弥散性血管内凝血22课件

DisseminatedIntravascularCoagulationHuangHonghuiDept.ofHematology,RenjiHospitalDisseminatedIntravascularCoa1DefinitionDIC:clinicopathologicsyndromewidespreadintravascularcoagulationisinducedbyprocoagulantsthatareintroducedintoorproducedinthebloodcirculationandovercomethenaturalanticoagulantmechanisms.DefinitionDIC:clinicopatholog2EtiologyEtiology3弥散性血管内凝血22课件4StageofhypercoagulabilityStageofhypocoagulabilityStageofsecondaryfibrinolysisStageofStageofStageof5PathophysiologyStageofhypercoagulabilityStageofhypocoagulabilityduetoexcessofconsumptionofbloodcoagulationfactorsStageofsecondaryfibrinolysisPathophysiologyStageofhyperc6TypingofDICTypingofDIC7ClinicalfeaturesBleedingThromboembolismCirculatorydisturbance,shockMicroangiopathichemolyticanemiaClinicalfeaturesBleeding8ClinicalfeaturesBleedingMechanismconsumptionofhemostaticcomponentsincludingplatelets,fibrinogen,andothercoagulationfactors;secondaryfibrinolysis;anticoagulanteffectsoffibrinogen/fibrindegradationproducts;manifestationsSkinandmucosa:petechiae,ecchymosis,oozingfromveni-punctures,arteriallines,catheters,andinjuredtissues;internalorgan:massivebleedingintothegastrointestinal,lungs,centralnervoussystem,ororbit.ClinicalfeaturesBleeding9弥散性血管内凝血22课件10弥散性血管内凝血22课件11弥散性血管内凝血22课件12ClinicalfeaturesThromboembolismClinicalfeaturesThromboemboli13弥散性血管内凝血22课件14Clinicalfeatures

Circulatorydisturbance,shock

ⅫⅫakininogenkallidiniformationof FibrinopeptideAmicrovascularthrombi FibrinopeptideB thrombindilatationofthebloodvesslesreturnedbloodvolume↓vasospasm

hemorrhage

SHOCKcirculatingbloodvolume↓

diseasesunderlyingDIC

ClinicalfeaturesCirculatory15ClinicalfeaturesMicroangiopathichemolyticanemiaMechanismErythrocytesareinjuredmechanicallyduringpassagethroughfibrinnetworksinthemicrocirculation.

Manifestationproductionofschistocytesandmicrospherocytes;jaundice,hemoglobinuria,anemia.ClinicalfeaturesMicroangiopat16DirectionofbloodflowFibrinDirectionofFibrin17弥散性血管内凝血22课件18LaboratoryfeaturesBasicbloodexaminationsPlateletcount:BPC↓Peripheralbloodsmear:schistocytes(inapproximately50%ofcases)LaboratoryfeaturesBasicblood19弥散性血管内凝血22课件20LaboratoryfeaturesThecoagulationdefectPartialthromboplastintime(PTT)ProthrombintimeThrombintimeFibrinogenconcentrationLaboratoryfeaturesThecoagula21LaboratoryfeaturesTestsforfibrinolysisFibrinogendegradationproducts(FDP)D-dimerPlasmaprotamineparacoagulationtest(3P)EuglobulinlysistimeLaboratoryfeaturesTestsforf22LaboratoryfeaturesOtherlaboratoryfindings(molecularmarkers)F1+2Thrombin-ATⅢcomplex(TAT)FibrinopeptideA(FPA)SFMC(solublefibrinmonomercomplex)AntithrombinⅢProductsofplateletactivation:β-TG,PF-4,TXB2,GMP-140PIC(plasmin-α2plasmininhibitorcomplex)

LaboratoryfeaturesOtherlabor23 Ⅹa prothrombin thrombin+ATⅢ TAT

F1+2 fibrinogen fibrinmonomer FPA,FPB Polymerization solublefibrin plasmin ⅩⅢa FDP cross-linkedfibrinSFMC:FDP(X)+FM+Fg Ⅹa 24LaboratoryfeaturesLaboratorydatachangewithremarkablerapidityinDIC,andindoubtfulcases,itisoftenimportanttorepeatthetestsatfrequentintervals,evenevery8to12hoursandobservingthedynamicsoftheprocess.LaboratoryfeaturesLaboratory25Diagnosticcriteria

------ISTHDICscoreDiagnosticcriteria

261.Riskassessment: doesthepatienthaveanunderlyingdisorderknowntobeassociatedwithovertDIC? Ifyes:Proceed. Ifno:Donotusethisalgorithm.1.Riskassessment:272.Orderglobalcoagulationtests plateletcount, prothrombintime, fibrinogen, fibrin-relatedmarker2.Orderglobalcoagulationte283.Scoreglobalcoagulationtestresults.

•Plateletcount (>100=0;<100=1;<50=2) •Elevatedfibrinrelatedmarker(e.g.D-dimers;fibrindegradationproducts) (noincrease=0;moderateincrease=2;strongincrease=3) •Prolongedprothrombintime (<3s=0;>3but<6s=1;>6s=2) •Fibrinogenlevel (>1.0g/L=0;<1.0g/L=1)3.Scoreglobalcoagulationte294.Calculatescore

If≥5:compatiblewithovertDIC:repeatscoredaily If<5:suggestive(notaffirmative)fornon-overtDIC:repeatnext1–2days.4.Calculatescore30DifferentialdiagnosisDICandsevereliverdiseaseDICandTTPDifferentialdiagnosisDICand31ThedistinctionbetweenDICandsevereliverdiseaseDICSevereliverdiseaseMicrocirculationdisturbanceEarly,commonLate,seldomJaundiceMild,seldomSevere,verycommonRenalfunctionabnormalityEarly,commonLate,seldomRBCinjuryCommonrareFⅧ:C↓NProductionofplateletactivationandmetabolism↑NFPA↑↑N/↑(mild)D-dimer↑N/↑(mild)ThedistinctionbetweenDICan32Thedistinctionbetween

DICandTTPDICTTPOnsetandcourseAbrupt,ShortcourseAcute/insidious,longcourseMicrocirculationdisturbancecommonSeldomJaundiceMild,seldomSevere,verycommonFⅧ:C↓NProteinC↓NFPA↑NF1+2↑ND-dimer↑NCharacterofthrombusFibrinthrombusPlateletthrombusThedistinctionbetween

DICa33TreatmentManagementofunderlyingdisordersintensiveantibiotictreatmentinpatientswithgram-negativebacteremia;hysterectomyinpatientswithabruptioplacenta;resectionofanaorticaneurysm;debridementofcrushedtissues;chemotherapyofacuteleukemia;supportivecare:fluids,pressors,dialysis,andrespiratoryandventilatormanagement.TreatmentManagementofunderly34HeparinHeparin35mechanism

lysine sites

active arginineserine reactivecenter centerThrombin antithrombin heparinmechanism lysine36Treatment:anticoagulation

1.heparinIndicationsformsmanifestedbythrombosisoracrocyanosisformsthataccompanycancer,vascularmalformations,retaineddeadfetus,acutepromyelocyticleukemia.Treatment:anticoagulation

1.h37Treatment:anticoagulation

1.heparinDosageTheoptimaldosageofheparinisthesourceofsomedisagreement;50u/kg,intravenousinfusion,Q6h5000-10000u,subcutaneously,Q12-24h

Treatment:anticoagulation

1.h38Treatment:anticoagulation

1.heparinLaboratorymonitoringaPTT:aprolongationofbetween1.5and2timesnormal;CT;Reversalofheparineffect1mgprotaminesulfate:100uheparininfusedintravenouslyrateofinfusion<5mg/minTreatment:anticoagulation

1.h39Treatment:anticoagulation

1.heparinlow-molecular-weightheparin(LMWH)Treatment:anticoagulation

1.h40Treatment:anticoagulation

1.heparinLMWHCharacteristicsPosseshigheranti-Ⅹaactivitythananti-thrombinactivity;Longerhalf-timeandahigher,morereliablebioavailabilityAlowerincidenceofbleedingcomplications.Usage75-150IUAⅩa/Kg.d,subcutaneously,×3-5days.Treatment:anticoagulation

1.h41Treatment:anticoagulation

2.othersAT-ⅢDecreasethedoseofheparin;Improvetheresponse.Dose:1500-3000uBid-Tid,intravenousinfusion×5-7days;Treatment:anticoagulation

2.42Treatment:

Antiplateletdrugs

Indicationsinhypercoagulabilitystate;thediagnosisofDICisstillnotcertain;inmildcases.Usagecompounddansheninfusion 20-40mlBid-Tid×3-5daysLowmolecularweightdextran500-1000ml/d ×3-5daysTiclopidine(噻氯匹定)250mgBidp.o.×5-7daysDipyridamole(双嘧达莫)500mg/d×3-5days;Treatment:

Antiplateletdrugs43Treatment:

Haemostaticsupportplateletconcentratesplateletcount<20×109/Lorhaveseverelife-threateningbleeding;freshfrozenplasma(FFP)10-15ml/kgbodyweightwhentheINRofPTisgreaterthan1.5;cryoprecipitate1-4unit/10kgbodyweightwhenthefibrinogenconcentrationis0.8g/lorless.Fibri