PHUONG PHAP PHAN TICH KHi TRONG MAU ThS.BS. Vit Trén Thién Quan - PGS. TS. BS. Lé Thi Tuy er Lan MUC TIEU 1, M6 ta duge chi dinh khi mau déng mach 2. Dinh gid duge tigu chudn khi mau déng mach Mo ta duge gidi han binh thuong cia PaO2, PaCO2, pH. Phan tich duge oxy héa mau Phan tich duge PaCO2 aye Phan tich duge cn bang toan kiém ty, 1 DAICUONG te Khi méu déag mach cung cép théng tin vé pH, phan dp va néng d6 cua 02 va COZ trong méu dong mach, déng thai gitip'chan dodn cae roi loan t é trong co thé. Day la m6t phurong phap thim do ehire nang ho hip kiém quan trong trén lim sing. Cée chi sé thu durge tir may phan tich khi trong mit salu. Bang le Céic chi sd thu dege tie may phéin tich khi trong ma 1. Cie chi so do true tiep Phin 4p oxygen (Partial Pressure of Oxygen - Po2) ide ~ Pos) = Phan dp carbon dioxide (Partial Pressure of Carbon dit = pH. 2. Cée chi sé tinh toan = Néng d6 HCOy thit sur (Actual bicarbonate COs \) = Néng dé HCOs- chudn héa (Standard bicarbonate — HCOs'St) — Kiém dém (Base Buffers - BB) Scanned with CamScannerss - BE) bao (Base Excess of Extrace! JJular Fluid - BE wel) = Kiém du dich ngoa = COs téng céng (Total C2 CO=1) rial Po. ch (Alveolarar = Khuynh ap oxygen qua ming phé nang-mao mt Gradient - AaDPO:) : 3. Cée chi s6 dge trén toan a3 = Shunt: Qs/Qr = Théng khi khoang chét: Vo/Vr (Cae thong tin ti Ki mau dong mach c6 thé chia thinh 3 nhom: 1. Kha nang oxy hoa mau 6 phoi: P,O2, AaDPO>. va ose pliva 2. Khi nang thong khi cia phdi: PCO». 3, Tinh trang thang bing toan kiém: pH, pCOs. HCO¥ A. HCO¥ St. BB. BE. Bhect va COxT * 2. CHi DINH PHAN TICH Ki Khi mau déng mach duroc chi dinh khi phuong phép xm lén, nén can nhac trénh lam nhu sau: we. uy nhicn day far mot . Cac cht dinh khi mau do emach n didn, phain’da vai tim ngs ¢ 1. Khicé nghi ngér suy hé hip: dé ch | Khi str dung oxy: dé cho chr dinh, dink nniee do vat theo iv cu « 2. 3, pS theo doi mite théng khi phé nang. thong khi khoang chét 4 | Khi tha may: dé cdi dit ede thong s6 may ther. theo di hiGu qui v1 quyet din cai may. 5, Khicé nghi ngé réi loan thang bang toan Kiem: dé phin Toat 161 loan, sae dinh mire d6, tinh toan lung toan kiém phai cho bénh nhan va tim nguyen nin iu ling ngue hay ving buny eas i 6. Banh gid chite ning hé hap tnudc khi g ty Rich Rhdie dé thes ctor tial tran 7. Trong cap ciru hdi sinh va ede inh cung cp oxy cho mo. Scanned with CamScanner/ 3. CA i ini x : "AC CHI SO DANH GIA KHA NANG OXY HOA MAU CUA PHOL 3.1 Cie i aera 1 Cac img dung ctia chi sé phan sip oxy trong mau dong mach ~ PaO: 3.1L Dinh nghia Phan dp oxy (Po2) trong mau La dp suit phan cia khi oxy 3 edn bing yor mau PO; trong mau déng mgch ky higu li PaO PO; trong mau tinh mach tron ky higu la POO dong mach - PaO: 3.1.2. Gidi han binh thicdng ctia phan dp oxy trong mau 10: imme) Bang 2: Gigi han binh tinedng ctia phan dp oxy trong meu dong mach Pe Di tugng TPaQe (mmtty) = Nenoi lon, trem me | Gisi han duis 80 = Trésosinh | 40-70 * (Gigi han ds: = Nguii gid Negudi gid PaO: (mmHg) = 140° tudi han trén ki dir oxy mus (hy pererverniny, Bae th hoor mete PaO? cao hon mite gidi han dudi i thiéu oxy mau (hypoxen 3.13 Ynghia ciia chi sb PaOz PaO> phan anh kh ning oxy hda méu eta phot 3.13.1 Dinh gid khd ndng avy hoa mdy cut phot Ding PaO: dé danh gid kha nang oxy hoa miu cua phoi Bang 3. Ste thay ddiciia chi sé PaO: Y nghia va edch wily ==] hia vit cach ww ly Sy thay doi cia PaQz | ¥ PaOr dink thudng | Vige nisin oxy tu phor fa hinh thuon hi hing cin thay ddr ge ve he hap Thang thei Scanned with CamScannerPadz cao. Vige nhin oxy tai phoi da du. C6 nguy co ngé dée oxy — can phai fim giam a0 \uiine trir Khi dae biét cin duy tri PaO cao Lu ¥ d6i vGi tre sor sinh, nit fio tre thigu tha Khéng duge qui 75 mmtiy, Vige nhan oxy tai phdi khong di, Cain kigm tra che rang phi (tinh shunt, chup X-auzng ling gue, lim test thim do chite ning ho Thay déi F,0z cho vao vivhay diéu chinh cae tho the, PaO; thép mii Dieu tr nguyén nhin 6 phdi hay tim gay ra thigu oxy mau, néu 06 t 343.2 Chan dodn vi phan dé suy- Ai hap Bang 4. Phan dé suy ho hap & tre em vi nguai lin bang chi sé Pac Pad: 60-79 Nhy 3.1.3.3 Theo doi két qué diéu tri trong ox Can lam phan tich khi mau dong mach truée kh Sau khi cho oxy, o6 thé theo doi bing SpOs, luy nhign truimg hop ng lam hi mau déng mach, Bang phan loai sau gitip danh vid higu qua vai hirone din each vartey wen Bang 5. Gié tri dir desin cua PaO: Alu ches hs Os Bg “on FiO: PaO2 (mm) 030 > 150 0.40 200 0.50 | 250 1,00 |= s00 Scanned with CamScanner3.1.3.4 Danh gid higu qua khi cho the oxy Bang 6. Danh gid hiéu qua khi cho the oxy va cach x Nv PaO2(mmiig) TY nghia va cach wily | PaQ2< 60 Giam oxy miu chwra dieu ehinh direc, new Pat an whe | hon 60 mmilg dit ed ting FiO> 60 dir | Bénh nhan sé bi g oxy qndu néu ngimy oxy. nhimg CO Goan (xem Bang 5) _| thé giam FiO2 dug PaO: > PaO: dirdodn | Gidm oxy mau Ga digu chinh qua du. — 6 thé khang gam oxy mau Kh ging ens une phat | giam FiO» ain din | _ - 3.2. Khuynh ap oxy gitra phé nang va mau dong mach (AaDPO2) 3.21 Dink nghia “AaDPOs li sy chénb Iéch gitta phin ap o”trone phé nang va trom *%, mau dong 3.2.2. Tri sb binh thudng ctia AaDPO. Bang 7. Tri so binh thc aDPOs theo FiO: sta + FiOz ‘AaDPO: (mmHg) 10, ngireri 20 1004 ro tren 60 wt = 50, o neuter 30-60 ud 3.2.3 Yughia ‘AaDPOs gia tang c6 thé do si it thuromy rane tim, Do d6, néu da logitrit bénh ly tim mach & su trao di khi tai nu mé phoi. xy hoa mau dng mach shy phos best hunt phai-trii thi APO: phan anh Néu PaO2, PaCO>, va pH bat throng. ma AaDPO> inh therdmg. thi este ror loan ny khong do bénh Iy etia nhu mé phoi. Scanned with CamScannerTHONG KHiCUA PHOL NANG ta chi sO quan trong nat dé 4 CAC CHI SO DANH GIA KHA Phan ap carbon dioxide trong miu dng mach ~ PaCOz dénh gid kha ning théng khi cia phoi. 2s ver mat 4.1 Dinh nghta Phan ép CO2 trong mau (Pov) lip suit phin ea bhi COs Peo trong mau ding mach ky higu li PaCOz Pco2 trong mau tinh mach trén ky higu la PCO: 4.2 Giéihan binh thudng cia PaCO2 wrong Bang 8: Khodng bin thrang vi chap nhdn duge ¢ ‘miu déng mach (PaCO) sie phen dip carbon divide PaCO2 (mmHg) Khoang tri so binh thing ‘4025 Khoang gigi han chap nhan due 40:10 fd PaCOz khéng thay doi theo tuoi tic. sim khi déi tugng gia ting thong khi, PaCO2 cé + Dolo ling, sg hai. + Lén dé cao hon 2.500 m. PaCOz cao (hypercapnia) khi lurgng CO2 trong mau dgng mach quit mic 45 mm am duce 3 mill PaCOz thép (hypocapnia) khi lurong CO: trong mxiut dng mach 43° ¥ nghia PaCO> phan anh truc tiép vige mire dé thang khi phé nang €6 phi hop vi tow ds chuy eon héa ciia co thé hay khong. 4.4 Danh gid tinh trang théng khi phé nang So sénh PaCO2 ctia bénh nhin voi khoang PaCQ- binh thes thé phan Joai 3 tinh trang thong khi phe nang (Bang 17) 40: Sumdtya ta Bang 9. PaCO2 vi tinh trang thing khi phé nang PaCOz [Tinh trang]. “| ¥ ngh Nuwyee abi (mmHg) | théng khi nga, guyén hain z _! Scanned with CamScannerMite thong hi phu - ; j ng khi pha hop 5 | Binh thuimg | vdi tinh trang chuyén he Giam thong Khu phen. Giim thing | Mée thing Khithip tom >45 théng | khi phé nang an cdu thai CO: cua co ees turd miu | <35 | Tang théng khi Mie thong khi cao hon | Giam pH ad an hu clu thai COs ctaca| es H@ thin kinh bi kich thich thé, Cho tho may qua mite 4.5 Chan don suy hé hdp tang than Suy hé hap duge chin don khi PaCO: > 50 mmily = Suy hé hp man tinh: pH o mite binh thuime \h trang thong khi khoang chét tinh trang thong khi khoang chét Ding PaCO: dé dinh — Théng khi khoang chét lam tang cong ho khi phé nang. Do dé cin phai nhin biét sir high khi khoang chét dé kip thoi khic phuc. Neuii ta thug ding chi so aede do lireng thor Wor ei F : 7? 1a ty IS gitra lurgng khi Khoang chet va Kor lu thong. 77 laity IE giita lang ig r We — Binh thudn; lat -04 — Néu bénh nhin dang thé may Gi ap le duomg thi “04 0 Onhém bénh nhin thé may nay, néu Be ox Taco gia ting thong khi Khoang ehct a thing Khi phat Vi. stu Khi da chon tan $26 thé doe duge trén tosin db tr PaCOs 48.06 mite sin xudit COs (VCO thich hop. Scanned with CamScannerNG TOAN KIEM § CAC CHISODANH GIA THAN SA pH (puissance Hydrogen) miu dng mach SLI Dink nghia viele Nongdg trong huyét twong Fi 0,0000004 mole L.. pH huyet tueny Nogll"), sé hi 7.40, Ata li pH eta huyét trong miu dng mach S12 Khoing gidi han cia pHt , Bling 10. Gi an bin hung vid cp win dave: cn pl fay wong, nan dong mach (pHay Gibi han pita Binh thang 7.40 40.05 Chip nhin duge [7.40 0.10 S13 ¥ nghiaci pH. PH cho bidt trang thi thing bang toan kigm <735 >—_—_1 745 H trong gidi han binh thuomg thi ta co ‘rang ti thing Bing toa Kigwn inh thong Nhumg cd lu j tinh trang rditogn ‘thang bing tean kiém hin hop dea dn mit pli binh thrimg, ~ HH toan cing véi PaO, giim ti dei hw thi ory or ms ~ Khi PaCOs ting mi pit binh tring {i tnd rag dome CO ma gidin [a cap tinh. 52 Bicarbonate thye t (Actual bicarbonate 11COr) S21. Dink nghia HCOs'A hin doh rng d hue tbicrhonste ny hse tng 5.22 Khoing gidi han cia HCOy Béng 12, Gi han binh thucing va chip nhin dire ena. HCO. GiGi han HCOvA (mmol Scanned with CamScannerding tro a ig trong cha i ig chan doin, phan loai vi) dinh nguyen nbiin rér loan thane: bane town Bang 13. Céte nguvén nh iv bien dai che sé Bicarbonate thie 16 HCO A HCOsA ting do HCONA gi hoa hoje Toan chuyén hoa ho Dap img bitcho toan hé hip | Dap img bit cho kiém ho ha Laeu ¥: Phaii luda Tudn phan tich HCOvA eung vai pil va pCOs 3.3. Kiém durdich goal bio — Base Excess Standard Base Excess ($ $3.1 Dinh nghia 4 in extracellular fluid (BE eet Dai diga cho lugng kigm dur cua toarred thé. chinh xe hon kiém dir trong maw 5.3.2 Khoing gidi han cia BEecf ing Béing 14. Gioi han bink thurdng viehip whin din cus Bh oh Gioi han BEcet (mmol) Binh thuong #3 Chap nhin duge | 25 Dau durong li du kiem, dau dim la thigu kiem, 5.3.3 Ynghia cia chi sé BEecf Tir tri sé BEecf nay. ngwii ta tinh ra hong acid (khi bi kiem hoad hove bron base bj toan héa) cain phai bit nur sau: skeet (nm Lurgng acid hay base cin bit = z BEeef (mmol/L): Lirong kiém dic trong moi lit dich ngoui baw BW (kg): Trong long co thé tinh biing bx. Scanned with CamScannerphan nich Tyy nhign, chi nén cho 1/2 lugng acid ay hase edn ba vir tn 1 Jé dieu chin Kh trong miu 30 phit saw hi cho. Lin saw nay s@ tinh rate sO can thet de Gres chin Van chét cho bgnh nhin. Trén diy 1a S chi sé quan trong nhit trong phin tich khi trong mau (70s. PCO PHL HCOr va BEeef), durge tém tit trong phu luc $ 54° Bicarbonate chuiin (Standard bicarbonate S41 Dinh nghia HCOs'St la HCOx khi PaCO: = 40 mmilg. bio hoa vii oxy St 14 m6t chi s6 vé rdi loan thang bang toan hig su thay di cia [HCOs] do PaCO: hi hap. 54.2. Tri sé bink thong HCOs St binh thuimg la 24 = 2 mEq/l. 1COr sv) © Dodo. HOO Jo chuyén haa ma Rhine by nbicu be 54.3, ¥nghia cita chi sé HCO St ‘Ngudi tado HCOs St'dé dinh Iugng anh hu Tuy nhién, dé 06 mét tr sé: 86 kiém dém. ‘ua sur thay doi cust Pal) Bang 15. Gié tri binh thirdng cua cic chi'se «hi much, Thong |Don vi [1 dpléch chudn 2d lchchuan $ (ISD £0) | 738-742 FaCO: [mnie PaOz [mmHg HCOs’ | mmol/L Rn» 1 mmol L i 2 Két qua hi mau dGng mach duge phan tich theo cic buwe sau day 6.1 Hoi bénh sir va khiim Kim sing Day la bude rat quan trong. cite thing tin kim sing sf boi tre ratt hice ele agidi két qua khi mau déng mach Scanned with CamScanner62 Kigm tra xem két HCOy miu tinh mach (« Henderson Hassebach) qu phiin tich khi trong miu ¢6 chinh xic khong? do tt total COs) = HCOy A méuddng mach (do te phumg tinh +3 mmol/L. Quy Tie Sé 8; pH 76°75 14 73 720074 Hg so 88 GS SR 48 258% 28 HCOs tinh toain = He sé x P 'aCOz thre 18 cua bénb al |HCOs tin toan— HCOs thwre té cua bénh nh: uve <4 > ket qua tin Bing 16, Ticomg quan gitea pH miu vi ph [H] ommol'L 7.00 100 7.05 89 7.10 715 720 7.25 730 735 7.40 | 145 7.50 155 7.60 165 63D: Xem phin cic et h gid nh trang oxy héa oxy hot miu eua phi 6.4 Danh gid tinh tryng thong khi Xem phin cite chi inh gid Kha nang theng bhi cut phir 6.5 Dinh gid tinh trang thing bing toan kitm. Xie dinh nguyén hain gay ri logn Pat gap, osmotal gap, Cl’ mde tiéu, K* huy PaC Os vi thing bing toan kigm (iin ¢6 anton emg...) Scanned with CamScannern dure mé ta Sut thay d8i H’, pH, HCOs, PaCOs trong ce rétlogn thing bing toan by trong Bang 17, Bang 17. Tam wit ste thay déi ctia H’, pH. HCQs, PaCO: trong edie 10 foun the bang toan kiém RGi loan Te | pl | HCOs | PaCO; | Ba trir Toan chuyén | v F115 mote peal ico Kiem chuyen t + t 69 Tmmilg Pal Lmmel hod | [cos Toan no hip | vt FL eip AT mmol HCO. 10 | mmlly PaCO | Man HCO | 10mm Kiém ho hip [Lt T TV Gp 28 =a mmily PaCO: 4 Man: = S$ mmel HCO Jommtlg Paco, Cac buée dinh ‘inh trang thing bing 103 vkidm duge trinh big trons f Khoang tréng Anion (Anion Gap): in cl sé qian trong trang chan héa. Trong co U cde ion dong (cation) baw yom Na KGa Mg Sohal ahigu khoaing chat khéc, cic ion 4m (anion) bao gdm Ch. HCOr, POS, SO. albumen va cae acid hit co khic, Téng s6 cation bing tong 56 anion, do dé thye si khong eo khoang tréng anion. Thy té, vi chi do Na", HCOe . Cl va bo qua dé cén bing véi cic cation. nén xuat hign khoany ron Khag dane anion tir chin cr anion by qua nay. Gid tr) binh thurong cua Anion Gap la 12» 2 mmol + Anion gap = ((Na"] + [K°) =({CE] = [HCO sp) Qrudng hep ew de by + Anion gap = [Na"]= (CL ] © [HCO sy ¢thue 18 tiny C6 thé ding toan d6 (inh 2) dé ae dink to trans thine Ivins tor nhanh chéng, nhung ¢@ nguy coke MOL tot Hoan ho hap ev the to Joan don gid, Do do, ton dé tuy tign li, nhumg Khong the thay thé su tint) tear bn cede phwrong trinh nhur di néu duge. Scanned with CamScannerPhd iia as ua an : in eh bay tren iy chi li burde du dé de dink vat phain bigt c foan kigm. Burde ké tigp 1a tim c roi haan thang bi yyén nhin gay rei loan thang bing toan Kem 6 hac nhue anion tong, Cl trong nude tigu bén ean eae théng tin vé bah cde thiim dé chite nang hé hip, twain ho’n khic. nnhur ede noi logn khi trong miu dé digu wi. Digu gap, osmolal gap, K* huy si, kim sing v: cain dén cite tris Hinh 1: Lirwdé dank gid thang bdng oan kiém pH < 7.36 Toan pH 745 a @P.C0z :toanhdhip HCO, | toan PICO: hem NOMAD @Toan HHciip hay man? —chuyin hoa Kim HH cp hay man? og + Cp: yplt= 0,08 SE + Mon upl= 03 =H «ht: pe = 003 = Anion gapedting? =, THOnAp co bud Nong? bi oreo 2 i2e2mEqt “|S tvearoonae HT) + 8 2 U™ + loa AG 1: sb rbiloanchuytn Pico: do PxCO: do ACO: < 40 PCO. > $0 hoard tse ying? ——cagton = thdo hon abr nay ton Pico oti P.CO. be Cato atn,_ cose Mm @Tinn bicarbonate dtu chon RMD, 4 Ta HCOs tude kh xdy 12 AG nquyén phat gover shat teanchuyéatoe Bcarcenate "e: {o + (anion gap - 12) “Ye, ' ’ % 224s2 <2422 % cokemkiém — CokEmtoan huyén hoa chuyénhoa rguyén phat nguyen phat Scanned with CamScannerHinh 2: Todn dé dé xée dink tink trany thang bang toan di Scanned with CamScanner‘our anu Ny Ruy Seu WSO Ded, HLL wep Buns yy = ‘ou OS Runny | tu uo Ruan dew cod | Sue SuEIZOrd | aN 'wOLLONBN | 4x0 Suu ey eB yULG | Axo dp ued Buys wey Sunp ns voyy funy) Suemp ava a on Suip dy ya wiySu x gsiy ua uéy WI pus Suow npg yop upyd Buoa yunyo os 19 ono Buap Bug ya viydu x gy Bug Scanned with CamScannerNong d6 H+|Cho biét tinh wang trong miu, do | toan kiém cia mau. bing pH Theo doi diéu tri pH =-log(H"] | loan thang bing toan kiém. 7,40 = 0,05 pH ting: kim héa mau pH gidm: toan Diu hiéu lém sing cua cdc roi Joan thang bing toan kiém rat tré, can theo doi bing may phan tich khi trong mau. pH mau cé thé binh thudng, loan thang mn hap. jam co thé hd ing oxy cho mé. Khoa agi at. Khoa phéi, thin. Khoa than nhgn t20. Khoa san s6c dic bigt. Cée khoa cé sit dung iy thé vi oxy. wet. MF mmol HCOr i phan tang: chuyén bat cho - | BEeet khong bi an boi PaCOe, Khoa phéi, than. Khoa thin nbn 0. Khoa sin séc dic biét. Cie khoa ¢6 sir dung | may tha va oxy. Khoa noi tidt. Khoa phdi. than. Khoa thin nhin tao. Phai phan tich kém vi pCO: | va ptt Khoa sin sie die biét Cae khoa co swe dung y tho va oxy. Scanned with CamScannerTALLIEU THAM KHAO. 1. Ganong W, ¥ coon Wi Ganong's review of medical physiology 26th ed. McCraw il . Is New York.,2019, tang 607.688 } Hall J.E, Textbook of Mel f 2015, trang 497-560, ical Physiology. 13th ed., Elsevier Inc.. Philadelphs West 1B. Respiratory Physiology. The essentials, 10th ed, Williams & Wilkins. Baltimore, 2015, . Mottram C. 4. - (2018) Ruppel’s Manual of Pulmonary Function Testing - 1 Edition, Elsevier, LE Thi Tuyét Lan (2015) Phin tich khi tong miu. trong Hunb san hee sta! do chite nang ho ). Nha xuat ban Y hoe. CAU HOI TY’ LUQNG GIA Hay phan tich cae két qui khi miu dong mach sa p02 1. Khi mu dng mgch 1: Na 135 mBq/1, C1 93 mEq/l. HCO* 30 Le mmHg, FiO: 40%, PaCO> 80 mmHg PaCO: 80 mmHg, pH: He une 2. Khi mau dgng mach 2: Na, 130 mEq/l. C1 80 mEq, HCOs 1mh mmHg, FiO: 21%, PaCO2 25 inmlly. pil: 7.2 6 3. Khi miu dgng mach 3: Na 123 mg (1:99 mig 1 HC mmHg, Fi0z 60%, PaCO> 10) munlgeplt: 7.51 4, Khi mau dong mach 4: Na 125 meq TCL 100 meg LK mmHg, FiO: 44%. HCOr 8 mba |. PaCO. 28 mmily. phe 7.0 vo nib gy FPA: 30 2.8 mig 1 PaO 60 Scanned with CamScanner