TEG技术与检验科及应用ppt课件

1、TEG 技术与检验科haemoscope大纲 凝血原理 TEG 分析仪的普通概念 TEG 技术的运用 普通检测 肝素酶检测 血小板图检测 TEG质控 TEG软件正常凝血Its all about balance 凝血 可控的 激活 可控的 抑制 血凝块 最后的结果 可控的 抑制 出血事件 血栓摘自：血栓与止血实验诊断的现状与开展；摘自：血栓与止血实验诊断的现状与开展；301医院；从玉隆等，医院；从玉隆等，2002，9；中华检验医学杂志；中华检验医学杂志 目前对凝血检测的认识目前对凝血检测的认识Interactive凝血的组成:Virchows 三角外伤外伤“暴露暴露初始的凝血酶反响初始的凝血酶

2、反响 胶原vWFVVVVVV监测凝血步骤血块强度血块强度初始的凝血TF血流外表血流外表第二阶段凝血第三阶段凝血凝血监测相互关系出血血栓药理学药理学感染炎症感染炎症机械缘由机械缘由病理性疾病病理性疾病目前对凝血的各种学说 级联反响学说 细胞学根底方式学说 6系统方式学说凝血反响方式级联反响方式初始凝血初始凝血第二阶段第二阶段凝血凝血第三阶段第三阶段凝血凝血监测: 级联反响方式PT 和 aPTT 凝血因子的功能 血浆根底 凝血时间 初始的纤维蛋白构成 7.5%EPL 15%N/ACI功能紊乱4-8 min47- 741-4 min55-73 mm-3.0 3.00-8%0-15%TEG 技术参数解

3、析凝血时间凝血时间R是反应从凝血系统启动直到纤维蛋白凝块形成之间的一段潜伏期。血块动力血块动力K评估血凝块强度达到某20 mm时的时间，主要反应纤维蛋白原的功能和水平。Alpha评估纤维蛋白块形成及相互联结（凝块加固）的速度，反应纤维蛋白原功能。血块强度血块强度MA即最大幅度，直接反映纤维蛋白与血小板通过Ga+/XIIIa相互联结的最强的动力学特性，代表纤维蛋白凝块的最终强度主要反应血小板功能GMA 转化而来，反应血块的重力 dynes/cm2.G = 5000*MA/(100-MA)凝血总体凝血总体CI综合凝血指数, R, K, alpha, MA结合推算出。CI=0.2454R+0.018

4、4K+0.1655MA-0.0241a-0.0220 ）血块稳定性血块稳定性LY30EPL MA出现后30分钟内血块消融的比例%。MA出现后预计的血块消融的%。TEG 诊断表示图(Kaolin)US Patent 6,787,363低凝低凝高凝高凝纤溶亢进纤溶亢进从从a至至o步骤的参考文献步骤的参考文献a: 1,2,3,5,6,7,8,9,13,14b: 1,2,3,5,6,7,8,9,11,13,14c: 1,11,12,15,18,19,21d: 1,2,3,5,6,7,8,9,11,13,26e: 1,2,3,5,6,7,8,9,11,13,14,26f: 1,2,3,5,6,7,11,

5、13g: 1,2,3,5,6,7,8,9,11,12,13,26,27h: 1,2,3,5,6,11,13i: 1,2,3,4,5,6,7,8,9,14,26j: 1,2,3,4,5,14k: 1,10,11,12,15,19l:10,11,15,16,17,18,19,20,21,22,23,24,25m:10,11,15,16,17,18,19,20,21,22,23,24,28n: 10,11,15,17,18,19,20,o:10,11,16,17,18,19,20,21,22,23,24,25 从从a至至o步骤的参考文献步骤的参考文献 Mallett SV, Cox JA. Thro

6、mbelastograph? Analysis. British Journal of Anaesthesia. 1992,69:307-313.Mallett SV, Cox JA. Thrombelastograph? Analysis. British Journal of Anaesthesia. 1992,69:307-313.Kang YG, Gasior TA. Blood Coagulation During Liver, Kidney, Pancreas, and Lung Transplantation. Perioperative Transfusion Kang YG,

7、 Gasior TA. Blood Coagulation During Liver, Kidney, Pancreas, and Lung Transplantation. Perioperative Transfusion Medicine. 1998.Medicine. 1998.Kang Y. Thrombelastograph? Analysis in Liver Transplantation. Seminars in Thrombosis and Hemostasis. 1995. V21 Supplement 4.Kang Y. Thrombelastograph? Analy

8、sis in Liver Transplantation. Seminars in Thrombosis and Hemostasis. 1995. V21 Supplement 4.Kang YG, Lewis JH, Navalgund A, Russell MW, Bontempo FA, Niren LS, Starzl TE. Epsilon-aminocaproic Acid for Treatment of Kang YG, Lewis JH, Navalgund A, Russell MW, Bontempo FA, Niren LS, Starzl TE. Epsilon-a

9、minocaproic Acid for Treatment of Fibrinolysis During Liver Transplantation. Anesthesiology. 1987:66(6):766-773.Fibrinolysis During Liver Transplantation. Anesthesiology. 1987:66(6):766-773.Kang YG, Martin DJ, Marquez J, et al. Intraoperative Changes in Blood Coagulation and Thrombelastograph Monito

10、ring in Liver Kang YG, Martin DJ, Marquez J, et al. Intraoperative Changes in Blood Coagulation and Thrombelastograph Monitoring in Liver Transplantation. Anesthesia and Analgesia. 1985. 64(9):888-896.Transplantation. Anesthesia and Analgesia. 1985. 64(9):888-896.Kang YG, Monitoring and Treatment of

11、 Coagulation. Hepatic Transplantation. 1986. 151-173.Kang YG, Monitoring and Treatment of Coagulation. Hepatic Transplantation. 1986. 151-173.Von Kier S, Smith A. Hemostatic product transfusions and adverse outcomes: focus on point-of-care testing to reduce transfusion Von Kier S, Smith A. Hemostati

12、c product transfusions and adverse outcomes: focus on point-of-care testing to reduce transfusion need. J Cardiothorac Vasc Anesth 2000;14(3 Suppl 1):1521.need. J Cardiothorac Vasc Anesth 2000;14(3 Suppl 1):1521.Shore-Lesserson L, Manspeizer HE, Deperio M, et al. Thromboelastography-guided transfusi

13、on algorithm reduces transfusions in Shore-Lesserson L, Manspeizer HE, Deperio M, et al. Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Anesth Analg, 1999,88:312-plex cardiac surgery. Anesth Analg, 1999,88:312-319.Spiess BD. Perioperative Coagulatio

14、n Monitoring. Perioperative Transfusion Medicine. 1998.Spiess BD. Perioperative Coagulation Monitoring. Perioperative Transfusion Medicine. 1998.Gibbs NM, Crawford GPM, Michalopoulos N. Thrombelastograph Patterns Following Abdominal Aortic Surgery. Anaesth. Intens Gibbs NM, Crawford GPM, Michalopoul

15、os N. Thrombelastograph Patterns Following Abdominal Aortic Surgery. Anaesth. Intens Care. 1994:22: 534-538.Care. 1994:22: 534-538.Spiess BD, Ivankovich AD. Thrombelastograph? Analysis: A Coagulation-Monitoring Technique applied to Cardiopulmonary Spiess BD, Ivankovich AD. Thrombelastograph? Analysi

16、s: A Coagulation-Monitoring Technique applied to Cardiopulmonary Bypass. Monograph of the Society of Cardiovascular Anesthesia. Ed. Ellison and Jobes: 1988.Bypass. Monograph of the Society of Cardiovascular Anesthesia. Ed. Ellison and Jobes: 1988.Sharma, SK. Philip, J; Whitten, CW. MD; Padakandla, U

17、B. MD; Landers, DF. Assessment of Changes in Coagulation in Parturients with Sharma, SK. Philip, J; Whitten, CW. MD; Padakandla, UB. MD; Landers, DF. Assessment of Changes in Coagulation in Parturients with Preeclampsia Using Thromboelastography. Clinical Investigations Anesthesiology. 90(2):385-390

18、, February 1999.Preeclampsia Using Thromboelastography. Clinical Investigations Anesthesiology. 90(2):385-390, February 1999.Sharma S.K.; Vera R.L.; Stegall W.C.; Whitten C.W. Management of a Postpartum Coagulopathy Using Thrombelastography. Journal Sharma S.K.; Vera R.L.; Stegall W.C.; Whitten C.W.

19、 Management of a Postpartum Coagulopathy Using Thrombelastography. Journal of Clinical Anesthesia, Volume 9, Number 3, May 1997, pp. 243-247of Clinical Anesthesia, Volume 9, Number 3, May 1997, pp. 243-247从从a至至o步骤的参考文献步骤的参考文献 Whitta RKS, Cox DJA, Mallett SV. Thrombelastograph? Analysis reveals two c

20、auses of haemorrhage in HELLP syndrome. British Whitta RKS, Cox DJA, Mallett SV. Thrombelastograph? Analysis reveals two causes of haemorrhage in HELLP syndrome. British Journal of Anaesthesia. 1995:74:464-468Journal of Anaesthesia. 1995:74:464-468Caprini JA, Arcelus JI, Laubach M, et al. Postoperat

21、ive hypercoagulability and deep-vein thrombosis after laparoscopic Caprini JA, Arcelus JI, Laubach M, et al. Postoperative hypercoagulability and deep-vein thrombosis after laparoscopic cholecystectomy. Surgical Endoscopy. (1995) 9: 304-309.cholecystectomy. Surgical Endoscopy. (1995) 9: 304-309.R. R

22、ai, E. Tuddenham, L. Regan. Pre-pregnancy thrombophilic abnormalities are associated with subsequent spontaneous abortion R. Rai, E. Tuddenham, L. Regan. Pre-pregnancy thrombophilic abnormalities are associated with subsequent spontaneous abortion HUM REPROD.1999. 15: 168-169HUM REPROD.1999. 15: 168

23、-169Tuman KJ, Spiess B, McCarthy R, Ivankovich AD. Effects of Progressive Blood Loss on Coagulation as Measured by Tuman KJ, Spiess B, McCarthy R, Ivankovich AD. Effects of Progressive Blood Loss on Coagulation as Measured by Thrombelastograph? Analysis. Anesth Analog. 1987:66:856-63.Thrombelastogra

24、ph? Analysis. Anesth Analog. 1987:66:856-63.Caprini JA, Zuckerman L, Cohen E. Vagher JP, Lipp V. The Identification of Accelerated Coagulability. Thrombosis Research. Caprini JA, Zuckerman L, Cohen E. Vagher JP, Lipp V. The Identification of Accelerated Coagulability. Thrombosis Research. 1976:9:167

25、-180.1976:9:167-180.H. W. Grant G. P. HadleyPrediction of neonatal sepsis by thromboelastography. Pediatr Surg Int. 1997:12:289-292.H. W. Grant G. P. HadleyPrediction of neonatal sepsis by thromboelastography. Pediatr Surg Int. 1997:12:289-292.Kaufmann CR, Dwyer KM, Crews JD, Dols SJ, Trask AL. Usef

26、ulness of Thrombelastograph?Analysis in Assessment of Trauma Patient Kaufmann CR, Dwyer KM, Crews JD, Dols SJ, Trask AL. Usefulness of Thrombelastograph?Analysis in Assessment of Trauma Patient Coagulation. Journal of Trauma, Injury, Infection, and Critical Care. 1997:V42, No4.Coagulation. Journal o

27、f Trauma, Injury, Infection, and Critical Care. 1997:V42, No4.Vig S, Chitolie A, Bevan DH, Halliday A, Dormandy J. Thromboelastography: A Simple Screen for Hypercoagulable States, Vig S, Chitolie A, Bevan DH, Halliday A, Dormandy J. Thromboelastography: A Simple Screen for Hypercoagulable States, Hy

28、perhomocysteinaemia and a Predictor of Failure Following Peripheral Arterial Intervention. Abstract presented at the Surgical Hyperhomocysteinaemia and a Predictor of Failure Following Peripheral Arterial Intervention. Abstract presented at the Surgical Research Meeting, Royal Free Hospital, London,

29、 England, December 2, 1999.Research Meeting, Royal Free Hospital, London, England, December 2, 1999.Ng KF, Lo JW. The development of hypercoagulability state, as measured by thrombelastography, associated with intraoperative Ng KF, Lo JW. The development of hypercoagulability state, as measured by t

30、hrombelastography, associated with intraoperative surgical blood loss. Anesth Intensive Care, 1996, 24:20-25.surgical blood loss. Anesth Intensive Care, 1996, 24:20-25. Ruttmann TG, James MFM, Viljoen JF. Haemodilution Induces a Hypercoagulable State. British Journal of Anaesthesia. Ruttmann TG, Jam

31、es MFM, Viljoen JF. Haemodilution Induces a Hypercoagulable State. British Journal of Anaesthesia. 1996:76:412-414.1996:76:412-414.Mardel SN, Saunders FM, Allen H, Menezes G, Edwards CM, Ollerenshaw L, Baddeley D, et al. Reduced quality of clot formation with Mardel SN, Saunders FM, Allen H, Menezes

32、 G, Edwards CM, Ollerenshaw L, Baddeley D, et al. Reduced quality of clot formation with gelantin-based plasma substitutes. British Journal of Anaesthesia. 1998;80:204-207.gelantin-based plasma substitutes. British Journal of Anaesthesia. 1998;80:204-207.Heather BP, Jennings SA, Greenhalgh RM. The s

33、aline dilution test - a preoperative predictor of DVT. Br. J. Surg. 1980;V67:63-65.Heather BP, Jennings SA, Greenhalgh RM. The saline dilution test - a preoperative predictor of DVT. Br. J. Surg. 1980;V67:63-65.从从a至至o步骤的参考文献步骤的参考文献D. Royston and S. von Kier. Reduced haemostatic factor transfusion us

34、ing heparinase-modified thrombelastography during D. Royston and S. von Kier. Reduced haemostatic factor transfusion using heparinase-modified thrombelastography during cardiopulmonary bypass. Br J Anaesth 86:575-578, 2001.cardiopulmonary bypass. Br J Anaesth 86:575-578, 2001.Mongan P, Hosking M. Th

35、e Role of Desmopressin Acetate in Patients Undergoing Coronary Artery Bypass Surgery. Anesthesiology. Mongan P, Hosking M. The Role of Desmopressin Acetate in Patients Undergoing Coronary Artery Bypass Surgery. Anesthesiology. 1992:77:38-46.1992:77:38-46.Ng KFJ, Lam CCK, Chan LC. In vivo effect of h

36、aemodilution with saline on coagulation: a randomized trial. Br J Anaesth 2002; 88: Ng KFJ, Lam CCK, Chan LC. In vivo effect of haemodilution with saline on coagulation: a randomized trial. Br J Anaesth 2002; 88: 47580.47580.Colman RW et al. Haemostasis and Thrombosis, Basic Principles and Clinical

37、. Neoplasia 2001; 3: 371384. Colman RW et al (eds) Colman RW et al. Haemostasis and Thrombosis, Basic Principles and Clinical . Neoplasia 2001; 3: 371384. Colman RW et al (eds) Haemostasis and Thrombosis, Basic Principles and Clinical . Neoplasia 2001; 3: 371384.Haemostasis and Thrombosis, Basic Pri

38、nciples and Clinical . Neoplasia 2001; 3: 371384.Lbid, pp. 1534-1538Lbid, pp. 1534-1538Lbid, pp. 795-804Lbid, pp. 795-804Hensley FA, Martin DE. A. practical approach to cardiac anesthesia, 2. nd. ed. Boston: Little,. Brown and Company,2001,451-461.Hensley FA, Martin DE. A. practical approach to card

39、iac anesthesia, 2. nd. ed. Boston: Little,. Brown and Company,2001,451-461.Van der Linden, J, et al. Aprotinin decreases postoperative bleeding and number of transfusions in patients on clopidogrel undergoing Van der Linden, J, et al. Aprotinin decreases postoperative bleeding and number of transfus

40、ions in patients on clopidogrel undergoing coronary artery bypass graft surgery. Circulation 2005;112: I276-I280.coronary artery bypass graft surgery. Circulation 2005;112: I276-I280.7000.7000.TEG治疗指点TEG参数值参数值临床分析临床分析建议治疗建议治疗说明说明R 4 min酶动力型高凝抗凝药物#低体温状态：如果手术后病人体温很低，我们建议将病人的一个血样的测试温度设置为与病人体温相同的温度，另一个血

41、样的测试温度设置为37。那么病人凝血状况的差异可能是由于体温过低造成的。如果低体温病人正在出血，但他的凝血状态在37是正常的，则意味着当他的体温回升后，出血就会停止。另一方面，如果血样在37显示凝血异常的，而病人在出血，那么我们应该对病人的凝血异常进行治疗，直到其血样在37测量是正常的，因此此时如果低体温病人仍然持续出血，原因可能就是体温过低造成的。#DDAVP：MA值介于4654之间时反映有轻微的血小板功能不良，可通过加入高VWF因子、因子水平的血浆，或者通过其他未确定的机理，采用DDAVP来提高血小板效力，或加入1u血小板。反之，也可以考虑延迟或忽略治疗，等待病人自己的血小板功能恢复。如果

42、TEG测试得出了正常的弹力图，而病人仍在出血：考虑考虑VWF因子疾病因子疾病：VWF因子缺乏。血凝块功能是好的，但由于血小板-内皮间的粘附性差，造成血凝块不能粘附到受损的血管位置。建议采用DDAVP（释放VWF因子）或FFP/冷沉淀（含有VWF因子）。考虑抗血小板药物作用考虑抗血小板药物作用：采用血小板图检测抗血小板治疗的影响。考虑机械性出血考虑机械性出血：如果排除了VWF因子缺乏和抗血小板药物的影响，最后应该考虑是由于手术原因造成出血。复温和MA的关系：在复温过程中血样的MA值比鱼精蛋白中和后血样的MA值低57mm左右。因此在手术的复温阶段中建议采用诊断树。如果病人没有接受过肝素治疗，则以自

43、然血为基础评估凝血状态。因为我们推荐在模拟条件下运行病人的血样，因此，在病人血液中不存在肝素时，建议不需用肝素酶杯进行检测。11min R 14 min凝血因子x 4 FFP or 16 ml/kg1、5、2646mm MA 54 mm血小板功能0.3mcg/kg DDAVP27、11#41mm MA 73血小板型高凝抗血小板治疗R73酶动力型和血小板型高凝抗血小板治疗和抗凝药物1、11、10、28 45纤维蛋白原水平0.06 u/kg 冷沉淀5LY307.5%, C.I.3.0原发性纤溶亢进抗纤溶药物5、1LY307.5%, C.I.3.0继发性纤溶亢进抗凝药物5、1、15LY307.5%,

44、 C.I.3.0血栓前状态抗凝药物11、15大纲 凝血原理 TEG 分析仪的普通概念 TEG 技术的运用 普通检测 肝素酶检测 血小板图检测 TEG质控 TEG软件TEG 解析低凝形状出血血栓急性出血风险急性出血风险血制品管理血制品管理再探查再探查TEG 解析低凝形状未成熟的血块消融未成熟的血块消融凝血酶产生降低凝血酶产生降低弱的血凝块弱的血凝块动力动力/外科缘由外科缘由血小板粘附降低血小板粘附降低血小板抑制药血小板抑制药低凝血因子呵斥低凝低凝血因子呵斥低凝可利用的工具CLOT血滴图低血小板数量低血小板数量/功能呵斥低凝功能呵斥低凝运用举例患儿：女,4岁7个月,反复出血伴贫血4余年,加重半年.

45、急诊：出血伴贫血缘由待查,血友病可疑.常规检查:重度小细胞低色素性贫血;白细胞;中性粒细胞;血红蛋白;血小板计数;肝功;肾功;凝血四项;凝血因子 (、)活性TEG检测：血小板功能/计数异常血小板功能检测：血小板聚集功能测试血小板膜糖蛋白GPb/a确诊：血小板无力症解放军总医院临检科李健、丛玉隆、邓新立 、小儿内科杨光 2006年12月12日第86卷第46期低纤维蛋白原呵斥低凝低纤维蛋白原呵斥低凝The TEG 分析仪检测肝素的存在绿色 = kaolin 和肝素酶 (KH)黑色 = 只需kaolin (K)R 值 KH = K 提示没有肝素存在R 值 KH K 提示有肝素存在肝素检测的敏感性除了

46、抗FXa活性测试以外.,TEG普通测试的敏感性比其他传统凝血测试对低浓度UFH, LMWH, DPD高.TEG肝素酶测试能检测出极低浓度(0.005 U/ml)的UFH,LMWH,DPD.对于低浓度(0.005-0.05 U/ml)的UFH ,TEG肝素酶测试的敏感性比抗FXa活性测试高.TEG Blood Coagul Fibrinolysis. 2006 Mar;17(2):97-104. Coppell JA, Thalheimer U, Blood Coagul Fibrinolysis. 2006 Mar;17(2):97-104. Coppell JA, Thalheimer U,

47、 Zambruni A, aHaemophilia Centre and Haemostasis Unit bLiver Zambruni A, aHaemophilia Centre and Haemostasis Unit bLiver Transplantation and Hepatobiliary Medicine, Royal Free Hospital, UK.Transplantation and Hepatobiliary Medicine, Royal Free Hospital, UK.肝素检测的敏感性对于残留肝素的抗凝效果，对于残留肝素的抗凝效果，ACTACT比比aPT

48、T, TEGaPTT, TEG和全血肝素测试的敏感性更低。和全血肝素测试的敏感性更低。Heparin detection by the activated coagulation time: a comparison of the Heparin detection by the activated coagulation time: a comparison of the sensitivity of coagulation tests and heparin assays.sensitivity of coagulation tests and heparin assays.ACT Car

49、diothorac Vasc Anesth. 1997 Feb;11(1):24-8. Murray DJ, Brosnahan WJ, Cardiothorac Vasc Anesth. 1997 Feb;11(1):24-8. Murray DJ, Brosnahan WJ, Department of Anesthesia, Washington University School of Medicine, St. Louis, MO 63110, Department of Anesthesia, Washington University School of Medicine, St

50、. Louis, MO 63110, USA.USA.肝素检测的敏感性 TEG TEG 能及时准确地反映血凝块的构成、溶解的全过程，对术中的异常出血能在短时间内作定性诊断，尤其是在鱼精蛋白综合肝素不全时，能及时准确地反映血凝块的构成、溶解的全过程，对术中的异常出血能在短时间内作定性诊断，尤其是在鱼精蛋白综合肝素不全时，TEG TEG 的的R R 值明显添加，其敏感性与特异性明显优于值明显添加，其敏感性与特异性明显优于ACTACT。血栓弹性描记仪的临床运用初探血栓弹性描记仪的临床运用初探刘克玄刘克玄 黄文起黄文起 等等. . 中山医科大学附属第一医院麻醉科中山医科大学附属第一医院麻醉科 2000

51、2000年年 12 12卷卷 3 3期期 肝素检测的敏感性虽然术后虽然术后ACTACT恢复到术前程度恢复到术前程度, ,但鱼精蛋白难以中和敏感性小分子量肝素但鱼精蛋白难以中和敏感性小分子量肝素, ,剩余肝素仍影响术后凝血功能剩余肝素仍影响术后凝血功能, ,不能仅凭不能仅凭ACTACT判别鱼精蛋白中和肝素的称心判别鱼精蛋白中和肝素的称心程度程度, ,提示我们提示我们, ,体外循环中应选用大分子量肝素抗凝。用肝素酶中和肝素的体外循环中应选用大分子量肝素抗凝。用肝素酶中和肝素的TEGTEG可反映实践凝血功能可反映实践凝血功能, ,迅速排除肝素影响迅速排除肝素影响, ,也可在体外循环中进展监测也可在体

52、外循环中进展监测, ,及早提供凝血异常的资料及早提供凝血异常的资料, ,指点术后治疗。指点术后治疗。用血栓弹力图评价体外循环中凝血功能的改动用血栓弹力图评价体外循环中凝血功能的改动王仕刚、倪虹王仕刚、倪虹 、龚庆成。阜外心血管病医院体外循环科、龚庆成。阜外心血管病医院体外循环科 20032003年年1010月第月第1919卷第卷第5 5期期 TEG 解析低凝形状支持的研讨Royston D and von Kier S. Br J Anaesth. 2001; 86:575. Reduced hemostatic factor transfusion using heparinase-modi

53、fied thrombelastography during cardiopulmonary bypass (CPB)在体外循环手术中用肝素酶检测减少凝血因子的运用组组对照组对照组(n=30)TEG-检测检测(n=30)输血病人105*FFP 冰冻新鲜血浆(units)165*血小板 (units)91*12 hr胸腔引流 (ml)390470Prospective, randomly controlled studyCardiac surgical patientsp 0.05CTD = chest tube drainageFFP = fresh frozen plasmaThrombel

54、astography-guided algorithm reduces transfusions in complex cardiac surgery心外科的输血在TEG指点下减少Shore-Lesserson L, et al. Anesth Analg. 1999; 88:312-9 随机对照 心外病人 只针对手术病人p 0.05CTD = chest tube drainageFFP = fresh frozen plasmaRBC = red blood cells# 输血病人输血病人对照对照(n=53)# 输血输血TEG-检测检测(n=52)RBC红细胞红细胞术中1723术后1610

55、总计3122FFP 冰冻新鲜血浆冰冻新鲜血浆术中83术后112*总计164*Platelets 血小板血小板术中85术后93总计157*24 hr 胸腔引流胸腔引流(ml)901702TEG 图形正常 为什么病人还在出血？外科缘由外科缘由? (90% 能够能够)血管内皮相关的问题血管内皮相关的问题?血小板抑制药的运用血小板抑制药的运用?Changes in transfusion therapy and re-exploration rate after institution of a blood management program in cardiac surgical patients

56、运用血制品管理制度后输血和再探查的改动再手术的类型监测内容常规检查 (单位)TEG (单位)Total28/4885.7%9/5911.5%*CABG16/3554.5%6/4431.4%*开心手术12/1339.0%03/1482.0%*Spiess BD, et al. J Cardiothorac Vasc Anesth. 1995; 9:168.TEG 解析高凝形状出血血栓急性血栓风险急性血栓风险血栓构成的风险分层血栓构成的风险分层检测药物疗效检测药物疗效低纤维溶解活性低纤维溶解活性过多的凝血酶产生过多的凝血酶产生血小板活性亢进血小板活性亢进TEG 解析高凝形状血小板型高凝血小板型高凝

57、酶动力型高凝酶动力型高凝酶动力和血小板型高凝酶动力和血小板型高凝Stratification of thrombotic event using TEG MA 用TEG MA进展血栓事件分层高 MA 是评价缺血事件最敏感的参数80% 敏感性非心外手术病人 (n=240)McCrath et al. Analg Anesth 2005; 100:1576PCI (n=192)Gurbel et al. JACC 2005; 46:1820TEG 解析纤溶亢进出血血栓“急性急性 凝血风险凝血风险原发纤溶和继发纤溶的区别原发纤溶和继发纤溶的区别TEG 解析高纤溶形状过多的纤溶酶过多的纤溶酶过多的纤维

58、蛋白构成过多的纤维蛋白构成 TAFI 活性缺乏活性缺乏TAFITAFI：凝血酶激活的纤溶抑制物：凝血酶激活的纤溶抑制物 原发性纤溶亢进原发性纤溶亢进继发性纤溶亢进继发性纤溶亢进纤维蛋白溶解原发 vs. 继发大纲 凝血原理 TEG 分析仪的普通概念 TEG 技术的运用 普通检测 肝素酶检测 血小板图检测 TEG质控 TEG 软件PlateletMapping血小板图是什么 检测高凝的程度和抗血小板治疗对血小板功能的抑制效果 以病人的最大血小板功能作为参考点 测定病人血小板相对于参考点被抑制的比例血小板图的实际根底 Tanaka KA, Sato N, Kelly AB, Szlam F, Lev

59、y JH. Monitoring Platelet Function during Tanaka KA, Sato N, Kelly AB, Szlam F, Levy JH. Monitoring Platelet Function during Cardiopulmonary Bypass in the Presence of Tirofiban. Anesth Analg. 2003; 96, SCA 53.Cardiopulmonary Bypass in the Presence of Tirofiban. Anesth Analg. 2003; 96, SCA 53.Waters

60、JH, Anthony DG, Gottlieb A, Sprung J. Bleeding in a Patient Receiving Platelet Waters JH, Anthony DG, Gottlieb A, Sprung J. Bleeding in a Patient Receiving Platelet Aggregation Inhibitors. Anesth Analg. 2001;93:878-882.Aggregation Inhibitors. Anesth Analg. 2001;93:878-882.Stogermuller B, Stark J, Wi