Dch truyn s dng trong lm sng

I. Khi nim:
Gm nhng loi dung dch c a vo co th trong mt thi gian nht nh nhm mc ch iu tr khc nhau. Mc ch
iu tr rt a dng, do vy dch truyn cng c nhiu loi khc nhau v yu cu i vi chng cng rt cao m trn thuc t
rt kh p ng y .
Yu cu ca mt loi dch truyn l tng:
1. C th a nhanh vo mch mu mt khi lng ln: Truyn nhanh, nhiu nhm khi phc nhanh khi lng tun hon
trong mt s loi sc v gim khi lng mu lu hnh (KLMLH).
2. C kh nng gi lu trong lng mch: Su tn ti ca dch truyn trong lng mch cn duy tr t nht l 24 gi. iu ny
quyt nh tnh bn vng, hiu qu v nguy co nc t chc, to iu kin cho kh nng b p ca co th.
3. Bi tit qua thn nhanh chng: o thi nhanh qua thn rt c nghia v mt gii c, truyn qu ti v nc t chc.
4. C kh nng ci thin tnh lu huyt ca mu: Tnh cht ny nhm gim nht ca mu, ci thin h thng vi tun hon,
ngn cn su ng vn ca hng cu, tiu cu...
5. C tnh cht sinh hoc gn ging vi tnh cht ca mu: C tnh khng th, trao i kh, khng nh hng ti chc nng
ng chy mu..
6. Khng c tnh khng nguyn: Tnh khng nguyn ca dch truyn s gy hin tng gii phng Histamin, phn ng phn
v..., khng m bo tnh an ton cho cc ln truyn dch tip theo.
7. Khng c c tnh: L iu kin cn thit cho tt c cc loi thuc khi a vo co th. Vi dch truyn, khi cn s dng vi
khi lng ln, n hon ton khng c kh nng nh hng xu ti chc nng gan, thn, tim mch v chuyn ho...
8. Hon ton ho hp vi mu ca bnh nhn v mt s loi thuc khc: iu co bn l khng thay i cc c tnh sinh - l -
ho hoc ca mu ngi bnh. Trong iu tr cn dng chung vi mt loi thuc khc (khng sinh, tr tim mch....) th tnh
cht ca dch truyn vn c gi nguyn tc dng.
9. C kh nng truyn vo co th qua nhiu ng khc nhau: Tinh mch, ng mch, di da, trong xong, vt xp...cho
php d dng s dng, p ng c vi tnh a dng ca lm sng, k c khi khng choc c tinh mch.
10. Gi thnh r, d s dng, bn vng trong nhng iu kin bo qun khc nhau (nhit , m, nh sang...).
II. Phn loi dch truyn:
Dua vo tnh cht, tc dng ca dch truyn m ngi ta phn ra cc loi khc nhau. Tuy nhin su phn loi cng ch mc
tong i do tc dng ca chng an xen nhau v mc ch iu tr khc nhau.
A. Dung dch tinh th (Cristltic !olution"
L cc dch c th thot ra khi lng mch i vo khong k. Thng l mt hn hp ca natri clorua vi cc dung dch sinh l
khc, trong ch yu l natri. Su phn phi ca natri trong co th quyt nh ti su phn b ca cc dch tinh th truyn
vo. Natri l ion chnh ca dch ngoi bo v chim ti 80% lng ion ca dch khoang ngoi mch do natri truyn vo
khuch tn ch yu ra ngoi lng mch. Chnh v vy, cc dch tinh th ch yu lm tng th tch khong k, ch c khong
20% lm tng c th tch trong lng mch.
Chng c s dng trong cc trng hp mt nc ngoi t bo v mt mu. Trong trng hp mt mu cp tnh (hoc
gim khi lng tun hon cp tnh) c su huy ng dch k vo trong lng mch v chng phi c b p. Vic truyn dch
tinh th b p lng dch k thiu ht kt hp vi truyn mu lm tng mt cch r rng t l cu sng trn thuc nghim
cng nh trn lm sng, n lun c s dng u tin trong cc trng hp chn thong.
1. Dung dch mui atri chlorur!: Dung dch mui Natrichclorure c ba loi:
- L dung dch tinh th cha 9 gr natri clorua trong mt lt nc ct (dung dch 0, 9%). C c tnh u trong nhe so vi
huyt tong, pH acide nn c nguy co nhim toan chuyn ha v tng clo mu tuy him gp.
- Natrichlorure u trong 7. 5%; 10%, (Hypertonic Saline) s dng cho cc trng hp mt mui nhiu hon mt nc.
- Natri chlorure nhc trong (Hypotonic Saline): C nng Natri chlorure thp hon 9%o, v nh vy p luc thm thu ca
dung dch s thp hon p luc thm thu ca mu ngi bnh thng.
". Dung dch #ing!r lactar!:
L mt dung dich tong i cn bng cc thnh phn in gii cha trong n nh l natri, kali v canxi, cn lactate c thm
vo nh mt cht m. Dung dch ringer lactate cng thng c s dng trong hi sc chn thong tr cc trng hp
chn thong so no do c c tnh hoi nhc trong so vi huyt tong. Lactate vo co th c chuyn thnh bicacbonate
trong gan v hot ng nh mt cht m. Ringer latate khng c u im g so vi huyt thanh mn ng trong. Chng
cng c mt s nhc im: ngoi cc sn phm mu v mu th cn nhiu thuc khng tong hp vi ringer lactate v c th
kt ta vi canxi. Cc dung dch lactate cng khng c dng trong trng hp suy thn v suy thng thn. Canxi cng
nguy him trong trng hp thiu khi lng tun hon v n to thun li cho vic khng ti ti mu trong hi sc sc mt
mu.
#. Dung dch dinh d$%ng:
1. Dung dch $lucid:
1.1 Dung dch $luco%!: l mt trong nhng cht cung cp nng lng chnh cho co th hot ng.
Dung dch glucoza c hai loi: ng trong 5%, u trong 10%, 20%, 30% .S dng Glucose u trong dng cho tr em phi
ht sc thn trong, cn nhc ky v theo di cn thn. Khi truyn nhiu cn thm Insulin 1IV/4 Glucose (on v/4g glucose).
Dung dch glucose v thiu mu no:Thng thng, hydrate carbone c th lm nng thm cc tn thong thiu mu, c
bit l cc di chng thn kinh do ngng tim. Phn ln nng lung cung cp cho no l do glucose. Trong trng hp thiu mu
no, truyn glucose, do chuyn ho ym kh, s sn sinh mt lng ln acide lactic. Lng acide ny tch t ti ch s cng
lm gim lu lng mu no v lm nng thm cc tn thong thiu mu (trong cc nghin cu thuc nghim, cho thy vic
truyn glucose trong hi sc ngng tim phi lm tng t l t vong). Tm li, khi khng c cc ch nh c bit, khng nn
truyn glucose cho cc bnh nhn c nguy co thiu mu no.
1." Dung dch &ructo%! '( )or*it:
Dung dch Fructose, Sorbit ch dng cho cc bnh nhn tng ng mu nng v n c tc dng ko di thi gian gii phng
Glucose t gan v gim nh cao nng Glucose mu. Tuy vy tng dung lng ca gan i vi cc cht thay th ny rt
hn ch. Trong cc trng hp bnh nhn khng dung np c Fructose, Sorbit th truyn dung dch ny rt nguy him do
vy ch s dng cc co s c phong tin theo di.
". Dung dch +,it amin:
Nhu cu Axit amin ca co th l 0, 5 - 2g/kg/ngy. Khi truyn cc dung dch axit aminbao gi cng truyn km dung dch
Glucose trnh qu trnh chuyn ho to Glucose t Axit amin, lng axit amin a vo tt nht chim khong 10 - 20%
tng lng Calo cn thit.
Cc dung dch Axit amin thng s dng: Moriamin, Nutrisol, Aminosteril, Aminoplasma... Trong mt s loi cn b sung
thm mt lng nh cht khong, vitamin....
-. Dung dch .i/id: 0.i/o1undin2 3ntrali/o%2 .i/o'!ndu%...4.
Dung dch Lipid cha cc cht bo cn thit v cung cp nhiu nng lng. Nhu cu ca co th 0, 5 - 3g/kg/ngy.
Khi truyn Lipid cn phi truyn tc chm v truyn ng thi vi dung dch Glucose, Axit amin.
Theo t l Glucose/lipid/Axitamin = 5 5/30/1 5.
Khng c pha ln thuc, cht in gii vi dung dch Lipid.
Chng ch nh trong cc trng hp sc nng, toan mu, hn m gan giai on cui, xo va ng mch, tng m mu, nhi
mu co tim cp.
C. Dung dch &'o (dd thy th( huy(t t$)ng":
Dch keo l cc dung dch cha cc phn t c trong phn t cao kh c th vn chuyn qua thnh mch bnh thng. Cc
phn t ny b gi li trong khoang mch mu v gy nn mt luc thm thu (goi l p luc keo thm thu hay p luc keo) n
gi dch th trong khoang mch mu.
S dng trong cc trng hp mt mu cp hoc gim khi lng tun hon. N c kh nng chim ch trong lng mch ln
hon l cc dch tinh th. a s cc phc hi sc thng kt hp dch keo v dch tinh th cng lc khi phc li th tch
mu trong lng mch v th tch dch k
Cn c vo cu trc ho hoc phn dung dch keo thnh cc nhm sau:
1. h5m dch D!,tran 06oly%acharid!4.
L cc dung dch ng c kch thc phn t khc nhau. Trong lng phn t ( TLPT)trung bnh 30.000 - 70.000 Dalton, dua
vo trong lng phn t ngi ta chia ra hai loi:
- Dextran c TLPT ln (60.000 - 70.000 Dalton): Dextran M 70.000 Dalton, Dextran 70, nkovertin 70, Macrodex,
Polyglukin.
- Dextran c TLPT nh (30.000 - 40.000 Dalton) Dextran M 40.000 Dalton, nkovertin 40, Rheo macrodex, Rheopolyglukin.
Tu theo kch thc phn t nh hay ln m Dextran c th tn ti trong co th 3 - 7 ngy. Thuc o thi qua thn, mt
phn tch luy t chc lin kt v b ph hu ti bi cc t bo lin vng.
Dung dch Dextran c pH t 5, 5 - 6, 5, nn khi truyn nhiu c th gy toan mu.
". h5m dch 6olyg!lin 0$!latin4:
L nhng chui Polypetide c thu phn t Gelatin hoc l cht gelatin ho tan trong dung dch mui ng trong. TLPT ca
Gelatin t 20.000 - 30.000 Dalton. Thuc c kh ht Calci (Ca

) nn c th truyn chung vi mu.

Gelatin o thi nhanh qua thn: Sau 2 gi ch cn li mt na, mt phn rt nh b ph hu t chc. Cc dung dch Gelatin
c hin nay: Gelaundin, Heamaccel.
-. h5m dch 6oly'inyl/irolydon 06764:
L cht tng hp c TLPT 12.000 - 40.000 Dalton. Do TLPT nh nn PVP c xu hng thot ra khi lng mch trong nhng
ngy u. Thuc c kh nng hp ph cht c trn b mt cao v gp phn ci thin h thng vi tun hon. Thuc c
lu (vi nm) v d bo qun.
Liu dng: 300ml - 400ml, sau 12 gi c th dng li. Khi truyn nhanh PVP c th gy tt huyt p, mt, kh th.
PVP dng trong lm sng l Haemovinyl (M 30.000 - 40.000 Dalton) v Haemodex ( M 12.000 Dalton).
8. h5m dch dng tinh *t9 :ydro,y ;thyl +midon 0:;+4
HA l mt amidon tng hp, ng dng dung dch 6% dng thay th albumine do albumine qu t.
c tnh: N to c p luc keo thm thu l 30 mmHg, kh nng chim ch trong lng mch ca HA cao hon mt cht so
vi albumine 4%. Thi gian bn hu trong huyt tong di hon so vi albumine vi 50% tc dng thm thu trong 24 gi.
Tri vi albumine, HA c o thi ch yu qua thn. Khi truyn HA, amylase mu c th tng gp 2-3 ln i khi ko di
n 5 ngy. y l do chuyn ha ca HA ch khng phi do vim tu. Khi truyn HA cho bnh nhn vim tu phi theo di
v nh gi bnh bng lypase. Khng c nguy co xy ra ri lon ng mu liu thng thng (33 ml/kg) ngi trc c
chc nng ng mu bnh thng. Phn ng d ng c th xy ra nhng him. HA khng phi l proteine nn c th lm h
protide mu do ho long.
Trong lm sng, dung dch HS hay s dng l HAS - Steril 6%, 10%, mi lt cha 60, 100gam Poly (0, 2 Hydroxy thyl)
Starch. Liu ti a khng qu 2g/kg/ngy.
Cc *+n , c-n .i(t &hi l/ ch0n dch truyn.
1. <=c d>ng huy?t @ng.
Khi mun khi phc khi lng tun hon mt cch nhanh chng, cn s dng dch keo. c c cng mt th tch tun
hon, cn phi s dng th tch dch tinh th gp 2-4 ln dch keo v thi gian truyn cng phi gp i. Cc dch keo cng
hiu qu hon lm tng lu lng tim v kh nng vn chuyn oxy. iu ny c nghia r rng khi chc nng tim mch b
suy gim, cn khi thiu khi lng tun hon t v chc nng tim mch tt th ch cn dch tinh th l .
". guy cA /hB /hCi.
Nu huyt ng ph hp v m bo c p luc ng mch phi bt di 20 mmHg th ph phi khng bao gi xut hin cho
d l truyn dch tinh th hay dch keo. Nhng chc chn rng nguy co ph phi s ln hon khi truyn dch tinh th.
Khi tnh thm mao mch phi tng ln, cc dch keo c th i ra khi khoang mch mu v nm li trong khong k, lm tng
nguy co ph phi nh trong hi chng ARDS.
-. D?t EuF lGm %(ng.
iu quyt nh l thuc t lm sng, trong sc gim khi lng tun hon, t l cu sng l nh nhau cho d s dng dch tinh
th hay dch keo. Thm ch nu trong sc mt mu nng, kh nng chim ch trong lng mch ca dch keo l nhanh hon th
kt qu lu di ca c hai loi dch l nh nhau.
D. 1u *2 cc ch( 3h4m c5 mu:
Mc ch ca truyn mu l duy tr vic cung cp oxy tho ng cho t chc, nhng trn lm sng ngi ta dua vo
hematocrite v Hb.
Hematocrite l tng l khong 30% l cho chuyn ho i kh, tong i thp lm gim nht mu v tng lu lng
mu ngoi vi. Cng nh vy vi Hb, nhng Hb t lm nh hng n nht. Hb l tng l khong 10 gr%.
1. H=u to(n /hn.
Mt on v chun mu ton phn cha 4 50 ml mu v 50- 60 ml dung dch bo qun chng ng, thng thng dng citrate
bt hot Ca

, glucose cung cp nng lng cho hng cu, phosphate duy tr pH ca ti mu bnh thng. Mu
ton phn phi c bo qun nhit t 1- 6
0
C.
Mu ton phn bo qun nh vy c th c 21 ngy nhng cc tiu cu ch c th gi c trong 1- 2 ngy. Cc hng
cu cng cht dn v gii phng ra rt nhiu K

, nht l vo nhng ngy cui.

Ch nh: Cc trng hp ang chy mu cp tnh.
Thng thng mu ton phn c tch ring cc thnh phn ngay sau khi ly, vic ct tr lu di khng tt v cc tiu cu
s cht nhanh chng sau 24 48 gi v c th gy ri lon ng mu.
". Dhi hIng cu.
Khi huyt cu.
Cha 200 ml huyt cu (hng cu v bch cu) v 10 ml huyt tong. Hematocrite giao ng t 60- 90% v Hb t 23- 27 gr
%. Khi Hb 20 gr% th nht ca mu tng ln rt nhiu. Hin c nhiu cht bo qun c th lm h nht xung gn
bng ca mu ton phn.
Ch nh: Cc trng hp thiu mu, gim hemoglobine nhng khng c thiu khi lng tun hon. C th lm gim nht
ca khi huyt cu khi truyn bng cch truyn cng vi huyt thanh mn ng trong.
Khi hng cu tch bch cu.
Cc bnh nhn mang khng th khng bch cu, phi tch b bch cu trong khi huyt cu trc khi truyn (bng ly tm
hoc loc), tuy vy cng khng th tch c hon ton. Chng vn cn cha khong 10- 30 % bch cu, hematocrite gim i
10- 30% so vi khi huyt cu.
Ch nh cho cc bnh nhn thiu mu c tin s phn ng rt run khi truyn mu m khng c tan mu.
Khi hng cu ra.
l cc khi hng cu c ra bng huyt thanh mn ng trong loi b ton b bch cu v huyt tong, nh ly
b huyt tong lm gim c nguy co d ng. Chng khng cn proteine huyt tong v mt i i a s cc bch cu,
hematocrite cng thp hon khi huyt cu, tong ong vi hematocrite ca khi hng cu tch bch cu. Chng ch c
th bo qun c trong vng 24 gi.
Ch nh cho cc trng hp thiu mu c tin s d ng sau truyn mu, thiu ht IgA.
-. :uy?t tAng JhK:
lm cc khi huyt cu, ngi ta tch huyt cu t mu ton phn, phn cn li l huyt tong c mang ct gi nhit
18
0
C goi l huyt tong toi ng kh.
Mt on v huyt tong toi ng kh cha 200- 2 50 ml huyt tong, c th bo qun trong vng 1 nm, sau khi lm m tr
li phi s dng ngay trong vng 6 gi.
Ch nh khi thiu globine v cc yu t ng mu, qu liu cc thuc khng vitamine K. Nhng khng bao gi dng huyt
tong toi ng kh lm tng th tch huyt tong. N cng c nguy co truyn cc bnh truyn nhim v d ng nh
truyn mu bnh thng.
8. +l*umin:
Albumin chim hon 1/2 thnh phn m huyt tong. Chc nng co bn ca n l duy tr p luc keo - thm thu ( 80% )
1gAlbumin gi c 18ml dch t chc.
u im ca dung dch Albumin l qunh thp, lu gi trong lng mch ko di (thi gian bn hu 6 - 11 ngy). Khi s
dng cn truyn thm cc dung dch tinh th (NaCl).
Albumin c pha cc nng khc nhau: 5%, 10%, 20%, 2 5% (Albutein 5%, 20%, 2 5%).