出血、血栓与止血检测.ppt

血栓与止血检测(LaboratoryDiagnosticsinThrombosisandHemostasis),温州医学院检验医学院胡昕,ContentsandObjectives,BasictheoryofthebloodcoagulationsystemHowtocollectspecimens,storethem,andtransportthemtothelaboratoryDiscussScreeningandDiagnosticTests,Vocabulary1,clot(thrombus)fibrinolyticsystemdisseminatedintravascularcoagulationHenoch-Schnleinpurpura,止血和凝血系统,抗凝和纤溶系统,导言,apathologicalactivationofcoagulationmechanismsthathappensinresponsetoavarietyofdiseasesthemassive,ongoingactivationofcoagulationmayresultindepletionofplateletsandcoagulationfactors,whichmaycausebleeding.atimelyandreliablediagnosis,DisseminatedIntravascularCoagulation(DIC),Case1,thrombinfibrin-fibrinogenplasmin-plasminogenfibrindegradationproductextrinsicandintrinsicpathwaysantithrombinheparin,Vocabulary2,一.止血机制：机体的正常止血，主要依赖于完整的血管壁结构和功能，有效的血小板质量和数量，正常的血浆凝血因子活性及健全的神经体液调节。,第一节基础理论（止血、凝血和纤溶机制）,1.Hemorrhage(Bleeding),2.Hemostasis(WhiteThrombus),3.Coagulation(RedThrombus),BleedingandClotting-1,4.Restoration,5.Hemostasis(WhiteThrombus),6.Restoration,BleedingandClotting-2,二.凝血机制,血液由液体状态变为凝胶状态称为血液凝固，这一过程分为三条途径两个系统。,Thecoagulationcascade,Thecoagulationcascade,(依K因子：因子、）,三.抗凝系统：细胞抗凝作用体液抗凝作用AT-：最主要的生理抗凝活性物质。蛋白C和蛋白S系统。,四.纤溶系统,Vocabulary3,anticoagulantvonWillebranddiseasemyocardialinfarctionhemophiliawarfarinhyperfibrinolysis,contains3.2%(0.109M)sodiumcitrate,calciumionsplasmaisusedfortestingplateletrichplasma(PRP)isusedanticoagulanttherapysuchasheparinorwarfarinnotedonthetestrequestform,SampleCollection,第二节血栓与止血检测,一.血管壁检测,1.毛细血管脆性试验(毛细血管抵抗力试验、束臂试验，CRT，Tourniquettest)主要反映毛细血管结构和功能，也与血小板质和量有关。,TheWHOdefinitionofdenguehaemorrhagicfeverhasbeeninusesince1975;allfourcriteriamustbefulfilled:2.Hemorrhagictendency(positivetourniquettest,spontaneousbruising,bleedingfrommucosa,gingiva,injectionsites,etc.;vomitingblood,orbloodydiarrhea),Denguefever,2TemplateBleedingTime,TBT,二.血小板检测,ThePFA-100Analyzer,血小板功能检测plateletfunctionscreen,常见于一些高凝状态的疾病：心梗、脑梗、静脉血栓形成等。,PLT粘附、聚集功能降低常见于PLT无力症、vWD、骨髓增生性疾病等,三.凝血功能检查,3243s,1113s,MostcommoncausesHeparin(contaminationfromlinesortherapeutic)LupusAnticoagulantOthercausesLiverdisease(siteofproductionformostcoagulationfactors)ConsumptionofcoagulationfactorsasseeninDisseminatedIntravascularCoagulation(DIC)DeficienciesofcoagulationfactorsFVIII(HemophiliaAorVonWillebrandDisease),FIX,FXI,FXII,CausesforProlongedaPTT,CzarNicholasIIofRussiaandhisfamily(photographedc.1916)showinghiswifeAlexandra(whowasacarrierofhemophilia),hisfourdaughters,andhissonAlexis,perhapsthemostfamousEuropeanroyalwithhemophilia.,QueenVictoria,3243s,1113s,InternationalNormalizedRatio(INR)InternationalSensitivityIndex(ISI),ISI为所用凝血活酶试剂利用标准品的凝血活酶进行校正而得出的，致使每个实验室及每批试剂所测的INR具有可比性,CausesforProlongedPT,Deficienciesorabnormalitiesin:FVII(ExtrinsicPathway)FV,FX,FII(prothrombin),andFI(fibrinogen)BothPTandaPTTwillbeprolongedVitaminKantagonistsPTsensitivetoreductionsinthreeoffourvitaminK-dependentWarfarinmedicationmonitorLiverdiseaseSiteforsynthesisofvitaminK-dependentproteinsSiteforclearanceofcoumarins(warfarin)andcoagulationproteins,四、抗凝系统检测,AntithrombinIIIInhibitstheformationofthrombin.,增高：可导致出血，见于先天性凝血因子缺乏，如血友病；后天性凝血因子缺乏，如急性肝炎、肾移植、使用抗凝药物等。减低：可导致血栓形成，见于先天性缺乏和功能异常，如肺梗塞、深部静脉血栓等血栓性疾病；后天性减低，如DIC、慢性肝病、心肌梗塞等。,原发性纤溶primaryfibrinolysis,继发性纤溶secondaryfibrinolysis,1.血浆硫酸鱼精蛋白副凝固试验plasmaprotamineparacogulationtest,3P,2.D-二聚体,3.FDPs,五.纤溶功能检查,卫生部卫医发2000412号文件,一、停止使用出血时间测定项目的Duke法，但出血时间的检验项目不废除。若临床怀疑血管壁异常所致出血性疾病时（如血管性血友病、单纯性紫癜、过敏性紫癜等），可使用出血时间测定器法检测出血时间。二、停止使用凝血时间测定玻片法和毛细血管法，用活化部分凝血活酶时间（aPTT）或全血凝固时间（CT，试管法）测定进行替代。三、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，如临床有出血史时另加出血时间测定器法进行出血时间检测。,第三节检测项目的合理选择和应用,Primaryhemostasis,Secondaryhemostasis,superficialsitessuchastheskinandmucousmembranes,deepsubcutaneoustissues,muscles,joints,orbodycavities,Bleedingtime,Plateletcount,Plateletfunction,PT,aPTT,vWF,?medication,?F:C,?vesselwallstatus,?liver,lupus,?FVII,Reference,/medlineplus/medlineplus.html/unde