1、Chapter 11 Coagulation and anticoagulation disturbanceMain contents:n Review coagulation and anticoagulation processn Disseminated Intravascular Coagulation， DICCoagulation process:nIntrinsic System (內(nèi)源性）內(nèi)源性）nExtrinsic system （外源性）（外源性）nPlatelet （血小板）（血小板） a(a+Ca2+、PL)a、a、aCa2+PL （TF）TF-、Ca2+纖維蛋白纖維蛋

2、白 纖維蛋白單體纖維蛋白單體 纖維蛋白原纖維蛋白原Ca2+,XIIIa凝血酶原凝血酶原 凝血酶（凝血酶（thrombinthrombin） a Ca2+-CaMActin proteinShape changePKCDGTXA2TXA2G proteinPLC PIP2IP3PLAAPLA2血小板血小板 GPIIb/IIIa纖維蛋白原纖維蛋白原二聚體二聚體血小板血小板GPIIb/IIIavWF血小板血小板GPIb/IX 膠原膠原血管內(nèi)皮細(xì)胞血管內(nèi)皮細(xì)胞血小板活化聚集血小板活化聚集血栓形成過程血栓形成過程 血小板粘附在內(nèi)皮下膠原血小板粘附在內(nèi)皮下膠原血小板不可逆聚集并釋放血小板不可逆聚集并釋放C

3、oagulation process:nIntrinsic SystemnExtrinsic systemnPlatelet抗凝系統(tǒng)和纖溶系統(tǒng)抗凝系統(tǒng)和纖溶系統(tǒng)Anticoagulation process:nTM-PC TM-PC 系統(tǒng)系統(tǒng)nATIII, heparinATIII, heparinn內(nèi)皮細(xì)胞抗凝內(nèi)皮細(xì)胞抗凝Anticoagulation process:TM PC系統(tǒng)系統(tǒng)纖溶系統(tǒng)（纖溶系統(tǒng)（纖溶酶原激活物纖溶酶原激活物纖溶酶原纖溶酶原（ 纖溶酶纖溶酶（纖維蛋白及纖維蛋白及纖維蛋白原纖維蛋白原纖維蛋白纖維蛋白降解產(chǎn)物降解產(chǎn)物（FDP）（fibronogen/fibrin）NO/

4、PGI2/ADPaseAnticoagulation of vascular endothelial cellsAnticoagulation of vascular endothelial cellsDICnDisseminated or Diffuse Intravascular Coagulation* * ConceptConcept* * Etiology and Pathogenesis Etiology and Pathogenesis* * Predisposing Factors Predisposing Factors* * Types and Stages Types a

5、nd Stages* * Consequences Consequences* * Principles of management Principles of management 彌散性血管內(nèi)凝血彌散性血管內(nèi)凝血出血出血, , 貧血，休克甚至多器官功能障礙貧血，休克甚至多器官功能障礙nDisseminated intravascular coagulation（DIC）is a pathologic process and a life-threatening clinical syndrome in which widespread intravascular coagulaion is

6、 induced by certain cause of diseases. DIC has been one of the most intensively studied subjects in pathophysiology. The very complex mechanisms that trigger DIC involve processes of platelet adhesion and aggregation，the intrinsic and extrinsic pathways of coagulation；fibrin depositon and clot gener

7、ation，consumption of various coagulation factors and platelets as well as subsequent relatively inadequate concurrent fibrinolysisnExtensive data on autopsy findings in cases of DIC is always attributed to thrombi in microvessels，widespread hemorrhage，shock，and/or multiple organ necrosis as well as

8、dysfunction（Multiple Organ dysfunction Syndrome，MODS）The fatality rate associated with DIC is extremely high in hospitalsDIC processcoagulation shock, MODS and anemia1. Etiology and Pathogenesis of DICnInfectious diseasesnMalignant tumorsnObstetric accidentsnTrauma and operationEtiology of DIC:1. Pa

9、thogenesis of DIC (1) TF releasing initiating coagulation system(2) Damage of vascular endothelial cells disturbance of coagulation and anticoagulationendothelial cellsendothelial cellsAnticoagulation of vascular endothelial cellsNO/PGI2/ADPase(3) Extensive destruction of blood cells And activation

10、of platelets Red cells destruction: ADP platelet aggregation(2) Leukocytes destruction or activation: expression and releasing TF(3) Platelets activation (4) Other pro-coagulants entering circulationPathogenesis of DIC(1) TF releasing initiating coagulation system (2) Damage of vascular endothelial

11、cells disturbance of coagulation and anticoagulation(3) Extensive destruction of blood cells And activation of platelets(4) Other pro-coagulants entering circulation2.Factors influencing the formation and development of DIC orPredisposing Factors to DIC（DIC誘因）誘因）(1)Inappropriately conditioned monocy

12、tes-macrophages (單核單核-巨噬細(xì)胞受損）巨噬細(xì)胞受損） Macrophage (2) Impairment of liver functions(3) Hypercoagulable status （血液高凝狀血液高凝狀態(tài)）態(tài)）(4) Dysfunction of microcirculation2. Predisposing Factors to DIC(1) Impairment of the reticuloendothelial(2) Impairment of liver functions(3) Hypercoagulable status(4) Dysfunct

13、ion of microcirculation3. Types and Stages of DICStages of DIC3. Types and Stages of DICTypes of DIC -Classification by speedspeed3. Types and Stages of DICTypes of DIC -Classification by compensationcompensation4. Consequences of DIC nInhibit fibrin formationnInhibit platelet aggregationnInhibit th

14、rombinFDP confirming test:“D-二聚體檢查二聚體檢查”4. Consequences of DIC 4. Consequences of DIC4. Consequences of DIC RBC懸掛在纖維蛋白索上（掃描電鏡，左2000，右5200）4. Consequences of DIC 產(chǎn)后出血伴失血性休克、產(chǎn)后出血伴失血性休克、DIC12病例分析病例分析發(fā)表時(shí)間：2011-11-16 來源：中外健康文摘2011年第28期供稿 作者：張祥元n3.4DIC簡(jiǎn)易診斷標(biāo)準(zhǔn)：(1)原發(fā)病在及時(shí)的足量的綜合療法進(jìn)行中繼續(xù)惡化。(2)原因不明的出血傾向。(3)DIC篩選試

15、驗(yàn)血液抽出時(shí)已成高凝狀態(tài)（DIC早期)，血沉慢。(4)周圍血片中查見裂細(xì)胞和細(xì)胞碎片。(5)血管栓塞現(xiàn)象。(6)血小板進(jìn)行性減少10萬/mm3。(7)凝血酶原時(shí)間(Quick氏一期法)15秒，血漿纖維蛋白原200mg%。4同時(shí)每天監(jiān)測(cè)血小板（PLT）、凝血酶原時(shí)間（PT）、活化部分凝血活酶時(shí)間（APTT）、纖維蛋白原（Fbg）、硫酸魚精蛋白試驗(yàn)（3P）、纖維蛋白降解產(chǎn)物（FDP）和D-二聚體（DD）。5. Principles of management of DICSummary nDisseminated intravascular coagulation（DIC）is a patholo

16、gic process and a life-threatening clinical syndrome in which widespread intravascular coagulaion is induced by certain cause of diseases. DIC has been one of the most intensively studied subjects in pathophysiology. The very complex mechanisms that trigger DIC involve processes of platelet adhesion

17、 and aggregation，the intrinsic and extrinsic pathways of coagulation；fibrin depositon and clot generation，consumption of various coagulation factors and platelets as well as subsequent relatively inadequate concurrent fibrinolysisnExtensive data on autopsy findings in cases of DIC is always attribut

18、ed to thrombi in microvessels，widespread hemorrhage，shock，and/or multiple organ necrosis as well as dysfunction（Multiple Organ dysfunction Syndrome，MODS）The fatality rate associated with DIC is extremely high in hospitals產(chǎn)科彌散性血管內(nèi)凝血產(chǎn)科彌散性血管內(nèi)凝血12例診治體會(huì)例診治體會(huì)n關(guān)鍵詞關(guān)鍵詞 彌散性血管內(nèi)凝血彌散性血管內(nèi)凝血 產(chǎn)科產(chǎn)科 診斷與治療診斷與治療 產(chǎn)科彌散性血管內(nèi)凝血產(chǎn)科彌散性血管內(nèi)凝血(DIC)是分娩期嚴(yán)重是分娩期嚴(yán)重并發(fā)癥之一，病情急劇，發(fā)展迅速，嚴(yán)重者危并發(fā)癥之一，病情急劇，發(fā)展迅速，嚴(yán)重者危及及 孕產(chǎn)婦的生命。孕產(chǎn)婦的生命。 1 臨床資料1.1 病例：患者年齡2641歲，平均(31.3.8)歲；院外轉(zhuǎn)入3例，院內(nèi)發(fā)生9例；產(chǎn)前發(fā)生6例，產(chǎn)后發(fā)生6例。誘因：急性羊水栓塞1例，遲發(fā)性羊水栓塞2例，中、重度妊娠高血壓綜合征合并胎盤早剝3例，外傷致胎盤早剝1例，發(fā)生出血性休克4例，死胎引