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诊断学_出血与血栓性疾病的实验诊断课件

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诊断 出血 血栓 性疾病 实验 课件
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单击此处编辑母版标题样式 单击此处编辑母版副标题样式 1 长治医学院 郭旭霞 出血与血栓性疾病的实验诊断 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial l 主要内容 l血栓与止血的生理基础 l出血与血栓性疾病常用实验室检查 l血栓与止血实验检查的临床应用 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial l血管壁在止血与抗血栓形成中的作用 l血小板的形态结构与功能 l凝血与止血功能 l纤溶机制 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Vessel wall s function in hemostasis and antithrombosis 血管壁在止血与抗血栓形成中的作用 l止凝血功能 l血管收缩 l促进platelet粘附 聚集 释放 l促进凝血系统激活 l抑制fibrinolysis l抗血栓形成功能 l合成和释放PGI2 No thrombomodulin TM l合成粘多糖类anticoagulant l合成和释放tissue factor pathway inhibitor TFPI l合成和释放 t PA u PA Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Platelet s conformation and function 血小板的形态结构与功能 l Platelet thrombocyte 的生成 l Platelet形态 l Platelet membrane glycoprotein GP 血小板膜糖蛋白 l Platelet的生理功能 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 活化血小板 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 凝血过程 Blood clotting course 血液凝固是血液由液体状态转为凝胶状 态的过程 也简称为凝血 凝血过程基本上是一系列凝血因子有限 水解的过程 凝血过程一旦开始 各个 凝血因子便一个激活另一个 形成一个 瀑布 样的反应链直至血液凝固 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 内源性凝血途径 intrinsic pathway 由 于血液接触异物表面或负电荷物质如心血管 内膜受损或血液抽出置于玻璃管内 只靠血 液本身的各种凝血因子就可完成的血液凝固 过程 外源性凝血途径 extrinsic pathway 依 靠血管外组织释放的组织因子来启动的血液 凝固过程 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 凝血过程的三个阶段 凝血酶原激活物的生成 凝血酶的生成 纤维蛋白的生成 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Intrinsic pathwayExtrinsic pathway 血管损伤 a a PK K PF3 a Ca2 PF3 凝血活酶 可溶性纤维蛋白 不溶性纤维蛋白 Ca2 Ca2 凝血酶 Ca2 a Ca2 a 纤维蛋白原 纤维蛋白单体 a Ca2 Common pathway HMWK 第一阶段 第二阶 段 第三阶段 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 电 镜 下 的 血 凝 块 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial l依赖维生素K的凝血因子 IIII 凝血酶原凝血酶原 参与共同途径的激活参与共同途径的激活 VIIVII 稳定因子稳定因子 参与外源凝血途径的激活 参与外源凝血途径的激活 IXIX 血浆凝血活酶成分血浆凝血活酶成分 PTC PTC 参与内源凝血途径的激活参与内源凝血途径的激活 X X 处于内源 外源及共同途径之间处于内源 外源及共同途径之间 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial PCAPC TM IIa Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 纤维蛋白溶解系统 简称纤溶系统 是 指纤溶酶原经特异性激活物使其转化为纤 溶酶 PL 以PL降解纤维蛋白和其他蛋白 质的过程 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial t PA u PA Kallikrein FIIa Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 纤维蛋白原 非交联纤 维蛋白 交联纤维 蛋白 凝血酶 因子 纤 溶 酶 纤 溶 酶 纤 溶 酶 B 1 42 A 极附属物 A B C H X Y D E片段 B 15 42 A 极附属物 X Y D E 片段 A 碎片 A B C H D 二 聚体 二 聚体 复合物 DD E 复合 DY YD 碎片X Y D E Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 出血和血栓性疾病的实验检查出血和血栓性疾病的实验检查 l临床表现 皮肤及粘膜出血 瘀点 反复出现瘀斑或血肿 l 选择实验检查项目 筛查试验 确诊试验 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 血管收缩 血小板 组织因子 XII因子 血管损伤初期止血二期止血 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 血栓与止血检验仪器 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 血液标本采集 l采血 清晨 空腹 静脉采血 一针见血 l抗凝 106 mmol L枸 橼酸钠抗凝 血液与 抗凝剂为9 1 轻轻 混匀 l运送 室温 20 5 保存 最好立 即送检 时间应不超 过2小时 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial l出血时间 Bleeding time BT l血小板聚集试验 platelet aggregation test PAgT l血小板膜糖蛋白测定 ELISA法 FCM 法等 l血小板自身抗体测定 初期止血缺陷的检验 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 凝血 二期止血 功能检测 l凝血酶原时间 l活化部分凝血活酶时间 l纤维蛋白原定量 l凝血酶时间 l凝血因子检测 l凝血分子标志物检测 凝血时间测定 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 我国卫生部 2000 214文件精神 l停止使用出血时间测定项目的Duke法 但出血 时间测定这一检验项目不废除 若临床怀疑血 管壁或血小板功能异常所致出血性疾病时 可 使用出血时间测定器法检测出血时间 l停止使用凝血时间测定的玻片法和毛细管法 用部分凝血活酶时间 APTT 或全血凝固时间 CT 试管法 测定进行替代 l停止使用一般外科手术前的常规出血时间检测 用活化部分凝血活酶时间 APTT 血浆凝血 酶原时间 PT 和血小板计数 PLT 联合检测取代 如患者临床有出血史可另加出血时间测定器 法进行出血时间检测 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 血浆凝血酶原时间 prothrombin time PT l适应证 外源凝血途径因子异常的筛查 口服香豆素类抗凝药治疗监测 DIC筛查 肝功能检查 维生素K缺乏的监测 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 血浆凝血酶原时间 prothrombin time PT l结果报告形式 PT秒数 大于正常对照3秒以上有临床意义 凝血酶原活动度 prothrombin activity PA PT比值 PTR 被检PT 正常对照PT 国际标准化比值 international Normalized Ratio INR PTRISI WHO等国际权威机构规定 对口服抗凝剂的患者 必须使用INR作为抗凝治疗监护的指标 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 凝血酶原时间测定prothrombin time PT l参考范围 PT 11 14s 3s 有临床意义 PA 80 120 PTR 0 8 1 2 INR 0 8 1 2 l临床意义 PT延长 l先天性凝血因子缺陷 l获得性凝血因子异常 严重肝病 维生素K缺乏症 DIC等 l口服香豆素类抗凝药治疗监测 PT缩短 l血液高凝状态 如DIC早期等 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 活化部分凝血活酶时间 activited partial thrombplastin time APTT l适应证 内源凝血途径因子异常的筛查 异常抗凝物增多的筛查 普通肝素抗凝治疗的监测 vWF 异常的筛查 l参考范围 一般为30 45s 对照血浆10s有意义 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial APTT 测定的临床意义 l临床意义 APTT延长 l因子 的含量严重减少 如血友病 血管性血友病 l严重的因子 缺乏 如严重肝病 l纤溶活性增强 如DIC l血循环中抗凝物增多 类肝素抗凝物 狼疮抗凝物增多 l普通肝素治疗 APTT缩短 l主要见于血栓前状态和血栓性疾病等 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 凝血功能过筛实验凝血功能过筛实验 APTT N PT A APTT N PT A 外源外源 凝血途径缺陷凝血途径缺陷 因子因子VIIVII缺陷症缺陷症 遗传性遗传性 获得性获得性 APTT N PT NAPTT N PT N 正常人 非凝血系疾病正常人 非凝血系疾病 因子因子XIII XIII 缺陷症缺陷症 因子因子XIIIXIII定性试验定性试验 APTT A PT N APTT A PT N 内源内源 凝血途径缺陷凝血途径缺陷 有有出血症状出血症状 因子因子VIII IXVIII IX XIXI缺陷症缺陷症 无无出血症状出血症状 因子因子XII HMWKXII HMWK PK PK 缺陷缺陷 APTT A PT A APTT A PT A 共同共同 途径缺陷途径缺陷 因子因子X V II I X V II I 缺陷症缺陷症 遗传性遗传性 获得性获得性 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 血浆纤维蛋白原定量 Fibrinogen FIB l适应证 纤维蛋白异常的检查 DIC的筛查 血液高凝状态 急性时相反应的筛查 l参考范围 2 00 4 00 g L l临床意义 减低 肝脏疾病 DIC中晚期 原发性纤溶亢进 低 或无纤维蛋白原血症 溶栓治疗等 增高 血栓前状态或血栓性疾病如脑梗塞 心机梗 塞 非特异急性相反应如急性感染 外科手术后 恶性肿瘤 糖尿病等 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 凝血酶时间 Thrombin time TT l适应证 筛查纤维蛋白原异常 抗凝血酶物质 如纤维蛋白 降解产物 肝素或类肝素 l参考范围 16 18s 对照血浆3s以上有临床 意义 lTT延长的临床意义 血浆FDP增高 如DIC 纤维蛋白原 0 75g L或有结构异常 异常高球蛋白血症 如多发性骨髓瘤 巨球蛋白血 症 循环肝素样物质增多 见于严重肝脏 胰腺疾病 肝素治疗 如抗凝治疗 体外循环 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 血液流变学检测 l全血粘度检测 l血浆粘度检测 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 一 出血性疾病中的应用 l出血性疾病的筛查 l BT 血管 血小板的相互作用 l PLT和MPV 血小板数量和体积 l PT FIB 外源凝血途径因子 l APTT 内源凝血因子 抗凝物 vWF l TT 抗凝物 肝素 FDP Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 初期止血异常所致出血性疾病筛查 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 二期止血异常所致出血性疾病筛查 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 出血性疾病的确诊 l血管疾病 vWF定量及功能测定 l血小板疾病 血小板自身抗体测定 骨髓检查 血小板膜糖蛋白 GPIb GPIIb GPIIIa GPIX 测定 血小板释放功能 ATP释放 测定 血小板代谢功能 TXB2 测定 l凝血因子缺陷病 单个凝血因子活性及含量检 测 l抗凝物质增多 肝素测定 因子抑制物 狼疮 抗凝物测定 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 弥漫性血管内凝血的实验诊断 l筛查试验 PLT PT FIB l确诊试验 TT FDP D Dimer 3P PLG 2 AP AT III l分子标志物 凝血酶原片段1 2 F1 2 纤维蛋白肽A FPA 凝血 酶 抗凝血酶 III TAT 复合物 纤溶 酶 抗纤溶酶 PAP 复合物测定 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial DIC诊断标准 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial DIC诊断标准 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 二 血栓性疾病中的应用 l反映血管内皮细胞受损的分子标志物 vWF Thrombomodulin TM l反映血小板活化的分子标志物 活化GPIIb IIIa P Selectin CD62P l反映凝血亢进的分子标志物 F1 2 FPA l反映抗凝物质活化的分子标志物 TAT l反映纤溶亢进的分子标志物 D Dimer PAP l反映血流状态异常的指标 血液粘度 红细胞 变形性等 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial l1 口服抗凝药监测 华法令 香豆素等 PT l2 肝素治疗监测 APTT TT AT III 抗凝血酶III Heparin Xa 抗Xa因子活性测定 适用于低分子量 肝素治疗 l3 溶栓治疗监测 链激酶 尿激酶 蛇毒等 一级监测 PT TT FIB 二级监测 PLG 纤溶酶原 a2 AP a2 抗 纤溶酶 D Dimer D 二聚体 FDP 纤 维蛋白降解产物 三 抗凝及溶栓治疗情况监测三 抗凝及溶栓治疗情况监测 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 如何监测口服抗凝药 lPT 为首选指标 l维持PT在正常对照值的1 5 2 0倍 应用INR值 国际标准化比率 作为监测指标 INR 2 0 3 0 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 不同情况抗凝治疗适宜的INR范围 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肝素治疗监测 lAPTT 普通肝素 5000 10000u 24hr 不测 10000u 24hr APTT延长至正常参考值的1 5 1 7倍 10000u 30000u 24hr APTT延长至正常参考值的1 5 2 5倍 l血浆肝素浓度检测 在APTT为 正常参考值的1 5 2 5倍时 血浆肝素浓度为0 2 0 5u ml时 为肝素治疗的最佳选择 l低分子肝素治疗 抗Xa浓度监测 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial l血栓与止血的生理基础 l血管壁 l血小板 l凝血与抗凝 l纤溶 l血栓与止血的实验室检查 l初期止血缺陷的检验 l凝血与抗凝血功能检测 l血液流变学检测 l纤溶检测 l血栓与止血实验检查的临床 应用 l出血性疾病 lDIC l血栓前状态 l抗凝药监测 小 结 summary l临床常说的一期止血 二期止血指的是什么 l用口服抗凝剂进行抗凝治疗时 首选什么监测 试验 l用肝素进行抗凝治疗时 首选什么监测试验 l为什么接触系统因子缺乏临床上不出现出血现 象 反而表现出不同程度的血栓形成倾向 思考题思考题thinking subjectthinking subject Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 二00六年二月二十七日
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本文标题:诊断学_出血与血栓性疾病的实验诊断课件
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