内科学-培训课件PPT
内科学-培训课件PPT,内科学,培训,课件,PPT
DisseminatedIntravascularCoagulation(DIC)TanHuo(1030158)(1030158),MD/Ph.D,ProfessorDept.ofHematology,The1stAffiliatedHospital,GMUThe risk factors and etiology of DICThepathogenesisofDICThepathophysiologyofDICTheclinicalfeaturesofDICThediagnosisofDICThetherapyofDICCONTENTSWhatIsDIC?Itsconsideredan“acquiredbleedingdisorder”ItsnotadiseaseentitybutaneventthatcanaccompanyvariousdiseaseprocessesItsaParadoxicalClinicalPresentation“clotting and hemorrhage”TheDefinitionAnacquiredsyndromecharacterizedbythe intravascular activation of coagulation withlossoflocalizationarisingfromanycausedamagetothemicrovasculatureif sufficiently severe,it can produce organdysfunctionUnderlyingConditionsAssociatedwithDICBasicdiseaseratioofthediseasetoall(%)Infectiondiseases36.94Obstetriccomplications24.81Malignancies24.21Surgeryandtrauma4.34Iatrogenicfactor1.45Otherfactors8.25WhatIsTheCausesOfDIC?DICandInfectiousDiseaseSeveresepsisisthemostcommonclinicalconditionassociatedwithDICBacterialinfectionoccursin30-50%ofGram-sepsisLipopolysaccharide(endotoxin)Gram+sepsisexotoxin(e.g.staphylococcala-haemolysin)DICandseveretraumaEspeciallyseenafterbraintraumareleaseoffatandphospholipidCytokineactivationsimilarpatterntoseveresepsis“Systemicinflammatoryresponsesyndrome”aftertrauma50-70%associatedwithDICDICandCancerSolidtumoursmetastaticcancer10-15%Haematologicalcanceracuteleukaemia 15%Cancerpro-coagulanttissuefactorAcutepromyelocyticleukaemiaDICandhyperfibrinolyticstateDICandObstetricalDisordersAbruptioplacentae,amnioticfluidembolism,fetaldeathinutero,septicabortionReleaseofthromboplastin-likematerialUsuallyshort-livedandself-limitingPre-eclampsiaDICandGiantHaemangiomaLocalactivationofcoagulationsystemsystemicdepletionoflocallyconsumedclottingfactorsandplateletsActivatedcoagulationfactorsreachsystemiccirculationDICGianthaemangioma25%Largeaorticaneurysm0.5-1%TheriskfactorsandetiologyofDICThe pathogenesis of DICThepathophysiologyofDICTheclinicalfeaturesofDICThediagnosisofDICThetherapyofDICCONTENTSHowIsTheDICHappen?PathologicPathwaysExtrinsic(endothelial)Shock or traumaInfections(gram positive and gram negative sepsis,aspergillosis)Obstetric complications(eclampsia,placenta abruptio,fetal death syndrome)Malignancies:APL,AML,cancers of the lung,colon,breast,prostateIntrinsic(bloodvessel)Infectious vasculitis(certain viral infections,rocky mountain spotted fever)Vascular disordersIntravascular hemolysis(hemolytic transfusion reactions)Miscellaneous:snakebite,pancreatitis,liver diseaseDICischaracterizedbytheincreasinglossoflocalizationorcompensatedcontrolincoagulationactivation.PathogenesisofDICIncreasedthrombingenerationDepressionofphysiologicanticoagulationmechanismDelayedremovaloffibrinduetoimpairedfibrinolysisActivationofThrombinistheFocusinDICactivationofprothrombininhibitingATactivationof Plateletactivationoffibrinolysisactivationof、activationofVthrombinTheriskfactorsandetiologyofDICThepathogenesisofDICThe pathophysiology of DICTheclinicalfeaturesofDICThediagnosisofDICThetherapyofDICCONTENTSFormationofMicrothrombusDisfunctionofCoagulationDisturbanceofMicrocirculationTheriskfactorsandetiologyofDICThepathogenesisofDICThepathophysiologyofDICThe clinical features of DICThediagnosisofDICThetherapyofDICCONTENTSClinicalFeaturesOnsetmaybeAcuteorChronicAcuteDICDevelops rapidly over a period of hoursPresents with sudden bleeding from multiple sitesTreated as a medical emergencyChronicDICDevelops over a period of monthsMay be subclinicalEventually evolves into an acute DIC patternSignsandSymptoms MostcommonsignofDICisbleeding -manifested by ecchymosis,petechiae,and purpura-bleeding from multiple sites either oozing or frank bleeding-cool and or mottled extremities may be noted-dyspnea and chest pain if pleura and pericardium involvement-hematuriaTHE FUNCTION OF ORGANS FAILURE MicrothrombusLocalnecrosis&ulcermayappearMicroangiopathichaemolyticanaemiaPeripheralbloodpictureAnaemiaThrombocytopeniaFragmented red cells(schistocytes)AfeaturecommontoseveralconditionsDICThrombotic thrombocytopenic purpuraHaemolytic Uraemic SyndromeMainFeaturesofDICFeaturesAffectedPatients(%)Bleeding64Renal dysfunction25Hepatic dysfunction19Respiratory dysfunction16Shock14Central nervous systemdysfunction 2TheriskfactorsandetiologyofDICThepathogenesisofDICThepathophysiologyofDICTheclinicalfeaturesofDICThe diagnosis of DICThetherapyofDICCONTENTSHow To DiagnoseHow To Diagnose DIC DIC?DiagnosisofDICClinicalsettingLaboratorytestsCriteriaUnderlying disease known to be associatedInitial platelet count 100 109/L,or rapid decline in BPCProlongation of clotting times(PT&APTT)Presence of fibrin degradation productsLow levels of coagulation inhibitors(e.g.antithrombin)Low fibrinogen level in severe casesconsumptivecoagulopathy SecondaryfibrinolysisProthrombintime(PT)Activated PTT(APTT)Plateletcount(PLT)Fibrinogen(Fbg)Antithrombin(AT)Factor:CFibrindegradationproduct(FDP)Fibrindegradationproduct(FDP)D-dimerD-dimer3Ptest3Ptest Solublefibrinmonomer(SF)LaboratoryfindingsinDICDIC:Phases OvertDIC Decompensated form Non-overtDIC More subtle hemostatic dysfunctionTheInternationalSocietyofThrombosisandHaemostasis(ISTH)TheJapaneseMinistryofHealthandWelfare(JMHW)TheJapaneseAssociationforAcuteMedicine(JAAM)DifferentialDiagnosisSeriousHepatitis hepatic function(jaundice,FVIII,D-Dimer)Primaryhyperfibrinolysis only factordecreaseThromboticThrombocytopenicPurpura(TTP)vWF-cleaving protease(vWF-cp)MechanismofVWF-CPinpathogenesisofTTPUL-VWFbloodvesselVWF-CPnormalVWFmultimersbloodvesselVWF-CPdeficiencyTTPMicro-thrombusformationTheriskfactorsandetiologyofDICThepathogenesisofDICThepathophysiologyofDICTheclinicalfeaturesofDICThediagnosisofDICThe therapy of DICCONTENTSHowToTreatDIC?TreatmentofDIC Treatmentofunderlyingdisorder Anticoagulants Supplyclottingfactors&platelets OthersManagementofDICTreatmentofunderlyingdisorder very importantIdentify underlying cause and treatAll other therapies are temporizingAnticoagulantslow dose heparinlow molecular weight heparinnew thrombin inhibitors(ATIII independent)useful for clinically overt thromboembolism or extensive deposition of fibrinTheprincipleofheparin/LMWHtherapyEarlier period of DIC(hypercoagulation)Platelets&factors decrease,microthrombusAfter adding coagulation factors&plt in consumption hypocoagulation phase Refractoriness shockContraindication Active bleeding after operation&trauma Serious bleeding recently DIC caused by venene Severity defect of coagulation factors&obviously hyperfibrinolysisTheapplyingofanticoagulantsl Heparin 12500 U/d,5000U/6h,IV or H,35dl low molecular weight heparin(LMWH)75150 IUA/kg.d,H,35dUsingHeparinasanticoagulant,APTTmustbemonitored,thebestdoseofHeparinisthatwhentheAPTTisprolongedto1.52.0times.UsingLMWHdontneedtomonitorAPTTManagementofDICPlateletsandPlasmato treat bleeding tendency to cover an invasive procedure for patients with a high risk of bleedingClottingfactorconcentratesovercomes large volumes of plasmabut not advocated because:1)contains small amount of activated factors 2)DIC results in deficiency of multiple factorsConcentratesofcoagulationinhibitorsAntithrombin concentratereduces sepsis related mortalityimprovement of DIC and organ functionSupportive therapeutic option in severe DICAntifibrinolyticagentsGenerallynotrecommendedfibrinolysis is already impaired in DICmay enhance fibrin depositionForbleedinginDICassociatedwithprimaryorsecondaryhyperfibrinolysise.g.acute promyelocytic leukaemiaStratificationtherapyofDICConsumptive hypocoagulation period AnticoagulantsSupplyclottingfactors&plateletsDiffused microthrombus periodAnticoagulants Secondary hyperfibrinolysisSupplyclottingfactors&plateletsAntifibrinolyticagentsEarlier stageIntermediate stageAdvanced stageA 26 year-old female.She was noted to have disproportionate and asymmetric macrodactyl in her hands and feet several months after her birth.She was generally asymptomatic,had no easy bruising or other obvious mucocutaneous bleeding.And there was no mental retardation apparently.However,an antepartum hemorrhage resulted in miscarriage at six months of her pregnancy.The hemorrhage was severe and continued after an evacuation of the uterus and even a hysterectomy had been carried out.CasereportAlterations of DIC markers PlateletsAPTTPTTTFibrinogenATD-dimer(109/L)(s)(s)(s)(g/L)(%)(g/L)Beforesplenectomy7161.720.122.80.65019.1Aftersplenectomy11037.214.418.22.91833.22Proteussyndrome小小 结结lDICDIC的诊断必须包括基础疾病、临床表现和实验的诊断必须包括基础疾病、临床表现和实验室依据三方面室依据三方面l实验室依据应包括实验室依据应包括凝血因子消耗和纤溶系统激活凝血因子消耗和纤溶系统激活两方面的证据两方面的证据 l动态监测实验室结果和临床观察至关重要动态监测实验室结果和临床观察至关重要 l单一的实验室指标诊断单一的实验室指标诊断DICDIC的价值十分有限,联的价值十分有限,联合应用多个指标可能明显改善合应用多个指标可能明显改善DICDIC的诊断的诊断小小 结结u 治疗治疗DIC 的关键是治疗基础疾病或消除诱因的关键是治疗基础疾病或消除诱因 u 在治疗原发病基础上进一步采取分期分在治疗原发病基础上进一步采取分期分层层综合治疗原则综合治疗原则u 对于危重非出血对于危重非出血DIC患者,推荐使用预防剂量的肝素或低患者,推荐使用预防剂量的肝素或低 分子量肝素预防新的血栓形成分子量肝素预防新的血栓形成u 替代治疗制剂的使用主要依据临床出血症状情况而定,替代治疗制剂的使用主要依据临床出血症状情况而定,实验室检测仅作为参考实验室检测仅作为参考 u 一般而言,抗纤溶治疗不作为首选一般而言,抗纤溶治疗不作为首选ThanksThediagnosisandtreatmentofDICremainextremelycontroversial!
收藏
编号:48597396
类型:共享资源
大小:155.03MB
格式:ZIP
上传时间:2022-01-12
30
积分
- 关 键 词:
-
内科学
培训
课件
PPT
- 资源描述:
-
内科学-培训课件PPT,内科学,培训,课件,PPT
展开阅读全文
- 温馨提示:
1: 本站所有资源如无特殊说明,都需要本地电脑安装OFFICE2007和PDF阅读器。图纸软件为CAD,CAXA,PROE,UG,SolidWorks等.压缩文件请下载最新的WinRAR软件解压。
2: 本站的文档不包含任何第三方提供的附件图纸等,如果需要附件,请联系上传者。文件的所有权益归上传用户所有。
3.本站RAR压缩包中若带图纸,网页内容里面会有图纸预览,若没有图纸预览就没有图纸。
4. 未经权益所有人同意不得将文件中的内容挪作商业或盈利用途。
5. 装配图网仅提供信息存储空间,仅对用户上传内容的表现方式做保护处理,对用户上传分享的文档内容本身不做任何修改或编辑,并不能对任何下载内容负责。
6. 下载文件中如有侵权或不适当内容,请与我们联系,我们立即纠正。
7. 本站不保证下载资源的准确性、安全性和完整性, 同时也不承担用户因使用这些下载资源对自己和他人造成任何形式的伤害或损失。
装配图网所有资源均是用户自行上传分享,仅供网友学习交流,未经上传用户书面授权,请勿作他用。