dic彌散性血管內(nèi)凝血診斷和治療進(jìn)展課件

,單擊此處編輯母版標(biāo)題樣式,單擊此處編輯母版文本樣式,第二級(jí),第三級(jí),第四級(jí),第五級(jí),醫(yī)學(xué)ppt,*,單擊此處編輯母版標(biāo)題樣式,單擊此處編輯母版文本樣式,第二級(jí),第三級(jí),第四級(jí),第五級(jí),醫(yī)學(xué)ppt,*,單擊此處編輯母版標(biāo)題樣式,單擊此處編輯母版文本樣式,二級(jí),三級(jí),四級(jí),五級(jí),*,DIC,的現(xiàn)狀,CURRENT ASPECT OF DIC,1,醫(yī)學(xué)ppt,DIC,不是一種獨(dú)立的疾病而是一個(gè)由多種病因引起的出血性病理過(guò)程，其特征是微循環(huán)內(nèi)發(fā)生廣泛的纖維蛋白沉積和血小板聚集，導(dǎo)致彌漫性微血栓形成，繼發(fā)性凝血因子和血小板大量消耗以及纖溶亢進(jìn)，從而引起微循環(huán)障礙、出血與溶血等一系列嚴(yán)重的臨床癥狀。,國(guó)際血栓與止血學(xué)會(huì)的,DIC,定義：,DIC,是多種原因與成分引起的全身性血管內(nèi)凝血過(guò)程。,DIC,的病理變化主要在微血管，并引起微血管病變，嚴(yán)重時(shí)可導(dǎo)致臟器功能障礙。,2,醫(yī)學(xué)ppt,Underlying Conditions Associated with DIC,Basic disease ratio of the disease to all(%),Infection diseases 36.94,Obstetric complications 24.81,Malignancies 24.21,Surgery and trauma 4.34,Iatrogenic factor 1.45,Other factors 8.25,3,醫(yī)學(xué)ppt,DIC is characterized by the increasing loss of localization or compensated control in coagulation activation.,4,醫(yī)學(xué)ppt,DIC pathogenesis is not just related to“coagulation gone haywire,”but fully involves all components of the inflammatory and innate immune response.,5,醫(yī)學(xué)ppt,6,醫(yī)學(xué)ppt,不同原因,DIC,的臨床特征,不同疾病引起的,DIC,的臨床表現(xiàn)不同。敗血癥,DIC,易發(fā)生腎臟損害；早期以組織缺血為特征，然后才有明顯的出血。創(chuàng)傷后,DIC,可能表現(xiàn)有成人呼吸窘迫綜合征。,APL,引起的,DIC,主要表現(xiàn)為出血。,7,醫(yī)學(xué)ppt,彌散性血管內(nèi)凝血診斷與治療中國(guó)專家共識(shí)（,2012,）,臨床表現(xiàn)：因原發(fā)病不同而差異較大,1,出血：特點(diǎn)為自發(fā)性，嚴(yán)重者可發(fā)生危及生命的出血。,2,休克或微循環(huán)衰竭：早期即出現(xiàn)腎、肺、大腦等器官功能不全。,3,微血管栓塞,4,微血管病性溶血,8,醫(yī)學(xué)ppt,彌散性血管內(nèi)凝血診斷與治療中國(guó)專家共識(shí)（,2012,）,DIC,的實(shí)驗(yàn)室檢查包括兩方面，一是反映凝血因子消耗的證據(jù)，包括,(PT,、,APTT,、纖維蛋白原濃度及血小板計(jì)數(shù)；二是反映纖溶系統(tǒng)活化的證據(jù)，包括,FDP,、,D,一二聚體、,3P,試驗(yàn)。,9,醫(yī)學(xué)ppt,國(guó)際血栓與止血學(xué)會(huì)的分步驟分級(jí)診斷標(biāo)準(zhǔn),1,誘發(fā)因素：患者是否有與,DIC,有關(guān)的基礎(chǔ)疾??？如果有，繼續(xù)以下步驟；如果沒(méi)有，不再繼續(xù),2,一般的凝血試驗(yàn)（血小板計(jì)數(shù)，,PT,，纖維蛋白原，,sFM,或,FDP,）,3,對(duì)一般的凝血試驗(yàn)結(jié)果進(jìn)行積分,血小板計(jì)數(shù)（,100=0,；,100=1,；,50=2,）,纖維蛋白相關(guān)標(biāo)志物增高（如,sFM,或,FDP,）（不高,=0,；輕度增高,=1,；明顯增高,=2,）,PT,延長(zhǎng)（,3sec,但,6sec=2,）,纖維蛋白原水平（,1.0g/l=0,；,5,：符合,DIC,；每日重復(fù)做檢測(cè),如,5,：提示（但不肯定）為非顯性,DIC,；每,12,日重復(fù)檢測(cè),10,醫(yī)學(xué)ppt,麻省大學(xué)醫(yī)學(xué)中心對(duì),DIC,的常用指標(biāo)的評(píng)價(jià),檢測(cè)指標(biāo) 敏感性（,%,）特異性（,%,）診斷效率（,%,）,1,單個(gè)試驗(yàn),血小板計(jì)數(shù),97 48 67,PT 91 27 57,APTT 91 42 57,TT 83 60 70,Fbg 22 100 65,AT 91 40 70,FDP 100 67 87,D-D 91 68 80,破碎紅細(xì)胞,23 73 51,2,聯(lián)合試驗(yàn)（幾個(gè)試驗(yàn)均為陽(yáng)性）,PT+APTT+TT 83 11 51,PT+APTT+Fbg 22 100 65,PT+APTT+FDP 91 71 86,FDP+D-D 91 94 95,11,醫(yī)學(xué)ppt,D-,二聚體在,DIC,患者明顯增高,12,醫(yī)學(xué)ppt,彌散性血管內(nèi)凝血診斷與治療中國(guó)專家共識(shí)（,2012,）,1,治療基礎(chǔ)疾病及去除誘因：分別采取控制感染、治療腫瘤、積極處理病理產(chǎn)科及外傷等措施，是終止,DIC,病理過(guò)程的最為關(guān)鍵和根本的治療措施。,2,抗凝治療：阻止凝血過(guò)度活化、中斷,DIC,病理過(guò)程。應(yīng)在處理基礎(chǔ)疾病的前提下，與凝血因子補(bǔ)充同步進(jìn)行。臨床上常用普通肝素和低分子量肝素。,13,醫(yī)學(xué)ppt,彌散性血管內(nèi)凝血診斷與治療中國(guó)專家共識(shí)（,2012,）,3,替代治療：適用于有明顯血小板或凝血因子減少證據(jù)且,DIC,未能得到控制、有明顯出血表現(xiàn)者。,(1),新鮮冷凍血漿等血液制品，也可使用冷沉淀。纖維蛋白原水平較低時(shí)，可輸入纖維蛋白原。,14,醫(yī)學(xué)ppt,彌散性血管內(nèi)凝血診斷與治療中國(guó)專家共識(shí)（,2012,）,(2),血小板懸液：未出血的患者,PLT2010,9,/L,，或者存在活動(dòng)性出血且,PLT5010,9,/L,的,DIC,患者。,(3)F,及凝血酶原復(fù)合物：偶在嚴(yán)重肝病合并,DIC,時(shí)考慮應(yīng)用。,4,其他治療：,(1),支持對(duì)癥治療：抗休克治療，糾正缺氧、酸中毒及水電解質(zhì)平衡紊亂。,15,醫(yī)學(xué)ppt,16,醫(yī)學(xué)ppt,彌散性血管內(nèi)凝血診斷與治療中國(guó)專家共識(shí)（,2012,）,(2),纖溶抑制藥物：臨床上一般不使用，僅適用于有明顯纖溶亢進(jìn)的臨床及實(shí)驗(yàn)證據(jù)，繼發(fā)性纖溶亢進(jìn)已成為遲發(fā)性出血主要或唯一原因的患者。,(3),激素治療：下列情況可予以考慮：基礎(chǔ)疾病需糖皮質(zhì)激素治療者。感染中毒性休克合并,DIC,已經(jīng)有效抗感染治療者。并發(fā)腎上腺皮質(zhì)功能不全者。,17,醫(yī)學(xué)ppt,英國(guó),DIC,治療指南（,2009,）,The cornerstone of the treatment is treatment of the underlying condition.Transfusion of platelets or plasma should be reserved for patients with bleeding.Severe hypofibrinogenaemia may be treated with fibrinogen or cryoprecipitate.In cases of DIC where thrombosis predominates,heparin should be considered.Patients with DIC characterised by a primary hyperfibrinolytic state and who present with severe bleeding could be treated with lysine analogues.,18,醫(yī)學(xué)ppt,意大利,DIC,治療指南（,2012,）,The treatment of the underlying disease.We do not suggest the use of AT or rFVIIa.Heparin or LMWH is not suggested except for thrombo-embombolic prophylaxis in patients without active bleeding.In patients with sepsis/DIC we suggest the use of hr APC.In patients with DIC and active bleeding we suggest transfusion therapy(platelets,plasma,cryoprecipitate).In patients with chronic DIC or without active bleeding we do not suggest transfusion therapy based only on laboratory parameters.,19,醫(yī)學(xué)ppt,Expert consensus for the treatment of DIC in Japan,2010,In asymptomatic or bleeding DIC,LMWH,synthetic protease inhibitor(SPI),and AT are recommended.In case of severe bleeding,SPI is recommended since it does not cause a worsening of bleeding.Blood transfusions are also required in cases of life threatening bleeding.In the organ failure type,including sepsis,AT has been recommended.DIC with thrombosis and may thus require strong anticoagulant therapy,such as LMWH,UFH,and DS.,20,醫(yī)學(xué)ppt,DIC and hyperfibrinolysis in acute promyelocytic leukemia,Zhaoyue Wang,Jiangsu Institute of Hematology,The Affiliated Hospital of Soochow University,China,21,醫(yī)學(xué)ppt,Alterations of SFC,FDP and D-dimer in APL patients,n SFC(mg/L)FDP(pg/L)D-Dimer(pg/L),Control 40 49.716.4 215.363.2 177.143.9,DIC 15,958.6202.3,*,764.497.8,*,151662788,*,Non-DIC 35 316.9195.4,*,322.8175.2,23661135,DIC corrected 6 376.7123.6,*,366.9113.7,25791679,Compare with control,，,*,P005,，,*,P001,，,*,P 0001,；,Compare with DIC,，,P005,，,P001,，,P,120s,，,TT 15.8s,，,Fg 3.1g/L,，血小板,16510,9,/L,。擬診為,DIC,。追問(wèn)病史，因,10,年前瓣膜置換每日服用華法林（近半年為,3mg/d,），未作監(jiān)測(cè)。,36,醫(yī)學(xué)ppt,晚期肝硬化的凝血改變,男，,52,歲，晚期肝硬化肝功能衰竭，牙齦出血，皮膚少量瘀斑。,APTT48.2s,，,PT31.4s,，,TT19.1s,，纖維蛋白原,0.87g/L,，凝血酶原,31%,，因子,42%,，因子,22.7%,，因子,104%,，因子,64%,，因子,37.8%,，,56.6%,。,37,醫(yī)學(xué)ppt,VOD,女，,22,歲。,ALL,化療后復(fù)發(fā),3,次，接受來(lái)自母親的半相合骨髓移植。術(shù)后第,5,天出現(xiàn)腹痛、腹脹、黃疸與肝腫大；體重每日增加,10,斤。全身皮膚粘膜廣泛出血。,T-BIL 84.5,mol/L,，,ALT 1820 U/L,，,AST 2670U/L,