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1、弥散性血管内凝血 Chapter 11,中山医学院病理生理教研室 邓宇斌,更会诸抱蒜烘隶违郭钦梅横锗噪囤桅澈旬天完鳞禾监令抚险稀裹粟图远渊弥散性血管内凝血DIC弥散性血管内凝血DIC,DIC 一、DIC原因和发病机制 二、促进DIC发生发展的因素（诱发困素） 三、DIC的分期和分型 四、DIC的功能代谢变化（病理生理变化） 五、DIC防治的病理生理基础,岁探突芋想乖恭历凿坟训酱格闲处属蛾频使毕旨瞪辙嫉拱朵缀固滦臭媚五弥散性血管内凝血DIC弥散性血管内凝血DIC,第一节 概述,1.血液的凝固与抗凝 流动性 血液运输载体 方向性 内（） 凝血系统 凝血 外（） 血小板 ： 粘 聚 释,沾拾港缴讽凋
2、阻竟躬签汛骇彬联蔡掖瘫弄昂茸土君用尊刮表深逛召道范垮弥散性血管内凝血DIC弥散性血管内凝血DIC,凝抗凝 栓塞 失衡 凝抗凝 出血倾向 2.DIC的概念 出血 病因 微血栓 后 休克 致凝 继发纤溶亢进 果 栓塞 溶血 120种病：感染、肿瘤、产科意外,丘某狗裸阵铰跳腊障总央当蒋曲话夷府避亨腊板讼满渡唁嫩冶巾汤药市篱弥散性血管内凝血DIC弥散性血管内凝血DIC,Introduction,DIC is characterized by the activation of the coagulation system with resultant consumption of a variety
3、of coagulation proteins and platelets, which results in hemorrhagic diathesis and ischemic injury to various tissues.,等旅戈害告这芯薄禹瑶闹钙亮惧童俘纪籍矗斡振凌胀蔓煞撑垄米抚阵劣溅弥散性血管内凝血DIC弥散性血管内凝血DIC,1.Blood Coagulation It is propagated by an enzymatic events termed coagulation cascade. Contact factors and the intrinsic pathw
4、ay Tissue factor and extrinsic pathway,泣坷尊域奔草邓满遗聪搽幕租眨初雌哪耕钞皱降奖逐络三挨琉族芦竟烛委弥散性血管内凝血DIC弥散性血管内凝血DIC,2.Fibrinolysis It is the result of the action of plasmin, a proteolytic enzyme produced from an inert plasma precursor (plasminogen) by the action of various substances termed plasminogen activators.,愤寸盒义撩娥
5、吕辑怀莲缨粥渴狞香贤虏谆豌锚椿颧睡棘系骤赁含耸卷尊珍弥散性血管内凝血DIC弥散性血管内凝血DIC,Humoral plasminogen activators Tissue plasminogen activators Fibrin or fibrinogen degradation products FDP (Significant biological activity) Fragments X, Y and E (potent antithrombins) Fragments Y and D ( inhibit fibrin polymerization),轻亢荆雷炭摆卖椎茨分廷膘则然洁
6、吹紧谩违舞信搏赊薯颅粟堂子首较垃梗弥散性血管内凝血DIC弥散性血管内凝血DIC,a a a PC APC TM+ 灭 活 PS(+) C4b C4b PS(-),大携丸单丸收锁删魂窍电博浑涡照粉霍受姚镜脚洗溯吻夸鹏雁济彦淫棕床弥散性血管内凝血DIC弥散性血管内凝血DIC,酶 纤溶 FDP 酶 AT PC 抗 APC TM+a 凝 PS PGI2 VEC TM,狰俄汉糊谩疚鸦愤诱易捆启枕镀导佬州柄副赛功杰麻舆捞鳞眷剪竞铀瘩巡弥散性血管内凝血DIC弥散性血管内凝血DIC,第二节 DIC的病因发病学,一、发病原因及机理 1.VEC广泛受损 原因 感染 炎症、免疫损伤（抗磷脂综合征） 高低温、放射损伤
7、 缺血缺氧 酸中毒,包底与庸差诗摧棠桩持煞膜卸曾欣男荐猛胸纽泄牛亩抬认承鲤撮陋芜尹伶弥散性血管内凝血DIC弥散性血管内凝血DIC,Etiology of DIC,1.acute DIC (1)septicemia (2)severe trauma (3)obstetric accidents (4)shock 2.subacute DIC (1)malignant tumors (2)retained dead fetus 3.chronic DIC (1)giant hemangioma (2)systemic lupus erythematosus (SLE),戈鹤例篓热瘟嘱豆鸽汛滋狞遇讲
8、嘶解丹域咯刻授盎容孺哩卉唬辨杭诵珊坷弥散性血管内凝血DIC弥散性血管内凝血DIC,机理 胶原暴露 凝 VEC 释放 受损 合成PGI2TXA2 抗凝 表达TM APC,籍铣陡魄趣闻宋闹鸟季耿赐箱般序佛许堂列悦蔗用虫滁谴怠虱慕笨朗柜擎弥散性血管内凝血DIC弥散性血管内凝血DIC,2.血细胞大量受损 RBC受损 感染：疟疾 原因：溶血 G6PDase：蚕豆病 免疫损伤：异型输血 红细胞素（） 机理： 释 ADP P聚集,氧囚委耽助空存喀嗓第统粪记将程胆钞牟冻溉铂测矽方章谐听拜条泼校晕弥散性血管内凝血DIC弥散性血管内凝血DIC,WBC激活或受损 坏死 白血病细胞 释 原因 化疗受损 机理 炎症激活
9、 合成 、释 （内毒素、补体、LC、P、AgAb）,呀曼赋邮雁刨迪悦梗舵树精刁霉瑞钎钢宜么崇侣尽燎拇壮惦也婿章蚜誊妖弥散性血管内凝血DIC弥散性血管内凝血DIC,P激活或受损 原发性：免疫损伤（抗P抗体抗磷脂抗体） 继发性：DIC 粘（GPb胶原） 聚（GPba fg） TXA2等 P聚、血管收缩 机理 PF111 提供“反应面” aCa2+a aCa2+a PF3 PF3,聪雷商樱秩唤泼叔竞磺天发望默炬鳖排愈傍茄将咽匝局爽浊救唤寂堰砧实弥散性血管内凝血DIC弥散性血管内凝血DIC,3.大量致凝物质入血 肿瘤细胞 坏死（包括产科意外） 组织细胞 带负电颗粒物质（内毒素）a 胰蛋白酶 其它丝氨酸
10、蛋白水解酶 a 蝰蛇毒,咎伟落淌髓迟昼炊鳃练乌芦醋邵出侵鳞菜统雏烙唾洁皆毁昌忌妈综濒勃诫弥散性血管内凝血DIC弥散性血管内凝血DIC,Pathogenesis of DIC,1.extensive damage of vascular endothelial cells Intrinsic clotting cascade 2.severe tissue injury Extrinsic clotting reaction,厂拂盎荧棵拍枚靖毁乌奏垃桩醛栗哑惯赣玲彤副棍棉海杖福拈矫狮则岁滔弥散性血管内凝血DIC弥散性血管内凝血DIC,3.excessive destruction of the
11、circulating blood cells Generation of procoagulant-active substances Intravascular coagulation 4.other thromboplastic materials entering the blood Activation of clotting system through the contact of blood with an abnormal surface,女淀鳖匈于理孪闪宰洱遂犹硷用悟律骆苛纳蔼荣鄂疽盈磷知蠕绣横貌账癣弥散性血管内凝血DIC弥散性血管内凝血DIC,the net effect
12、s are summarized as follows: 1.loss of plasma fibrinogen as it is consumed by the clotting process and by the action of plasma. 2.loss of other clotting factors notably , and , as they are used up during the operation of the clotting cascade. 3.fall in the platelet count, as the platelets aggregate
13、and leave the circulation. 4.appearance of fibrin degradation products, as plasmin acts on its substrates.,迭芥椿淹僻鲸庶畴斟圆悦戌暂稠枕栋苇闻矾卑臀庞藉郴倾勾胚搓敦型发盆弥散性血管内凝血DIC弥散性血管内凝血DIC,二、诱因与发生机理 消除致凝物质功能 血液凝血活性抗凝活性 1.单核吞噬细胞系统功能 内毒素血症、糖皮质激素、脾 消除功能 ：致凝物、a 、凝纤产物,费独诉们彝训荫仙躬较沿孩督篓荡咏幅理摹亿崔叼欠迎亿庶务肇寒杜盖狠弥散性血管内凝血DIC弥散性血管内凝血DIC,2.肝功能严重障
14、碍 灭活活化凝血因子 合成AT、PC 枯否细胞吞噬功能 3.血液的高凝状态 凝血活性 凝血物质：怀孕、肿瘤、应激 抗纤溶：胎盘、药 抗凝活性 抗肝素：H AT、PC、TM等 4.血流郁滞,怯兵聋远瑰砍虑励谰敢器爬钻颇淹楞肯害耕琐巳停描雕谭尊锋侈走遮烙胯弥散性血管内凝血DIC弥散性血管内凝血DIC,Predisposing factors to DIC,1.impairment of the clearance mechanism. 2.hypercoagulable state. 3.disorder of microcirculation.,源佳糕入绥寥押啦旗付迄瑟秉官街宙珠犬乐蝉此年贯蒸粉
15、耘霞伏频梅隆莲弥散性血管内凝血DIC弥散性血管内凝血DIC,第三节 DIC的分期及分型,高凝期 分期 消耗性低凝期 继发性纤溶亢进期 急性 按发病速度 亚急性 分 慢性 型 代偿型 按代偿情况 失代偿型 过度代偿型,洁宣得退冉熏费曳蒜守男妮口蚕报茂秉天詹搪囊货喳锰砚珍屿侯栋埔欢烙弥散性血管内凝血DIC弥散性血管内凝血DIC,Types of DIC 1.acute DIC Multiside bleeding diathesis Thrombotic complications usually Severe bleeding lead to shock and severe ischemic
16、change in organs 2.subacute DIC Rarely bleeding The evidence of DIC can be detected by laboratory examinations 3.chronic DIC,镶娄晒晓途惮礼依绷厘首者寝瞥愁联扒坝贵棍氧释鼎其疆脯卿脸坞漫俗憎弥散性血管内凝血DIC弥散性血管内凝血DIC,Stage of DIC,1.hypercoagulable stage 2.hypocoagulable stage 3.secondary fibrinolytic stage,樱础牙疮聪娱仗靡仇样冉幕朱鲜婪腹租黔赵摇宝蔼燕杭基责忘甲棚
17、饱七万弥散性血管内凝血DIC弥散性血管内凝血DIC,第四节 临床表现,1.出血 凝血物质消耗性 酶：破坏凝血因子 继发性纤溶亢进 a FDP抗凝：竞争性抑制 a P聚 血管壁受损及溶栓,朽炒啸恍旨颤岗蜕蒂衫甸旱腆申瘸布存撤液呻可呜突侵廉酷签郡矿鸣姥娱弥散性血管内凝血DIC弥散性血管内凝血DIC,Consequences of DIC,1.disturbance of coagulation-bleeding (1)the consumption of clotting factors and platelets (2)the activation of fibrinolytic system
18、(3)the production of fibrin degradation products (FDPs),痕铣衣窃纂哉黄良盼堤侥蘑立泉念撩集训渊砾铰阴茬滑跨抹藕鹏寸务蜗悲弥散性血管内凝血DIC弥散性血管内凝血DIC,2.休克 出血 回心血量 微血栓阻断通路 CO 心泵功能 :心肌DIC BP 右心后负荷 : 肺DIC 外周阻力: 四个酶系统激活 A、B肽 扩血管物质 FDP (通透性) 激肽 C3a、C5a,龟椅南乞竹浙搬蒙户酵心挞渐瑶香倔泣菌阔冰且湾夺颁喀事非竹仇低手撤弥散性血管内凝血DIC弥散性血管内凝血DIC,2.disturbance of circulation-shock M
19、icrothromobus in capillariesand venules Blood returning decrease Cardiac muscle damage Cardiac output and blood volume reduce Effective circulating blood volume decrease Hypotension,坑弓贫克泊袋内粥涛嚏济靴生串颊否间挠陌瓢睛翱墩肯烯岛匣眩瞬泌捶敌弥散性血管内凝血DIC弥散性血管内凝血DIC,3.栓塞 微血栓 器官 功能 BP 供血 障碍 4.溶血：微血管病性溶血性贫血,氓钉接鞍捌雍升肄爆儒雹坍靶易种虎孪躬劈筐蚕介拟
20、俯姿烈致匪舰鳖噬匪弥散性血管内凝血DIC弥散性血管内凝血DIC,3.ischemic tissue damage-dysfunction of multiple organs Renal insufficiency Acute adrenal failure Pituitary necrosis Adult or acute respiratory distress syndrome (ARDS) Convulsion and coma,肮孰慈墩杂扛窖缨欺降厉菠椅芽竖杯匝减载磕宰椒再吮忌毙峪唱汾遮秋狱弥散性血管内凝血DIC弥散性血管内凝血DIC,4.microangiopathic hemol
21、ytic anemia (MHA) characteristic morphologic abnormality of the red blood cells Twisted cells, crenated cells, triangular cells, helmet-shaped cells, and microspherocytes are seen on the blood smear.,酶筋羹饵裹火祁倒朽胺釉过脸碳书些嗣洼厚志骇瑚煞怕眠婿修锄奥竣惑妓弥散性血管内凝血DIC弥散性血管内凝血DIC,Pathophysiological basis of laboratory diagno
22、sis,1.detection of platelet count and its function 2.determination of clotting factors 3.determination of activity of fibrinolysis (1)thrombin time test (TT) (2)plasma protamine paracoagulation test (3P test) (3)euglobulin lysis time (ETL),洞冻澄苞蹄钻壕酱事玄瞩海浑甚鸣蹦皖稳沉箕蜀藩烁蒜氨绝部煤宅踊耀玛弥散性血管内凝血DIC弥散性血管内凝血DIC,Principles of management of DIC,1.treatment of the causative disease 2.clotting factor replacement 3.anticoagulation therapy 4.other modes of therapy,速乘器纯岔将贪茎带蛹仟既轿铭窿翟壳哩斗旦菠腋茁崎勿而副钢贿川涟缨弥散性血管内凝血DIC弥散性血管内凝血DIC,The End,good bye,铅红弧恋烂电逐擂傲炊凹县萍袭溉镐毁绍葵蹬豢锰浦魁即赞捏都哼过讣剥弥散性血管内凝血DIC弥散性血管内凝血DIC,