2010

Bo co thc tp
Ha sinh lm sng
Qu trnh thc hnh v kt qu t c khi thc hnh lm sng ti Khoa xt nghim Sinh ha Bnh vin Nhi T

ng Ngc H: T 33-Y4I i hc Y H Ni 10/21/2010

TRNG I HC Y H NI

KHOA K THUT Y HC

BO CO THC TP LM SNG
Chuyn ngnh: Ha Sinh

Chuyn thc tp:

THC

HNH LM SNG TI KHOA XT NGHIM SINH HA

C quan thc tp: Khoa Sinh ha Bnh vin Nhi Trung ng a ch: S 18 ng 879 La Thnh, ng a, H Ni

Cn b hng dn:TS.Trn Th Chi Mai BSCK1.L Thi Hot Cn b theo di:CNh. Thu Hng Sinh vin thc hin:ng Ngc H T 33 Lp Y4I

H Ni, Thng 10 nm 2010

LI CM N
Trc tin em xin chn thnh cm n c Trn Th Chi Mai, ch L Thi Hot v c Nguyn Thu Hng tn tnh hng dn, gp , gip v ng vin em trong qu trnh thc tp. Em xin chn thnh cm n Ban lnh o Bnh vin Nhi Trung ng, khoa Sinh ha to iu kin cho em c thc tp ti khoa Sinh ha, cm n qu thy c, cc c ch v cac anh ch nhn vin trong khoa nhit tnh gip em trong sut qu trnh thc tp. Em cng xin gi li cm n n anh L Xun Tng, nhn vin khoa Sinh ha, bnh vin Nhi Trung ng v ch L Th Phng,cu sinh vin khoa KTYH, trng H Y H Ni cung cp ti liu tham kho v hng dn em trong vic hon thnh bo co thc tp. Nhng li cm n sau cng xin dnh cho cha m, cc em trong gia nh v cc bn b ht lng quan tm cng nh to iu kin tt nht em hon thnh qu trnh thc tp, hon thnh bo co thc tp. D c rt nhiu c gng, song lun vn chc chn khng th trnh khi nhng thiu xt v hn ch. Knh mong nhn c s chia s v nng kin ng gp qu bu ca cc thy c gio, cc bn cng hc. ng Ngc H

NH GI KT QU THC TP
H v tn cn b hng dn thc tp: ................................................ n v thc tp: Khoa Sinh ha Bnh vin Nhi Trung ng a ch: S 18 ng 879 La Thnh, ng a, H Ni in thoi: 84.4.8343700 (258)Fax: . Email: ................................................Website:................................... H tn sinh vin thc tp: ng Ngc H Lp:Y4I T 33 - Khoa K thut Y hc Thi gian thc tp: t ngy 20/9/2010 n ngy 23/10/2010

im

NI DUNG NH GI: .. ..
Xc nhn

MC LC
LI CM N ................................................................................................................................... 3 NH GI KT QU THC TP ................................................................................................. 4 MC LC ........................................................................................................................................ 5 MC TIU ....................................................................................................................................... 6 NI DUNG BO CO ..................................................................................................................... 8 A. I. BO CO KT QU GII QUYT CC MC TIU THC TP ..................................... 8 Cch t chc qun l mt khoa XN Ha sinh lm sng .................................................. 8

II. Vn hnh v nguyn l cc my xt nghim ha sinh trong cc phng xt nghim chc nng ........................................................................................................................................ 12 III. Quy trnh ly, x l, bo qun v d tr bnh phm .................................................... 22 IV. Tin hnh ni kim tra cht lng XN .......................................................................... 24 V. B. Trin khai cc vn an ton phng XN ...................................................................... 26 KT QU T C QUA T THC TP ................................................................. 29

KT LUN..................................................................................................................................... 32 CC TI LIU THAM KHO....................................................................................................... 33

MC TIU
Nm c cch thc t chc qun l mt phng XN ho sinh bnh vin. Nm c quy trnh ly, x l, bo qun v d tr bnh phm. Hiu c quy trnh ni kim tra v thc hin qu trnh ni kim tra. Trnh by c nguyn tc v cch vn hnh mt s my XN ho sinh. Nm c v bit cch trin khai cc bin php an ton phng xt nghim. Vit bo co thu hoch sau khi i thc hnh bnh vin.

LCH LM VIC C TH
T ngy 20/9/2010 ngy 22/9/2010

Ni dung Tun 1 T 20/9/2010 n 24/9/2010 2 T 27/9/2010 n 01/10/2010 3 T 4/10/2010 n 8/10/2010 4 T 11/10/2010 n 15/ 10/2010 5 T 18/ 10/2010 n 22/ 10/2010

Cng vic c phn cng - Ly bnh phm - Tr KQ XN - TPT - nh tnh Pro, Xton,t trng - Ly tm bnh phm - o kh mu - Nhp d liu vo s

a im

PK Min ph

Phng T nhn php xt v thc hin mc hon thnh - Quan Kh tt st, gip n/vin - Thc hnh - Quan Tt st, gip n/vin - Thc hnh - Quan Tt st, gip n/vin - Thc hnh - Nghe hng dn - Thc hnh Kh tt

Nhn xt ca Nhn xt ca cn cn b theo di b hng dn

Phng Nc tiu

Phng Mu

Phng Hnh chnh

- Hon thnh bo co thc tp

i cc - Nghe phng hng dn - Tham kho ti liu

(ang thc hin)

NI DUNG BO CO
A. BO CO KT QU GII QUYT CC MC TIU THC TP
I. Cch t chc qun l mt khoa XN Ha sinh lm sng
1. Tng quan v khoa Sinh ha Bnh vin Nhi Trung ng - T chc nhn s + Khoa Sinh ha c 14 cn b cng chc gm c cc hc v: Tin s, thc s, bc s chuyn khoa, bc s. c nhn, k thut vin v h l + Ngi ph trch khoa hin ti; o Ts. Trn Th Chi Mai Quyn trng khoa o BSCK II. L Thi Hot Ph trng khoa o CNh. Nguyn Thu Hng iu dng trng - Lch s pht trin Khoa Sinh ha c thnh lp t nm 1968 cng vi quyt nh thnh lp ca Bnh vin + Trng khoa cc giai on: o T 1969 n 1978: BS. Nguyn Tn Phc o T 1979 n 1985: BS. Nguyn Ho Th o T 1986 n 2000: TS. Hong Vn Sn o T 2001 n 2005: BS. Th Ngc Yn o T 2005 n nay: TS. Hong Hnh Phc + Cc thnh tu chnh t c o n nay khoa thc hin c khong 100 loi XN sinh ha c cht lng o Tch cc tham gia cng tc nghin cu khoa hc o Hon thnh xut sc mi nhim v c giao o Lin tc t danh hiu lao ng gii

- Cc hot ng chnh + Hot ng XN phc v iu tr o p ng mi yu cu chn on sm, phc v iu tr o Thc hin cc test nhanh, sng lc phc v chn on v iu tr sm o Thc hin cc XN chuyn su, s dng cc k thut cao phc v chn on v nghin cu khoa hc + Dich v y t chnh o Thc hin cc XN sinh ha thng qui o Thc hin cc XN chuyn su: Hormon, Tumormarkerm, ELISA, EIA, sc k min dch + Nghin cu khoa hc: Vi cc cng trnh nghin cu o Hng s sinh ha tr em o Nghin cu hot mt s Enzyme chuyn ha hng cu bnh nhn HbE, -Thalassemia o CRP trong phn bit vim no do nhim khun v virus o K thut min dch trong bnh Microglobulin + o to o Thng xuyn t chc o to chuyn mn, k thut cho nhn vin trong khoa nng cao trnh o C tham gia o to cho bc s cc tnh v hc v sinh vin y khoa - Hp tc trong nc v quc t + Thng xuyn trao i k thut vi cc n v bn trong v ngoi nc + Tham gia chng trnh kim tra cht lng International do Lin on Chu Thi Bnh Dng ch tr

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- D kin tim nng hot ng Pht trin thm cc k thut XN chuyn khoa su, gp phn nng cao cht lng chn on, iu tr v nghin cu khoa hc 2. V cch qun l v phn cng cng tc
Ph trch nhm XN chung BS CK II: L Thi Hot Ph trch nhm XN thng quy, Lm XN chung Nghin cu khoa hc Q.Trng khoa Ts Trn Th Chi Mai Ph trch nghin cu khoa hc Kim tra CL XN. Lm cc XN c bit

KTV trng CN Nguyn Thu Hng - Qun l hnh chnh s sch - Phn cng KT quy ch chc trch - Qun l kho, tham gia lm XN

Nhm XN c bit Min dch ,enzym

Nhm XN mu thng quy

Nhm XN nc tiu, phn,nc dch

H L V sinh khoa phng Ra dng c, tr KQ XN

!!! Mi sng u c giao ban rt kinh nghim v trin khai cng tc mi t 8h 8h30 3. Cc phng chc nng - Phng ly bnh phm - Phng nhn bnh phm - Cc phng XN chc nng bao gm

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+ Phng xt nghim nc tiu, phn, nc dch. + Phng lm cc xt nghim sinh ho thng thng. + Phng lm cc xt nghim c bit. + Phng lm cc xt nghim min dich, in di. - Kho ho cht bao gm: Kho lnh bo qun cc ho cht cn nhit thp t2- 8 C v kho bo qun cc loi bt kh.Kho ho cht c bo qun c nhng ho cht c.VD nh: Cc thuc c bng A, cyanua, bacbiturat Kho c kho 2 ln kho v 1 ngi gi cha kho. - Phng ra dng c: L phng ra li cc dng c thu tinh nh ng nghim hay pipet... hay cc vt dng c th ti ch...Trong tng lai s tin ti s dng cc dng c dng mt ln trnh sai s v anton hn. Cc dng c s c tin hnh ra theomt quy trnh:cc dng c c ngm trong cc dung dch st trng ty ra cao sau c em hp sy hay phi kh ty vo cht liu ca vt dng. - Phng nhn vin : L ni ngh ngi sinh hot ca nhn vin trong khoa. Cc phng c b tr theo 1 chiu, mc ch l khng cho bnh nhn vo trong khu vc lm vic ca nhn vin xt nghim trnh tnh trng ln xn mt trt t ...ng thi cc xt nghim c a ti cc phng xt nghim mt cch hp l nht. * Phng ly mu c t chc ngoi khu xt nghim trnh tnh trng ng c v trc tip ly bnh phm l mu cho khu xt nghim. Cch lm ny gip cho vic xt nghim c chnh xc hn v ly mu ng k thut trnh c tnh trng ly mu khng ng k thut ca cc h l hay y t ca bnh vin . * Cc phng cn li c b tr ln lt bt u t phng nhn bnh phm v phn pht ti cc phng xt nghim cn li. * Cc y t hoc h l c th trc tip mang bnh phm l mu, nc dch, nc tiu ... ti cc phng chc nng lm cc xt nghim.

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* Mi phng u c cc KTV ph trch cng vic ca mnh v hng dn cho bnh nhn hoc ngi nh bnh nhn lm theo ng yu cu ca tnh cht cng vic. * Mi phng c trang b 02 thng rc phn loi rc theo tnh cht tin cho vic phn loi * Rc sinh hot ng vo ti c mu xanh v rc y t c ng vo ti c mu vng v c thugom hng ngy. Cc vt sc nhn c cho vo cc l nha..

II.

Vn hnh v nguyn l cc my xt nghim ha sinh trong cc phng XN chc nng

1. Phng XN nc tiu, phn v nc dch Phng c b tr u hnh lang, do mt KTV ph trch v cc thit b, dng c vt t trong phng bao gm: - 01 my phn tch nc tiu t ng Uri-Screen 100 01 t ht 01 gi ng cc ho cht XN Cc dng c lm XN nh pipet, ng nghim, u cn, khay ng... Que th nc tiu

Phng lm cc xt nghim v nc tiu nh: * Tng phn tch nc tiu: c lm bi mytng phn tch nc tiu gm c 11 ch s bao gm: T trng nc tiu, pH, cc bch cu , hng cu , Nitrit, Bilirubil, urobilinogen, cc th Cetonic, Acid Ascobic, Glucose, Protein. My tng phn tch nc tiu t ng l mt my quang k khc x c s dng o bn nh lng 10 thng s trong nc tiu bng cch s dng thanh nhng nc tiu. Cc bng n 2 cc pht ra nh sng c s dng nh ngun sng v thi gian o uc ti u ho phn ng ho hc v s to mu xy ra trong vng phn ng ca thuc th.

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u o trong my cha 3 bng n c cc bc sng khc nhau. Que th c t mt v tr c nh v bt u o di chuyn trn mi bc m ca thuc th, bt u t v tr tham chiu ni h thng quang hc bt u hot ng. Trong qu trnh o, my kim tra v tr ca tng thanh th di u o bng cch kim tra mt cch chnh xc dng nh sng khc x uc o. Nu que nhng c t thiu chnh xc th my s thng bo li. ng nc tiu c nhn ti phng s oc nh s i chiu so snh vi thng tin ca phiu xt nghim. Nc tiu oc lc u dng mt thanh th nhng vo ng nghim (nghing ng nghim nc tiu mao dn n ht vch trn cng),p mt thm xung di ,dng giy thm nc tiu cn st li mt di v lng ca thanh ,sau bt my t thanh th vo v lm theo cc thao tc hng dn ca my. Sau 1 pht c kt qu in ra. Ngoi ra em cn thy c s dng dng c l t niu k o t trng nc tiu. c chnh xc kh cao . My ch o cc ch s bn nh lng do vy mun o nh lng th cn phi o my bn cc XN routine. * Cc XN nc tiu 24h bao gm: nh lng protein noc tiu: th bng thuc th ome nu c vn c chng t c nng cao trong nc tiu th cn pha long noc tiu tu nng (Do my khng th c c nhng kt qu c nng cao trong nc tiu). Cn c hai ng mt ng chng v mt ng th v cng i o quang phng routine, o ng trng trc. nh lng ng , mui mt , sc t mt nh lng Glucose (Nh my sinh ho t ng lm ) nh lng protein( Dng my screen master 3000 lm ) Mui ( clo ) (Nh my sinh ho t ng lm ) Phn ng Pandy (ta globulin bng phenol) * Cc XN v dch no tu bao gm 4 XN:

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Ta cng tin hnh pha long nu nh nng ca cc thnh phn trong nc tiu cng cao qua mc cho php. Cc dch chc d khc cng lm cc XN tu theo yu cu ca bc s. * Cc XN v phn bao gm: nh lng stecobilinogen trong phn Phn ng Benzidin (mu trong phn ) Tm cn thc n trong phn ( nh gi kh nng tiu ho ) Nghim php Schwasnman ( trypsin phn )

KT kt qu Ghi li cc kt qu vo s theo di .k xc nhn v tr KQ Cc kt qu c tr ti phng, nhn chung nhanh c kt qu XN. Bnh phm c lu n sng hm sau. 2. Phng ly mu, nhn bnh phm v vo s Phng ly mu c t chc ngoi khu xt nghim trnh tnh trng ng c v trc tip ly bnh phm l mu cho khu xt nghim. Cch lm ny gip cho vic xt nghim c chnh xc hn v ly mu ng k thut trnh c tnh trng ly mu khng ng k thut ca cc h l hay y t ca bnh vin. phng ny ly mu tnh mch, mao mch; mu ng mch t c ly hn ch yu ly bnh phng. Quy nh v vic tr bnh phm: Cc XN ly mu trc 11h th tr KQ vo 3h30 cng ngy Cc XN ly mu sau 11h th tr KQ vo sng hm sau Cc XN HIV th tr KQ vo chiu hm sau.

Bnh nhn hoc ngi nh bnh nhn ly kt qu ti phng v k tn xc nhn. Mu ly phi c tun theo quy trnh ly mu cht ch .Thng ly khong 23ml.Mu cho XN nghim ho sinh cho vo ng thu tinh to hn v mu khng chng ng,cho huyt hc cho vo ng nghim nha nt xanh c chng ng. Ngi ly mu s ghi thng tin ca bnh nhn vo mt quyn s ly mu.

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Phi chun b y dng c trc khi lm, dng c phi c v trng ,ghi y thng tin c nhn vo ng mu. Dn BN khng n trc khi ly mu ,khng vn ng mnh. Mu c ly v vn chuyn ti cc phng XN chuyn trch trong vng 30 pht.Mu ca khoa ho sinh thng c ng ly huyt thanh.
3. Phng vn hnh cc my sinh ha t ng

Cc XN dng n my ho sinh t ng c gi l cc XN thng quy (Routine)c lm ti phng XN ho sinh. Phng Routine gm c cc my mc thit b sau : My o kh dng lm cc XN v kh mu ng mch.

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My XN Ho sinh bn t ng Screen master 3000 hot ng da trn

nguyn tc o quang v dng nh lng cc cht sinh ho thng thng v thng c dng o nng cc cht trong nc tiu v dch no tu.(khong 17 ch s )

Cn phi ch l theo quy trnh v o hai ng :ng trng trc v ng th sau . My iu nhit gi nhit cao cho bnh phm chc nng nh t m My ly tm ly huyt thanh dng cho XN T lnh bo qun thuc th v ho cht dng c ... T ht ht khng kh v mi trong phng. My in gii :

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hot ng trn nguyn l in cc chn lc ion o nng cc ion trong mu hoc trong nc tiu . i vi mu th s dng huyt thanh v khng phi pha long .Cn i vi nc tiu th phi pha long theo nh yu cu s dng my c dn trn tng. Cn ch l lc huyt thanh trc khi cho vo ht xem c ng hay khng cho kim vo gn ti y ht c lng HT . Cui cng quan trng nht l cc my sinh ho t ng.Cc my ny khng c t chung mt phng m t cc phng khc nhau .Nguyn l ca cc my Ho sinh t ng u da trn nguyn l o quang : Nhiu cht ho hc c th to mu nh phn ng vi cc cht ho hc khc, mu to c c hp th cc i mt bc sng no ; bc sng c s dng o mt quang hc ,t tnh ra nng cht cn thit da vo nh lut Lamber- Beer It= Io.10^-aCL Trong Io l cng nh sng chiu ti, It l cng nh sng truyn qua mitrung a l hng s hp th , C l nng cht hp th , l l chiu dy ca mitrung .

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Cc my ho sinh t ng bao gm : My OLYMPUS AU 400 My c nhiu u im so vi cc my trc c th lm c khong 400 test/gi. My c dng lm cc XN thng quy v c th lm in gi , ngoi ra quan trng hn l my c th nh
H.3 My OLYMPUS AU 400

lng nng cc thuc c trong mu phc v iu tr ghp gan , ghp thn (nh lng cyclosporine,tacrolimus..) Hin my vn cha c ng dng i tr v ch yu c dng nh lng nng mt s thuc nh nu trn.Gi thnh cho mi XN vn cao. - My OLYMPUS AU 2700

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- Cc my khc gm c

My Cobas b 221

My EBA 21

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My T60 UV Visible Spectrophotometer 4. Phng cc XN min dch, in di Phng lm cc XN v nh lng cc yu t min dch da trn cc phng php nh: o min dch c: nh lng cc IgG, IgD, IgE, IgM, nh lng CPR. c im ca KT ny l cn c khng th c hiu. Kt ngng kt Latex : c im l ngng kt thnh vng MD Enzym EIA/ELISA :nhn bit s c mt ca khng nguyn trong c

th thng qua s kt hp c hiu vi khng th v c gn vi mt cht gn E v to thnh phc hp .Phc hp ny c gi li bng s gn t tnh qua nhiu ln ra v c o s pht quang trong bung ti K thut ny c dng nh lng nng cc enzym, hormon...nh T3, T4, testosterone, progesterone... Min dch CHIA,EMIT..... Phng XNmin dch gm c cc thit b dng c:

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T lnh bo qun cc ho cht , thuc th ...;Cn in t cn ho cht

cn chnh xc cao ,cn phn tch , khuy t c tc dng un si v khuy dung dch ... Gi, khay ng cc ho cht , thuc th cc loi .. o My min dch ADVIA

Centaur : L my quan trng nht

trong phng . My hot ng da trn nguyn l k thut min dch ho hc pht quang IAC (Immuno Assay Chemiluminecene ) Cht cn tm l KN(hoc KT ) trong bnh phm kt hp vi KT hoc KN trong gi c t tnh v AE cht phat quang to phc hp min dch v oc gi li trong cuvette nh mt nam chm v khng b mt i trong qu trnh ra . nhit 37 C phc hp MD c ho tan nh dung dch acid v khi thm dd Base vo th P Ho Pht quang c khi pht .nh sng pht ra c o trong bung ti . Cng nh sng to ra s oxy ho ca AE .H thng s tnh ton ra nng cc cht cn tm. Cng nh sng t mc ti a ngay giy u tin. Cc phn ng min dch c dng trong my MD theo cc nguyn l : Ki bnh m kp (Sandwich format) Kiu cnh tranh (Compentitive format) gm
Hnh 5 my ADVIA Centaur

thuc th c gn PMP cht bt

+ Kiu cnh tranh m KN c gn vi AE + Kiu cnh tranh m KT c gn vi AE + Kiu bt gi KT (Antibody Capture Format) My min dch ADVIA Centaurthc hin c cc nhm XN sau:

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nh lng cc hormone tuyn gip : T3 , T4 , FT3, FT4, TSH nh lng cc hormone sinh sn: FSH, LH, Testosteron ,Estradiol , Cc cht ch th ung th: alpha FP, PSA, CEA, CA-125, CA-199,... Bnh v mu : Ferritin , Acid Folic , Vit B12 XN v bnh tim mch myoglobin, CK-MB nh lng thuc v theo di cc thuc iu tr: Digoxin, Gentamixin... Bnh ly nhim:HAV-M, HAV-T, HBsAg-M, HBsAg- G,Rub-M, Tox G; Chc nng tuyn thng then : Cortisol XN v d ng :IgE , cc d nguyn ... Phng cn tin hnh in Cc phn t protein v di protein bng my in di : ADN c trng lng phn t v khi lng khc nhau th di chuyn v cc + ca in cc vi tc khc nhau nh m c

Progesterol..

Tox- M...

th phn tch c thnh phn ca Protein...

III.

Quy trnh ly, x l, bo qun v d tr bnh phm

1. Cch ly v bo qun mu: Chun b dng c: - ng nghim thy tinh 5-10 ml, nt ng nghim - Kim tim, bm tim (nn ding loiaj kim tim, bm tim v khun, dng 1 ln) - Dy tht (nn bng cao su mm, n hi tt). - ng nghim thng c chng ng bng heparin hoc khng cn chng ng Chun b bnh nhn: - Ni chung nn ly mu bnh nhn vo bui sng sm, bnh nhn nhn i 12 ting, (tr nhng bnh nhn cp cu)

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- Trc khi ly mu cn cho bnh nhn ngh trong khong 15-20 pht Cch ly mu: - Thng ly mu tnh mch khuu tay, dng dy tht v tr trn khuu tay 2-3 cm, chc kim vo tnh mch,ko nh bm tim xem kim chc chn vo tnh mch hay cha. Ht s lng mu cn thit (1.5-2ml)ri b garo rt kim nhanh v dt khot. B u kimi ri mi bm mu vo ng nghim chun b sn. - i vi bnh nhi c th ly mu tnh mch trn hoc cng chn. Cch bo qun mu mu: - Thi gian bo qun cho php vi cc mu huyt thanh v huyt tng l khong 4 gi nhit phng xt nghim v trn 1- 2 ngy 2-8oC. Mun gi li mu lu hn th cn nhit di OoC. i vi cc mu nh lng enzyme cn tun theo cc qui nh c th ca phng php nh lng. - Trn thc t c nhng cht tng i bn vng nhit 20 oC trong khong thi gian di hn nh Cl , K, Na, Mg, Fe, hemoglobin, acid uric, cholesterol, triglyceride, phosphatidNhng cng c nhng cht thay i nng rt nhanh nh NH3, glucose 2. Ly v bo qun nc tiu: Dng c: - Bnh ch nc tiu, thng thng dng bnh thy tinh c chia theo ml hoc lt, hoc ng nghim thy tinh 10-15ml, c ra sch sy kh v c nt. Cch ly nc tiu: - Xt nghim nc tiu ti +Ly nc tiu bui sng, gia dng Xn nh tnh. + Dng c: sch, kh, v trng, khng ln cc cht ty ra, dn nhn c cc thng tin v bnh nhn. + Bnh nhn dng thuc, nc ngt thc phm c mu s nh hng ti kt qu xt nghim. + Bng cm quan, nc tiu phi trong c mu vng nht. +Bo qun: ni thong mt, trnh nh sng trc tip. + Gi n phng XN trong vng 30 pht. + Nc tiu 24h: bo qun tu theo loi XN. - Nc tiu mi ly nn lm ngay trnh s phn hu ca mt s cht lm nh hng n kt qu xt nghim. - Mt s xt nghim sinh ho cn ly nc tiu 24h, tu theo cht cn lm xt nghim m s dng cc cht bo qun nc

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tiu khc nhau: v d xt nghim protein, t trng, cc cht in gii, glucose, ure, creatinin, trong nc tiu 24h thng dng dung dch HgCl 1% hoc acid boric 1% 2ml bo qun cho tng lng nc tiu 24h khong 1l. - xc nh cc cht catecholamin, acid vanyl mandelic s dng acid cholohydric c (1-2ml) cho lng nc tiu 24h. - Cch ly nc tiu 24h: ly vo gi qui nh v d t 7h sng hm trc n 7h sng hm sau, gom tt c s lng nc tiu vo dng c ra sch v v trng, sau khi ly nc tiu ln u mi cht bo qun, ton b nc tiu 24h c bo qun ch mt, o th tch, ly khong 50ml xt nghim Bo qun nc tiu:: - Ni chung khi phn tch cc cht trong nc tiu nn dng nc tiu ti, nhit phng xt nghim. - Nu cha phn tch mu ngay c th mu nc tiu 2-8oC trong vng 3 ngy, i vi mc ch phn tch hormon hoc nng thuc, iu kin ny thuc khng b phn hy. - Nu cn gi mu lu hn 3 ngy th phi mu < 0oC. - Ni chung khng nn dng ha cht bo qun nc tiu. 3. Ly v bo qun bnh phm dch no ty: - Dch no ty l lp dch trong cc khoang di mng nhn bao bc xung quanh no ty, trong ng ni ty, no tht, bo v cho trung ng thn kinh. Mi thng tn d nh u lm nh hng n tnh cht ca dch no ty. Phn tch nhng bin i c th chn on c mt s bnh v thn kinh, theo di c s tin trin ca bnh. - Ly dch no ty tng i phc tp i hi bc s c kinh nghim. Khi chc dch no ty nn hng bnh phm vo 2 ng nghim ring c nt cao su. - Nn tin hnh phn tch ngay rnh hin tng phn hy ng. - Do tch cht kh ly ca bnh phm nn trong qu trnh lm xt nghim phi ht sc thn trng trnh phi ly li bnh phm.

IV.

Tin hnh ni kim tra cht lng XN

- KTCL XNl cc phng php xc nh xc thc v chnh xc ca mt phng php xt nghim, v l mt trong nhng phng php nhm m bo kt qu xt nghim ng tin cy. - Ni kim l h thng kim tra cht lng trong ni b mt phng XN nhm theo di v gim st mi kha cnh ca qu trnh thc hin XN ti phng XN, m bo kt qu ca XN c tin cy

25

trc khi tr cho ngi bnh hoc khoa lm sang v a ra bin php sa cha kp thi nu c sai s. Ngoi ra ni kim tra cn nhm mc ch nh gi h thng phng XN, phng php o lng, thuc th, ha cht, my mc v tay ngh k thut vin. - Khoa mnh t s dng huyt thanh kim tra (Huyt thanh c hang sn xut nh lng chun nng ) tin hnh ra my, sau mi chy huyt thanh bnh nhn. Nu kt qu nm trong khong cho php ca hang th tip tc chy XN. Nu kt qu sai lch khng cho php th phi hiu chnh li my. - Chng em c tham kho s liu ca anh l Xun Tng trong mt ln tin hnh kim tra chnh xc v xc thc qua vic nh lng nng protein ton phn trong huyt thanh QC hai mc l Normal v Pathology. Kt qu o ca mc P : Ln 1 Ln 2 Ln 3 Ln 4 Ln 5 Ln 6 Ln 7 Ln 8 Ln 9 Ln 10 63.5 63.6 61.6 63.2 67.8 60.3 65.2 62.8

64.3(g/L) 65.2

C X trung bnh =X = (x1+x2+x3++xn):n =63.8 lch chun SD = [(X xi)2]:[n 1]= 1.98 CV= SD/X100% =3.15% Gi tr ca mu P l 71g/L nh vy chnh xc chp nhn c! Tuy nhin xc thc khng cao. Ta c nh gi nh sau: Kt qu nm trong khong 2SD do vy chp nhn c v CV=3.15 < 5% chp nhn c nh vy my v k thut tin hnh XN chp nhn c Nguyn nhn gy ra sai s:

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+ Do k thut ca ngi lm xt nghim khng chun - y l nguyn nhn ch yu gy nn sai s ny + Do ha cht v dng c - Ni kim tra phi tin hnh hng ngy hoc t nht l hng tun.

V.

Trin khai cc vn an ton phng XN

1. M u: Do tnh cht cng vic, nhng ngi lm vic trong phng xt nghim ni chung v phng xt nghim ha sinh ni ring lun phi tip xc vi nhng bnh phm, nhng ha cht c hi do vy vic m bo an ton phng xt nghim lun l vn c quan tm hng u m bo sc khe cho nhn vin phng xt nghim. 2. Cc vn v an ton phng xt nghim. An ton phng xt nghim bao gm cc vn v an ton cho ngi lm xt nghim v an ton cho ton b phng xt nghim Trch nhim ca ngi lm xt nghim: S lm vic hiu qu, chun xc v an ton ca nhn vin phng xt nghim l yu t quyt nh t c mt ni lm vic khng c s c v tai nn. V vy ngi lm xt nghim cn phi tun th cc quy nh v an ton sau: - Hiu bit v tun theo cc phng php lm vic trong phng th nghim c thit lp. - Nhanh chng thng bo cc tnh trng khng an ton cho trng labo. - Cam kt thc hin cng vic mt cch an ton v s dng cc thit b bo v c nhn. - To thi quen lm vic khoa hc: Mc o blouse, i dy, eo gng tay, khu trang, i m, u tc gn gng. Khng n, ung, ht thuc trong phng xt nghim. Khng dng pipet ht dch trc tip bng ming ,m phi dng pipet t ng hoc qu bp cao su.

27

Ra tay thng xuyn khi xong th nghim. Gi gn ngn np, sch s ni lm vic. Gi ni lm vic lun sch s, ngn np, khng c ba bi cc dng c s dng. - Cc ha cht,dng c, trang thit b cn ng ch, dng xong phi xp li gn gng ngay. - Thc hin cc thao tc k thut ng - Bit v tr t thuc cp cu, hiu qu trnh cp cu v bit cch x l chun xc khi c s c xy ra. - Trnh s dng cc thit b in t nh in thoi di ng, my tnh c nhn trong phng xt nghim. - Khng eo n trang, khng dng m phm trong phng xt nghim An ton v s dng thit b. - Cc thit b phi c ch c bit v an ton khi s dng trong phng th nghim. Ngi ph trch phi ra cc ni quy cho vic s dng an ton cc thit b, ng thi yu cu s dng phi tun theo cc ni quy s dng mt cch an ton cc thit b . - Khng c vn hnh my khi: Khng quen dng, cha hiu bit v cha c php dung An ton v s dng ha cht a) Nhn bit cc quy c v nhn mc - Ghi nhn thuc th,ha cht v dung dch r rng. - Ghi nhn bo hiu nguy him khi s dng cc ha cht c hi v c khu vc s dng ring. b) Bo qun v s dng ha cht. - trnh nhm ln v cc s c khi s dng ha cht c hi, phi c hiu bit v c tnh ha cht s s dng. iu ny c bit quan trng vi vic vn chuyn, pha ch cc ha cht v mt s c th to ra cht

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c hi, d chy, d n. V d: acid acetic khng pha vi acid cromic, acid nitric; cht lng d chy khng pha vi nc oxy gi, acid nitric. - Cn sp xp, bo qun ha cht theo s lng v c tnh ha cht trnh cc s c.Cc ha cht thng dng cn sp xp ring.Vic sp xp khng nn ch da theo vn A, B, C m cn cn c sp xp theo c tnh ha hc ca ha cht. - Cn thn vi cc cht d chy v cc cht c kh nng chy. c) Cc ha cht c - Nhng ha cht c l nhng cht c th gy cht ngi hoc gy bnh nu n phi, ung phi, ngi phi hoc tip xc trc tip qua da, mt,. - Cn ht sc thn trng khi thao tc, tip xc vi cc ha cht c. - Phi thc hin nghim chnh vic s dng cc trang thit b c nhn ph hp khi thao tc vi cc ha cht c. An ton v phng , chng chy n - Phng th nghim no cng s dng rt nhiu thit b in,my mc. in git trc tip c th gy cht ngi, sc, bng; in c th gy chy, n .v vy cc phng th nghim p hi c trang b bnh cha chy CO2; phi c thit k c cc vi nc cha chy. - Phi c cc bng ch dn ni c vi nc cu ha, ni nhng dng c chng chy, cc ngi lm th nghim phi tp luyn nh k v kim tra thao tc chnh xc i vi thit b cu ha.

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B. KT QUT C QUA T THC TP

1. Nhng ni dung kin thc l thuyt c cng c Trong qu trnh thc tp em c cng c rt nhiu kin thc l thuyt trn lp v trong c nhng vn m bn thn em thy c cng c r rng nht l: Kin thc v cc cht chng ng dng cho cc loi xt nghim thch hp o Vn t ra: EDTA, heparil, natricitrat u l cc cht chng ng nhng ti sao khi ly mu lm xt nghim ha sinh li phi ly vo ng chng ng bng heparil, xt nghim mu lng li phi chng ng bng natricitrat m khng dng c cht chng ng khc? o Cng c: 1. Calcium rt cn thit trong qu trnh ng mu. Sodium citrate, sodium oxalate, EDTA kt hp vi ion calcium v ngn cn chng tham gia vo qu trnh ng mu. Do , xt nghim sinh ha khng dng nhng cht ny v s nh hng n kt qu. 2. Vn tc lng mu c coi nh l cht nh du (marker) khng c hiu ca hin tng vim. Fibrinogen cng l mt marker khc ca hin tng vim. Khi thy vn tc lng mu cao, BS s lm thm xt nghim o fibrinogen trong mu l v l do . Heparin, can thip vo qu trnh ng mu bng cch ngn cn khng cho thrombin tc dng ln fibrinogen thng qua vic thnh lp antithrombin.Nh vy, xt nghim vn tc lng mu phi s dng nhng cht chng ng khng c tc dng ln fibrinogen. Tht ra c nhiu cht ngn cn s ng mu nhng nhng cht m mnh c th ng dng c thc t cng kh t.Heparin th n tc ng trn fibrinogen v ko nh hng n kt qu cng thc mu nh: hng cu, bch cu, tiu cu, ure huyt, hay bt c ci g. Cn cc cht citrate hay EDTA th n c tc ng vi Ca2+, citrate th ta, EDTA th to phc... nhng cn 1 s phn ng khc na nh phc to vi Na, K hay c th nh hng n kt qu xt nghim. Kin thc l thuyt v nguyn tc phn ng tng XN ring bit trn thanh th nc tiu

30

o T trng nc tiu: Th nghim ny phn nh nng ion trong nc tiu v tng quan cht vi phng php o khc x. Vi s c mt ca cc cation, cc proton s c gii phng bi mt loi thuc th hn hp, to nn s thay i mu ca cht ch th Bromthymol c mu xanh da tri sang mu xanh l cy ri sang mu vng. S c mt ca protein nng t 100 n 500mg/dL hoc cc cetoacid, t trng c c c xu hng tng. o pH nc tiu: Giy trn thanh th cha cc cht ch th: methyl, phenolphthalein v xanh bromthymol o Cc bch cu: Xt nghim ny th hin s c mt ca cc enzyme esterase ca cc bch cu c ht. Cc enzyme ny c tc dng thy phn este ca indoxyl v indoxyl c gii phng s phn ng vi mui diazonium cho mt sn phm mu tm. o Nitrit: XN ny da trn nguyn tc ca phn ng Griess c hiu vi nitrit. Pht hin s c mt ca nitrit c vi khun to nitrit trong nc tiu bng s i mu t hng n trn thanh th. o Protein: XN ny dc trn nguyn tc s thay i nng protein ph thuc v mt cht ch th v pH o Glucose: Da trn phn ng c hiu glucoseoxidase/ peroxidase o Cc th cetonic: Da trn nguyn tc ca phn ng Legal o Urbilinogen: Nguyn tc l mui diazonium phn ng tc th vi urobilinogen to nn mt cht azo c mu o Bilirubin: Nguyn tacs da trn s kt hp ca bilirubin vi mui diazonium s cho mu o Hng cu: Hemoglobin v myoglobin xc tc cho s oxy ha cht ch th l hydroperoxid hu c cha trong giy ca thanh th Nguyn tc chung nh lng kh mu Kh mu c nh lng bng phng php o in th: Da trn s o lng hiu in th gia hai in cc nhng trong mt dung dch ion nh gi tnh trng nc v in gii y l mt yu t quan trng trn lm sang. Cn nh lng nhng thng s sau: o Nng cc cht in gii huyt thanh: Na, K, CLUre v Creatinin huyt thanh

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o Tnh trng thng bng acid base: pH, pCO2, pO2 o Nng albumin huyt thanh, ASTT huyt thanh o Th tch nc tiu 2. Nhng k nng thc hnh c hc hi o K nng thc hnh trn my tng phn tch nc tiu o K nng thc hnh trn my o kh mu o K nng thc hnh trn my ly tm o K nng nhp d liu, lu v tr kt qu XN o K nng ly bnh phm trn tr em 3. Nhng kinh nghim thc t c tch ly Nhng kinh nghim thc t trong cch lm vic ti mt phng XN bnh vin Trung ng, phong cch lm vic hin i, hiu qu v rt trch nhim cng nhng k nng trong vic thc hin nhng XN rt chun xc

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KT LUN
Sau qu trnh thc tp em hiu c cch thc t chc qun l ca khoa Ho sinh bnh vin NhiTW. Em cng c kin tp v thc tp lm mt s XN thng quy di s hng dn ca cc C, ch, anh, ch phng XN.Em cng hiu c nguyn l hot ng ca cc my ho sinh t ng v lm c cc XN trn my t ng ng thi cng tip nhn bnh phm, vo s, kin tp cc c ly mu. Bn cnh em cng c tin hnh tm hiu mt phn cng vic ni kim tra v hiu c mt s quy nh trong vic thc hin an ton lao ng trong phng xt nghim ...Trong qu trnh thc tp em c s hng dn nhit tnh ca i ng cn b nhn vin bnh vin, gip em hon thnh kho thc tp ny. V em tin sau ny khi ra trng lm vic chng em s khng cn b b ng m s t tin vi nhng kin thc thuc trong thi gian. Em xin chn thnh cm n !

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CC TI LIU THAM KHO

1/ Quy trnh s dng cc my sinh ho t ng 2/ Quy trnh s dng my ADVIA Centaur 3/ Quy trnh s dng cc my ho sinh khc 4/ Sch thc tp Ho sinh 5/ Mt s giy gii thiu v hng dn s dng cc ho cht v thuc th 6/ Mt s hnh nh,ti liu tm kim trn Internet V mt s ti liu tham kho khc