rl huyet hoc trong ngoai khoa

8/14/2019 RL Huyet Hoc Trong Ngoai Khoa

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NGOI KHOA LM SNG-2007

RI LON CM MU-NG MU TRONGNGOI KHOA

1-i cng:

Qu trnh cm mu-ng mu bnh thng bao gm hai giai on:

o Cm mu nguyn pht (cm mu ban u) (hnh 1): Din ra ngay tc khc C hai yu t quan trng: tiu cu (kt tp to thnh nt chn tiu cu) v

thnh mch (hin tng co mch). Tiu cu kt dnh vo ni thnh mchb tn thng trc ti p hay thng qua cu ni vWF (yu t vonWillebrand).

Hnh 1- Cm munguyn pht

o Cm mu th pht (ng mu) (hnh 2): din ra chm (vi pht ti vi gi), dnn vic hnh thnh cc mu ng.

Qu trnh ng mu bt u bn ngoi lng mch (con ng ngoi sinh) hay bn tronglng mch (con ng ni sinh). C con ng ngoi sinh v ni sinh u dn n vichot ho yu t X, bt u con ng chung. Yu t X hot ho s chuyn prothrombin

thnh thrombin. Thrombin c hnh thnh s chuyn fibrinogen thnh fibrin. Cc sifibrin c hnh thnh s ph ln nt chn tiu cu, to thnh cc mu ng.

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Sau vi gi, cc mu ng bt u co li. Qu trnh co cc mu ng s lm cho hai mpvt thng thnh mch p li gn nhau, to iu kin cho tn thng mau phc hi.

Sau vi ngy, hin tng tiu si huyt bt u. Cc si fibrin s b ly gii bi plasmin.

Hnh 2- Cm mu thpht

Nhm c ch qu trnh ng mu qu mc, thc y s tiu cc mu ng mt khi tnthng thnh mch c sa cha, trong huyt tng lu hnh cc yu t trung hosau y:

o Prostacyclin (PGI2): do cc t bo ni mc mch mu tng hp. Tc dng: gydn mch v c ch s kt tp tiu cu.

o Antithrombin III (ATIII): c ch hot ng ca thrombin. Heparin, c snxut t basophil v mast cell, c tc dng hot ho antithrombin III.

o Protein C (cng vi cofactor protein S): c ch yu t Va v VIIIa.Thrombomodulin, c sn xut bi cc t bo ni mch, kt hp vi thrombinv sau hot ho protein C.

o Plasmin: phn ct fibrin thnh cc sn phm ging ho ho tan c.Cc xt nghim nh gi qu trnh cm mu-ng mu:

Qu trnh cm mu ban u:o S lng tiu cu

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o Thi gian chy muo Tm sot bnh von Willebrand:

vWF antigen (vWF:Ag): nh lng protein vWF trong tun hon bngphng php ho nghim min dch.

Hot ng vWF (vWF:RCo): nh gi hot ng chc nng ca vWF. Hot ng ca yu t VIII (VIII:C): vWF c tc dng n nh yu t VIII.

Mt vWF protein trong huyt tng lm gim VIII:C.

Qu trnh ng mu:o Thi gian thromboplastin (aPTT):

nh gi cc yu tng mu theo con ng ni sinh (kininogen TLPTcao, prekallikrein, XII, XI, IX, VIII) v con ng chung (fibrinogen, II,V, X).

aPTT ko di: c s thiu ht hay c ch bt c yu tng mu no, tryu t VII.

Dng theo di qu trnh iu tr bng heparin.o Thi gian prothrombin (PT):

nh gi cc yu tng mu theo con ng ngoi sinh. Nu PT ko di, cn kt hp vi aPTT nh gi cc yu tng mu:

PT ko di, aPTT bnh thng: bt thng (thiu ht hay c ch)yu t VII.

C PT v aPTT ko di: bt thng xy ra con ng chung. Ch s INR (international normalized ratio): c dng theo di iu

tr khng ng vi warfarin.

INR= (PT ca BN/PT chng)ISI(ISI: ch s nhy-international sensitivity index)

Gii hn ca iu tr warfarin: INR=2-4o Thi gian thrombin: nh gi s thiu ht v cht lng v s lng ca

fibrinogen.

2-Tnh trng gim ng mu:

2.1-Tnh trng gim ng mu mc phi:

2.1.1-Thiu vitamin K:

Vitamin K cn thit cho qu trnh tng hp 4 yu tng mu (II, VII, IX, X) v 2 yut khng ng t nhin (protein C v S).

Nguyn nhn ca s thiu ht vitamin K:

o Chn ung khng y o Dinh dng qua ng tnh mcho

Hi chng km hp thuo Vng da tc mt, d mt

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o TC = 10.000-20.000: chy mu c th t pht.o TC < 10.000: chy mu t pht v thng trm trng.

iu tr chng gim tiu cu:

o Loi b cc nguyn nhn, ngng x dng cc loi thuc gy gim tiu cuo Truyn tiu cu lng: (khi c bin chng chy mu)o Corticoid (c chnh trong mt s trng hp)

2.1.4-Ri lon chc nng tiu cu:

Nguyn nhn ca ri lon chc nng tiu cu (bng 1):

o Hu ht l do thuc (aspirin, thuc ho tr, ru, estrogen, thiazide, khng sinh(sulfamide), quinidine, quinine, metyldopa).

o Tnh trng tng ur huyt tngo

Ri lon chc nng tiu cu do di truyn (hi chng Bernard-Soulier).Kiu c im Nguyn nhn

Bt thng mng Hi chng Bernard-SoulierBt thng ht (thiuht alpha)

Hi chng tiu cu xm (gray platelet syndrome)Bm sinh

Thiu mt yu thuyttng

Bnh von Willebrand

Sn xut tiu cu btthng

Tng sinh tu, d sn tuMc phi

Ri lon chc nngtiu cu bnh thng

Bnh ton thn (tng ur huyt tng, bnh gan), thuc.

Bng 1- Nguyn nhn ca ri lon chc nng tiu cuTriu chng (bng 2):

Ri lon tiu cu Thiu ht cc yu tng muV tr ch y mu Da, nim Su trong c, khpim xut huyt (+) (-)Mng xut huyt Nh , nng Ln, sc

Xut huyt trong c, kh p Him PhbinXut huyt sau cc vt ct nh Phbin HimXut huyt sau phu thut Tc th, nh Chm, trm trng

Bng 2- So snh biu hin chy mu ca cc ri lon ng mu

iu tr ri lon ng mu do ri lon chc nng tiu cu:o Do thuc: ngng cc loi thuc.o Tng ur huyt tng:

Demopressin (DDAVP-diamino-8-D-argininevasopressin): 0,3g/kgTDD hay pha trong 50 mL NaCl 0,9% TTM trong 30 pht.

Trng hp nng: thm phn muo Khi c bin chng chy mu: truyn tiu cu lng.

2.1.5-Gim thn nhit:

Gim thn nhit l nguyn nhn ph bin nht nhng t c nghn nht trong ngoikhoa

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Thng gp nht sau truyn mu khi lng ln

Nguyn tc iu tr: lm m BN cng sm cng tt.

2.1.6-ng mu ri rc trong lng mch (DIC-disseminated intravascularcoagulation):

ng mu ri rc trong lng mch l mt ri lon ng mu nng, c t l t vong cao.C ch sinh l bnh hc: s mt cn bng gia hot ng to cc mu ng cathrombin v hot ng tiu cc mu ng ca plasmin, biu hin bng:

o Hot ng tng ng (s hnh thnh cc huyt khi trong lng mch)o Hot ng tiu si huyt (hin tng chy mu)o S suy chc nng ca cc cquan

Cc bnh cnh lm sng kt hp vi DIC: chn thng nng, nhim trng, thai k,truyn nhm nhm mu, rn cn, mt s bnh l c tnh

Chn on DIC:o Tm sot DIC:

Xt nghim tm sot: PT, D-dimer, fibrinogen, s lng tiu cu Bt thng 2/4 xt nghim: c kh nng DIC Bt thng 3/4 xt nghim: nhiu kh nng DIC Bt thng c 4 xt nghim: hu nh chc chn DIC

o DIC th cp tnh: PT v aPTT ko di, s lng tiu cu v fibrinogen gim (bng 3) D-dimer, FDP, fibrin monomer tng

o DIC th bn cp: PT v aPTT ko di hay bnh thng, s lng tiu cu v fibrinogen

gim nh hay trung bnh

D-dimer, FDP, fibrin monomer tng nhiu tr DIC:

o iu tr cc bnh l kt hp: khng sinh trong nhim trng, can thip phu thutcc trng hp chuyn d c bin chngy l bc iu tr quan trng nht.

o B xung cc thnh phn mu b thiu ht: truyn tiu cu, cryoprecipitate (bxung fibrin), FFP

o Heparin (vic s dng cn ang bn ci)2.2-Tnh trng gim ng mu bm sinh:

2.2.1-Hemophillia:

Hemophillia l mt ri lon bm sinh, di truyn theo nhim sc th X, gy thiu ht yut VIII (hemophilia A) hay IX (hemophilia B).

Chn on hemophillia da vo:

o aPTT ko di

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o PT, thi gian chy mu v s lng tiu cu bnh thng (bng 3)o Gim yu t VIII (hemophilia A), hay IX (hemophilia B)

Lng gi mc ca hemophillia: nng yu t VIII (hay IX):

o < 1% mc bnh thng: nngo 1-5% mc bnh thng: trung bnho > 5% mc bnh thng: nh

iu tr hemophillia:

o DDAVP: dng qua ng TM hay kh dung, c tc dng nng tm nng yut VIII trong hemophilia A th nh.

o Cc ch phm ca yu t VIII v IX: tinh khit thp tinh khit TB tinh khit cao

VIII Cryoprecipitate Humate-P

Koate-HPFacoe VIII-SD

Proliferate-OSD

AHF-M

AlphanateHemophile-MMonoclate-P

Recombinate

IX KonyneProplex T

Profilnine HTBebulin VH

MononineFactor IX-SDAlphanine-SD

BeneFIX

Yu cu ca vic iu tr hemophillia l nng nng cc yu t VIII (hay IX) ln:

o Trn 30% mc bnh thng: trc khi thc hin cc cuc tiu phu hay BN bchy mu nh.

o Trn 50% mc bnh thng: trc khi thc hin cc cuc trung phu hay BN bchy mu trung bnh.

o 100% mc bnh thng: trc khi thc hin cc cuc i phu hay BN b chymu nng.

2.2.2-Bnh von Willebrand:

Bnh von Willebrand ri lon ng mu do di truyn ph bin nht (chim khong 1%dn s). 80% bnh th nh.

C ch ca bnh von Willebrand: gim v s lng hay cht lng ca yu t von

Willebrand (vWF). Vai tr ca vWF: thc y s gn kt tiu cu vo ni thnh mch btn thng v n nh yu t VIII.

Phn loi bnh von Willebrand:

o Typ 1 (70-80%): gim s lng vWF mc nho Typ 2: gim cht lng vWFo Typ 3: gim s lng vWF mc nng

Chn on bnh von Willebrand:

o S lng tiu cu: bnh thngo Thi gian chy mu: ko di

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o Von Willebrand typ 1 v 3: vWF:Ag gim, VIII:C gimo Von Willebrand typ 2: VIII:C bnh thng, vWF:RCo gim vut tri hn so vi

vWF:Ag

iu tr bnh von Willebrand:

o Chy mu nh: DDAVPo Chy mu trung bnh: cryoprecipitateo Phng nga khi phu thut: DDAVP, bt u cho trc m 1 giv ko di sau

m 2-3 ngy, kt hp vi cryoprecipitate nu cuc phu thut ln.

Ri lon Slng tiu cu PT aPTTGim tiu cu Th p Bnh thng Bnh thng

Ri lon chc nng tiu cu Bnh thng Bnh thng haythp

Bnh thng

Chy mu do nguyn nhn thnh

mch

Bnh thng Bnh thng Bnh thng

Bnh von Willebrand Bnh thng Bnh thng Ko di Hemophillia A Bnh thng Bnh thng Ko di DIC Th p Ko di Ko di

Bng 3- Kt qu xt nghim ca mt sbnh l chy mu

2.3-Truyn mu:

2.3.1-Chnh truyn mu:

o Mt mu do chn thng, bnh l, phu thuto Thiu mu, bao gm bnh hng cu limo Cc ri lon ng mu (von-Willebrand, hemophilia)o Suy gim min dcho Leukemiao Bt tng hp nhm Rh tr ssinh

2.3.2-Cc thnh phn ca mu c truyn v chnh:

2.3.2.1-Mu ton phn:

Chun b:

oLy mu t tnh mch ngi cho

o Xt nghim nhm mu v: Khng nguyn b mt ca virus vim gan B (HBsAg) Khng th khng nhn ca virus vim gan B (anti-HBc) Khng th khng virus vim gan C (HBC) Khng th khng virus gy suy gim min dch mc phi HIV-1 v HIV-2

(anti-HIV-1, anti-HIV-2)

Khng th khng virus gy gim lympho bo T (human T-lymphotropicvirus) (anti-HTLV-1, anti-HTLV-2)

Xt nghim huyt thanh giang mai

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o Chng ng.o ng gi (200 mL)o Bo qun (ti a 42 ngy)

Ch nh: mt mu c p tnh do bnh l (lot d dy-t trng, v dn tnh mch thc

qun), chn thng hay phu thut.2.3.2.2-Hng cu:

Chun b: mu ton phn c quay ly tm ly phn hng cu lng bn di cho vocc dung dch bo qun. Thi gian lu tr 21-42 ngy.

c im: lm tng kh nng vn chuyn oxy (tng hematocrit v Hb) nhng hn chc s tng th tch trong lng mch.

Chnh:

o Theo bnh l: Thiu mu mn tnh do suy thn, cc bnh l c tnh Thiu mu trn BN suy tim Thiu mu trn BN ln tui, suy kit

o Theo nng Hb: Hb < 7 g/dL: cn phi truyn mu (hay hng cu) Hb > 10 g/dL: him khi cn phi truyn mu (hay hng cu) Hb gia 7 v 10 g/dL: tu thuc vo tnh trng BN v tnh cht ca cuc

phn thut m quyt nh c nn truyn mu (hay hng cu) hay khng.

2.3.2.3-Huyt tng:

Huyt tng l phn dch cn li sau khi mu ton phn c tch ly hng cu.

Huyt tng cha albumin, globulin v cc yu tng mu.

Huyt tng ti ng lnh: mu ton phn, trong vng vi giu k t khi c ly tngi cho, c trch ly phn huyt tng. Phn huyt tng ti ny sau cng lnh, bo qun, v ho lng trc khi truyn cho BN. Thi gian bo qun c th t1-7 nm. Huyt tng ti ng lnh cha y cc yu tng mu.

Chnh truyn huyt tng ti ng lnh:

o Cc ri lon ng mu do thiu cc yu tng mu (bnh gan, thiu vitaminK, truyn mu khi lng ln, bnh ng mu ri rc ni mch...)o Liu php thay th huyt tng (plasma exchange)

2.3.2.4-Tiu cu:

Tiu cu c ly t phn huyt tng giu tiu cu (phn huyt tng ngay trn phnhng cu lng sau khi ly tm). Phn huyt tng ny sau c quay ly tm c ctiu cu m c.

Thi gian bo qun: ti a 5 ngy.

Chnh truyn tiu cu: cc ri lon ng mu do gim tiu cu hay suy chc nng tiu

cu. C th:

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o TC < 10000.o TC < 50000 v c biu hin chy mu vi mch (oozing) hay chun b cho th

thut xm ln/phu thut.

o Cuc phu thut c bin chng, phi truyn hn 10 n v mu v c du hiuchy mu vi mch.

o Ri lon chc nng tiu cu (thi gian chy mu hn 15 pht, bt thng ccxt nghim nh gi chc nng tiu cu) trn BN c ban xut huyt, mng xuthuyt, chy mu vi mch hay chun b cho th thut xm ln/phu thut.

2.3.2.5-Cc cht phn tch thuyt tng:

Huyt tng c thc phn tch thnh cc thnh phn ring bit. Cc thnh phn nyc x l bng nhit hay cc dung dch dit trng trc khi bo qun.

Cc cht c phn tch t huyt tng:

o Yu t VIII m co Yu t IX m co Albumino Cc globulin min dcho Anti-thrombin III m co Cht c ch alpha-1 proteinase m c...

2.3.2.6-Cryopricipitate:

Cryopricipitate l phn ca huyt tng cha cc yu tng mu vi nng cao.

Cryopricipitate c chnh ngn nga hay iu tr cc ri lon ng mu trongbnh hemophilia hay von-Willebrand.

2.3.3-Tai bin v bin chng:

Cc phn ng do truyn mu:

o Trm trng nht l phn ng tn huyt do bt tng h p nhm mu. Triuchng c th xy ra sau mt vi gin mt vi ngy. Chn on: nu BN tnhto s cm nhn ngay c bt thng trong c th. Nu BN m, triu chng sth hin bng tnh trng tt huyt p, hemoglobin niu v chy mu vi mch lanto. Chn on xc nh: mang ngay mu mu truyn (hay mu dy truyn mu)cng mu mu BN (ly v tr khc) xung ngay phng xt nghim. X tr:ngng ngay vic truyn mu, truyn dch duy tr HA, li tiu vi manitol.

o Cc phn ng khng tn huyt: thng l do tc ng ca khng th trong mungi nhn i vi bch cu hay protein trong mu c truyn. Triu chngthng l st v n lnh.

Nhim trng t mu ngi cho: do Epstein-Barr virus, cytomegalovirus, HIV, giang mai,st rt, yersinia enterocolitica...

Bin chng ca truyn mu khi lng ln:

o H thn nhito Gim tiu cuo Thiu ht cc yu tng mu

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o Ri lon kim toan: nhim kim hay nhim toan chuyn ho, tu thuc vo khilng mu c truyn v mc chuyn ho ca acid lactic v citrate thnhHCO3

- trong cth ngi nhn.

o Gim can-xi huyt tngo Tng kali huyt tngo Tng i lc ca hng cu vi oxy: mu lu tr c nng 2,3-DPG thp, do

hng cu tng i lc vi oxy khi c truyn vo cth ngi nhn, lm gimcung cp oxy cho t bo. Mt vi gisau khi truyn, lng 2,3-DPG tng trliv hin tng ny s chm dt.

2.3.4-Mt s phng php truyn mu c bit

2.3.4.1-Truyn mu tthn:

Phng php:

o Mu c ly t chnh BNo Mi tun c th ly c 1 n v muo Ti a c th ly c 6 n v muo Vic ly mu ngng ti thiu 72 gitrc mo Cn b xung cht st cho BN tu xng c nguyn liu tng hp cc t

bo mu mi.

Chnh: trc cc cuc phu thut c kh nng mt nhiu mu (chnh hnh, tim, mchmu ln...). Khi s mt mu xy ra, ly mu c lu tr trc ca chnh BNtruyn li cho BN.

Nu cuc m khng cn truyn mu, lng mu c d tr phi bi m khngc truyn cho ngi khc.

2.3.4.2-Pha long mu trc m:

Trong phng php pha long mu trc m, mu c ly ngay trc cuc m. Lngmu mt c bi hon y bng dch truyn. Theo cch ny, mu BN b pha longhn. Do , nu c mt mu trong lc phu thut, lng mu tht s b mt s t hn.

Mu c ly trc m sc truyn trli cho BN sau m

Khi chnh phng php ny, cn ch l BN phi sc chu ng tnh trng thiumu do mu b pha long trong lc phu thut.

2.3.4.3-Truyn mu hon hi:

Ni dung: mu c thu hi trong lc phu thut v truyn trli cho BN.

Mu c truyn phi khng b dy trng. Nu c tn thng ng tiu ho phi hp,khng c truyn mu hon hi cho BN.

Cn c thit b tp trung hng cu. Hng cu sau c ra trc khi truyn.

Nu truyn li mu ton phn, mu phi c kim tra xem c b tn huyt hay khng.

3-Tnh trng tng ng mu:

3.1-Nguyn nhn:

Tnh trng tng ng mu nguyn pht (c tnh di truyn):

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o Bt thng yu t V (yu t V Leiden): l nguyn nhn tng ng mu nguynpht ph bin nht. Yu t V Leiden c tnh khng vi Protein C.

o Prothrombin 20210: c s t bin ca gene chu trch nhim tng hpprothrombin. BN c nng prothrombin trong huyt tng tng cao hn mcbnh thng.

o Chng tng homocystein huyt tng nguyn pht: lm xho ni mc mchmu, ph hu cu trc collagen thnh mch.

o Thiu ht antithrombin IIIo Thiu ht Protein C v S

Tnh trng tng ng mu th pht:

o Thai ko Lin quan n estrogen (thuc nga thai, ch phm thay th estrogen,

tamoxifen).

o Chn thng, phu thutoNhim trng huyto Cc bnh l c tnh (20% cc trng hp huyt khi khng r nguyn nhn c

lin quan n bnh l c tnh).

o Cc nguyn nhn khc: tng sinh tu, tng lipid huyt tng, tng homocysteinhuyt tng th pht, khng th khng phospholipid, hi chng thn h

3.2-Chn on:

Tnh trng tng ng mu c thc nghn khi:

o Huyt khi xut hin khi tui cn tr (di 50)o Gia nh cng c ngi b huyt khio Huyt khi ti pht nhiu lno Huyt khi v tr bt thngo Ph n xy thai nhiu ln

Tu thuc vo nguyn nhn, cc xt nghim sau c thc chnh:

o Cng thc mu ton bo PT, aPTTo Khng th khng nhn, khng th khng phospholipido Khng protein C hot ho (APC resistance)o Homocysteino Phn tch t bin gen tng hp Protein Co Protein C, Protein So Antithrombin IIIo Yu t VIII

3.3-iu tr huyt khi:

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Thi iu tr huyt khi mch mu ph thuc vo vic nh gi nguy cxy ra huytkhi (bng 4, 5).

Th p Trung bnh CaoB huyt khi mch mu ln

u vC yu tnguy cv

Khng c yu tgia nh

Tui trn 50 vB huyt khi mch mu ln

u vKhng c yu tnguy cv

Khng c yu tgia nh

Tui nh hn 50 v khng cyu tnguy c, hay

Huyt khi ti pht, hocC yu tgia nh(*)

Bng 4- Nguy cxy ra huyt khi mch mu(*)Yu tgia nh: gia nh c ngi trc h b huyt khi khi di 50 tui.

tr tun hon tnh mch:Btng ko di (sau phu thut, taibin mch mu no, chn thng tu

sng)Dn tnh mchBo phBnh tim (suy tim huyt, rung nh,nhi mu ctim)

Trng thi tngngTn thng ni mc:

Chn thng trc tipPhu thut (c bit phu thut bngv chnh hnh)t thng tnh mch (c bit tnhmch i)

Bng 5- Yu tnguy cca huyt khi mch mu

Nguy ccao: iu tr khng ng sut i.

Nguy ctrung bnh: iu tr khng ng theo hon cnh (khi c yu t nguy c).

3.4-Thuc khng ng:

3.4.1-Heparin:

Heparin l cht khng ng t nhin, c chit xut t mast cell v basophil.

Cch hot ng ca heparin l xc tc qu trnh bt hot thrombin, yu t Xa v IXa

bi antithrombin III.Khi iu tr vi heparin, thi gian thrombin v aPTT ko di, PT khng thay i.

Thi gian tc dng khi iu tr vi heparin: ngay tc th nu s dng qua ng TM v20-60 pht nu TDD.

Liu s dng heparin (bng 6):

Khi u: Bolus 80 U/kg (ti a 12.000 U)Truyn TM 18 U/kg/gi(ti a 2700 U/gi)

iu chnh:

aPTT < 40 80 U/kg bolus; tng tc truyn ln 4 U/kg/giaPTT = 40-54 40 U/kg bolus; tng tc truyn ln 2 U/kg/giaPTT = 55-80 GinguynaPTT = 81-99 Gim tc truyn xung 2 U/kg/giaPTT > 99 Ngng 1 gi; gim tc truyn xung 3 U/kg/gi

Bng 6- Liu sdng heparin

Theo di bng xt nghim khi s dng heparin:

o aPTT: trc khi iu tr, mi 6 gisau khi iu tr cho n khi n nh th ngymt ln. Tiu chun n nh: aPTT th hai ln ring bit trong ngy u tronggii hn iu tr.

o S lng tiu cu: tin hnh hng ngy.

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o PT: tin hnh hng ngy.o Hct, Guaiac, tng phn tch nc tiu: tin hnh hng ngy.

Ch :

o Khng s dng aspirin, dipyridamole, NSAID ng thi vi heparin.oNgng s dng heparin khi tiu cu 100.000.

Bin chng chy mu khi s dng heparin :

o T l xy ra bin chng: 5-10%.o Cc yu t lm tng nguy cchy mu: tui > 60, hu phu, chn thng, tng

huyt p, lot d dy-t trng, suy gan, suy thn, ang s dng aspirin,dipyridamole, NSAID, BN c cc ri lon ng mu bm sinh hay mc phi.

o iu tr: chy mu nh: ngng s dng heparin. Chy mu nng: trung ho bngprotamine sulfate. Liu protamine sulfate: 1 mg/100 U heparin trong tun hon.

Nu ang truyn heparin, liu protamine sulfate c tnh ton trung ho liu heparin mi gi.

3.4.2-Heprin trng lng phn t(TLPT) thp:

Heprin TLPT th p (bng 7) bt hot yu t Xa vi mc ln hn so vi bt hotthrombin. Do , vi liu iu tr, thi gian thrombin v aPTT khng thay i ng k,vic theo di bng cc xt nghim ny trnn khng cn thit.

Tn thuc Liu lng Dalteparin (Fragmin) 100 U/kg x 2 /ngy Enoxaparrin (Lovenox) 100 U/kg x 2 /ngy Nadroparin (Fraxiparin) 225 U/kg x 2 /ngy

Reviparin (Clivarin) 100 U/kg x 2 /ngyTinzaparin (Logiparin) 175 U/kg, mt ln/ngy

Danaparoid (Orgaran)(chdng cho BN b gim TC do heparin)

750 U x 2 /ngy

Bng 7- Liu sdng ca mt sheparin TLPT thp

3.4.3-Warfarin:

Cch hot ng ca warfarin: c ch s chuyn vitamin K sang th hot ng, do lm gim cc yu tng mu ph thuc vitamin K (II, VII, IX, X) v protein C v S.

Warfarin hp thu tt qua ng rut, nhng cn thi gian 4-5 ngy c tc dng khngng.

Nn bt u iu tr bng warfarin vi liu thp (5 mg/kg/ngy), sau iu chnh tn ch s INR mong mun. Trong hu ht cc trng hp, INR trong khong 2-3 l .

Nu BN chun b phu thut: ngng warfarin 7 ngy trc phu thut, chuyn sang sdng heparin nu cn chnh dng thuc khng ng. Ngng heparin ngay trc khi

phu thut.

Bin chng: chy mu xy ra vi t l 10-20%. iu tr: tu thuc vo mc chy mu,c th dng vitamin K hay FFP.

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