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Zhao Mingyao BMC.ZZU Coagulation-anticoagulation balance & imbalance of haemostatic system Chapter 9
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Section 1 Overview of haemostatic system Thrombin Fibrin Plasmin FDP ?..... Coagulation and blood flowing
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Clot formation (electron microscope)
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TF liver endothelium TM
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Ⅷ、Ⅸ、 Ca 2+ + plt Ⅹ、Ⅴ、 Ca 2+ + plt Complex formation of clotting factors Plt
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1.Prothrombin activator formation 2. Thrombin formation 3.Fibrin formation 3 steps of coagulation
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Section 2 Imbalance in haemostatic system
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Coagulation system Extrinsic system Intrinsic system Anticoagulation system VEC Microcirculation TFPI, PC, PS, AT-III, Heparin Coagulation status Change TF XIIa other factor fibrinolysis balance & imbalance of Coagulation-anticoagulation
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Major types 1.Bleeding disorder: inherited ~ & acquired ~ 2.Thrombogenesis and thrombotic disorders 3.Blood vessel abnormity: VEC, Factors activation 4.Fibrinolytic factors abnormity
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Twinkle Dwivedi‘s body ooze blood through her eyes, feet and even her head everyday von Willebrand factor
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Section 3 Disseminated Intravascular Coagulation (DIC)
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Concept of DIC Acquired blood coagulation disorder = thrombosis + / or bleeding Coagulation is always the initial event
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Part 1 Etiology of ~ Acute ~ : infection ( G- & G+ ) 30% obstetric accident 18% serious trauma 10% malignant tumor 9% Amniotic fluid embolism; abruptio placentae Retained dead fetus Rheumatologic illness
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Part 2 Pathology of DIC Fibrin deposition, thrombosis Bleeding Edema Organ failure
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Part 3 Pathogenesis of DIC 1. Hypercoagulation ? 2. Consumptive hypocoagulayion ? 3. Secondary fibrinolysis ?
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1.TF release into blood and hyperexpression Septicemia Injury Obstetric accident Tumor TF - VIIa Ca 2+ ? ? ? ?
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2. VEC lesion (1) TF (1) TF expression: (2) TFPI↓: Degradation of TM/PC and HS/AT-III system (3) Fibrinolysis inhibited: t-PA ↓, PAI-1↑ (4) Plt adherence and aggregation: Collagen exposure, though NO, PGI 2 and ADP enzyme ↑ (5) XII activation: XII+HMWK+PK(prekallirein) +XI
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I mpaired VEC + Plt Normal VEC
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3.Entrance of procoagulant to blood ① Snake venom ② Metastatic tumor ③ Pathogenic microorganism ④ Foreign particles: amniotic fluid ⑤ Trypsin (proteolytic enzyme)
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4.blood cell damage (1) RBC: TF, ADP (2) WBC: leukemia, endotoxin,, IL-1, TNFa (3) Plt:
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Part 4 Predisposing factors for DIC
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(1)Mononuclear phagocyte system dysfunction GC and particles closing MPS
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巨噬细胞吞噬 Macrophage colibacillus coccus
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iv ET 18 ~ 24 Hr Iv thorium dioxide iv ET General Shwartzman Reaction GSR
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(2) Liver dysfunction Deactivation: IX, X, XI, Replenishing: plasminogen, α 2 -antiplasmin, AT-III, PC Release TF
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(3)Hypercoagulable state Pregnancy : clotting factors ↑, plt ↑, but t-PA, u-PA, AT-III, PC ↓; TF rich in placenta Acidosis: heparin activity↓ CF activity ↑ Plt aggregation ↑
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Activity of TF tissue activity of TF ( u/mg ) Liver 10 muscle 20 Brain 50 lung 50 Placenta 2000
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(4) Microcirculation dysfunction *Blood stagnation *Plt aggregation *Acidosis: VEC damage
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Part 5 Clinical classification of ~ 1.Acute ~ : several hrs ~ 1 or 2 d 2.Subacute ~: some days, malignancies, retained dead fetus 3.Chronic ~ : over months, connective tissue disorder SLE
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Part 6 Typical clinical manifestation of ~ Bleeding Shock MOF(MODS) MHA
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1. Bleeding (1)Consumption of coagulant and plt (2)activation of fibrinolytic system (3) formation of FDP fibrin monomer to polymerize(Im) thrombin (IIa) plts inhibit
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Patient with DIC bleed DIC 出 血(腹 主动脉 瘤术后)
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2.Organ dysfunction Thromboembolism ischemia Ischemia-reperfusion injury Inflammatory reaction out of control in body
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3.Shock Bleeding Coronary thrombosis Vascular dilation Microcirculatory thrombosis
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4. 4. Microangiopathic Hemolytic Anemia Schistocyte > 2% RBC: * mechanic damaged * fragile [' ʃ istəsait
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RBC hang on fibrin rope net ( screen electroscope L 2000 , R 5200 )
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Part 7 P Part 7 Principles of prevention and treatment for DIC 1.Management of the underlying disorder 2.Improving the microcirculation 3.Reconstructing the balance of coagulation and fibrinolysis heparin/AT-III/PC+low mol dextran +dipyridamole+ PC +EACA /or streptokinase, urokinase Epsilon-Aminocaproic Acid (EACA)
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Pathophysiological Basis of DIC diagnosis & Treatment Diagnosis 1.Disease history 2.Clinic manifestation 3.Lab test 3+1
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Lab test 3+1 Screen test (3 items) 1.Plt: <100 000/mm 3 ( 100 000 ~ 300 000) 2.Plasma fibrinogen count: <150 mg% (200~400) 3.PT: prolonged 3 sec (13~15 sec ) Confirm test 3P test 1.D-dimer or “3P ” positive The plasma-protamine-paracoagulation-(3-P-) test
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Coagulation test Ⅻ Ⅺ plt Ⅴ Ca 2+ Ⅹ TF( Ⅲ ) Ⅶ Ca 2+ plt Ⅷ Ⅸ Ⅱ Ⅰ ⅠmⅠm Ca 2+ ⅠmⅠm ⅠmⅠm ⅠmⅠm Ⅹ III I net fibrin plasmin FDP ACT APTT PT
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DIC Score Relates to Mortality Rate in Adults with Severe Sepsis Overt DIC No Overt DIC
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Fbg IIa D-dimer Test XⅢaXⅢa PLn FDP ( D monomer ) A,B,C,X,Y,D,E FDP ( D dimer ) Second fibronolysis A,B,C,X,Y,D,E Fbn FM Primary fibronolysis PLn
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Keep equilibrium anywhere and anytime Zhao Mingyao
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