NG DNG

KH MU NG MCH
TRONG THC HNH LM SNG

TS. BS PHM TH NGC THO

B MN HSCCC H Y DC TP.HCM
 Case 1

Bnh nhn n, 32 tui, tin cn i tho

ng nhp vin trong tnh trng l m.
M = 118, HA = 90/50, t = 370C, th 32
l/ph
Glucose = 750 mg/dl
Acetoacetic acid = 250mg/dl
Na = 136
K = 6.3
Cl = 95
BUN = 38 mg/dl, Crea = 1.2 mg%
 Case 1

Bnh nhn n, 32 tui, tin cn i tho

ng typ 1 nhp vin trong tnh trng l
m. M = 118, HA = 90/50, t = 370C, th
32 l/ph
Glucose = 750 mg/dl
Acetoacetic acid = 250mg/dl
Na = 136
K = 6.3
Cl = 95
BUN = 38 mg/dl, Crea = 1.2 mg%

Chn on: i tho dng type 1, hn

m nhim toan ceton, tng kali mu
 Case 1

Bnh nhn n, 32 tui, tin cn i tho

ng nhp vin trong tnh trng l m.
M = 118, HA = 90/50, t = 370C, th 32
l/ph
KMM
Glucose = 750 mg/dl FiO2 = 21%
Acetoacetic acid = 250mg/dl pH = 7.04
Na = 136 PaCO2 = 25
K = 6.3 HCO3 = 5
Cl = 95 BE = -22
BUN = 38 mg/dl, Crea = 1.2 mg% PaO2 = 125
SaO2 = 95%
 Phn tch KMM

PH gim toan mu
KMM HCO3 gim toan chuyn ha
FiO2 = 21%
PCO2 gim kim h hp
pH = 7.04
Toan chuyn ha nguyn pht,
PaCO2 = 25
kim h hp b tr
HCO3 = 5
PaCO2 d on = 1.5 x 5 + 8 =
BE = -22
15.5
PaO2 = 125
SaO2 = 95%
PaCO2 d on < PaCO2 o
c
toan h hp km theo
 Phn tch KMM
KMM
FiO2 = 21%
AG = 136 (95+5) = 36
pH = 7.04 nhim acid c nh:
PaCO2 = 25 ketones acid
HCO3 = 5 Lactate = 30 mg/dl
BE = -22 Delta AG/ Delta HCO3 = 24/19
PaO2 = 125 >1
SaO2 = 95% kim chuyn ha i km
Na = 136 Kim chuyn ha c th do thiu
K = 6.3 nc do li niu thm thu
Cl = 95
 Case 1

1. Toan chuyn ha tng anion gap: nhim

ketones do i tho ng v tng acid
lactic do huyt p thp
2. Kim chuyn ha: do thiu dch
3. Toan h hp i km: do gim tri gic
 Case 2

Bnh nhn nam, 65 tui, tin cn

vim ph qun mn, nhp 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
 Case 2

Bnh nhn nam, 65 tui, tin cn vim

ph qun mn, nhp cp cu trong tnh
trng kh th. M = 130, HA= 130/90,
t= 38,5C, th 32 l/ph, SpO2= 70%
KMM Na = 139
FiO2 = 0,21 K = 4.1
PH = 7.25 Cl = 89
PaCO2 = 70
HCO3 = 34 WBC = 13 k/ul
PaO2 = 39 Hb = 17 g/dl
SaO2 = 52% Hct = 51%
 Phn tch KMM

KMM
FiO2 = 0,21 PaO2 gim suy h hp gim
PH = 7.25 oxy mu
PaCO2 = 70 PaO2 < 40 mmHg
HCO3 = 34 PaO2/FiO2 = 39/0.21 = 185 < 200
PaO2 = 39
SaO2 = 52% gim oxy mu nng
 Phn tch KMM

PCO2 tng suy h hp tng CO2

KMM PH gim toan mu
FiO2 = 0,21 HCO3 tng kim chuyn ha
PH = 7.25
Toan h hp nguyn pht, kim
PaCO2 = 70
HCO3 = 34 chuyn ha b tr
PaO2 = 39 Delta pH/Delta PaCO2= 0.15/30=
SaO2 = 52% 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 tu)
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 Pw)] [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
 Case 3

BN n tr tui b qu liu thuc ng v

ru
M, kch thch au p ng chnh xc,
tn s th 8 l/ph
Kh mu: pH 7.15, PaCO2 =71 mmHg,
PaO2 56 mmHg trong iu kin kh
phng
 Case 3
Toan h hp cp (pH/PCO2 = 0.008)
Gim oxy mu
Tnh AaDO2:
PAO2 =[0.21 x (760 47)] [1.25 x 71] = 61
AaDO2 = 61 56 = 5
Gim oxy mu do gim thng kh
Chn on: ng c thuc ng v ru, toan
h hp cp
iu tr: t NKQ
 PHN TCH KMM

Mt kt qu phn tch kh mu ng
mch c th cho chng ta bit c
s b :
Chn on xc nh suy h hp, d on
c ch gy ra suy h hp (gim thng kh,
gim oxy mu hoc c hai c ch ).
Nhn ra nhng ri lon toan kim phi hp
phc tp
Phi hp vi lm sng gip chn on
nhng nguyn nhn n giu
 17

Nguyn nhn gim oxy mu

cao gim FiO2

Gim thng kh ph nang

Gim kh nng khuch tn kh

T l V/Q khng tng xng

Shunt
 Nguyn nhn suy h hp gim oxy mu
Km theo tng CO2?
c khng

Gim thng kh (PAO2 - PaO2)?

(PAO2 - PaO2) c khng

Gim thng p ng vi PO2 trong kh

Ch c gim kh v c ch oxy?
thng kh ht vo
khc

khng c cao
trung tm h hp FIO2
Bnh l thn kinh c
Shunt V/Q, gim
khuch tn
mismatch
 SUY H HP GIM OXY MU
V/Q mismatch

Xp phi
Thm nhim ph nang ARDS
vim phi Bnh m k phi
ph phi Dp phi
SHUNT KHONG CHT
V/Q = 0 V/Q =
Thuyn tc phi
Shunt trong tim Bnh mch mu phi
Shunt mch mu trong phi Bnh ng th
(COPD, hen)
Nguyn nhn tng CO2 mu

Tng sn xut CO2: tng chuyn ha,

st, rung git c, overfeeding...

Gim thi CO2:

Gim thng kh ph nang

Bt thng V/Q
 p ng b tr

Ri lon Thay i Thay i p ng

nguyn pht nguyn pht b tr b tr

Toan h hp Tng PCO2 Tng HCO3 Kim chuyn ha

Kim h hp Gim PCO2 Gim HCO3 Toan chuyn ha

Toan chuyn ha Gim HCO3 Gim PCO2 Kim h hp

Kim chuyn ha Tng HCO3 Tng PCO2 Toan h hp

 Cng thc d on b tr

Ri lon chuyn ha:

Toan chuyn ha : gim HCO3
kim h hp: gim PCO2
PCO2 mong i= (1,5 x HCO3) + 8 2
Kim chuyn ha: tng HCO3
toan h hp: tng PCO2
PCO2 mong i= (0,7 x HCO3) + 21 2
 Cng thc d on b tr

Ri lon h hp:
Ri lon h hp cp:
pH = 0.008 x PaCO2
Toan h hp cp: tng PCO2
kim chuyn ha: tng HCO3
pH mong i = 7,4 [0.008 x (PaCO2 40)]
Kim h hp cp: gim PCO2
toan chuyn ha: gim HCO3
pH mong i = 7,4 + [0.008 x (40 - PaCO2)]
 Cng thc d on b tr

Ri lon h hp:
Ri lon h hp mn:
pH = 0.003 x PaCO2
Toan h hp mn: tng PCO2
kim chuyn ha: tng HCO3
pH mong i= 7,4 [0.003 x (PaCO2 40)]
Kim h hp mn: gim PCO2
toan chuyn ha: gim HCO3
pH mong i= 7,4 + [0.003 x (40-PaCO2)]
 Cc bc c KMM

pH = 7,35 7,45
PCO2 = 35 45
HCO3 = 22 - 26

B1: xc nh ri lon nguyn pht

B2: nh gi p ng b tr
B3: s dng GAP/GAP nh gi
toan chuyn ha hn hp
 B tr h hp

pH / CO2
[7.4 patient pH] / [patient CO2 40]

0.003 0.008

< 0.003 0.003 0.003-0.008 0.008 > 0.008

Toan h Toan h Toan h hp Toan h Toan h

hp mn hp mn cp trn hp cp hp cp
+ kim (b hon nn mn (khng + toan
chuyn ton) (b tr mt b tr) chuyn
ha phn) ha
 Do Anion gap

Cation = Anion
Na + UC = (Cl + HCO3 ) + UA
Na - (Cl + HCO3 ) = UA UC
Anion gap = UA UC = 12 4
 Anion gap

Anions khng o Cations khng o

Albumin (15 mEq/L)* Calcium (5 mEq/L)
Organic Acids (5 mEq/L) Potassium (4.5 mEq/L)
Phosphate (2 mEq/L) Magnesium (1.5 mEq/L)
Sulfate (1 mEq/L)
Total UA: (23 mEq/L) Total UC: (11 mEq/L)
Anion Gap = UA - UC = 12 mEq/L

Nu albumin gim 50%, anion gap = 4 mEq/L

AG hiu chnh = AG o c + 2,5 x (4,5 Alb mu)
 Nguyn nhn
toan chuyn ha theo Anion gap
TNG AG KHNG TNG AG
Toan lactic Tiu chy
Toan ceton Truyn nhiu NaCl 0.9%
Suy thn giai on cui Suy thn
Ng c Methanol Toan ha ng thn
Ng c Ethylene glycol Li tiu Acetazolamide
Ng c Salicylate Ni niu qun - rut
 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
 PHN TCH KMM

Phn tch KMM cn phn tch in gii

i km
Khng qun tnh Anion gap v cc cng
thc c tnh b tr
Phi hp vi bnh cnh lm sng
 Case 4

Bnh nhn nam, 30 tui c a ra khi

hin trng v chy trong tnh trng l
m ch n bnh vin
M = 110, HA = 90/60, bng khng ng
k, th nhanh 32 l/ph, SpO2 = 95%
 Case 4

PH = 7.45
PaO2 = 80 Lactate = 15 mg/dl
PaCO2 = 30
[COHb] = 65%
HCO3 = 20

SaO2 = 35%

Chn on: ngt khi, ng c CO mc

nng
 i hi lm sng

SpO2 khng th theo di trong mt

s tnh hung nh ng c CO
[COHb] o mt nhiu thi gian
Lactate o ti khoa sinh ha mt
nhiu thi gian, kh lp li theo di
iu tr
cn c nhng my c th o ngay
ti ging bnh
Yu cu i vi my o KMM

My o pH/ Kh mu (PO2, PCO2, pH)

CO-Oximetry
in gii (Na, K, Ca, Cl)
Hematocrit, Hemoglobin
Glucose / Lactate
Bilirubin, ure (BUN)
 Yu cu k thut

tin cy cao
T chun ha
Nhanh
60 giy, truyn ti, lu tr d liu
Hiu qu, tit kim ha cht
Th tch mu nh
Tin li, linh hot
Dng cho nhiu loi dch: mu, dch lc, nc
tiu
Giao din d s dng
COBAS b 221

Cobas b 221
Mt s loi my KMDM

My kh mu - in gii
 Ni no cn

Khoa Cp cu
Khoa Hi sc
Phng m
Khoa phng bnh nng
Khoa h hp
...
 NG DNG
TRONG THC HNH LM SNG
 o nng hemoglobin bng
my kh mu ti khoa ICU so vi
phng xt nghim

r2 = 0.98

95%CI= 0.97
0.99

P < 0.0001

Critical Care 2002, 6:72-75

o nng in gii bng my
kh mu ti khoa ICU so vi
phng xt nghim

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

o nng in gii bng my
kh mu ti khoa ICU so vi
phng xt nghim

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

o nng in gii bng my
kh mu ti khoa ICU so vi
phng xt nghim

P < 0.001
r2 = 0.68

P = 0.268
r2 = 0.72

Int J Emerg Med (2009) 2:117 120

o nng kali bng my kh
mu ti khoa Cp cu so vi
phng xt nghim

Phng xt nghim: 3.95 mmol/L

ABG analyzer: 3.46 mmol/L
= 0.49 mmol/L
r2 = 0.904 (95%CI 0.839 - 0.943, p <
0.01)

J Med Assoc Thai. 2009 Jul;92(7):925-9.

S dng khng dch truyn trong cp
cu bnh nhn chn thng trc nhp
vin lin dn n BE v pH gim nhiu hn
My phn tch kh mu ng mch l cng
c hu ch gip theo di v hi sc bnh
nhn trc nhp vin
 o nng in gii toan kim
bng my kh mu ti phng
m so vi phng xt nghim

H s tng quan (r)

Ca: 0.85
K: 1 Hb: 0.95
Na: 0.86 Hct: 0.98
pH: 0.99
pCO2: 0.98
pO2: 0.99
HCO3: 0.93
BE: 0.93

Anaesthesist. 1997 Aug;46(8):704-14.

 o nng in gii toan kim
bng my kh mu ti phng m
so vi phng xt nghim
My phn tch kh mu
d s dng
ng tin cy
tin dng
v v vy thch hp khng ch i vi
phng m m cn c th s dng cho cc
khoa lm sng, phng khm, hoc khi kt
qu t phng xt nghim cha c hoc
mt nhiu thi gian

Anaesthesist. 1997 Aug;46(8):704-14.