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1、TEG 技术与检验科,,大纲,凝血原理 TEG 分析仪的一般概念 TEG 技术的应用 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,血栓与出血的形成是多因素、多系统病理生理变化的结果，涉及到血管内皮、血小板、凝血因子、抗凝因子、纤溶系统及血液流变学的变化。这些因素是“对立统一”的。 所谓“对立”，是指它们的功能是相反的，有的促凝、有的抗凝；所谓“统一”，是指诸因素在神经和体液的调节下，达到平衡，保持健康生理状态。 一旦平衡被打破，或是形成血栓，
2、或是出血不止。,摘自：血栓与止血试验诊断的现状与发展；301医院；从玉隆等，2002，9；中华检验医学杂志,目前对凝血检测的认识,凝血因子,血小板,血管,凝血的组成: Virchows 三角,纤维蛋白溶解,纤维蛋白溶解,外伤,“暴露”,初始的凝血酶反应, ,胶原 vWF,V,V,V,V,V,V,监测凝血 步骤,血块强度,血小板,初始的凝血,TF,血管,血流表面,凝血因子反应,第二阶段凝血,血小板,第三阶段凝血,凝血监测 相互关系,出血,血栓,感染炎症,病理性疾病,目前对凝血的各种学说,级联反应学说 细胞学基础模式学说 6系统模式学说,凝血反应模式 级联反应模式,血管,血小板,凝血因子,纤维溶解
3、,初始凝血,第二阶段凝血,第三阶段凝血,监测: 级联反应模式 PT 和 aPTT,凝血因子的功能 血浆基础 凝血时间 初始的纤维蛋白形成 5% 总凝血酶 PT/INR: coumadin(华法林) aPTT: 肝素 凝血连续反应的一个阶段,PT: 10-12 sec INR: 0.9-1.1,aPTT: 28-34 sec,http:/www.diaglab.vet.cornell.edu/clinpath/modules/coags/coag.htm Accessed 7/29/06,INR = international normalized ratio,监测: 级联反应模式 常规检查,血
4、小板计数 初始的凝血 正常值: 100-300K/ml 低: 血小板减少症 高: 血小板增多症 数量vs. 功能 纤维蛋白原水平 初始和第二阶段凝血 正常值: 200-400 mg/d 急性阶段的蛋白,监测: 常规检查 纤维蛋白溶解,(一)纤溶活性的检测 优球蛋白溶解时间(euglobulin lysis time,ELT) 纤维蛋白平板溶解试验(lysis test of fibrin plate) 组织纤溶酶原激活物(t-PA)测定 尿激酶(uk)测定 纤溶酶原(PLG)测定(发色底物法) 纤溶酶测定(刚果红显色法) (二)纤溶抑制物检测 纤溶酶原激活物抑制物(PAI)测定 a2-纤溶抑制
5、物(a2-PI)测定 (三)纤维蛋白(原)降解产物(FDP)测定 血浆硫酸鱼精蛋白副凝试验(plasma protamine paracoagulation te st,3P试验) FDP乳胶凝集试验(latex agglutination test,LAT) 血浆D-二聚体测定,监测 细胞基础模式,大纲,凝血原理 TEG 分析仪的一般概念 TEG 技术的应用 普通检测 肝素酶检测 血小板图检测 TEG质控 TEG软件,TEG 分析仪 特点,两个独立的通道,温度显示 & 控制,电脑数据收集 & 储存,TEG 技术 原理,TEG 技术 血块形成过程,TEG 技术,血块弹性的改变 血块发展的过程:
6、 凝血时间（与PT、PTT类似） 血块硬度的速度 血块最大时的强度 血块稳定性 (消融),血栓弹性描记仪 全血的凝血全过程监测分析,普通检测 凝血全过程描记：判断 低凝高凝纤溶亢进 肝素酶检测 监测肝素作用：普通肝素低分子肝素类肝素物质 血小板图检测 检测不同的抗血小板药物的疗效，为个性化抗血小板治疗提供科学依据,参数r,凝血状况,凝血成分,低凝,高凝,功能紊乱,4-8 min,47- 74,1-4 min,55-73 mm,-3.0 3.0,0-8%,0-15%,TEG 技术参数解析,TEG 诊断示意图(Kaolin),US Patent 6,787,363,低凝,高凝,纤溶亢进,从a至o步
7、骤的参考文献,a: 1,2,3,5,6,7,8,9,13,14 b: 1,2,3,5,6,7,8,9,11,13,14 c: 1,11,12,15,18,19,21 d: 1,2,3,5,6,7,8,9,11,13,26 e: 1,2,3,5,6,7,8,9,11,13,14,26 f: 1,2,3,5,6,7,11,13 g: 1,2,3,5,6,7,8,9,11,12,13,26,27 h: 1,2,3,5,6,11,13 i: 1,2,3,4,5,6,7,8,9,14,26 j: 1,2,3,4,5,14 k: 1,10,11,12,15,19 l:10,11,15,16,17,18,1
8、9,20,21,22,23,24,25 m:10,11,15,16,17,18,19,20,21,22,23,24,28 n: 10,11,15,17,18,19,20, o:10,11,16,17,18,19,20,21,22,23,24,25,从a至o步骤的参考文献,Mallett SV, Cox JA. “Thrombelastograph? Analysis“. British Journal of Anaesthesia. 1992,69:307-313. Kang YG, Gasior TA. “Blood Coagulation During Liver, Kidney, Pan
9、creas, and Lung Transplantation.“ Perioperative Transfusion Medicine. 1998. Kang Y. “Thrombelastograph? Analysis 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-aminocapro
10、ic Acid for Treatment of 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 Monitoring in Liver Transplantation.“ Anesthesia and Analgesia. 1985. 64(9):888-896. Kang
11、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 need. J Cardiothorac Vasc Anesth 2000;14(3 Suppl 1):1521. Shore-Lesserson L, Manspeiz
12、er HE, Deperio M, et al. Thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. Anesth Analg, 1999,88:312-319. Spiess BD. “Perioperative Coagulation Monitoring.“ Perioperative Transfusion Medicine. 1998. Gibbs NM, Crawford GPM, Michalopoulos N. “Thrombelast
13、ograph Patterns Following Abdominal Aortic Surgery.“ Anaesth. Intens Care. 1994:22: 534-538. Spiess BD, Ivankovich AD. “Thrombelastograph? Analysis: A Coagulation-Monitoring Technique applied to Cardiopulmonary Bypass.“ Monograph of the Society of Cardiovascular Anesthesia. Ed. Ellison and Jobes: 19
14、88. 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, February 1999. Sharma S.K.; Vera R.L.; Stegall W.C.; Whitten C.W. Manag
15、ement of a Postpartum Coagulopathy Using Thrombelastography. Journal of Clinical Anesthesia, Volume 9, Number 3, May 1997, pp. 243-247,从a至o步骤的参考文献,Whitta RKS, Cox DJA, Mallett SV. “Thrombelastograph? Analysis reveals two causes of haemorrhage in HELLP syndrome.“ British Journal of Anaesthesia. 1995:
16、74:464-468 Caprini JA, Arcelus JI, Laubach M, et al. “Postoperative hypercoagulability and deep-vein thrombosis after laparoscopic cholecystectomy.“ Surgical Endoscopy. (1995) 9: 304-309. R. Rai, E. Tuddenham, L. Regan. Pre-pregnancy thrombophilic abnormalities are associated with subsequent spontan
17、eous abortion HUM REPROD.1999. 15: 168-169 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. Caprini JA, Zuckerman L, Cohen E. Vagher JP, Lipp V. “The Identification of Accelera
18、ted Coagulability.“ Thrombosis Research. 1976:9:167-180. 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. “Usefulness of Thrombelastograph?Analysis in Assessment of Trauma Patient Coag
19、ulation.“ Journal of 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, Hyperhomocysteinaemia and a Predictor of Failure Following Peripheral Arterial Intervention. Abstrac
20、t presented at the Surgical 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 surgical blood loss. Anesth Intensive Care, 1996, 24:20-25. Ruttmann TG,
21、James MFM, Viljoen JF. “Haemodilution Induces a Hypercoagulable State.“ British Journal of Anaesthesia. 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 gelantin-based plasma substitutes.“ British Journ
22、al of Anaesthesia. 1998;80:204-207. Heather BP, Jennings SA, Greenhalgh RM. “The saline dilution test - a preoperative predictor of DVT. Br. J. Surg. 1980;V67:63-65.,从a至o步骤的参考文献,D. Royston and S. von Kier. Reduced haemostatic factor transfusion using heparinase-modified thrombelastography during car
23、diopulmonary bypass. Br J Anaesth 86:575-578, 2001. Mongan P, Hosking M. “The Role of Desmopressin Acetate in Patients Undergoing Coronary Artery Bypass Surgery.“ Anesthesiology. 1992:77:38-46. Ng KFJ, Lam CCK, Chan LC. In vivo effect of haemodilution with saline on coagulation: a randomized trial.
24、Br J Anaesth 2002; 88: 47580. 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. Lbid, pp. 1534-1538 Lbid, pp. 795-804 Hensley FA, Martin
25、DE. A. practical approach to cardiac 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 coronary artery bypass graft surgery. Circulation 2005;11
26、2: I276-I280. 7000,TEG治疗指导,大纲,凝血原理 TEG 分析仪的一般概念 TEG 技术的应用 普通检测 肝素酶检测 血小板图检测 TEG质控 TEG软件,TEG 解析 低凝状态,出血,血栓,急性出血风险,血制品管理 再探查,TEG 解析 低凝状态,未成熟的血块消融,凝血酶产生降低,弱的血凝块,动力/外科原因 血小板粘附降低 血小板抑制药,低凝血因子造成低凝,可利用的工具 CLOT血滴图,低血小板数量/功能造成低凝,应用举例,患儿：女,4岁7个月,反复出血伴贫血4余年,加重半年. 急诊：出血伴贫血原因待查,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
27、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） 中华医学杂志2006年12月12日第86卷第46期,低纤维蛋白原造成低凝,The TEG 分析仪,检测肝素的存在,绿色 = kaolin 和肝素酶 (KH) 黑色 = 只有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,除了抗FXa活性测试以外.,TEG普通测试的敏感性比其他
28、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检测与传统凝血检测(PT,aPTT,TT,抗FXa活性测试)对UFH, LMWH, DPD监测结果的比较 Blood Coagul Fibrinolysis. 2006 Mar;17(2):97-104. Coppell JA, Thalheimer U, Zambruni A, aHaemophilia Centre and Haemostasi
29、s Unit bLiver 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，ACT比aPTT, TEG和全血肝素测试的敏感性更低。,Heparin detection by the activated coagulation time: a comparison of the sensitivity of coagulation tests and heparin assays. ACT检测肝素:凝血测试与肝素测试敏感性的比较,Cardiothorac Vasc
30、Anesth. 1997 Feb;11(1):24-8. Murray DJ, Brosnahan WJ, Department of Anesthesia, Washington University School of Medicine, St. Louis, MO 63110, USA.,肝素检测的敏感性,TEG 能及时准确地反映血凝块的形成、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 的R 值明显增加，其敏感性与特异性明显优于ACT。,血栓弹性描记仪的临床应用初探 刘克玄 黄文起 等. 中山医科大学附属第一医院麻醉科, 现代医学仪器与应
31、用2000年 12卷 3期,肝素检测的敏感性,虽然术后ACT恢复到术前水平,但鱼精蛋白难以中和敏感性小分子量肝素,残余肝素仍影响术后凝血功能,不能仅凭ACT判断鱼精蛋白中和肝素的满意程度,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TEG可反映实际凝血功能,迅速排除肝素影响,也可在体外循环中进行监测,及早提供凝血异常的资料,指导术后治疗。,用血栓弹力图评价体外循环中凝血功能的改变 王仕刚、倪虹 、龚庆成。阜外心血管病医院体外循环科中华胸心血管外科杂志2003年10月第19卷第5期,TEG 解析 低凝状态,支持的研究,Royston D and von Kier S. Br J
32、 Anaesth. 2001; 86:575.,Reduced hemostatic factor transfusion using heparinase-modified 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使用,Prospective, randomly controlled study Cardiac surgical patients,p 0.05 CTD = chest tube drainage FFP = fresh frozen plasma,Thrombela
33、stography-guided algorithm reduces transfusions in complex cardiac surgery 心外科的输血在TEG指导下减少,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 0.05 CTD = chest tube drainage FFP = fresh frozen plasma RBC = red blood cells,TEG 图形正常 为什么病人还在出血？,外科原因? (90% 可能) 血管内皮相关的问题? 血小板抑制药的使用
34、?,Changes in transfusion therapy and re-exploration rate after institution of a blood management program in cardiac surgical patients使用血制品管理制度后输血和再探查的改变,Spiess BD, et al. J Cardiothorac Vasc Anesth. 1995; 9:168.,TEG 解析 高凝状态,出血,血栓,急性血栓风险,血栓形成的风险分层 检测药物疗效,低纤维溶解活性,过多的凝血酶产生,血小板活性亢进,TEG 解析 高凝状态,血小板型高凝,酶动
35、力型高凝,酶动力和血小板型高凝,Stratification of thrombotic event using TEG MA 用TEG MA进行血栓事件分层,高 MA 是评估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; 100:1576,PCI (n=192) Gurbel et al. JACC 2005; 46:1820,TEG 解析 纤溶亢进,出血,血栓,“急性” 凝血风险,原发纤溶和继发纤溶的区别,TEG 解析 高纤溶状态,过多的纤溶酶,过多的纤维蛋白形成,TAFI 活性不足,TAFI：凝血酶
36、激活的纤溶抑制物,原发性纤溶亢进,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 分析仪的一般概念 TEG 技术的应用 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,血小板图的理论基础,Tanaka KA, Sato N, Kelly AB, Szlam F, Levy JH. “Monitoring Platelet Function during Cardiopulmonary
37、Bypass in the Presence of Tirofiban.“ Anesth Analg. 2003; 96, SCA 53. Waters JH, Anthony DG, Gottlieb A, Sprung J. “Bleeding in a Patient Receiving Platelet Aggregation Inhibitors.“ Anesth Analg. 2001;93:878-882. Stogermuller B, Stark J, Willschke H, Felfernig M, Hoerauf K, Kozek-Langenecker SA. “Th
38、e Effect of Hydroxethyl Starch 200kD on Platelet Function.“ Anesth Analg. 2000;91:823-827. Nielsen VG, Geary BT, Baird MS. “ Evaluation of the Contribution of Platelets to Clot Strength by Thrombelastograph?Analysis in Rabbits: The Role of Tissue Factor and Cytochalasin D.“ Anesth Analg. 2000;91:35-
39、39. Mousa S, Khurana S, Forsythe MS. “Comparative In Vitro Efficacy of Different Platelet Glycoprotein IIb/IIIa Antagonists on Platelet-Mediated Clot Strength Induced by Tissue Factor with Use of Thrombelastograph?Analysis.“ Arterioscler Thromb Vasc Biol. 2000; V20: 1162-1167. McCarthy RJ, Tuman KJ,
40、 Chen B, Ivankovich AD. “Platelet Integrin Inhibition with c7E3 Enhances the Correlation between Platelet Aggregometry and Thrombelastograph(TEG) MA Values.“ Anesth Analg. 1998;86;S219. Greilich PE, Carr ME, Cooley MV, et al. “Dose Dependent Effects of c7E3 Fab on Modified Thrombelastograph?Analysis
41、 in Healthy Volunteers.“ Anesth Analg. 1998;86;S64. McNulty SE, Sasso P, Vesci J, Schieren H. “Platelet Concentrate Effects on Thrombelastograph?Analysis.“ Journal of Cardiothoracic and Vascular Anesthesia. December 1997:V11, No. 7, pp 828-830.,血小板图的理论基础,Heerden PVV, Gibbs NM, Michalopoulos N. “Effe
42、ct of Low Concentrations of Prostacyclin on Platelet Function in vitro.“ Anesthesia Intensive Care. 1997; 25: 343-346. Khurana S, Mattson JC, Westley S, ONeill WW, Timmis GC, Safian RD. “Monitoring platelet glycoprotein IIb/IIIa-fibrin interaction with tissue factor-activated Thrombelastograph?analy
43、sis.“ J Lab Clin Med 1997:V130, No. 4, 401-411. Greilich PE, Alving BM, ONeill KL, Chang AS, Reid TJ. “A Modified Thrombelastograph Method for Monitoring c7E3 Fab in Heparinized Patients.“ Anesth Analg. 1997;84:31-8. Klindworth JT, MacVeigh I, Ereth MH. “The Platelet Activated Clotting Test (PACT) P
44、redicts Platelet Dysfunction Associated With Cardiopulmonary Bypass (CPB).“ Anesth Analg. 1996;82;SCA99. Patel R, Tuman KJ, Patel RB, McCarthy RJ, Ivankovich AD. “Comparison of Thrombelastograph?Analysis and Platelet Aggregometry.“ Anesthesiology. Sept. 1991:V72, No 3A. Royston D. “Aprotinin Prevent
45、s Bleeding and Has Effects on Platelets and Fibrinolysis.“ Journal of Cardiothoracic and Vascular Anesthesia. 1991:5(6):18-23. Gaetano G, Bottecchia D, Vermylen J. “Effect of Platelets on Clot Structuration. A Thrombelastograph Study.“ Thrombosis Research. 1973:V3, 425-435.,血小板聚集 + 纤维蛋白网,弱纤维蛋白血块,XII
46、I,XIIIa,强的血小板-纤维蛋白血块,凝血因子/ 旁路,纤维蛋白原,静止的血小板,Kaolin 激活的血液样本,MAtotal (MAKH),纤维蛋白网,弱纤维蛋白血块,可溶性纤维 单体,弱的血小板血块,血小板聚集 (GPIIb/IIIa + 纤维蛋白原),血块发展,凝血酶,血小板被激活,凝血酶,XIII,XIIIa,纤维蛋白网,弱的纤维蛋白血块,纤维蛋白原,静止的血小板,肝素化的血样,MAfibrin,激活剂 F,XX,凝血因子/ 旁路,可溶性纤维 单体,纤维蛋白网,血块发展,XIII,XIIIa,血小板-纤维蛋白血块,肝素化的血样,MAPi,Activator F,X,X,ADP or
47、 AA,XX,凝血因子/ 旁路,纤维蛋白原,静止的血小板,凝血酶,可溶性纤维 单体,纤维蛋白网,血小板聚集 + 纤维蛋白网,血块发展,血小板聚集 (GPIIb/IIIa + 纤维蛋白原),结果,结果,TEG 分析和血小板抑制,对下列血小板抑制剂敏感 Aspirin阿司匹林 Clopidogrel (Plavix)波立维 Dipyridamol (Persantine)潘生丁 GPIIb/IIIa 抑制剂 (ReoPro, Aggrastat, Integrilin),血小板图的相关研究,血小板图的相关研究,PlateletMapping 检测,A 激活剂F ADP ADP 激活剂 AA AA
48、激活剂,抽血针管,Kaolin,CaCl2,枸橼酸化血样,PlateletMapping的血样准备,自然全血 + 肝素化全血 (绿盖试管) 1通道(KH): 自然全血 + 肝素酶杯 2, 3, 4通道: 肝素化全血 + 普通杯 枸橼酸化全血 (蓝盖试管) +肝素化全血(绿盖试管) 1通道(KH): 枸橼酸化全血 (+ CaCl2) + 肝素酶杯 2, 3, 4通道:肝素化全血 + 普通杯 肝素化全血 (绿盖试管) 1通道(KH): 肝素酶试管 + 肝素酶杯 2, 3, 4通道: 普通杯,PlateletMapping 计算和结果,% 抑制率 = 100 (MApi-MAf)/(MAt-MAf) * 100 % 聚集率 = (MApi-MAf)/(MAt-MAf) * 100 = inhibited platelet aggregation (IPA) 备注: MApi = MAADP or MAAA MAf= MAfibrin MAt = MAthrombin or MAKH,P1,ADP,AA,KH,MA = 69.1 mm:纤维蛋白原 + 凝血酶激活的血小板功能,MA = 10.0 mm: 纤维蛋白原 (没有血小板功能),MA = 69.3 mm: 纤维蛋白原 + ADP 激活的血小板功能,MA =