha ngay yu t XXa. ( cng hot ha yu t IX khi nng thp )

_ M ngoi sinh c khi ng bng yu t t chc ( TF ) hay Thromboplastin

c gii phng t m , t chc hay mch mau tn thng . Thromboplastin c ai

tnh cao vi yu t VII ( chuyn VIIVIIa) , to phc Thromboplastin-VIIa khi c

mt Ca2+ , PL v ng thi hot ha yu t XXa mt cach nhanh chng

_ Yu t Xa sinh ra , tac ng ln yu tV ( VVa ) cng vi phospholipid v s c

mt ca Ca2+ , chuyn thnh Prothrombinase gm phc : Xa , Va , PL- , Ca2+

_ Prothrombinase hot ha yu t IIIIa ( thrombin) ( c ch xem phn ni sinh )

. Yu t Thrombin sinh ra tip tc hot ha yu t IIa ( fibrin )

_ Ngoi ra , Thrombin cn tham gia CMB bng hot ha mnh TC , tham gia iu

ha M v khuch i chnh n bng hot ha yu t V , VII , VIII, XIII. c ch

chnh n bng hot ha Protein C.

Prothrombinase

( Va , Xa , Ca2+ , PL

)

Thrombin (IIa ) Prothrombin (II)

Tc gi s : L Vn Cng

Thromboplastin m Thrombin

X Xa

VII VIIa + Ca2+

V , PL , Ca2+

Prothrombinase ngoi sinh


24


3. Con ng M chung

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

(Fibrin monomer A v B ).Cac Fibrin monomer tri qua qua trnh polymer

haFibrin polymer ha tan ( Tuy nhin vn cn mt s Fibrin monomer A v B

cha kt hp vi nhau , tn ti dng t do )

_ Fibrin monomer ha tan Fibrin khng tan , nh yu t XIIIa v Ca2+. Yu t

XIIIa c hot ha nh Thrombin v c gia tc khi c mt Ca2+

C IM SO SNH M NI SINH M NGOI SINH M CHUNG

1. Yu t hot ha

_ Yu t tip xc

_ Tiu cu

_ Collagen

_ Thromboplastin m

(TF)

Thrombin ngun gc ni

sinh v ngoi sinh

2. Tc Chm , din ra vi pht Nhanh , t=15s nu chn

thng nng

Din ra mnh nh s hip

ng ca c ni v ngoi

sinh

3. Yu t tham gia

_ Yu t tip xc: XII,

XI , PK , H.M.W.K

_ IX , VIII , V , X ,II

_ Thromboplastin , VII

, X , V , II IIa , I

4. XN kho st

_ Thi gian mau ng (

lam , ng nghim

_ Thi gian Howell

_ Thi gian APTT

_ nh lng cac yu t

VIII,IX, X, XI, XII

_ Thi gian PT

_ nh lng yu t

VII, X, V , II

_ Thi gian TT

_ nh lngFibrinogen

Thrombin

Fibrinogen

(I)

Fibrin monome

Fibrin polymer ( Fibrin ha tan)

Fibrin khng tan

XIIIa XIII

Ca2+

Tc gi s : L Vn Cng


25


III. CC XT NGHIM KHO ST NG MU 1. Thi gian mu ng trn lam

_ Nguyn tc XN : Xac nh thi gian ng ca git mau ton phn da vo s xt hin

ca si Fibrin trong git mau trn lam knh

_ Mc ch ngha : Kho sat con ng M ni sinh , y l XN khng nhy , b nh

hng bi nhiu yu t

_ Tin hnh :

_ Dng c : 2 lam sch , a petri , kim chch , bong , ng h

_ Ha cht : cn 700

_ Bnh nhn : Anh b bnh l M g cha ? Ung thuc Aspirin khng ? iu tr

Heparin khng ? ( ch hi ko mt im , hoc s b nh hng n kt qu XN )

_ Quy trnh :

+) B1 : anh s , ghi tn lam knh

+) B2 : sat khun ngn ap tchch nhanh v bm ng hlau git mau u( lau b

m tn thng , do chc ln 1 TC ra nhiu nht , lau i ly cc git tip theo s kho st

u hn )nh mau ln 2 lam knh ( 5-10mm/git) cho lam 2 vo a petri , i trong

3 pht

+) B3 : Sau 3 , kho sat tng lam

Lam 1: nghing 450 ( khng lm v mt thong ) c 30s/450/ 1ln n khi xut hin

si Fibrin ( dung kim chch khu) th kho sat lam 2

Lam 2 lm y ht lam 1, c 30s/450/1ln n khi xut hin si Fibrin ( dung kim chch

khu) th bm ng h dng li . Ghi kt qu lm trn v mc kho st

_ Nhn nh kt qu :

+) Bnh thng : 5-10

+) Ko di : >15 Howell

+) Nghi ng : 10-15 , lm li bng APTT

Ch : thi gian mu ng < 5 khng c ngha chn on tnh trng Tng ng (T) ,

do n chu nh hng bi nhiu yu t : nhit , mi trng xung quanh , lng mu,.

_ Bin lun kt qu : Thi gian mu ng trn lam ko di trong cc trng hp

+) Bnh nhn ang dng Aspirin , hoc iu tr Heparin

+) Thiu ht yu t M ni sinh , c bit : IX , VIII , XI , trong bnh Hemophili A , B , C

+) C th c khang ng : khng ng lupus , FPDs ,

+) Bnh nhn suy gan nng , bnh hi chng thn h ,

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


http://www.youtube.com/watch?v=OQe4K3my6YY
http://www.youtube.com/watch?v=OQe4K3my6YY


26


2. Thi gian M trong ng nghim

_ Nguyn l XN : Cho mau tip xc vi thnh ng nghim khi ng con ng M

ni sinh , o thi gian t lc mau tip xc vi thnh ng nghim n khi mau ng cht

thnh khi

_ Mc ch ngha : Kho sat con ng M ni sinh

_ Tin hnh :

+) Dng c : B ly mau TM , 2 ng nghim sch loi 75 9,5mm trang nc mui

sinh l ( to mi trng ng trng trn thnh ng nghim trnh v HC ) , ng h

, ni 370

+) Bnh nhn : Anh b bnh l M g cha ? Ung thuc Aspirin khng ? iu tr


+) Quy trnh :

B1 : Trang nc mui sinh l , anh s, ghi tn ng nghim

B2 : Ly 2-3ml mau TMbm ng h v bm vo thnh ng nghim chia u 2

ngem 2 ng trong ni 370 trong 3

B3 :Sau 3 kho sat tng ng

ng 1 : nghing 450 ( khng lm v mt thong )c 30s/450/1 lnMau ng cht

thnh khi tip tc kho sat ng 2 , y ht ng 1

ng 2 : lm y ht ng 1 Mau ng cht thnh khi bm ng h dng lighi

kt qu lm trn n mc kho sat.

_ Nhn nh kt qu

+) Bnh thng : 5-12

+) Ko di : > 15 Howell

+) Nghi ng : 12-15 , lm li bng APTT

Ch : thi gian mu ng < 5 khng c ngha chn on tnh trng Tng ng (T)

Nhn xt : Thi gian mu ng trong ng nghim c nhiu u im hn M trn lam

do c thc hin 370C gn iu kin c th nht , mt khc n khng chu nhiu nh

hng bi mi trng xung quanh (bi , hi nc ) v do c chia bng bm nn lng

mu l chnh xc hn . Tuy nhin nhc im ca pp l dng mu ton phn.

_ Bin lun kt qu : Thi gian mu ng trn ng nghim ko di khi

Bnh nhn ung Aspirin , iu tr Heparin

Thiu ht yu t M ni sinh : XII , XI , PK , H.M.W.K , IX, VIII , X

C th c khang ng : cht khang ng lupus , FPDs,

Bnh nhn suy gan nng , Hi chng thn h,

ng 1 ng 2


http://www.youtube.com/watch?v=mXnGS1or5v

U
http://www.youtube.com/watch?v=mXnGS1or5vUhttp://www.youtube.com/watch?v=mXnGS1or5vU


27


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

_ Nguyn tc XN : Mau ton phn c chng ng bng Natricitrat 3,8% em

ly tm ly huyt tng giu tiu cuthm 1 lng ti u Ca2+. o thi gian t lc

phc hi Canci n khi huyt tng ng cht thnh khi.

_ Mc ch ngha : Kho sat con ng M ni sinh , anh gia giai on hot ha

yu t XXa SL v CL Tiu cu ( yu t 3 phospholipid )

Thi gian Howell ph thuc: Yu t VIII, IX, X ( XII, XI ,PK, H.M.W.K )

_ Tin hnh :

+) Dng c : B ly mau TM , 2 ng nghim sch loi 75 9,5mm, pipet , ng h,

ni 370

+) Ha cht : Dung dch CaCl2 0,025M ( pha t CaCl2 0,1M=100g CaCl2 ha tan

trong 1000ml nc ct , ly CaCl2 0,1M pha vi nc ct t l 1:3CaCl2 0,025M )

+) Bnh nhn : : Anh b bnh l M g cha ? Ung thuc Aspirin khng ? iu tr


+) Quy trnh:

B1: Ly >2ml mau TMcho vo l Natricitrat ti vch 2em ly tm 1000vng/10

B2: anh s, ghi tn ng nghimHt 0,2ml huyt tng cho vo 2 ng 0,2ml/1 ng

em 2 ng huyt tng v ng CaCl2 370 / 3

B3: Sau 3 kho sat tng ng :

ng 1 : Thm 0,2ml CaCl2 v bm ng hlc ngang n 9s( trn u) yn

trong 1nghing 450130 nghing 450 c 15s /nghing 450/1lnn khi

huyt tng ng cht thnh khibm ng h dng liT1 lm trn v mc kho

st.

ng 2 : lm y ht ng 1 n khi huyt ng chtbm ng h dng liT2 lm

trn v mc kho st

_Nhn nh kt qu :

Bnh thng : Howelltb = 130-230

Ko di > 60s so vi chng

Ch : Thi gian Howell ngn hn bnh thng khng phn nh c tnh trng

tng ng.

Nhn xt : Thi gian Howell c u im hn M trong ng nghim l dng huyt

tng giu tiu cu , loi b i HC , BC. V dng huyt tng giu TC nn khi

thi gian Howell ko di , khng th xc nh c do bt thng v yu t M

hay do TC y chnh l nhc im ca pp , tuy nhin n l XN thng xuyn

theo di iu tr Heparin.

_ Bin lun kt qu : Thi gian Howell ko di trong trng hp

Thiu ht yu t : IX , VIII , X


http://www.youtube.com/watch?v=6Rlvw2OwksU
http://www.youtube.com/watch?v=6Rlvw2OwksU


28


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

Bnh nhn ung Aspirin , iu tr Heparin

C th c khang ng : cht chng ng lupus , mnh FDPs ,.

Bnh Hemophili A , B ; Bnh suy gan nng ; Hi chng thn h

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

Bnh nhn ung Aspirin : c ch ngng tp TC mnh v tn ti sut i sng ca

TCTC khng tng hp ra cac men mi c nanh hng n CMB , v

M. C ch tc ng ca Aspirin nh sau:Aspirin c ch men cyclo-oxygenase

Ngn cn hnh thnh Thomboxan A2Nh c ch s ngng tp TC

iu tr Heparin : :Heparin l thuc chng ng ng tim ,n tc ng ln yu t

IIa(thrombin),Xa lm b.i c.trc yu t IIa ,Xa(to phc Xa-AT III-IIa-heparin

Mt tac dng yu t IIa , Xa. ng thi n gia tc hot ng cho cac yu t c ch

M t nhin khac nh AT III , HC II . c bit l AT III ( tc ng tng gp 2000-

3000 ln khi c mt heparin ) .

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

bn cht l cac IgG , IgM . Cac khang th ny lm kt ta PL ca TCc ch s

hot ha ca cac yu t cn phospholipid nh II , X.

Bnh suy gan gim tng hp yu t M

Hi chng thn h lm mt yu t M qua nc tiu ,.

Bnh Hemophili : Hemophili l bnh DT gen ln trn NST gii tnh X , bnh DT

cho . Bnh do thiu bm sinh yu t VIII ( hemophili A ) , yu t IX (hemophili B).

Trong Hemophili A hay gp hn chim 80-85% trng hp

4. Thi gian APTT (Thi gian Thromboplastin hot ha tng phn , thi

gian Cephalin-Kaolin)

_Nguyn l XN : Mau ton phn c chng ng bng Natricitrat 3,8% em ly

tm ly huyt tng ngho tiu cuthm Kaolin thng nht hot yu t tip xc

thm Cephalin thay yu t 3 phospholipid ca TCthm lng ti u Ca2+. o thi

gian t lc phc hi Ca2+ n khi huyt tng bt u ng ( xut hin mng ng )

_ Mc ch ngha : Thi gian APTT kho sat con ng M ni sinh , giai on

hot ha yu t XXa , khng ph thuc yu t 3- phospholipid ca TC , nn n l

xt nghim ti u nht nh gi M ni sinh

Thi gian APTT ch ph thuc yu t IX , VIII


29


_ Tin hnh :

+) Dng c : b ly mau TM , 2 ng nghim sch loi 75 9,5mm , pipet , ng h ,

ni 370

+) Ha cht : Actin-FS ( np xanh ), dung dch CaCl2 0,025 M



+) Quy trnh :

B1: Ly mau TMcho vo ng NatriCitrat 3,8% ti vch 2em ly tm

2000vng/10 ly huyt tng ngho TC

B2 : anh s ghi tn ng nghim

B3 : Ht 0,1ml huyt tng vo 2 ng nghim : 0,1ml/ngem 2 ng huyt

tng v ng dd CaCl2 vo ni cach thy.

B4 : Hot ha tng phn

Thm vo mi ng 0,1ml ACTIN FSlc uc 15s/lc u/3

B5 : Phc hi Canci : kho sat tng ng

ng 1 : Thm 0,1ml CaCl2 v bm ng hlc ngang n 9sa ngang tm mt

lc v quan sathuyt tng xut hin mng ngbm ng h dng liT1 ghi kt

qu c phn tch tc.

ng 2: Lm y ht ng 1 huyt tng xut hin mng ngbm ng h dng

liT2 ghi kt qu c phn tch tc.

_Nhn nh kt qu

Bnh thng : APTTtb = 30-40s APTTbnh/chng=0,9-1,15

Ko di > 8s so vi chng * Ko di : > 1,2

Bnh l >20s so vi chng

_ Bin lun kt qu : APTT ko di trong cc trng hp sau

Thiu yu t VIII , IX , X : bnh Hemphili A , B

C khang ng lu hnh : iu tr heparin , chng ng dng lupus , mnh FDPs,.

Bnh suy gan nng , Bnh Hi chng thn h ,.

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

iu tr Heparin :Heparin l cht chng ng ng tim ,n tc ng ln yu

t thrombin (IIa) ,Xa lm b.i c.trc yu t IIa ,Xa do to phc Xa-AT III-IIa-

heparin Mt tac dng yu t IIa , Xa. ng thi n gia tc hot ng cho

cac yu t c ch M t nhin khac nh AT III , HC II . c bit l AT III (

tc ng tng gp 2000-3000 ln khi c mt heparin ) .


http://www.youtube.com/watch?v=V9dCV1dkZtU
http://www.youtube.com/watch?v=V9dCV1dkZtU


30


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

ban bn cht l cac IgG , IgM . Cac khang th ny lm kt ta PL ca

TCc ch s hot ha ca cac yu t cn PL nh II , X.

Bnh suy gan gim tng hp yu t M

Bnh hi chng thn h lm mt yu t M qua nc tiu ,.

Ha cht ACTIN FS lm xt nghim thi gian APTT

ng 1 ng 2


31


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

prothrombin)

_Nguyn l XN : Mau ton phn c chng ng bng NatriCitrat 3,8% em ly tm

ly huyt tng ngho tiu cuthm 1 lng ti u hn hp Thromboplastin v CaCl2.

o thi gian t lc thm ha cht n khi huyt tng bt u ng .

_ Mc ch ngha : Kho sat con ng M ngoi sinh , qua nh gi cc yu t

VII, X, V, II. y l xt nghim kh nhy nh gi M ngoi sinh.

_Tin hnh:

+) Dng c : B ly mau TM , 2 ng nghim loi 75 9,5mm, pipet , ng h , ni

cach thy 370

+) Ha cht :

T sn xut t c th : Pha c th vi nc mui sinh l (dung dch m) theo t l c

50mg c th + 1ml NaCl 90/00 ngoay u lin tc trong 30

Thm 1ml CaCl2 0,025M ( t l 1:1 vi NaCl 90/00 ) lnght dch trong

pha trn lm XN

Mua t nh sn xut : L Thromborel ( np vng )



+) Quy trnh :

B1: Ly mau TMcho vo l Natricitrat ti vch 2em ly tm 2000vng/10

ly huyt tng ngho tiu cu


B3 : Ht 0,1ml huyt tng cho vo mi ng : 0,1ml/ng em 2 ng huyt

tng v ng ha cht 370C / 3.

B4 : Sau 3 , kho sat tng ng :

ng 1: Thm 0,2ml ha cht v bm ng h lc ngang n 9sa ngang tm mt

lc v quan sat n khi huyt tng bt u ngbm ng h dng li T1 gi

nguyn n phn tch tc

ng 2: Lm y ht ng 1 n khi huyt tng bt u ngbm ng h dng li

T2 gi nguyn n phn tch tc

_ Nhn nh kt qu

Bnh thng :PTtb = 11-14s * T l Prothrombin = 70-140%

Ko di : >2s so vi chng * Gim < 60% (cng gim t.gian cng ko di )

PTbnh/chng=0,9-1,15

ng 1 ng 2


32


Ko di : > 1,15

_ Bin lun kt qu : Thi gian PT ko di trong cc trng hp sau

Thiu ht yu t M ngoi sinh : VII , X , V , II

Thiu VTM K : iu tr ngoi tiu ha , dng khng sinh ko di , thiu bm sinh tr

s sinh,.

Dng thuc chng ng ng ung khang VTM K l dn xut ca Coumarin :

Wafarin ,.

C th c khang ng : iu tr heparin , khng ng dng lupus , FDPs,.

Bnh DIC , Bnh gan , Hi chng thn h ,

_ Lu : Xt nghim thi gian PT ph thuc nhiu vo ha cht thromboplastin ( v

nhiu hang sn xut khc nhau v t nhiu ngun : c th , phi , c ln,.). V vy

WHO a ra ch s INR-ch s bnh thng ha quc t ( International

normalized ratio =INR ) , cho mi xt nghim theo cng thc

= (

)

ISI- ch s nhy cm quc t ( Internation Sensitivity Index =ISI )

Ch s INR c dng theo di bnh nhn s dng thuc chng ng khng VTM K

an ton nn duy tr INR=2-4 . Nu 4 nguy c xut

huyt.

Gii thch mt s trng hp khin thi gian PT ko di :

Thuc chng ng ng ung l dn xut ca Coumarin , n cnh tranh vi VTM K

trong c thc ch hot ng ca cac yu t M ph thuc VTM K nh l : II , VII ,

IX , X , Protein C , Protein S . C ch tac ng nh sau ( theo TS- Nguyn Anh Tr ):

Thuc c tc dng c ch epoxyd reductasec, t lm tng t s oxyd / VTM K.

Lng oxyd nhiu s cnh tranh vi VTM K1 , vng cm thVTM K1 b gim hiu

lc.

iu tr Heparin :Heparin l cht chng ng ng tim ,n tc ng ln yu t

IIa,Xa lm bin i cu trc yu t IIa ,Xa(to phc Xa-AT III-IIa-heparin )Mt tac

dng yu t IIa , Xa. ng thi n gia tc hot ng cho cac yu t c ch M t

nhin khac nh AT III , HC II . c bit l AT III ( tc ng tng gp 2000-3000 ln

khi c mt heparin ) .


33


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

bn cht l cac IgG , IgM . Cac khang th ny lm kt ta PL ca TCc ch s hot

ha ca cac yu t cn PL nh II , X.

Mnh FDPs sn phm ca qu trnh tiu si Fibrin / Fibrinogen : Sn phm thoai ha

Fibrinogen/Fibrin l cac mnh X, Y , E , D ( s cp k phn TSH ).Cac mnh ny c

tac dng c ch ngng tp TC ( nh hng ti CMB v yu t ph thuc

phospholipid TC ). Ngoi ra mnh X, Y c ch s polymer ha ca

FibrinmonomeFibrinpolyme ( mnh E , D tc ng yu hn ). c bit cac mnh E ,

D tng hot ha PlasminogenPlasmin ( tng tiu Fibrinogen/Fibrin ) , thng qua vic

tng hiu lc cac cht hot ha Plasminogen : t-PA , Tcu-PA .,,,,

Bnh gan: Gan l c quan tng hp hu ht cac yu t tham gia qua trnh ng-Cm

mau .Trong bnh suy ganchc nng gan gimKh nng tng hp cac yu t M

gimri lon qua trnh M. Trong bnh vim gan tc mtKh nng to dch mt

gim , cng vi s tc mtDch mt khng/gim xung ta trng nh tng ha

lipid , to iu kin hp thu VTM K tan trong dunh hng n cac yu t ph

thuc VTM K.

Hi chng thn h : Gin mng lc cu thn , cng vi s km tai hp thu cac cht cn

thit ng thn Lm mt nhiu cac yu t M.

Ha cht lm xt nghim thi gian PT


34


6. Thi gian TT

_ Nguyn l XN : Mau ton phn c chng ng bng NatriCitrat 3,8% em ly tm

ly huyt tng ngho TCthm 1 lng ti u ha cht Thrombino thi gian t

lc thm ha cht n khi huyt tng bt u ng.

_ Mc ch ngha : Kho sat con ng M chung , anh gia Fibrinogen , giai on

u chuyn FibrinogenFibrin , nh Thrombin

_ Tin hnh

+) Dng c : B ly mau TM , 2 ng nghim sch , pipet , ng h , ni cach thy

+) Ha cht : L Thrombin ( 25 v/ml)

+) Bnh nhn : : Anh b bnh l M g cha ? Ung thuc Aspirin khng ? iu tr


+) Quy trnh :

B1: Ly mau TM >2mlcho vo l NatriCitrat ti vch 2em ly tm 2000vng/10 ly

huyt tng ngho TC

B2: anh s ghi tn ng nghim

B3: Ht 0,1ml huyt tng v 0,1ml NaCl 9o/oo ( n nh pH cho Thrombin v n l 1

enzym, c th thay bng dung dch m) cho vo 2 ng nghim (0,1ml huyt tng+0,1ml

NaCl 9o/oo) / 1 ngem 2 ng huyt tng 370/3

B4: Sau 3 kho sat tng ng

ng 1: Thm 0,1ml ha cht v bm ng hlc ngang n 9sa ngang tm mt

lc v quan sathuyt tng bt u ngbm ng h dng liT1 gi nguyn c

phn tch tc.

ng 2: lm y ht ng 1huyt tng bt u ngbm ng h dng liT2 gi

nguyn c phn tch tc.

Thrombin

Fibrinogen

(I)

Fibrin monome

Fibrin polymer ( Fibrin ha tan)


http://www.youtube.com/watch?v=SgzTJAucbb8
http://www.youtube.com/watch?v=SgzTJAucbb8


35


_ Nhn nh kt qu :

Bnh thng : TTtb=15-20s TTbnh/chng=0,85-1,15

Ko di : >5s so vi chng Ko di >1,15

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

Thiu ht yu t Fibrinogen :


36


BNG TM TT CC XT NGHIM CM-NG MU

Tn XN S lng

2 ngha

Gi tr bnh thng / bt

thng

1.BT (MC)

Kho sat qua trnh cm mau

ban u , qua anh gia :

yu t thnh mch + tiu cu

v yu t Willebrand ,

Fibrinogen

Mu chy ph thuc Cht lng thnh mch

S lng tiu cu

Cht lng tiu cu

Thiu yu t

Willebrand+Fibrinogen

+) Bnh thng :MC=1-4 +) Ko di : >6

+) Nghi ng : 4-6 khi phi

tin hnh li vi tai kia hoc

dng pp Ivy

2.Co cc

mu

Kho sat qua trnh CMB

, qua anh gia cht

lng v s lng ca tiu

cu , Fibrinogen , yu t

XIII

Co cc mu ph thuc

S lng v cht lng ca

TC

S lng v cht lng ca

Fibrinogen

Yu t XIII

Th tch khi HC(hematocrit )

Co cc mu nh gi 4 mc

Co hon ton :

HT 50-65% HC15

+) Nghi ng : 10-15 , lm li

bng APTT , Howell

Ch : thi gian mu ng < 5

khng c ngha chn on tnh

trng Tng ng (T) , do n

chu nh hng bi nhiu yu t

: nhit , mi trng xung

quanh , lng mu,.


37


4.M trn

ng

Kho sat con ng M ni

sinh

+) Bnh thng :

M = 5-12 +)Ko di >15

+) Nghi ng : 12-15

lm li bng Howell , APTT

Ch : thi gian mu ng < 5

khng c ngha chn on tnh

trng Tng ng (T)

Nhn xt : Thi gian mu ng

trong ng nghim c nhiu u

im hn M trn lam do c

thc hin 370C gn iu kin c

th nht , mt khc n khng

chu nhiu nh hng bi mi

trng xung quanh (bi , hi

nc ) v do c chia bng

bm nn lng mu l chnh

xc hn . Tuy nhin nhc im

ca pp l dng mu ton phn.

5.Howell

Kho sat con ng M ni sinh

, anh gia giai on hot ha yu

t XXa

Thi gian Howell ph thuc:

+)Yu t VIII, IX, X ( XII, XI

,PK, H.M.W.K )

+) SL v CL Tiu cu ( yu t 3

phospholipid )

Bnh thng :

Howelltb = 130-230 Ko di > 60s so vi chng

Ch : Thi gian Howell ngn

hn bnh thng khng phn nh

c tnh trng tng ng.

Nhn xt : Thi gian Howell c u

im hn M trong ng nghim l

dng huyt tng giu tiu cu ,

loi b i HC , BC. V dng huyt

tng giu TC nn khi thi gian

Howell ko di , khng th xc

nh c do bt thng v yu t

M hay do TC y chnh l

nhc im ca pp , tuy nhin n

l XN thng xuyn theo di iu

tr Heparin.

6.APTT

Thi gian APTT kho sat con

ng M ni sinh , giai on

hot ha yu t XXa , khng

ph thuc yu t 3- phospholipid

ca TC , nn n l xt nghim ti

u nht nh gi M ni sinh

Thi gian APTT ch ph thuc

yu t IX , VIII

Bnh thng :

APTTtb = 30-40s Ko di > 8s so vi chng

Bnh l >20s so vi chng

APTTbnh/chng=0,9-1,15 Ko di : > 1,2


38


7.PT

Kho sat con ng M

ngoi sinh , qua nh gi

cc yu t VII, X, V, II. y l

xt nghim kh nhy nh gi

M ngoi sinh

Bnh thng :

PTtb = 11-14s Ko di : >2s so vi chng

T l Prothrombin = 70-140% Gim < 60% (cng gim t.gian

cng ko di )

PTbnh/chng=0,9-1,15 Ko di : > 1,15

8.TT

Kho sat con ng M

chung , anh gia Fibrinogen ,

giai on u chuyn

FibrinogenFibrin , nh

Thrombin

TT ph thuc : nng

Fibrinogen trong mu , cht

lng Thrombin

Bnh thng :

TTtb=15-20s Ko di : >5s so vi chng

TTbnh/chng=0,85-

1,15 Ko di >1,15

ng 1

ng 2


39


TIU SI HUYT

1. Qua trnh M to ra cc mau ng cm mauTuy nhin , nu cc mau ng ny c

tn ti mi trong lng mch s gy nn nguy c tc mch ngn nga u xy ra ,

trong c th c c ch Tiu si huyt lm tan cc mau ng sau khi tn thng

lnh mnh.

2. Tiu si huyt (TSH) c s tham gia ca yu t plasminogen trong mau , n khng gy

tac ng TSH, m cn phi c cac cht hot ha t-PA , Tcu-Pa , chuyn thnh Plasmin ,

gy ra tac ng tan cc mau cha si Fibrin/ Fibrinogen.

3.Tuy nhin , nu hot ng TSH lan trn c th dn ti bin chng chy mau , do , cn

c cac yu t c ch qua trnh TSH. Cac cht c ch TSH y gm 2 nhm

Nhm 1l : c ch s hot ha PlasminogenPlasmin , thng qua bt hot yu t hot

ha Plasminogen l t-PA , Tcu-PA

Nhm 2 gm : Cac cht khang PlasminLm mt tac dng tiu cc mau ca Plasmin

_ Sn phm ca qua trnh TSH , li tham gia iu ha M mc khac nhau. ( s trnh

by r phn sn phm TSH )


40


I. CHT THAM GIA TIU SI HUYT

A - Plasminogen v Plasmin

TN C IM VAI TR

1.Plasminogen

_Bn cht l chui Euglobulin

gm 791aa

_ Sn xut ti gan , c mt trong huyt

tng , TB BC on trung tnh , mng TC

,b mt TB ni mc, dch bao khp.

_ Nng trong mau : 0,13-0.2 g/l

_ Plasminogen tng trong 1 s bnh :

Nhim trng , phn ng vim , thai nghn

Gim trong bnh gan , iu tr chng

ng ,.

_ Plasminogen khng bn vng vi nhit

v pH trung tnh , b mt hot tnh 560C

_ L tin t khng hot

ng ca Plasmin.

_ V vy , nu cha c s

xut hin ca Fibrin th tac

ng tiu si huyt cha

xy ra.

2.Plasmin

_ Do ngun gc hnh thnh t

plasminogen , nn v cu to , trnh t sp

xp aa , tnh KN ging plasminogen

_ Plasmin hot ng pH trung tnh

_ Plasmin ch hnh thnh khi

trong c th c cc mau

ng , vi s c mt ca si

Fibrin. Ch bnh thng

trong c th khng c

plasmin.

_ Plasmin c ph tac dng

rng , n khng ch phn

hy Fibrin/Fibrinogen , m

cn phn hy c yu t :

v-WF , V , VIII , XIIIa ,......


41


II. CHT HOT HA PLASMINOGEN

_ Plasminogen mun phat huy tac dng phi c hot ha , hnh thnh nn Plasmin.

C rt nhiu cht hot ha Plasminogen , c bit quan trng y l 2 cht t-PA , v

Tcu-PA ( Urokiase )

TN C IM VAI TR

1. t-PA

_ t-PA sn xut ch yu TB ni

mc , 1 t c sx t TB cnh

biu m , Mu TC , BC mono,...

.

_ t-PA hot ha Plasminogen

cc i pH kim

_t-PA ch hot ha PlasminogenPlasmin

khi c s xut hin ca Fibrin.

_Tac dng lm tiu Fibrin ca t-PA rt

mnh :do t-PA v Plasminogen cng c

gn trc tip ln si Fibrin, v tr lysin.

_ Tac dng trn cng xy ra vi

Fibrinogen nhng t hn nhiu , do v tr

gn trn Fibrinogen b che khut.

2. Tcu-PA

(Urokiase)

_ Urokiase c sn xut bi TB

thn di dng tin cht Pro-

Urokiase v c o thi qua

nc tiu.

_ Pro-UrokiaseUrokiase , nh

s tac ng ca Plasmin

Kallikrein , XIIa

_ Urokiase ( Tcu-PA) hot ha

plasminogenplasmin , bng cach ct i 1

lin kt peptid : tc ng ny xy ra d c

hay khng s xut hin ca Fibrin

iu ny cho thy , Tcu-PA tiu

Fibrinogen nhiu hn tiu Fibrin.


42


S phi hp tc ng ca t-PA v Tcu-PA , trong hot ha PlasminogenPlasmin

MT S CHT C TC DNG HOT HA PLASMINOGEN KHC :

1. Staphylokiase (SPK)

_ Staphylokiase l 1 men do T cu vng ( S.aureus ) tit ra trong qua trnh sng ,

N to phc SPK-plasminogen , qua chuyn plasminogenplasmin. Phc ny s

b bt hot bi 2-antiplasmin ( 2-AP)

_Ngc vi Staphylokiase , TCV c men Coagulase , hot ha hnh thnh si Fibrin

bao quanh VKbo v VK trc tn cng ca TB , BC on ,.

2. Streptokiase (SK) ( c thm trong Vi sinh 2 )

_ Streptokiase l 1 men do Lin cu ( Streptococus) tit ra trong qua trnh sng.

_ Steptokiase cng to phc vi plasminogen SK-plasminogen,qua chuyn

plasminogenplasmin

3. Bat-PA

_Bat-PA c nc bt loi di ht mau , n cng l cht hot ha plasminogen

4. Yu t Kallikrein v XIIa

_ Khi c mt Kininogen CPT , n hot ha Pre-KallikreinKallikrein. Cht ny c

tac dng chuy Pro-UrokiaseUrokiase . Yu t XIIa cng c tac dng nh vy

5. Cc cht hot ha khng c hot tnh men v s t hot ha ca Plasminogen

_ Cc cht Clorofom , dn xut benzene , ure ,. Thc y chuyn plasminogen

thnh plasmin thng qua vic gii phng plasminogen khi cht c ch.

_ Plasminogen cng c th t hot ha thnh Plasmin 200C v pH=7,8

_ Trypsin v Plasmin cng c kh nng hot ha Plasminogen

Pro-Urokiase (Scu-PA)

TB thn

Urokiase ( Tcu-PA)

t-PA

TB ni mch

Plasminogen Plasmin

Fibrin

(ccng)

Sn phm thoai ha FDPs Tc gi s : TS- Nguyn Anh Tr


43


III. CC CHT C CH QU TRNH TIU SI HUYT

A. Cht c ch hot ha

Plasminogen B. Cht khng Plasmin

PAI-1 : c ch t-PA v tcu-PA

,bng cch to phc bt hot , c

kh hic ch hot ha

plasminogen

_Nng trong huyt tng :

1-100ng/ml

_ PAI-1 tng trong PNCT , ngi bo

ph , T , vim-nhim khun

1.2-Antiplasmin (2-AP )

_ 2-AP c tng hp t gan , c ch trc tip

plasmin , v c ch c cht hot ha plasminogen

(t-PA , tcu-PA )nhng chm

_ 2-AP gn c nh vo v tr hot ng ca

plasmin v c ch v tr hot ng , lin kt ny

lc u c th hi c , nhng v sau th khng

hi phc

_Ngoi ra, nh tac ng ca yu t XIIIa , 2-AP

lin kt trc tip vi chui Fibrin , t hn ch s

c nh Plasminogen vo Fibrin

PAI-2 : c ch t-PA hot ha ,

c bit l Tcu-PA

_ PAI-2 : tng ch yu khi c thai ,

LXM th M4 , M5, khi u,..

2.Antithrombin III ( AT III)

_AT III l cht c ph tac dng rng , ngoi c ch

hot ng yu t M , n cn l cht khang

plasmin. Bng cach to phc vi plasminmt tac

dng ca plasmin

3. 1-Antitrypsin (1-AT)

_ Nh ni phn II5 , Trypsin cng l cht c kh nng hot ha plasminogen.

_ 1-Antitrypsin cng ging AT III l cht c ph tac dng rng ngoi c ch hot ng

yu t M , n cn l cht khang plasmin lm mt tac dng ca Trypsin bng cach ct i

1 lin kt peptid

4. Cht c ch C1 _ Quay tr li vi phn II2 , Pro-UrokiaseUrokiase , nh s tc ng ca Plasmin, Kallikrein , XIIa.

_ Nh vy , cht c ch C1 c ch TSH bng cach ngn khng cho

Pro-Urokiase---------Urokiase hay cac cht hot ha plasminogen ph thuc h t/xc ni

chung

5. 2-Macroglobulin (2-MG) cng l 1cht khang Plasmin

S IU HA QU TRNH TIU SI HUYT


44


Pro-Urokiase (Scu-PA)

TB thn

Urokiase ( Tcu-PA)

t-PA

TB ni mch

Plasminogen Plasmin

Fibrin

(ccng)

Sn phm thoai

ha FDPs

PAI-1

PAI-2

1.2-Antiplasmin (2-AP )

2.Antithrombin III ( AT III)

3.1-Antitrypsin (1-AT)

4.Cht c ch C1

5. 2-Macroglobulin (2-MG)

Tc gi s : L Vn Cng ci bin


45


NHC LI S NG MU

X

XII XIIa +PK +Kininogen

XI XIa + Ca2+

IXa + VIII +Ca2++PL

Yu t tip xc

(XI , XII , PK , H.M.W.K )

V, PL , Ca2+ Prothrombinase

Prothrombin

(II)

Thrombin

( Ia )

Fibrinogen Fibrin monome

Fibrin ha tan + XIIIa+Ca2+

Fibrin khng tan

IX

Xa Thromboplastin+VIIa+Ca2+

Giai on 1

Giai on 2

Giai on 3

Tc gi s : L Vn Cng


46


NHC LI IU HA M CA CHT

C CH M

AT III

Thrombin

Kallikrein

IXa

Xa

XIa XIIa

VIIa

1-AT 2-MG

HC2

Cht c ch C1

TFPI

Va+VIIIa

Protein C Protein S

Tc gi s : L Vn Cng


47


IV. SN PHM CA THOI HA FIBRIN-MNH FDPs 1. Di tac ng tiu si Fibrin ca plasmin , sn phm ca qua trnh l cac mnh

FPDs ( Fibrin degradation products )

2. FPDs ch yu gm c 4 mnh ( chui ) : mnh X , mnh Y , mnh E , mnh D.

Trong mnh X-Y xut hin sm trong qua trnh thoai ha , mnh E-D xut

hin mun hn , khong sau 24h tac ng ca plasmin ln Fibrin.

3. Hiu lc sinh hc ca cc mnh FDPs ln qu trnh ng-cm mu

Cac mnh FDPschng ngng tp TCkim sot CMB v M , ngoi ra ha

hng ng BC monocyte.

Cac mnh X-Yc ch qu trnh polymer ha ca cc Fibrin monomerhn ch

qu trnh M ( Cc mnh E-D cng c tc ng ny nhng yu hn nhiu )

Cac mnh E-Dtng hiu lc ca cc cht hot ha plasminogen ( t-PA , tcu-PA ,

Kallikrein , XIIa,. )tng qu trnh TSH.

4. Hiu lc sinh hc ca cac mnh FDPs v c bn l c li cho c th , v chng

tham gia v h thng iu ha ng-cm mau v TSH , hn ch ti a qua trnh

tha , khng c li

_ Tuy nhin , trong mt s iu kin , th n l ngi n gy nn bin chng

bnh l huyt khi xut huyt.

V. CC XT NGHIM KHO ST QU TRNH TSH 1. Thi gian tiu euglobulin ( Nghim php Von-Kaulla )

_ Nguyn l XN : Huyt tng giu TC c pha long vi nc ct v acid

ha nhm lm ta yu t Fibrinogen v cc yu t hot ha TSH ( t-Pa ,

plasminogen hot ha ) , ng thi loi b cc yu t c ch TSH ( cht c ch

TSH , yu t VII t b ta). Sau ha tan ta vi nc mui sinh l , ri lm

ng tr li (nh Howell ).o thi gian t khi ng ti khi tan hon ton.

_ Mc ch ngha : anh gia mc hot ng ca h thng tiu si huyt

y l XN cn thit :

Theo di iu tr tiu huyt khi.

Chn on tnh trng tiu Fibrin tin pht v th pht , pht hin tnh trng tiu

Fibrin tim tang ( trong x gan , trc khi m tim )


48


_ Tin hnh :

+) Dng c : ng nghim , pipet , ng h , ni cach thy

+) Ha cht :A.acetic 2% ,

m Michaelis pH=7,35 ( empha long t l 1:4 vi NaCl 0,9%)

NaCl 0,9%

CaCl2 0,1M

+) Bnh nhn : Khng c dng thuc chng ng . Hi (Anh b bnh l M

g cha ? Ung thuc Aspirin khng ? iu tr Heparin khng ? ( ch hi ko

mt im , hoc s b nh hng n kt qu XN )

+)Quy trnh :

B1: Ly >2ml mau TMcho vo l Natricitrat 3,8% ti vch 2em ly tm

1500vng/10 ly huyt tng giu tiu cu.


B3: Ht 0,3ml huyt tng thm 3ml nc ctthm 1 git A.acetic 2% ,

kim tra c pH=5,2

B4: em ly tm 3000vng/15gn b phn trong (yu t c ch TSH) + gi li

phn trong ( yu t hot ha TSH)Dng giy thm, thm kh thnh ng (

loi b hon ton phn yu t c ch c th bm vo ng )

B5: Thm 0,3ml m Michaelis pH=7,35 ( pha )Dng que anh tan

tathm 1git CaCl2 0,1Mem vo ni 370C ch ngGhi thi im

ng v theo di thi gian tan hon ton , bng cch 15 nhc ng xem 1 ln.

_ Nhn nh kt qu : Thi gian tan tiu euglobulin bnh thng >60


49


Bnh l DICtiu th ht yu t M , yu t tiu Fibrinkhng th hnh thnh cc

ng hoc c ng nhng khng tan.

_ Cch phn bit hot ha Plasminogen qu mnh v tiu th ht

Thm 1 git huyt tng bnh thng vo dung dch euglobulin ri

thm Ca2+. Tin hnh nh KT , kt qu thu c :

+) C ng c nhng sau tan ngay tiu Fibrin qu mnh

+) C ng nhng >60khng tantiu th ht yu t hot ha

2. Nghim php ru (ethanol) v Nghim php Protamin sulphat

300ml huyt tng

3000ml nc ct

1 git A.acetic 2%

3000vng/15

m

Michaelis

pH=7,35

300ml 1 git Ca2+

vo ni 370C


50


_ Nguyn l XN: Thrombin tac ng ln Fibrinogen cac Fibrinmonomer ri tri qua

qua trnh polymer ha thnh Fibrin . Mt t Fibrinmonomer khng c polymer ha s

to thnh phc ha tan vi Fibrinogen v cc mnh FDPsPhc ny s c phat hin

nh Ethanol / Protamin sulphat do b gel ha.

_ Mc ch ngha : Nghim phap ru (ethanol) v Nghim phap Protamin sulphat

dng tnh chng t trong mu mau XN c phc hp ha tan l bng chng ca tnh

trng ng mau ri rac lng mch DIC. y l xt nghim chn oam DIC , tuy nhin

trng hp m tnh khng c ngha loi tr DIC.

_ Tin hnh :

+) Dng c : ng nghim , pipet , ni cach thy , may ly tm

+) Ha cht : Ethanol 50% , Protamin sulphat 1%

Chng(+): thm 0,1ml thrombin (0,2 v NIH/ml) vo 0,9ml huyt tng citrate

370/30si Fibrin s hnh thnhem quay ly tm phat hin r hn.

+) Bnh nhn : Khng c dng thuc chng ng . Hi (Anh b bnh l M g cha ?

Ung thuc Aspirin khng ? iu tr Heparin khng ? ( ch hi ko mt im , hoc s b

nh hng n kt qu XN )

+)Quy trnh nghim php ethanol

B1:Ly mau TM >2mlcho vo l Natricitrat 3,8% ti vch 2em ly tm 1000vng/10

ly huyt tng giu TC.

B2: anh s , ghi tn ng chng , ng th

B3: Ht 0,45 ml huyt tng giu TCthm 0,15ml Ethanol 50% y nt kn

370C/40 ly ng ra xem c gel ( ng ) kt qu (+) .

+) Quy trnh nghim php Protamin sulphat

Ht 1ml huyt tng giu TC cho vo 2 ng chng/ng th thm vo mi ng

0,05ml protamin sulphatt trong ni cach thy 3 Kt qu (+) khi c gel.

+) Nhn nh kt qu :

_ C gel (+) Bnh nhn c tnh trng DIC

_ Khng gel (-) Phi hp vi cc XN khc , cha loi tr DIC

Ch : Khng nn pha t cn 70 , cn 90 thnh cn 50 v s khng chnh xac. Do pha

nhiu ln gy ra sai s. Nn s dng cn tuyt i pha. Nu pha thp hn 50 th khng

to gel. Ln hn 50 s kt ta fibrinogen. Do o ngi ta thy 50 l tt nht.


51


3. nh lng D-Dimer trong huyt tng

_ Sn phm thoai ha Fibrin (FDPs) gm 4 mnh X-Y-E-D .

Sn phm thoai ha cui cng l D-D ( D-Dimer) . Nh vy

D-Dimer xut hin khi hnh thnh cc mu ng v cc mu

ng t tiu bi plasmin.

_Nguyn l XN :Dng ht latex gn KT n dng chng li

Fibrin D-dimerqua nh lng Fibrin D-dimer c trong

huyt tng.

_Nng bnh thng: Fibrin D-dimer = < 200 mg/l

_ Mc ch ngha : y l xt nghim c gia tr chn

oan huyt khi hay khng , tc mch do huyt khi hay do

nguyn nhn khac

D-dimer bnh thng : loi tr s hin din ca huyt khi trong c th

D-dimer tng cao : gp trong DIC , tuy nhin 1 sinh l bnh thng cng gp , nn

n khng c hiu chn oan cho bnh no c , cm lm thm cac XN khac.

Dng c ha cht :

B kit xt nghim D-dmimer gm :

+) Latex Reagent : hn dch latex gn KT , KN D-dimer

+) D-dimer hiu chun

+) Dung dch m pha long

+) Chng m , chng dng

+) Tm card thc hin phn ngBan nh lng bng tay

Tin hnh

_ Ly mau TM chng ng Natricitrat 3.8% ly tm 2500 vng/15 ly huyt

tng ngho TC

_ Ban nh lng ( lm bng tay )

+) Trong vng trn trn tm card lm xt nghim , thm 20l huyt tng cn kim

tra ( khng pha long )

+) Trong vng trn khac trn card , thm 20 l chng dng

+) Trong vng trn khac trn card , thm 20 l chng m

+) Thm vo mi vng trn 20 l Latex Reagent nghing v trn trong 3

+) Kim tra ngng kt , so sanh vi chng dng v chng m anh gia kt qu.

+) Trng hp dng tnh , ban nh lng bng cach pha long huyt tng cn

kim tra theo t l 1/2, 1/ 4, 1/8, 1/6


52


Mu kim tra Nng g/ml

nguyn Pha 1/2 Pha 1/4 Pha 1/8 Pha 1/6

(-)


53


Thuc th, ho cht

Dng thrombo-wellcotest kit (Wellcome reagents LTD. Beckenham, Kent)

Tin hnh k thut

- Tch huyt thanh:

+ Ly 2ml mu vo mt ng nghim chuyn dng cho xt nghim FDP (c cha

thrombin v cht c ch tiu m mu ng nhanh v ngn nga tiu si huyt invitro).

+ ng mu vo thng cch thu 37C cho n khi cc mu bt u co, quay ly tm

tch ly huyt thanh lm xt nghim.

- Thc hin phn ng: + Pha long huyt thanh 1/5, 1/20 vi m glycin c trong b kit.

+ Ly mt git hn dch mi pha long ca huyt thanh nh vo phin knh vi

mt git dch treo latex. Lc phin knh nh nhng cho n khi nhn thy ng-ng t bng mt

th-ng (thi gian khng qu 2 pht).

- Nu cht xt nghim l n-c tiu cng lm t-ng t nh- huyt thanh: cho 2 ml n-c tiu

vo ng chuyn dng, t vo thng cch thu 37C khong 30 pht, sau lc n-c tiu

qua giy lc hnh a (Whatman GF/B). Thc hin phn ng vi n-c tiu khng pha long

v pha long 1/5.

Kt qu

- Huyt thanh: nu ng-ng kt pha long 1/5 th l-ng FDP trong huyt thanh khng

qu 10 g/ml, nu ng-ng kt pha long 1/20 th l-ng FDP trong huyt thanh khng

qu 40 g/ml.

- N-c tiu: Nu ng-ng t n-c tiu khng pha long th FDP khng qu 2 g / ml, Nu

pha long 1 /5 th FDP c trong n-c tiu nguyn khng pha long khng qu 10 mg /

ml

- Kt qu ca ph-ng php dng latex t-ng t vi ph-ng php dng hng cu x l bng

acid tanic nh-ng n cho kt qu nhanh v tin cho nhng phng xt nghim khng lm

th-ng xuyn.


54


4.2 : nh l-ng FDP da vo ph-ng php min dch c ch ng-ng kt hng cu

Nguyn l FDP c tnh khng nguyn, s phn ng vi khng th khng fibrinigen ng-i.

Khi cho vo huyt thanh c FDP, khng th khng fibrinogen ng-i s b trung ho v do

gim kh nng ng-ng kt hng cu -c gn fibrinogen (c ch ng-ng kt hng cu)

Chun b thuc th, ho cht v dng c

a. Thuc th:

- Dung dch m pH 7,2

- KH2PO4 0,15 M 23,9 ml

- Na2HPO4 0,15 M 76 ml

- NaCl 0,85 % 100 ml

- Dung dch m phosphat citrat pH 6,4

- 0,35 th tch Na2HPO4 0,15 M

- 0,65 th tch KH2PO4 0,25 M

- 1 th tch Natri citrat 0,1 M

a. Huyt thanh ng-i bnh th-ng v huyt thanh bnh: - Ly 3 ml mu khng chng ng vo ng nghim c sn 10 mg cht c ch: acid amino

caproic (hoc cht c ch Kuniet).

- thng cch thu 370C trong 3 gi.

- Quay ly tm 3000 vng/pht trong 10 pht, tch ly huyt thanh.

b. Huyt t-ng chng:

- Trn huyt t-ng citrat ca nhng ng-i bnh th-ng cng nhm hng cu h ABO.

- Ly tm mnh 3000-5000 vng/pht trong 20 pht. nh l-ng fibrinogen trong huyt

t-ng .


55


c. Huyt thanh chng fibrinogen ng-i:

- Tim fibrinogen ng-i cho th to khng th. Khi c hiu gi cao t yu cu th ly mu

th khng chng ng thu huyt thanh, kim tra bng in di min dch v hiu gi khng

th tr-c khi l-u tr.

d. Hng cu ng-i nhm O hoc hng cu cu

- Ly 20ml mu, chng ng bng 3 ml ACD hoc citrat, mu l-u tr 2 ngy tr-c khi

cm nhim.

- X l hng cu vi acid tanic 1/200.000:

+ Ra hng cu 7 ln bng m pH 7,2.

+ Pha hng cu 5% trong m pH 7,2

+ X l vi acid tanic: 1 th tch hng cu 5 % vi 1 th tch acid tanic 1/200.000.

nhit phng (c th trong gii hn 22- 37 C ) trong 20 pht.

- Ra hng cu 3 ln bng m pH 7,2 v cui cng pha thnh hng cu 5 % trong m.

e. Dng c vi ng-ng kt, khay nha nhiu hng l.

Tin hnh k thut

a. Hiu gi khng th :

- Cm nhim hng cu

+ Hng cu 5% tip xc vi huyt t-ng ng-i pha long 1/250 trong dung dch m pH

7,2.

+ Hng cu 5% tip xc vi huyt thanh pha long 1/250

(1 th tch hng cu, 1 th tch huyt t-ng hoc huyt thanh pha long 1/250 370C

trong 30 pht).

+ Ra hng cu 3 ln ri pha li 5%.

- Chn nng khng huyt thanh

+ Pha long khng huyt thanh bng dung dch m pH 7,2 c cha 1% gelatin trn hai

hng l.

+ Hng l 1 s c thm hng cu 5% tip xc vi huyt t-ng pha 1/250


56


+ Hng l 2 c thm hng cu tip xc vi huyt thanh pha 1/250

+ nhit phng, sau 1-2 gi c ng-ng kt

+ Nng khng huyt thanh -c dng l nng ln hn 2 pha long so vi pha

long cui cng cn ng-ng kt.

b. nh l-ng FDP :

- Pha long huyt t-ng chun (Pool -c nh l-ng fibrinogen) trong m pH 7,2 c 1

% gelatin vi nng : 1/30, 1/90, 1/270, 1/540(Vi cc mu kim tra v huyt thanh

bnh th-ng (c cht c ch) th pha 1/3, 1/9, 1/27...)

- Cho 0,05 ml huyt thanh hiu gi chn vo mi l 10-30 pht 4C, thm vo mi

l 0,05 ml hng cu 5% cm nhim nhit phng 2 h.

Kt qu

- Chng d-ng l hng c huyt t-ng chun.

- Chng m l hng c huyt thanh ng-i bnh th-ng.

- Mc ng-ng kt pha long ca mu cn kim tra -c so snh vi huyt t-ng

chun.

Th d; huyt t-ng chun c cha 300mg/l, fibrinogen c ch ng-ng kt 1/600 th mi

pha long s l:

300 1000 1 = 0,5g/ml.

100 6000

Nu c ch ng-ng kt xy ra 1/80 ca hng mu cn kim tra th trong mu s c

0,5g/ml 80/1 =40g/mlFDP.

Bnh th-ng FPDs trong huyt thanh c t 0-5g/ml.

Nguyn nhn sai lm

- Nng acid tanic khng thch hp x l hng cu

- Khng huyt thanh khng m bo cht l-ng.


57


5. Xc nh s c mt cc cht khng ng ng ni sinh

_ Nguyn l

Thi gian mt xt nghim ng mau ko di do: thiu ht mt hay nhiu yu t M

hoc s c mt ca cht khng ng lu hnh.

Pht hin khng ng lu hnh da vo kh nng b ca cc yu t ng mu.

Thi gian ng ca hn hp 1 th tch huyt tng bnh thng v 1 th tch huyt

tng ca bnh nhn thiu ht 1 hay nhiu yu t ng mau s gn bng thi gian

ng ca huyt tng bnh thng.

Trai li, thi gian ng ca hn hp 1 th tch huyt tng bnh thng v 1 th tch

huyt tng ca bnh nhn c cht khang ng lu hnh s ko di gn bng thi gian

ng ca huyt tng bnh nhn.

_ Chun b

+) Dng c:ng nghim, pipet, ni cach thy, may ly tm

+) Ha cht:

- Natri citrat 3,8%

- Cephalin Kaolin

- CaCl2 M/40

- Huyt tng chng

+) Bnh nhn: Khng s dng cac thuc chng ng.

+) Tin hnh

- Ly mau, chng ng bng natricitrat 3,8% theo t l 1/10

- Ly tm tach huyt tng ngho tiu cu

- Pha hn hp huyt tng chng v huyt tng bnh theo t l 1:1

- Chun b 3 ng nghim, anh s 1,2,3

- ng 1 cho 0,1 ml hn hp huyt tng bnh nhn v huyt tng chng

- ng 2 cho 0,1 ml huyt tng chng

- ng 3 cho 0,1 ml huyt tng bnh nhn

- Thm vo mi ng 0.1 ml Cephalin Kaolin 37oC/ 3 pht.

- Thm 0,1 ml CaCl2 M/40 vo ng 1, bm ng h. Lc ti 9s, quan sat mng ng v

ghi kt qu.

- Kho sat ng 2 v 3 tng t. Ghi kt qu.

+) Kt qu:

Khi thy kt qu thi gian ng ca mu huyt tng hn hp chng v bnh gn vi

thi gian ng ca huyt tng bnh chng t s c mt ca cac cht khang ng lu

hnh.


58


Ch s Rosner: (+) ( )

( )

_ Nhn nh kt qu:

< 12 khang ng ni sinh (-)

12 15 khang ng ni sinh nghi ng.

> 15 Khang ng ni sinh (+)

C cac cht khang ng cac yu t: VIII, IX, XI, XII

Cc cht khng ng ni sinh bao gm:

+ Antithrombin III (AT III): khang XIIa, XIa, IXa, Kallinkrein ...

+ 1 Antitypsin: kallikrein, XIa

+ Cht c ch C1: kallikrein, XII, XIa

+ Protein C, Protein S: VIIIa

+ Khang th khang yu t VIII

+ Khang th khang yu t IX

+ Cht c ch trong bnh Lupus ban : gy ta phospholipid

Ngoi ra cn mt s yu t khac nh: nexin protease 1, 2 Macroglobulin

_ Cc yu t nh hng kt qu xt nghim:

+) Cht lng cephalin kaolin

+) Huyt tng chng tp hp ca t hn 10 ngi.

6.1 Xt nghim xc nh s c mt ca cc cht khng ng ngoi sinh

Nguyn l

Thi gian mt xt nghim ng mau ngoi sinh ko di do: hoc thiu ht mt hay nhiu

yu t ng mau hoc s c mt ca cht khang ng lu hnh.

Nguyn l phat hin khang ng lu hnh ngoi sinh da vo kh nng b ca cac yu t

ng mau. Thi gian ng ca hn hp 1 th tch huyt tng bnh thng v 1 th tch

huyt tng ca bnh nhn thiu ht 1 hay nhiu yu t ng mau s gn bng thi gian

ng ca huyt tng bnh thng. Trai li, thi gian ng ca hn hp 1 th tch huyt

tng bnh thng v 1 th tch huyt tng ca bnh nhn c cht khang ng lu hnh s

ko di gn bng thi gian ng ca huyt tng bnh nhn.

Dng c:

- ng nghim, pipet, ni cach thy, may ly tm


59


Ha cht:

- Natri citrat 3,8%

- Thromboplastin

- CaCl2 M/40

- Huyt tng chng

Bnh nhn:

- Khng s dng cac thuc chng ng.

Tin hnh

- Ly mau, chng ng bng natricitrat 3,8% theo t l 1/10

- Ly tm tach huyt tng ngho tiu cu

- Pha hn hp huyt tng chng v huyt tng bnh theo t l 1:1

- Chun b 3 ng nghim, anh s 1,2,3

- ng 1 cho 0,1 ml hn hp huyt tng bnh nhn v huyt tng chng

- ng 2 cho 0,1 ml huyt tng chng

- ng 3 cho 0,1 ml huyt tng bnh nhn

- Pha hn hp thromboplastin : CaCl2 M/40 theo t l 1:1.

- Thm 0,2 ml hn hp thromboplastin calci vo ng 1, bm ng h. Lc ti 9s, quan sat

mng ng v ghi kt qu.

- Kho sat ng 2 v 3 tng t. Ghi kt qu.

Kt qu:

Khi thy kt qu thi gian ng ca mu huyt tng hn hp chng v bnh gn vi thi

gian ng ca huyt tng bnh chng t s c mt ca cac cht khang ng lu hnh.

Ch s Rosner: (+) ( )

( )

anh gia kt qu:

< 12: khang ng ngoi sinh (-)

12 15: khang ng ngoi sinh nghi ng.

> 15: Khang ng ngoi sinh (+)

- C cac cht khang ng cac yu t: II, V, VII, X

Cc cht khng ng ngoi sinh bao gm:

+ Antithrombin III (AT III): Xa, Thrombin...

+ 1 Antitypsin: thrombin

+ 2 Macroglobulin: thrombin

+ Protein C, Protein S: thoai ha yu t V -> gian tip kim soat Xa v thrombin


60


+ Nexin protease 1

+ TFPI (tissue factor pathway inhibitor Cht c ch con ng yu t t chc)

+ Cht c ch trong bnh Lupus ban : gy ta phospholipid-> ng hng s chuyn

prothrombin(II) thnh thrombin(IIa). ng thi cnh tranh gy nh hng ti s hot ng

ca yu t X.

Cc yu t nh hng kt qu xt nghim:

- Cht lng thromboplastin

- Huyt tng chng tp hp ca t hn 10 ngi.

- Huyt tng qua 4 gi.

6.2 Xt nghim xc nh s c mt ca cc cht khng ng ( ni chung )

_ Nguyn l

Thi gian mt xt nghim ng mu ko di do: hoc thiu ht mt hay nhiu yu t ng mu hoc s c mt ca cht khng ng l-u hnh. Nguyn l pht hin khng ng l-u hnh da vo kh nng b ca cc yu t ng mu. Thi gian ng ca hn hp 1 th tch huyt t-ng bnh th-ng v 1 th tch huyt t-ng ca bnh nhn thiu ht 1 hay nhiu yu t ng mu s gn bng thi gian ng ca huyt t-ng bnh th-ng. Tri li, thi gian ng ca hn hp 1 th tch huyt t-ng bnh th-ng v 1 th tch huyt t-ng ca bnh nhn c cht khng ng l-u hnh s ko di gn bng thi gian

ng ca huyt tng bnh nhn. _ Dng c, thuc th, ho cht

- Bnh cch thu 37oC.

- ng nghim 75x9,5mm. - ng h bm giy. - Huyt t-ng chng. - Tu theo loi xt nghim cn tin hnh (thi gian prothrombin hay thi gian kaolin-

cephalin hot ho v.v) m chun b thuc th. _ Tin hnh k thut

- Ly mu tch huyt t-ng: nh- xt nghim thi gian Howell - Tin hnh xt nghim ng thi vi 3 mu huyt t-ng trong cng iu kin: + Mu huyt t-ng chng. + Mu huyt t-ng bnh. + Mu huyt t-ng hn hp chng v bnh theo t l 1/1. - Ghi thi gian ng ca c 3 mu. Trong mt s tr-ng hp, tin hnh li xt nghim vi c 3 mu sau khi 2 gi bnh cch thu 37oC. _ Kt qu

Thi gian ng ca mu huyt t-ng hn hp chng v bnh t l 1/1 ko di gn vi thi gian ng ca huyt t-ng bnh chng t s c mt ca khng ng l-u hnh. Cn tin hnh xc nh bn cht ca khng ng l-u hnh ny.


61


Thi gian

Cephalin Kaolin

Thi gian Prothrombin

Thi gian Thrombin

Cht khng ng l-u hnh chng:

Ko di Bnh th-ng Ko di Ko di

Bnh th-ng Ko di Ko di Ko di

Bnh th-ng Bnh th-ng Bnh th-ng Ko di

XII, IX, XI, VIII VIIa- thromboplastin t 61hoc. X, V, II Thrombin

7.Xc nh hot tnh yu t III ca Tiu cu.

_ Nguyn l: Hot tnh yu t 3 tiu cu xc nh bng s khc nhau ca thi gian -c

phc hi Calci ca huyt t-ng sau khi -c hot ha bi Kaolin tr-c v sau khi loi b

tiu cu. Bn nh l-ng -c nh gi qua -ng biu din thi gian ng ca huyt t-ng

bnh th-ng vi s l-ng tiu cu 50G/L , 25G/L 12,5G/L

Thuc th, ho cht

- Mu chng ng bng citrat natri3,8% t l 1/10 trong ng nghim nha hoc thy tinh

trng silicon. Quay li tm c huyt t-ng giu tiu cu v ngho tiu cu.

- Dng huyt t-ng ngho tiu cu pha long huyt t-ng giu tiu cu, c 50 109 v

12,5 109/ l, c th dng pool huyt t-ng ngho tiu cu ca ng-i bnh th-ng nh-ng

lu.

- Dng pool huyt t-ng ngho tiu cu bnh th-ng pha huyt t-ng giu tiu cu c s

l-ng tiu cu 50 109, 25 109 v 12,5 109/ l.

- CaCl M/ 40

- Kaolin 5mg/ml hoc celit 15mg/ml.

- m Michalis pH 7,3

Tin hnh k thut

- Trong cc ng nghim cha 0,1ml huyt t-ng c cha s l-ng tiu cu khc nhau: 50

109, 25 109 v 12,5 109/ l v ngho tiu cu chng, 50 109, 25 109 ; v ngho tiu cu

bnh.

- t vo thng cch thy 370C,cho thm 0,1 ml hn dch Kaolin 5mg/ml hay celit

15mg/ml lc u. ng 2 pht sau cho thm 0,1 ml CaCl M/ 40 bm ng h theo di thi

gian ng.

Kt qu


62


- S khc nhau gia thi gian ng ca ng huyt t-ng giu v ngho tiu cu ni ln hot

tnh yu t 3 tiu cu.

- Qua thi gian ng ca cc ng huyt t-ng chng ta v -ng thng chun trn giy bn

Logarit vi trc tung l thi gian ng, trc honh l cc nng tiu cu (50 109/l t-ng

-ng 100%, 25 109 /l t-ng -ng 50%...).T th ny tnh -c hot tnh yu t 3 tiu

cu ca bnh nhn qua thi gian ng.

Nguyn nhn sai lm

- Mu ly lu qu 3 gi mi lm xt nghim.

- Pha long tiu cu khng chnh xc.

8. nh lng yu t XIII

Nguyn l

Yu t XIII -c hot ho trong qu trnh ng mu nh Ion calci v thrombin. Yu t XIII hot ho lm n nh cc fibrin.

Khi c yu t XIII cc fibrin s khng ho tan trong dung dch ure 5 mol/l, cn cc fibrin -c to t huyt t-ng thiu yu t XIII s b tan.

Thuc th, ho cht

- Huyt t-ng Citrat ca bnh v ca chng.

- CaCl2 M/40

- Ure 5 mol/l (300 g/l)

Tin hnh k thut

- Chun b 2 ng nghim thu tinh 75 x12 mm

- Cho 0,2 ml huyt t-ng chng hoc bnh vo mi ng

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