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CÔ CHEÁ ÑOÂNG MAÙU. A. QUAÙ TRÌNH CAÀM MAÙU VAØ ÑOÂNG MAÙU B. ÑOÂNG MAÙU ÖÙNG DUÏNG TS. BS. LAÕ THÒ NHAÃN. MÔÛ ÑAÀU.

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CÔ CHEÁ ÑOÂNG MAÙU

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C che o ng ma u

C CHE ONG MAU

A. QUA TRNH CAM MAU VA ONG MAU

B. ONG MAU NG DUNG

TS. BS. LA TH NHAN


M a u

M AU

  • ong mau bao gom (cac qua trnh cam mau, ong mau, tieu fibrin) rat can thiet trong chuyen khoa huyet hoc, tim mach, tieu hoa, ngoai khoa, nhi khoa, truyen nhiem, lao khoa, ung th ... V vay ong mau co tam quan trong trong kien thc cua cac thay thuoc.

  • ay chung toi ch neu mot phan nho qua trnh cam mau, ong mau va mot so XN tng ng khi s dung mot so thuoc: khang TC, khang ong mau


A qua tr nh ca m ma u va o ng ma u

A. QUA TRNH CAM MAU VA ONG MAU

I. TIEU CAU (TC)

1. Vai tro va cac yeu to TC.

TC co 13 yeu to:

Yeu to 1: hoat hoa prothrombin thanh thrombin.

Yeu to 2: rut ngan thi gian ong cua fibrinogen

Yeu to 3: hnh thanh thromboplastin noi sinh e

chuyen prothrombin thanh thrombin.

Yeu to 4: chong heparin.

Yeu to 5: tac dung tng t fibrinogen.


C che o ng ma u

(Vai tro va cac yeu to TC)

Yeu to 6: chong tieu si huyet.

Yeu to 7: chuyen Prothrombin thanh thrombin.

Yeu to 8: chong thromboplastin cua TC.

Yeu to 9: tao ieu kien cho co cuc mau tot hn.

Yeu to 10: serotomin do TC hap thu t ng tieu hoa, hoat hoa he thong tieu fibrin, tieu cuc huyet.

Yeu to 11: thromboplastin cua TC.

Yeu to 12: on nh si huyet.

Yeu to 13: ADP.


C che o ng ma u

2. ac tnh chnh cua TC

2.1. Hap phu, van chuyen chat:

  • Hap phu serotomin t ruot non.

  • Hap phu adrenalin, no adrenalin, cac yeu to ong mau trong huyet tng.

    2.2. Ket dnh (adhesion):

  • TC dnh to chc di noi mac (collagen), co s tham gia cua yeu to canxi (von-Willebrand, fibronectin, thrombospondin).

  • Cac chat c che s dnh bamTC: promethazin, cocain, quinin, aspirin, serotonin.


A c t nh ch nh cu a tc

(ac tnh chnh cua TC)

2.3. Ngng tap (aggregation)

  • Ket dnh lan nhau tao nen cac ket chum TC va kha nang dnh TC vao be mat cua thanh mach goi la hien tng ngng tap TC.

  • Nhng chat gay ngng tap TC: thrombin, adrenalin, serotonin, acid arachidonic, thromboxan A2 .


C che o ng ma u

3. Chc nang cua TC

  • Bao ve noi mo: TC cung co va lam tang tnh ben vng cua thanh mach

  • Tham gia vao qua trnh cam mau: nh kha nang ket dnh, ngng tap, phong thch.

  • Tham gia vao qua trnh ong mau: TC tham gia qua trnh hoat hoa mang TC e chuyen yeu to XI thanh XIa, phong thch yeu to 3 TC tao phc hp IXa, VIIIa, Ca++ trong qua trnh ong mau.


C che o ng ma u

II. CAC YEU TO ONG MAU

Trc ay: co 12 protein tham gia qua trnh ong mau

Hien nay: cac yeu to III, IV, VI a bo, phat hien them prekallikrein, HMWK (high molecular weigh kininogen).

Cac yeu to ong mau:

  • Yeu to I (Fibrinnogen)

  • Yeu to II (Prothrombin)

  • Yeu to V (Proaccelerin)

  • Yeu to VII (Proconvertin)


C che o ng ma u

(Cac yeu to ong mau)

  • Yeu to VIII (Anti hemphilia A factor)

  • Yeu to XI ( Anti hemphilia B factor)

  • Yeu to X (Stuart factor)

  • Yeu to IX (PTA : Plasma-thromboplastin antecedent - tien chat thromboplastin huyet tng)

  • Yeu to XII (Hageman factor)

  • Yeu to XIII (Fibrin stabilizing factor)

  • Prekallikrein (Fletcher factor)

  • HMWK (Kininogen trong lng phan t cao)


C che o ng ma u

III. NHNG CHAT C CHE ONG MAU SINH LY

ay la mot he thong t ve, nham ngan chan nhng hien tng ong mau khong can thiet xay ra trong c the co the gay ra tac mach, co hai ho:

1. Ho cac chat c che cua serin protease

(serin protease tc la cac yeu to ong mau a c hoat hoa)

Gom 40 loai protein. Chat c che quan trong nhat la anti thrombin III


C che o ng ma u

Anti thrombin III (AT III) co vai tro c che hau het cac serin protease (tr yeu to VIIa). Manh nhat vi thrombin (IIa). AT III coi nh mot ong yeu to cua heparin.

AT III tao ieu kien e heparin gan vi serin protease, c che tac dung cua serin protease (XIIa, XIa, IXa, Xa va IIa).

Benh ly thieu hut AT III bam sinh, di truyen hoac mac phai hay gap tai bien huyet khoi hoac nghen mach.

(AT III trc ay cho rang co 6 protein khac nhau gay c che thrombin, at ten AT.I en AT.VI . Hien nay AT I, III ch la mot, 4 protein con lai ch la anti protease).


C che o ng ma u

2. Ho cac chat c che thuoc he thong protein C.

Protein huyet tng co 2 loai: Protein C (PC) , protein S (PS). Tong hp t te bao gan, phu thuoc vitamin K.

Protein mang co 1 loai : thrombomodulin. Tao ra t TB noi mac mach mau .

Di tac tac dung cua thrombin, trypsin, men hoat hoa yeu to X co mat trong noc ran Russell th PC c hoat hoa. Manh hn khi co mat thrombomodulin, manh hn na khi co mat PS, Ca++, phospho. PC hoat hoa co tac dung chong ong ong thi co hieu lc cua chat tien than tieu si huyet.


C che o ng ma u

IV. CAC YEU TO KHAC THAM GIA VAO QUA TRNH ONG MAU

1. Yeu to to chc (tissue factor = TF).

o la mot glycoprotein.

TF co hau het trong cac to chc co nhieu trong nao va phoi.

TF khong co trong cac te bao noi mac.

Phc hp TF phospholipid bien VII thanh VIIa.


C che o ng ma u

2. Tieu cau

3. Noi mac mach mau

  • Tren be mat noi mac co cha mot polysaccharid giong heparin co tac dung tang cng hoat ong cua AT III.

  • Nh tac dung cua thrombomodulin hoat hoa protein C.


C che o ng ma u

V. C CHE ONG MAU

1. Nhng giai oan qua cac con ng ong mau: Noi sinh va Ngoai sinh


C che o ng ma u

Kallikrein

Con ng noi sinh

S o: C che ong mau

HMWK

Prekallikrein

XII

XIIa

XI

XIa

Ca++

PL

IX

IXa

VIIIa

Ca++

PL

V

X

Xa

Va

TF.VIIa

II

IIa

XIII

Fibrin

(hoa tan)

Fibrinogen

TF + VII

XIIIa

Con ng ngoai sinh

Fibrin

(khong hoa tan)


C che o ng ma u

2. S o tong quat ve vai tro thrombin trong cac qua trnh cam mau, ong mau va tieu fibrin.

Xa

FDPs

Plasmin

Plasminogen

VIIIa

X

Fibrin

VIII

Fibrinogen

THROMBIN

Protein C

Hoat hoa tieu cau

(Dnh, ngng tap, phong thch)

Protein C hoat hoa

XI

VII

V

Antithrombin III

(AT.III)

XIa

VIIa

Va

Phc hp

Thrombin - AT.III


C che o ng ma u

(C CHE ONG MAU)

3. Moi quan he cua hai con ng ong mau noi sinh va ngoai sinh

  • Trong c the hai con ng ong mau noi sinh va ngoai sinh co moi quan he chat che va tac ong qua lai lan nhau, cu the:

  • Khi xay ra mot qua trnh ong mau (ac biet la trong cac trng hp benh ly) ca hai con ng ong mau eu c khi ong.

  • ong mau ngoai sinh co tac ong manh len con ng noi sinh, chung eu co hoat hoa yeu to IX va X.


Mo i quan he cu a hai con ng o ng ma u no i sinh va ngoa i sinh

(Moi quan he cua hai con ng ong mau noi sinh va ngoai sinh)

ong mau noi sinh khi tao ra thrombin thuc ay qua trnh ong mau theo con ng ngoai sinh, hoat hoa yeu to VII cua thrombin.

Yeu to XII c hoat hoa theo con ng noi sinh e tao ra c XIIa; tuy nhien khong phai la tat ca, ma mot so c hoat hoa ton tai dang cac manh co kch thc nho hn (goi la XIIf). Chnh XIIf co tac dung xuc tac e hoat hoa VII.


B o ng ma u ng du ng

B. ONG MAU NG DUNG

I. CAC XN THAM DO

1. Thi gian mau chay (bleeding time):anh gia yeu to TC, thanh mach, II, V, VII, X.

Thi gian mau chay keo dai gap:

  • Giam so lng TC (t mien hoac mac phai).

  • Chat lng TC kem.

  • Giam sc ben thanh mach.

  • Thng ton thanh mach do d ng hay do oc to.

  • Benh von-Willebrand.

  • Thieu nang cac yeu to II, V, VII va X


Ca c xn tha m do

(CAC XN THAM DO)

2. o sc ben mao mach

Thong thng o bang phng phap tang ap

Sc ben mao mach giam gap trong benh ly:

  • Giam TC.

  • Viem thanh mach d ng (benh Scholein Henoch).

  • Viem thanh mach do oc to (tuy loai va tuy mc o nhiem oc).

  • Co the giam trong benh von-Willebrand hoac benh roi loan chc nang TC.

  • Ngoai ra con co the giam ngi gia, thieu vitamin C, do the tang hoac co tnh gia nh.


Ca c xn tha m do1

(CAC XN THAM DO)

3. em so lng TC (platelet count)

  • Tr so bnh thng cua TC la: 150 350 x 109/l.

  • So lng TC giam trong:

  • Xuat huyet giam TC mien dch (ITP).

  • Suy tuy; Leucemie cap; Sot xuat huyet.

  • Sau tia xa hoac sau hoa tr lieu (cho BN b ung th).

  • Do mot so thuoc co oc tnh vi TC.

  • Hoi chng roi loan sinh tuy (MDS).

  • ong mau rai rac trong long mach (DIC).

    o tap trung TC giam: suy tuy, Leucemie cap; Glanzmann; sot xuat huyet (Dengue )


Ca c xn tha m do2

(CAC XN THAM DO)

  • So lng TC va o tap trung cua TC tang:

  • Hoi chng tang sinh tuy (MPS)

  • Tang TC lien phat.

  • X tuy vo can.

  • Leucemie kinh dong hat.

  • a hong cau tien phat.


Ca c xn tha m do3

(CAC XN THAM DO)

4. Co cuc mau (clot retraction)

  • anh gia lng fibrinogen, yeu to XI.

    5. Thi gian mau ong (coagulation time of whole blood)

  • La mot XN tham do tong quat toan bo qua trnh ong mau.

  • La mot XN khong ac hieu v: thieu bat ky yeu to ong mau nao cung eu co the lam thi gian mau ong keo dai.

    6. Thi gian phuc hoi calci (Howell)

  • La mot XN cha thc s nhay nham anh gia tnh trang tang va giam ong

  • ay la mot XN c s dung rat thng xuyen e theo doi ieu tr heparin.


Ca c xn tha m do4

(CAC XN THAM DO)

7. Thi gian prothrombin (PT) (thi gian quick)

Tham do toan bo yeu to cua qua trnh ong mau ngoai sinh (cac yeu to II, V, VII va X)

PT = 10 14s TL. prothrombin 80 100%

PT phu thuoc vao thromboplastin s dung e anh gia da vao INR (International normalized ratio).

e s dung cac chat khang vitamin K c an toan, duy tr INR trong gii han t 2 4


Ca c xn tha m do5

(CAC XN THAM DO)

Thi gian prothrombin keo dai (TL.prothrombin giam ) :

Benh ly giam hoac mat cac yeu to II, V, VII, X (x gan, vang da tac mat ) giai oan cuoi cua ong mau rai rac trong long mach (DIC), thieu bam sinh cac yeu to II, V, VII hoac X.

ieu tr chong ong bang cac thuoc khang vitamin K.


Ca c xn tha m do6

(CAC XN THAM DO)

8. Thi gian thromboplastin (cephalin kaolin - APTT - activated partial thromboplastin time )

APTT la thi gian phuc hoi calci (Howell) co cephalin kaolin.

Cephalin co tac dung nh yeu to 3 TC.

Kaolin co tac dung thong nhat hoat o cua s tiep xuc mau vi be mat ong nghiem. APTT = 30 40 giay.


C che o ng ma u

II. NHNG XN KHI S DUNG THUOC KHANG TC - KHANG ONG MAU

1. Thuoc khang ngng tap TC (Aspirin)

Thuoc c che chc nang TC nham muc ch chong nhoi mau, nghen mach. nham 2 phng dien.

  • Chong lai tac ong gia TC vi thanh mach nham can tr nhoi mau M.

  • Chong ket tu gia TC vi TC nham can tr s hnh thanh cuc mau ong.

    Thc te, thuoc chong ngng tap TC mi giai quyet c phng dien th 2 ngha la can tr TC ket tu vi nhau.


Thuo c kha ng ng ng ta p tc

(Thuoc khang ngng tap TC)

  • Theo doi khi ieu tr thuoc Aspirin cho XN

  • Thi gian mau chay keo dai , o tap trung TC , APTT (hoac Howell) keo dai , co cuc mau khong hoan toan , thi gian mau ong keo dai, dau hieu day that (+).

  • Chu y: khi dung aspirin khong anh hng en so lng TC (ma ch anh hng en s ngng tap TC) . Nen BN co the b xuat huyet khi so lng TC van cao.


C che o ng ma u

2. Thuoc khang ong (anti coagulant therapy)

2.1. Heparin:

  • Chu yeu c che ong mau theo con ng noi sinh

  • Tac ong manh len thrombin (IIa)

  • Heparin va AT III gay bat hoat cac serin protease (Xa, IXa)

  • ieu tr bang heparin theo doi XN: thi gian (mau ong, Howell, APTT) keo dai. nh lng AT III: giam, TC giam.


Thuo c kha ng o ng

(Thuoc khang ong)

2.2. Heparin co trong lng phan t thap (Fraxiparine ):(low molecular weigh heparin = LMWH)

  • LMWH chong Xa cao hn chong thrombin (IIa). V vay LMWH t/dung keo dai chong huyet khoi.

  • ieu tr LMWH theo doi XN:

  • nh lng hoat tnh chong Xa (Anti - Xa assay): la XN ac hieu (t lam).

  • Thong thng XN em so lng TC: e phong giam TC (mac du xuat huyet giam TC gap rat thap), XN em so lng TC trc ieu tr va sau o 2 lan / 1 tuan la can thiet .


Thuo c kha ng o ng1

(Thuoc khang ong)

2.3. Thuoc Khang Vitamin K (Warfarin):

  • Warfarin: dan suat coumarin, la mot khang vitamin K thong dung, c che hoat ong cac yeu to ong mau phu thuoc vitamin K: II, VII, IX, X, PC, PS.

  • XN theo doi khi dung Warfarin:

  • Thi gian Quick: keo dai; TL prothrombin giam.

  • nh lng yeu to II, VII, IX, X giam .

  • ieu tr warfarin duy tr ch so INR t 2 -3 la an toan.


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