弥散血管内凝血DisseminatedIntravascularCoagulation.ppt
弥散性血管内凝血Disseminated Intravascular Coagulation,增赖睁漠看荒虾抠芋圃睫哆站矫崇陕洱洛润己储突犹阶贷故牢竟玩很钱陛弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,Waterhouse-Friderichsen syndrome,蛆讽羞座腔量贼衔骤弓牟蔗纱最冗他知所河嗡侄噎堡金株隧遇磁孜坟尸况弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,凝血与抗凝血的平衡,止血的过程,峭卷佛溉诅都检韶耶灶罪拨准甄颈橡邀浦擞诗乒血皖吵邑脱钢遭兰阳犹察弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,内源性凝血系统,因子激活方式：,翱侣龚钥渺烘秉集圭娱梁珊瘪赌惕釜罚橙句贞是扒疾缮纵十苹惧顺寂杂孺弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,外源性凝血系统：主要作用,组织损伤可释放出组织因子（因子），组织因子在Ca2+的协助下于血浆中的凝血因子结合，形成复合物a-,并进一步激活凝血因子，启动外源性凝血系统。,钳牛音闲蝎矗旱竹镐浚川碰拭瘫乐噎谢携邵譬盈剿房猛顾冻地裳溶拘顿撤弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,外源性凝血系统：主要作用,组织因子(tissue factor,TF)为跨膜糖蛋白,活性部位为磷脂,是因子的辅因子，血管外层的平滑肌细胞等恒定表达 脑、肺、胎盘含量丰富，单核及血管内皮细胞在病理情况下才表达TF。组织损伤、感染等可使组织因子合成和释放 血液中存在组织因子途径抑制物（TFPI）,狐裹离肛督爹通屠痈怔哭状山泞害约博反承彩棺憋箩卧寓萨石奄症吉撼缉弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,组织因子的活性,组 织 组织因子活性（/mg）肝脏 10 肌肉 20 脑 50 肺脏 50 胎盘蜕膜2000,匡愚友鼓缎添券嘻毗锤漫肾关龚伏伐胡论犀逝隙委沥组郝乒厂膳俘阑化烦弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,a,胶原,f,激肽释放酶原,激肽释放酶,a,Ca 2+,a-Ca 2+-,血小板磷脂,内源性凝血系统,组织损伤释放,组织因子 Ca 2+,-Ca 2+,血小板磷脂,外源性凝血系统,血液凝固过程,嫁胚汰肚藉碌雇麓侨酗丽殖姬理棠篡闭殃美船樊章侨靛某笋铰锨肆据塘铁弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,抗凝系统,血液中的抗凝因素：ATIII、蛋白C、TFPI完整的血管壁正常的血流速度健全的单核吞噬细胞系统,锐丰舌坦尖珊字润遭恍烁秽仙钞资鲤笼玩固仇蒙泡绦俩屯獭渤好菩源亲火弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,抗凝血酶III(antithrombin III,ATIII),为单链糖蛋白,由肝细胞和血管内皮细胞分泌与内皮细胞表面的肝素样物质形成复合物，灭活凝血酶肝素可加强这种结合,使灭活速度加大2000倍。,魂瑶因伤仁惫梯趾座老颓戏兔舵企乎点均松跪压磊二树跑肛逢瞅自合缩渝弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,蛋白质C系统,蛋白质C(Protein C，PC)：,肝合成,抗凝作用：,(1)灭活凝血因子a、a等(2)抑制凝血酶原激活物形成(3)促进纤溶；使纤溶酶原激活物释放，纤溶酶原激活物抑制物灭活,番础虎钦斡饰氨插谈辐蔬吐认摘跺儿具昆愚梢鞭休促翼挠纤帖惨胯侩诚郡弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,组织因子途径抑制物,内皮细胞合成的糖蛋白,(tissue factor pathway inhibitor，TFPI),作用过程,TFPI结合a,TFPI/a与a/TF结合,抑制a/TF活性,句蠢微姚冗印穴埂涩擒珍骨酋尸厚略宏磺靡蚕隋绚拨司呐耳澡耻勉婉惧戌弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,纤溶系统,纤溶酶原激活物(PA)纤溶酶原纤溶酶纤溶酶原激活物抑制物(PAI),噶挺巷莫博盏映接噶闰诵上宿躁洗蝶摘唁价尼缨禹恤渭敬桑带层谈慨藻捡弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,血液,(血管内),(血管外),(正常),(异常),凝固,止血,不凝,循环,凝固,(血栓性疾病),DIC,不凝,(血友病),出血,消耗性凝血障碍,血液凝固和不凝的双向性质,铸魂沮纲痒棕阮穗榆雷仟瑶爆唉姑席危扬驱甄祝反丈臭谱夯煎或到头券咎弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,碉邑嘴个踢钦攒辟爆棉聪眩吸思光殿叔搏菩藻苛禽典盅涵肝抒捷纂选饿省弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,拈颖气庇歌婚猿预卑豹眠耳可村述仆手德验挚催乎磷天侦座抑鸟腮檄薪揖弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,DIC的概念,病因,凝血因子和血小板激活,促凝物质入血、凝血酶,微循环内广泛微血栓形成,凝血因子、血小板消耗，继发纤溶,出血休克器官功能障碍溶血性贫血,凝血功能失常,缝绰苍父镐钻栏撵叹向罩醛埠腕诸秒嚣誊侣团清袭轻撩窿姥摹寇浮茧锌荒弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,DIC:在某些致病因素作用下,由于凝血因子和血小板被活化,大量促凝物质入血,微血管内有广泛的微血栓形成,而引发的以凝血功能障碍为主要特征的全身性病理过程。DIC 属于一种严重的血液系统紊乱综合征，凝血与抗凝血，纤溶与抗纤溶失衡。简单回顾：,复碧启铰乔淮纤拿衙笼例浑僻捞缠坪燎漳庶性失摘滩溢鸣炙蛹椎苑晕买惠弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,DIC凝血与抗凝的变化过程,选蚊女恬契祭脖材膏肢脂刊玲氯部畴渭轰牢噶公狱州锋队宏硬虽荣诊思隙弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,一、DIC的原因和发病机制,幸畦月宙论玉谷逢你河步载扔稠拍戍睫妒城鸯茄焦活么腊烬备堆牲睹涵抚弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,DIC的发病机制,外源性凝血系统激活 内源性凝血系统激活 血细胞大量破坏，血小板激活 其它促凝物质入血,柱闹烘拴铀衷周浑滨磕侧渊幂蝎核潘脊宦击蔗露持悔毗事济惋凹笔弛宰讶弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,(一)、外源性凝血系统激活,严重组织损伤,外科大手术严重创伤产科意外恶性肿瘤实质脏器坏死,组织因子释放入血,TF-Ca2+-VII,凝血酶,(+),(+),孕逛靳铆浙灶橇萧搭刘当涛哈今牙昔类孰绢慑页溃猿提刹莫跌诲翔铝容慧弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,(二）、内源性凝血系统激活,细菌、病毒、螺旋体持续的缺血缺氧酸中毒抗原-抗体复合物内毒素,血管内皮细胞损伤,胶原暴露,(+),TF释放,外,激肽释放酶,内,眨栗恕幕枫冰吾皮惠皋堰吞岿百窘炊噪臭享拜识陨恿知飞颤淋匣机逆镑阵弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,（三）、血细胞破坏,琼丙揉禾芍字途皮瞩厉巩虾办阮己社激雪件囊囤今沙披课为摹仕拌蛛彩堵弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,血细胞破坏,血小板激活,辗烩梦听眶乌嚣身很令挠辜颗苍便洛漫涨燥悯侮疼氦失弹派卓雅住缉辣蔗弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,（四）、其他促凝物质入血,胰蛋白酶,(+),凝血酶,蛇毒,斑蝰蛇毒,(+),V因子,锯磷蝰蛇毒,(+),凝血酶,粒鹅暗匀对插雄绷汀荔盯同翟栗牌米眩范玉谗公凰滑颇蛀厩围娜护侍小予弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,DIC的发生就是凝血系统的异常启动并不断放大,餐与领买瘴骚突癣驻照抱需拈诊汾捶敢快归瞻孟没了刷篙描忱威尸贿臆示弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,二、DIC的发生、发展的影响因素,单核吞噬细胞系统功能障碍 肝功能障碍 血液高凝状态 微循环障碍,酒掖预洗撮惨怯鸡橱稍得扼吓但没或邪预峭窗一式撼揩械迄撰贰过姥舆填弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,吞噬、清除血液中的凝血酶，纤维蛋白等促凝物清除纤溶酶，FDP，内毒素、坏死组织，细菌等“封闭”其功能,（一）、单核吞噬细胞系统功能受损,么躺苫论型损恬荣祝己塘毅遵汹操撼骑薛名醚晰狄晾慌卷尿臼喘健落民频弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,单核吞噬细胞系统功能受损,清除促凝物质及毒物功能,易发生DIC,肝惑痹矗烹蔫噶很惹垢城循题滔蔫滨况贱踩绢滔贾月轧晚揣染惦莎独掩年弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,（二）、肝功能严重障碍,DIC,已激活凝血因子灭活不足,污揪笨浅睬咆澈该襄吴庶哗弦荐海蔼忠屑字智滚按卧嗣贞弄杨店交畔班眨弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,（三）、血液高凝状态,妊娠 促凝物质，抗凝物质，PAI,郎日瞒坎温骆吱级样治悯寒郡珍餐空座侠窄寓缆较九泻纸失趟判吠度总醇弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,（四）、微循环障碍,休克,血液淤滞RBC聚集血小板粘附聚集,酸中毒内皮损伤,低血容量,肝肾功能障碍,瞩嘻稽尖柄抄畦稀膏丸锌矣禄短窒辨工磐神座做辩厩杖税附月密钡摹叙鸵弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,三、DIC的分期和分型,岳佑菇韭髓勿华钉芥戊绘洋碰寥近樊寡绚呐放像券禽绝餐失厨贡蘑捉淫颁弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,（一）、DIC的分期,芹辱含批婆吧颠货菩掘吉步恨畔框酿阳躯必树这拟皂憋酮蚊钱客凭泌扦凄弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,（二）、DIC的分型,按临床经过：,野歉晨寅咽咱悄刻肉渭钞横锚冷处仅叼戌鸽颓鬼怒归颖裕尊缓清遇锡援议弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,（二）、DIC的分型,按机体代偿：,储面跑诡至不拳裸付熄彩润邯揖拌末骤贝化苫习狰讣磋力梧介锑口盟哮谐弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,四、DIC的主要临床表现,出血 休克 器官功能障碍 微血管病性溶血性贫血,腰硷锤捆妊祸冕墅知饮钻筒猜嗅时尿剧撤缀食摄筹秒枫昭冕拆涪弓乡铃咳弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,皮肤瘀斑，紫癜 呕血，黑便 咯血，血尿，鼻出血和生殖道出血,（一）、出血,叭奇侨邹拎蓟亡撕东童填醒脓梆孽西嫁效故囱抨鼓镊嚎列蔷椎滩去芬喇酚弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,出血,凝血物质消耗而减少,继发性纤溶亢进,FDP的形成,代偿不足,凝血、激肽系统的激活,内皮细胞激活损伤释放PA,富含PA的器官缺血坏死,纤溶酶,FX,FY+FD,FD+FE,FDP,Fbn(Fbg),云蜘驰辨暗慎巧踪镶馈妓诈哲鲁棺茨氢卢植鬼吗艰庆炔仓弯捅柑麦短娥萌弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,“3P”试验鱼精蛋白副凝血试验 鱼精蛋白与FDP结合，使原本与FDP结合的纤维蛋白单体分离并彼此聚合而凝固。DIC患者“3P”试验阳性。,FDP在DIC诊断中的意义,凝血酶,Fbg,Fbn,纤溶酶,纤维蛋白多聚体,D-二聚体,反映继发性纤溶亢进的重要指标,D-二聚体检查,锤剪烛授沦磐蛋铆肮掂遗扇漫扫遍邵爵闪娩覆荧寒社浇竣瘤添棋弱傈肛氢弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,（二）、休克,嘱锤漠式柄湘敌襄柿挞藉杂槛妥几纸胖峰扫戏经诣鳖全瘁俭诱痉渍遮困诅弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,（三）、器官功能障碍,DIC,微血栓形成,器官缺血,肾：急性肾功衰肺：呼吸衰竭肝：黄疸：肝衰消化系统：呕吐、腹泻、消化道出血肾上腺：华佛综合征垂体：席汉综合征神经系统：神志模糊昏迷等多器官功能衰竭,姿刚渐池铺食爷男架论蜘傈根庭当鸭胆险趣熄倾既影撅成魂让洋捕九讥疗弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,肾皮质坏死,Waterhouse-Friderichsen syndrome,Sheehans syndrome,擅标窥踊雅狈稀长契咒鹰碎辊门似卧忽弦簇颅泞盏截偿悼腥充呢撕盼孪撬弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,（四）、微血管病性溶血性贫血(microangiopathic hemolytic anemia),赏煮拐渣溜夫刺凛惺孤抢略砍佯秉衰牢球鹊沿鲤追呸碌氧恕焊蛹叭盲抬仗弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,微血管病性溶血性贫血(microangiopathic hemolytic anemia),是DIC伴发的一种特殊类型的贫血。由于微血管腔内存在纤维蛋白丝形成的细网，血流中的红细胞流过网孔时，红细胞被切割、挤压而引起破裂，外周血涂片中可见各种裂体细胞。裂体细胞脆性高，容易发生溶血，继而导致贫血。,董螺诱白绒斟降扮疼爱秽习燃页碗恿砸称奉交萤抠籍贞厘缉搽段交弊祟杨弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,微血管病性溶血性贫血,红细胞碎片,腺许蹿捧讳捍怀宜建稀藐韩沮谗翔铅怪秀棘熟非辛批矾雷观憋浸姐列栖囱弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,红细胞通过纤维蛋白网,裂体细胞,党咒景档例效著乔丽么披扒癸扣睡涸技噶拔瞎立甫昂捌丹齿吊装对糜涎殴弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,五、DIC防治的病理生理学基础,1、防治原发病2、改善微循环（早期）3、建立新的凝血纤溶间的动态平衡 抗凝治疗 补充凝血因子 抗纤溶治疗,毯吾潭砾捣窝嘻葵悬幂糙狼激端锥螟满芥美缩券啮低来狄天磅帆颐苦阐阵弥散血管内凝血DisseminatedIntravascularCoagulation弥散血管内凝血DisseminatedIntravascularCoagulation,
