XT NGHIM

KH MU NG MCH

NN BT U T U?
TS. Ngc Sn
Khoa Cp cu Bnh vin Bch Mai

Ni dung
1. Ch nh ca xt nghim kh mu
2. Khi nim c bn
3. Tip cn kt qu kh mu: ri lon n hay
kt hp?
4. Xu hng mi ca xt nghim kh mu
5. Nhng thn trng khi lm xt nghim kh
mu

Ch nh
Suy h hp do mi nguyn nhn: ti phi hoc
ngoi phi
Suy tun hon, sc do cc nguyn nhn
Suy thn v bnh l ng thn
Bnh ni tit: T nhim toan ceton, bnh v
thng thn, suy gip

Ch nh
Hn m, ng c
Bnh tiu ha: tiu chy, r rut, r ti mt
hoc rut non, ty tng
Cc ri lon in gii: tng gim kali, chlor
mu
Theo di iu tr: xy liu php, bnh nhn
th my, nui dng tnh mch, lc thn,
truyn dch v truyn mu s lng ln, iu
tr li tiu.

Sch v kh mu

Website v kh mu
http://www.acid-base.com/
http://www.qldanaesthesia.com/AcidBaseBook/
http://www.virtual-anaesthesia-textbook.com
/vat/acidbase.html#acidbase
http://ajrccm.atsjournals.org/cgi/content/full/162/6/2246
http://www.osa.suite.dk/OsaTextbook.htm
http://www.postgradmed.com/issues/2000/03_00/fall.htm
http://medicine.ucsf.edu/housestaff/handbook/HospH2002_C5.htm

ng c c kt qu kh mu

ng c c kt qu kh mu
Mt kho st ti 1 bnh vin trng i hc
70% bc s tham gia khng nh c th chn on
chnh xc cc ri lon thng bng toan kim v khng
cn phi hng dn thm v c kt qu kh mu
ng mch.
Khi yu cu chnh nhng bc s c kt qu ca
mt s cc kh mu ng mch thng gp, ch c
c chnh xc n 40%
Respir Care 1982;27:809-815

ng c c kt qu kh mu
Mt kho st ti bnh vin khc cho thy kt qu c
ri lon toan kim sai dn n SAI LM trong iu
tr trong 1/3 s kh mu c phn tch

Chest 1984;85:148-149

ng c c kt qu kh mu
Nhng kho st ny cng cho thy s yu km r rt
gia cc n v khng quan tm n c kt qu kh
mu.

Vn ny c th gy hu qu nghim trng ti khoa

HSCC v 9 trn 10 bnh nhn c cc ri lon thng
bng toan kim.
J Crit Care 1993;8:187-197

Cc thut ng c bn

Tnh trng toan (Acidosis): l mt tnh trng hoc qu trnh dn n gim pH

nu khng c nhng p ng th pht (b tr) vi yu t gy ra ban u.

Tnh trng kim (Alkalosis): l mt tnh trng hoc qu trnh dn n tng pH

nu khng c nhng p ng th pht (b tr) vi yu t gy ra ban u.

Toan mu: pH mu < 7,35 (hay [H+] > 44 nM )

Kim mu: pH mu > 7,45 (hay [H+] < 36 nM )

RL toan kim n: l ch c mt loi ri lon tin pht.

RL toan kim hn hp: l c t 2 loi ri lon tin pht tr ln xy ra ng thi.

http://www.anaesthesiamcq.com/AcidBaseBook/ab3_1.php#definitions

Ly mu lm xt nghim
kh mu ng mch

ng mch quay

ng mch tr

KT QU KH MU

Kt qu kh mu
Thng tin v tnh trng toan kim
pH
PaCO2
HCO3 [tnh ton vs o c]
Thng tin v xy ha mu
PaO2 [phn p xy]
SaO2 [ bo ha xy]

Phng trnh trung tm

PCO2

[H+] ( nEq/L) = 24

x
[HCO3 -]

[H+] (nEq/L) =

10 (9-pH)

Quy i c bn
pH

[H+]

7,7
7,5
7,4
7,3
7,1
7,0
6,8

20
31
40
50
80
100
160

Gi tr bnh thng
Bnh thng PaCO2 l 40 mmHg v [HCO3 ]
l 24 mEq/L, nng [H+] s l:

24 (40/24) = 40 nEq/L

T s PCO2/[HCO3- ]
Quyt nh s n nh nng [H+] ca dch
ngoi bo, do quyt nh pH ca dch .
Khi ri lon toan kim nguyn pht lm thay i
mt thnh t ca t s ny (PCO2; [HCO3- ]), th
p ng b tr s thay i thnh phn cn li
([HCO3- ], PCO2) gi cn bng t s
PCO2/[HCO3- ].

Thay i b tr
Khi ri lon nguyn pht l chuyn ha (thay i v
[HCO3 - ], p ng b tr l h hp (thay i v
PCO2), v ngc li.
iu quan trng cn nhn mnh rng hin tng b
tr gip hn ch s thay i pH mu ch khng ngn
nga c s thay i ny (b tr khng ng ngha
vi sa cha).

Khong tham chiu

Tham s Khong tham chiu
pH

Trung v

7,35-7,45

7,4

PaCO2

35-45 mmHg

40 mmHg

PaO2

90-100 mmHg

>90 mmHg

HCO3-

22-26 mEq/L

24 mEq/L

Ri lon toan kim chnh

Nguyn pht
H hp

Chuyn ho

B tr

CO2

(toan)

HCO3-

CO2

(kim)

HCO3-

HCO3- (kim)

CO2

HCO3- (toan)

CO2

Ca lm sng 1

BN nam 26 tui
Tin s nghin ma ty
c pht hin trong tnh trng bt tnh
Vo vin trong tnh trng tm, th chm
Kh mu:
pH: 7,0
PaCO2: 100 mmHg
PaO2: 40 mmHg
HCO3-: 24 mEq/L

Ca lm sng 1
Nguyn pht
H hp

Chuyn ho

B tr

CO2 (toan)

HCO3-

CO2 (kim)

HCO3-

HCO3-(kim)

CO2

HCO3- (toan)

CO2

pH: 7,0
PaCO2: 100 mmHg
PaO2: 40 mmHg
HCO3-: 24 mEq/L

TOAN H HP
CP HAY MN TNH?

Thay i k vng
Nguyn pht

Thay i k vng

Toan h hp cp

delta pH/delta PCO2 = 0,008

Toan h hp mn

delta pH/delta PCO2 = 0,003

delta pH/delta PCO2 = (7,4-7,0)/(100-40)

= 0,4/60 = 0,006 < 0,008
TOAN H HP CP MT B

Ca lm sng 2
Bnh nhn nam 38 tui, tin s nghin ru x gan. 1
tun nay kh th ho khc m ln mu. i tin phn
lng. Vo cp cu ti bnh vin tnh trong tnh trng
sc. Bnh nhn c truyn dch v Dopamin v
chuyn BVBM. Vo KCC A9 trong tnh trng l m,
vn tm u chi.
M=120, HA=70/40, t=390C, th 40
Glucose = 12 mmol/L
Na + = 142
K + = 3,9
Cl- = 113
Ure = 9 mmol/L, Creatinin = 216 mmol/L

Ca lm sng 2
Bnh nhn nam 38 tui, tin s nghin ru x gan. 1 tun nay
kh th ho khc m ln mu. i tin phn lng. Vo KCC
trong tnh trng l m, vn tm u chi.
M=120, HA=70/40, t=390C, th 40

Glucose = 12 mmol/L
Na + = 142
K + = 3,9
Cl- = 113
Ure = 9 mmol/L, Creatinin = 216 mmol/L
Chn on: Sc nhim khun/TD x gan ru

Ca lm sng 2
Bnh nhn nam 38 tui, tin s nghin ru x gan. 1 tun nay
kh th ho khc m ln mu. i tin phn lng. Vo KCC
trong tnh trng l m, vn tm u chi.
M=120, HA=70/40, t=390C, th 40
KMM
Glucose = 12 mmol/L
FiO2 = 80%
Na + = 142
pH = 7,09
K + = 3,9
PaCO2 = 36
Cl- = 113
HCO3- = 10,6
Ure = 9 mmol/L
BE = -17,7
Creatinin = 216 mmol/L
PaO2 = 84
SaO2 = 90%

Ca lm sng 2
TOAN CHUYN HA
KMM
FiO2 = 80%
pH = 7,09
PaCO2 = 36
HCO3- = 10,6
BE = -17,7
PaO2 = 84
SaO2 = 90%

Cu hi
1.Khong trng anion c tng khng?
2.B tr h hp th no?
3.C ri lon toan kim phi hp
khng?

Khong trng anion (Anion Gap)

Cations mmol/L
Natri

Kali

Anions mmol/L

103

5 Bicarbonate

26

Can xi

5 Albumin

17

Magie

Tng =

142 Chlo

Acid hu c
5

Phosphate

Sulphate

154 Tng =
154

Khong trng anion (Anion Gap)

KMM
FiO2 = 80%
pH = 7,09
PaCO2 = 36
HCO3- = 10,6
BE = -17,7
PaO2 = 84
SaO2 = 90%
Na + = 142
K + = 3,9
Cl- = 113
Lactate = 11

AG = 142 (113+10,6) =
18

B tr h hp
Nguyn pht

Thay i k vng

Toan chuyn ha

PCO2 = 1,5 HCO3- + 8 ( 2)

Kim
chuyn
ha
KMM

PCO2 = 0,7 HCO3- + 21 ( 2)

FiO2 = 80%
pH = 7,09
PaCO2 = 36
HCO3- = 10,6
BE = -17,7
PaO2 = 84
SaO2 = 90%

PaCO2 d on =
1,5 x 10,6 + 8 = 23,9
TOAN H HP KT HP

Gap/Gap
AG/HCO3 = (AG 12)/(24 HCO3)
AG: s tch t acid c nh
HCO3: s mt HCO3
Nu ch c toan chuyn ha tng anion gap do
tich t acid c nh
AG = HCO3 G/G = 1

Gap/Gap
Nu c toan chuyn ha tng Cl- cng xy ra,
HCO3 gim nhiu hn
Gap/Gap < 1
Nu c kim chuyn ha cng hin din,
HCO3 gim t hn tng AG
Gap/Gap > 1

KMM
FiO2 = 80%
pH = 7,09
PaCO2 = 36
HCO3- = 10,6
BE = -17,7
PaO2 = 84
SaO2 = 90%
Na + = 142
K + = 3,9
Cl- = 113
Lactate = 11

Ca lm sng 2
Delta AG/ Delta HCO3 =
6/13,4 <1
Toan chuyn ha do tng
Chlo mu i km

Ca lm sng 2
1. Toan chuyn ha tng anion gap: tng acid
lactic trn bnh nhn sc nhim khun
2. Toan chuyn ha do tng chlo mu: do truyn
qu nhiu dch NaCl 0,9%
3. Toan h hp i km: do mt c

Kt qu kh mu
Thng tin v tnh trng toan kim
pH
PaCO2
HCO3 [tnh ton vs o c]
Thng tin v xy ha mu
PaO2 [phn p xy]
SaO2 [ bo ha xy]

My o bo ha xy mao mch
SpO2

Tng i tnh
-Gim nhit
-Gim 2-3 DPG
-Gim |H+|
-CO
Gim i tnh
-Tng nhit
-Tng 2-3 DPG
-Tng |H+|

Ca lm sng 3
BN nam, 65 tui, tin s vim ph qun mn,
vo cp cu trong tnh trng kh th v khc
m vng nhiu. M=130, HA=130/90,
t=38,5C, th 32 l/ph, SpO2= 70%
Chn on: t cp COPD, suy h hp

Ca lm sng 3
Xt nghim
KMM
FiO2 = 0,21
pH = 7,25
PaCO2 = 70
HCO3 = 34
PaO2 = 39
SaO2 = 52%

Na = 139
K = 4,1
Cl = 89
WBC = 13 k/ul
Hb = 17 g/dl
Hct = 51%

Phn tch KMM

KMM
FiO2 = 0,21
PH = 7,25
PaCO2 = 70
HCO3 = 34
PaO2 = 39
SaO2 = 52%

PaO2 gim suy h hp gim oxy

mu
PaO2 < 40 mmHg
PaO2/FiO2 = 39/0,21 = 185 < 200

gim oxy mu nng

Phn tch KMM

KMM
FiO2 = 0,21
pH = 7,25
PaCO2 = 70
HCO3 = 34
PaO2 = 39
SaO2 = 52%

PCO2 tng suy h hp tng CO2

pH gim toan mu
HCO3 tng kim chuyn ha
Toan h hp nguyn pht, kim
chuyn ha b tr
Delta pH/Delta PaCO2 = 0,15/30=
0,005
0,003 < x < 0,008

Toan h hp cp trn nn mn, gim

oxy mu nng

Nguyn nhn gim oxy mu?

Alveolar-arterial O2 gradient
A-aDO2 = 2,5 + (0,25 x tui)
Kh phng: 7 14 mmHg
100% oxy: <70 mmHg

A-aDO2 bnh thng: gim thng kh v

tng CO2
A-aDO2 tng: V/Q mismatch, shunt, ri
lon khuych tn

Nguyn nhn gim oxy mu?

Alveolar-arterial O2 gradient
PAO2 =[FIO2 x (Pb PH2O)] [1,25 x PaCO2]
PAO2 =[0,21 x (760 47)] [1,25 x 70] = 62
Gradient = 62 - 39 = 23 mm Hg
Vy, bnh nhn gim oxy mu do:
Gim thng kh ph nang, tng CO2
Gim khuch tn kh v hoc bt thng V/Q,
shunt: vim phi, x phi

CCH C D HN?

DCH BI LIT 1952 TI COPENHAGEN (AN MCH)

DR. BJORN IBSEN

51

11/11/2013

RADIOMETER PRESENTATION

Lch s

Cobas b221
RADIOMETER PRESENTATION

ABL800 Flex
51

Cc thng s trong kt qu kh mu
17 thng s o c
Thng s toan kim
Thng s xy ha mu
Thng s in gii
Thng s khc: lactate, glucose
Cobas
B221

Ca lm sng 4
BN nam 60 tui
Tin s bnh thn mn do vim cu thn v i
tho ng type 2
3 ngy nay st cao rt run
T sng nay BN kh th tng ln

Kt qu kh mu

pH = 7,06
PaCO2 = 15 Cu hi
1.Chn on RL toan kim thuc
PaO2 = 88
loi g?
HCO3 = 7
2.Chn on ri lon in gii?
Na+ = 132
3.iu tr ca bn?
K+ = 6,4
Cl- = 90
KT Anion = 35

Ca lm sng 4

pH = 7,06
PaCO2 = 15
PaO2 = 88
HCO3- = 7

Na+ = 132
K+ = 6,4
Cl- = 90
KT Anion = 35

0,1 pH 0,6 mEq/L K+

Cu hi lm sng
Chn in gii trn kh mu hay t ha sinh?

in gii trn kh mu vs ha sinh

Int J Emerg Med (2009) 2:117 120

in gii trn kh mu vs ha sinh

Natri:
ABG: 138.1 mmol/L (SD
10.2 mmol/L)
AA: 143.0 mmol/L (SD
10.5 mmol/L )
p < 0.001
r2 = 0.9 (0.9 0.94)
Budak et al. BMC Anesthesiology 2012, 12:17

in gii trn kh mu vs ha sinh

Kali:
ABG: 3.5 mmol/L (SD 0.9
mmol/L)
AA: 3.7 mmol/L
(SD 1 mmol/L )
p < 0.001
r2 = 0.88 (0.81 0.92)
Budak et al. BMC Anesthesiology 2012, 12:17

in gii trn kh mu vs ha sinh

P < 0.001
r2 = 0.68

P = 0.268
r2 = 0.72
Int J Emerg Med (2009) 2:117 120

Thc hnh
in gii trn kh mu
Dng tnh ton khong trng anion
Pht hin sm nhng ri lon in gii km
hoc khng km ri lon cn bng toan kim

Ca lm sng 5
BN nam 23 tui
Tin s hen ph qun, iu tr bng thuc xt
hng ngy
t ny BN c st, khc m, kh th tng. BN
vo khm cp cu
Khm lm sng: th nhanh, mch nhanh, nhit
380C
Khm phi: ran rt, ran ngy 2 bn ph trng

Kt qu kh mu

pH = 7,36
PaCO2 = 32
PaO2 = 90
HCO3 = 18
Na + = 144
K + = 1,2
iCa + + = 0,5
Cl- = 95

Ha long mu

Heparin gn cht in gii

Bo qun mu trc
Thng s Thay i
pH
Gim
(pH v/hr)
pCO2
Tng
(mmHg/hr)
pO2
Gim
(mmHg/hr)

37oC
0,04
0,08

22oC
0,02
0,03

5 - 10

4 oC
< 0,01
0,5

Li trong quy trnh

Li
Errors
19-47%
1947%

Li
13-32%
*Errors in Laboratory Medicine, Bonini P, Pleboni M, Ceriotti F Rubboli F Clin Chem 48; 691 -698, 2002

Li
46-68%

Thc hnh
Sodium heparin:
Tng Sodium mu # 3 mmol/L
Khng s dng cho XN kh mu c ion
Lithium heparin: s dng cho XN kh mu c ion
Electrolyte Balanced Heparin: tt nht cho XN Calci ion
ha
Khng c s dng Sodium Heparin s dng trong
iu tr lm sng lm cht chng ng

Thc hnh
Vn chuyn v phn tch mu:
Cng st cng tt
Thi gian lu mu trc XN
cho php: 30 pht sau khi ly mu
Tt nht: 15 pht sau khi ly mu
Nhit bo qun: nhit phng

Kt lun
c kt qu kh mu phi da trn bnh cnh
lm sng v tip cn mt cch h thng tm
cc ri lon kt hp.
in gii , ng huyt v lactac mu l
nhng thng s h tr hu ch nh gi
bc tranh ton cnh ca BN.

Thay i k vng
Nguyn pht

Thay i k vng

Toan chuyn ha

PCO2 = 1,5 HCO3- + 8 ( 2)

Kim chuyn ha

PCO2 = 0,7 HCO3- + 21 ( 2)

Toan h hp cp

delta pH/delta PCO2 = 0,008

Toan h hp mn

delta pH/delta PCO2 = 0,003

Kim h hp cp

delta pH/delta PCO2= 0,008

Kim h hp mn

delta pH/delta PCO2 = 0,003

Kt lun

H HP

CHUYN HA

XIN CM N