TEG技術與驗科及應用

1、teg 技術與檢驗科技術與檢驗科大綱 凝血原理 teg 分析儀的一般概念 teg 技術的應用普通檢測肝素酶檢測血小板圖檢測 teg質控 teg軟件正常凝血its all about balance 凝血可控的 激活可控的 抑制 血凝塊最后的結果可控的 抑制 出血事件 血栓摘自：血栓與止血試驗診斷的現(xiàn)狀與發(fā)展；摘自：血栓與止血試驗診斷的現(xiàn)狀與發(fā)展；301醫(yī)院；從玉隆等，醫(yī)院；從玉隆等，2002，9；中華檢驗醫(yī)學雜志；中華檢驗醫(yī)學雜志 目前對凝血檢測的認識目前對凝血檢測的認識interactive凝血的組成:virchows 三角外傷外傷“暴露暴露”初始的凝血酶反應初始的凝血酶反應 膠原vwfvv

2、vvvv監(jiān)測凝血步驟血塊強度血塊強度初始的凝血tf血流表面血流表面第二階段凝血第三階段凝血凝血監(jiān)測相互關系出血血栓藥理學藥理學感染炎癥感染炎癥機械原因機械原因病理性疾病病理性疾病目前對凝血的各種學說 級聯(lián)反應學說 細胞學基礎模式學說 6系統(tǒng)模式學說凝血反應模式級聯(lián)反應模式初始凝血初始凝血第二階段第二階段凝血凝血第三階段第三階段凝血凝血監(jiān)測: 級聯(lián)反應模式pt 和 aptt 凝血因子的功能 血漿基礎 凝血時間 初始的纖維蛋白形成 7.5%epl 15%n/aci功能紊亂4-8 min47- 741-4 min55-73 mm-3.0 3.00-8%0-15%teg 技術參數解析凝血時間凝血時間r

3、是反應從凝血系統(tǒng)啟動直到纖維蛋白凝塊形成之間的一段潛伏期。血塊動力血塊動力k評估血凝塊強度達到某20 mm時的時間，主要反應纖維蛋白原的功能和水平。alpha評估纖維蛋白塊形成及相互聯(lián)結（凝塊加固）的速度，反應纖維蛋白原功能。血塊強度血塊強度ma即最大幅度，直接反映纖維蛋白與血小板通過ga+/xiiia相互聯(lián)結的最強的動力學特性，代表纖維蛋白凝塊的最終強度主要反應血小板功能gma 轉化而來，反應血塊的重力 dynes/cm2.g = 5000*ma/(100-ma)凝血總體凝血總體ci綜合凝血指數, r, k, alpha, ma結合推算出。ci=0.2454r+0.0184k+0.1655m

4、a-0.0241a-0.0220 ）血塊穩(wěn)定性血塊穩(wěn)定性ly30epl ma出現(xiàn)后30分鐘內血塊消融的比例%。ma出現(xiàn)后預計的血塊消融的%。teg 診斷示意圖(kaolin)us patent 6,787,363低凝低凝高凝高凝纖溶亢進纖溶亢進從從a至至o步驟的參考文獻步驟的參考文獻a: 1,2,3,5,6,7,8,9,13,14b: 1,2,3,5,6,7,8,9,11,13,14c: 1,11,12,15,18,19,21d: 1,2,3,5,6,7,8,9,11,13,26e: 1,2,3,5,6,7,8,9,11,13,14,26f: 1,2,3,5,6,7,11,13g: 1,2,3

5、,5,6,7,8,9,11,12,13,26,27h: 1,2,3,5,6,11,13i: 1,2,3,4,5,6,7,8,9,14,26j: 1,2,3,4,5,14k: 1,10,11,12,15,19l:10,11,15,16,17,18,19,20,21,22,23,24,25m:10,11,15,16,17,18,19,20,21,22,23,24,28n: 10,11,15,17,18,19,20,o:10,11,16,17,18,19,20,21,22,23,24,25 從從a至至o步驟的參考文獻步驟的參考文獻 1. 1.mallett sv, cox ja. thrombela

6、stograph? analysis. mallett sv, cox ja. thrombelastograph? analysis. british journal of anaesthesia.british journal of anaesthesia. 1992,69:307-313. 1992,69:307-313.2.2.kang yg, gasior ta. blood coagulation during liver, kidney, pancreas, and lung transplantation. kang yg, gasior ta. blood coagulati

7、on during liver, kidney, pancreas, and lung transplantation. perioperative transfusion perioperative transfusion medicinemedicine. 1998. 1998.3. 3.kang y. thrombelastograph? analysis in liver transplantation. kang y. thrombelastograph? analysis in liver transplantation. seminars in thrombosis and he

8、mostasis.seminars in thrombosis and hemostasis. 1995. v21 supplement 1995. v21 supplement .kang yg, lewis jh, navalgund a, russell mw, bontempo fa, niren ls, starzl te. epsilon-aminocaproic acid for treatment of kang yg, lewis jh, navalgund a, russell mw, bontempo fa, niren ls, starzl te. eps

9、ilon-aminocaproic acid for treatment of fibrinolysis during liver transplantation. fibrinolysis during liver transplantation. anesthesiology.anesthesiology. 1987:66(6):766-773. 1987:66(6):766-773.5. 5.kang yg, martin dj, marquez j, et al. intraoperative changes in blood coagulation and thrombelastog

10、raph monitoring in liver kang yg, martin dj, marquez j, et al. intraoperative changes in blood coagulation and thrombelastograph monitoring in liver transplantation. transplantation. anesthesia and analgesiaanesthesia and analgesia. 1985. 64(9):888-896. 1985. 64(9):888-896.6. 6.kang yg, monitoring a

11、nd treatment of coagulation. kang yg, monitoring and treatment of coagulation. hepatic transplantation.hepatic transplantation. 1986. 151-173. 1986. 151-173.7. 7.von kier s, smith a. hemostatic product transfusions and adverse outcomes: focus on point-of-care testing to reduce von kier s, smith a. h

12、emostatic 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.transfusion need. j cardiothorac vasc anesth 2000;14(3 suppl 1):1521.8. 8.shore-lesserson l, manspeizer he, deperio m, et al. thromboelas

13、tography-guided transfusion algorithm reduces transfusions in shore-lesserson l, manspeizer he, deperio m, et al. thromboelastography-guided transfusion algorithm reduces transfusions in complex cardiac surgery. anesth analg, 1999,88:312-plex cardiac surgery. anesth analg, 1999,88:312-319.9. 9.spies

14、s bd. perioperative coagulation monitoring. spiess bd. perioperative coagulation monitoring. perioperative transfusion medicineperioperative transfusion medicine. 1998. 1998.10.10. gibbs nm, crawford gpm, michalopoulos n. thrombelastograph patterns following abdominal aortic surgery. gibbs nm, crawf

15、ord gpm, michalopoulos n. thrombelastograph patterns following abdominal aortic surgery. anaesth. anaesth. intens care.intens care. 1994:22: 534-538. 1994:22: 534-538.11.11. spiess bd, ivankovich ad. thrombelastograph? analysis: a coagulation-monitoring technique applied to cardiopulmonary spiess bd

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17、ma, sk. philip, j; whitten, cw. md; padakandla, ub. md; landers, df. assessment of changes in coagulation in parturients sharma, sk. philip, j; whitten, cw. md; padakandla, ub. md; landers, df. assessment of changes in coagulation in parturients with preeclampsia using thromboelastography. clinical

18、investigations anesthesiology. 90(2):385-390, february 1999.with preeclampsia using thromboelastography. clinical investigations anesthesiology. 90(2):385-390, february 1999.13.13. sharma s.k.; vera r.l.; stegall w.c.; whitten c.w. management of a postpartum coagulopathy using thrombelastography. sh

19、arma s.k.; vera r.l.; stegall w.c.; whitten c.w. management of a postpartum coagulopathy using thrombelastography. journal of clinical anesthesia, volume 9, number 3, may 1997, pp. 243-247journal of clinical anesthesia, volume 9, number 3, may 1997, pp. 243-247從從a至至o步驟的參考文獻步驟的參考文獻 14.14. whitta rks,

20、 cox dja, mallett sv. thrombelastograph? analysis reveals two causes of haemorrhage in hellp syndrome. whitta rks, cox dja, mallett sv. thrombelastograph? analysis reveals two causes of haemorrhage in hellp syndrome. british journal of anaesthesia.british journal of anaesthesia. 1995:74:464-468 1995

21、:74:464-46815.15. caprini ja, arcelus ji, laubach m, et al. postoperative hypercoagulability and deep-vein thrombosis after laparoscopic caprini ja, arcelus ji, laubach m, et al. postoperative hypercoagulability and deep-vein thrombosis after laparoscopic cholecystectomy. cholecystectomy. surgical e

22、ndoscopy.surgical endoscopy. (1995) 9: 304-309. (1995) 9: 304-309.16.16. r. rai, e. tuddenham, l. regan. pre-pregnancy thrombophilic abnormalities are associated with subsequent spontaneous abortion r. rai, e. tuddenham, l. regan. pre-pregnancy thrombophilic abnormalities are associated with subsequ

23、ent spontaneous abortion hum reprod.1999. 15: 168-169hum reprod.1999. 15: 168-16917.17. tuman kj, spiess b, mccarthy r, ivankovich ad. effects of progressive blood loss on coagulation as measured by tuman kj, spiess b, mccarthy r, ivankovich ad. effects of progressive blood loss on coagulation as me

24、asured by thrombelastograph? analysis. thrombelastograph? analysis. anesth analog.anesth analog. 1987:66:856-63. 1987:66:856-63.18.18. caprini ja, zuckerman l, cohen e. vagher jp, lipp v. the identification of accelerated coagulability. caprini ja, zuckerman l, cohen e. vagher jp, lipp v. the identi

25、fication of accelerated coagulability. thrombosis research.thrombosis research. 1976:9:167-180.1976:9:167-180.19.19. h. w. grant g. p. hadleyprediction of neonatal sepsis by thromboelastography. pediatr surg int. 1997:12:289-292.h. w. grant g. p. hadleyprediction of neonatal sepsis by thromboelastog

26、raphy. pediatr surg int. 1997:12:289-292.20.20. kaufmann cr, dwyer km, crews jd, dols sj, trask al. usefulness of thrombelastograph?analysis in assessment of trauma kaufmann cr, dwyer km, crews jd, dols sj, trask al. usefulness of thrombelastograph?analysis in assessment of trauma patient coagulatio

27、n. patient coagulation. journal of trauma, injury, infection, and critical care.journal of trauma, injury, infection, and critical care. 1997:v42, no4. 1997:v42, no4.21.21. vig s, chitolie a, bevan dh, halliday a, dormandy j. thromboelastography: a simple screen for hypercoagulable states, vig s, ch

28、itolie a, bevan dh, halliday a, dormandy j. thromboelastography: a simple screen for hypercoagulable states, hyperhomocysteinaemia and a predictor of failure following peripheral arterial intervention. abstract presented at the surgical hyperhomocysteinaemia and a predictor of failure following peri

29、pheral arterial intervention. abstract presented at the surgical research meeting, royal free hospital, london, england, december 2, 1999.research meeting, royal free hospital, london, england, december 2, 1999.22.22. ng kf, lo jw. the development of hypercoagulability state, as measured by thrombel

30、astography, associated with intraoperative 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.surgical blood loss. anesth intensive care, 1996, 24:20-25.23.23. ruttman

31、n tg, james mfm, viljoen jf. haemodilution induces a hypercoagulable state. ruttmann tg, james mfm, viljoen jf. haemodilution induces a hypercoagulable state. british journal of anaesthesia.british journal of anaesthesia. 1996:76:412-414.1996:76:412-414.24.24. mardel sn, saunders fm, allen h, meneze

32、s g, edwards cm, ollerenshaw l, baddeley d, et al. reduced quality of clot formation 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. with gelantin-based plasma substitutes. british jou

33、rnal of anaesthesia.british journal of anaesthesia. 1998;80:204-207. 1998;80:204-207.25.25. heather bp, jennings sa, greenhalgh rm. the saline dilution test - a preoperative predictor of dvt. heather bp, jennings sa, greenhalgh rm. the saline dilution test - a preoperative predictor of dvt. br. j. s

34、urg. br. j. surg. 1980;v67:63-65.1980;v67:63-65.從從a至至o步驟的參考文獻步驟的參考文獻26.26. d. royston and s. von kier. reduced haemostatic factor transfusion using heparinase-modified thrombelastography during d. royston and s. von kier. reduced haemostatic factor transfusion using heparinase-modified thrombelastog

35、raphy during cardiopulmonary bypass. br j anaesth 86:575-578, 2001.cardiopulmonary bypass. br j anaesth 86:575-578, 2001.27.27. mongan p, hosking m. the role of desmopressin acetate in patients undergoing coronary artery bypass surgery. mongan p, hosking m. the role of desmopressin acetate in patien

36、ts undergoing coronary artery bypass surgery. anesthesiology.anesthesiology. 1992:77:38-46. 1992:77:38-46.28.28. ng kfj, lam cck, chan lc. in vivo effect of haemodilution with saline on coagulation: a randomized trial. br j anaesth 2002; ng kfj, lam cck, chan lc. in vivo effect of haemodilution with

37、 saline on coagulation: a randomized trial. br j anaesth 2002; 88: 47580.88: 47580.29.29. colman rw et al. haemostasis and thrombosis, basic principles and clinical . neoplasia 2001; 3: 371384. colman rw et al colman rw et al. haemostasis and thrombosis, basic principles and clinical . neoplasia 200

38、1; 3: 371384. colman rw et al (eds) haemostasis and thrombosis, basic principles and clinical . neoplasia 2001; 3: 371384.(eds) haemostasis and thrombosis, basic principles and clinical . neoplasia 2001; 3: 371384.30.30. lbid, pp. 1534-1538lbid, pp. 1534-153831.31. lbid, pp. 795-804lbid, pp. 795-804

39、32.32. hensley fa, martin de. a. practical approach to cardiac anesthesia, 2. nd. ed. boston: little,. brown and company,2001,451-461.hensley fa, martin de. a. practical approach to cardiac anesthesia, 2. nd. ed. boston: little,. brown and company,2001,451-461.33.33. van der linden, j, et al. aproti

40、nin decreases postoperative bleeding and number of transfusions in patients on clopidogrel 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;112: i276-i280.under

41、going coronary artery bypass graft surgery. circulation 2005;112: i276-i280.7000.7000.teg治療指導teg參數值參數值臨床分析臨床分析建議治療建議治療說明說明r 4 min酶動力型高凝抗凝藥物#低體溫狀態(tài)：如果手術后病人體溫很低，我們建議將病人的一個血樣的測試溫度設置為與病人體溫相同的溫度，另一個血樣的測試溫度設置為37。那么病人凝血狀況的差異可能是由于體溫過低造成的。如果低體溫病人正在出血，但他的凝血狀態(tài)在37是正常的，則意味著當他的體溫回升后，出血就會停止。另一方面，如果血樣在37顯示凝血異常的，而病人在

42、出血，那么我們應該對病人的凝血異常進行治療，直到其血樣在37測量是正常的，因此此時如果低體溫病人仍然持續(xù)出血，原因可能就是體溫過低造成的。#ddavp：ma值介于4654之間時反映有輕微的血小板功能不良，可通過加入高vwf因子、因子水平的血漿，或者通過其他未確定的機理，采用ddavp來提高血小板效力，或加入1u血小板。反之，也可以考慮延遲或忽略治療，等待病人自己的血小板功能恢復。如果teg測試得出了正常的彈力圖，而病人仍在出血：考慮考慮vwf因子疾病因子疾?。簐wf因子缺乏。血凝塊功能是好的，但由于血小板-內皮間的粘附性差，造成血凝塊不能粘附到受損的血管位置。建議采用ddavp（釋放vwf因子

43、）或ffp/冷沉淀（含有vwf因子）?？紤]抗血小板藥物作用考慮抗血小板藥物作用：采用血小板圖檢測抗血小板治療的影響?？紤]機械性出血考慮機械性出血：如果排除了vwf因子缺乏和抗血小板藥物的影響，最后應該考慮是由于手術原因造成出血。復溫和ma的關系：在復溫過程中血樣的ma值比魚精蛋白中和后血樣的ma值低57mm左右。因此在手術的復溫階段中建議采用診斷樹。如果病人沒有接受過肝素治療，則以自然血為基礎評估凝血狀態(tài)。因為我們推薦在模擬條件下運行病人的血樣，因此，在病人血液中不存在肝素時，建議不需用肝素酶杯進行檢測。11min r 14 min凝血因子x 4 ffp or 16 ml/kg1、5、2646

44、mm ma 54 mm血小板功能0.3mcg/kg ddavp27、11#41mm ma 73血小板型高凝抗血小板治療r73酶動力型和血小板型高凝抗血小板治療和抗凝藥物1、11、10、28 45纖維蛋白原水平0.06 u/kg 冷沉淀5ly307.5%, c.i.3.0原發(fā)性纖溶亢進抗纖溶藥物5、1ly307.5%, c.i.3.0繼發(fā)性纖溶亢進抗凝藥物5、1、15ly307.5%, c.i.3.0血栓前狀態(tài)抗凝藥物11、15大綱 凝血原理 teg 分析儀的一般概念 teg 技術的應用普通檢測肝素酶檢測血小板圖檢測 teg質控 teg軟件teg 解析低凝狀態(tài)出血血栓急性出血風險急性出血風險血制

45、品管理血制品管理再探查再探查teg 解析低凝狀態(tài)未成熟的血塊消融未成熟的血塊消融凝血酶產生降低凝血酶產生降低弱的血凝塊弱的血凝塊動力動力/外科原因外科原因血小板粘附降低血小板粘附降低血小板抑制藥血小板抑制藥低凝血因子造成低凝低凝血因子造成低凝可利用的工具clot血滴圖低血小板數量低血小板數量/功能造成低凝功能造成低凝應用舉例患兒：女,4歲7個月,反復出血伴貧血4余年,加重半年.急診：出血伴貧血原因待查,血友病可疑.常規(guī)檢查: 重度小細胞低色素性貧血; 白細胞;中性粒細胞;血紅蛋白; 血小板計數; 肝功;腎功; 凝血四項;凝血因子 (、)活性teg檢測：血小板功能/計數異常血小板功能檢測： 血小

46、板聚集功能測試 血小板膜糖蛋白gpb/a確診：血小板無力癥解放軍總醫(yī)院臨檢科（李健、叢玉隆、鄧新立 ）、小兒內科（楊光） 中華醫(yī)學雜志2006年12月12日第86卷第46期低纖維蛋白原造成低凝低纖維蛋白原造成低凝the teg 分析儀檢測肝素的存在綠色 = kaolin 和肝素酶 (kh)黑色 = 只有kaolin (k)r 值 kh = k 提示沒有肝素存在r 值 kh k 提示有肝素存在肝素檢測的敏感性除了抗fxa活性測試以外.,teg普通測試的敏感性比其他傳統(tǒng)凝血測試對低濃度ufh, lmwh, dpd高.teg肝素酶測試能檢測出極低濃度(0.005 u/ml)的ufh,lmwh,dpd

47、.對于低濃度(0.005-0.05 u/ml)的ufh ,teg肝素酶測試的敏感性比抗fxa活性測試高.tegteg檢測與傳統(tǒng)凝血檢測檢測與傳統(tǒng)凝血檢測(pt,aptt,tt,(pt,aptt,tt,抗抗fxafxa活性測試活性測試) )對對ufh, lmwh, dpdufh, lmwh, dpd監(jiān)測結果的比較監(jiān)測結果的比較 blood coagul fibrinolysis. 2006 mar;17(2):97-104.blood coagul fibrinolysis. 2006 mar;17(2):97-104. coppell ja, thalheimer u, zambruni a,

48、 coppell ja, thalheimer u, zambruni a, ahaemophilia centre and haemostasis unit bliver transplantation and hepatobiliary medicine, royal ahaemophilia centre and haemostasis unit bliver transplantation and hepatobiliary medicine, royal free hospital, uk.free hospital, uk.肝素檢測的敏感性對于殘留肝素的抗凝效果，對于殘留肝素的抗凝

49、效果，actact比比aptt, tegaptt, teg和全血肝素測試的敏感性更低。和全血肝素測試的敏感性更低。heparin detection by the activated coagulation time: a comparison of the heparin detection by the activated coagulation time: a comparison of the sensitivity of coagulation tests and heparin assays.sensitivity of coagulation tests and heparin

50、assays.actact檢測肝素檢測肝素: :凝血測試與肝素測試敏感性的比較凝血測試與肝素測試敏感性的比較 cardiothorac vasc anesth. 1997 feb;11(1):24-8. cardiothorac vasc anesth. 1997 feb;11(1):24-8. murray djmurray dj, , brosnahan wjbrosnahan wj, , department of anesthesia, washington university school of medicine, st. louis, mo 63110, department o

51、f anesthesia, washington university school of medicine, st. louis, mo 63110, usa.usa.肝素檢測的敏感性 teg teg 能及時準確地反映血凝塊的形成、溶解的全過程，對術中的異常出血能在短能及時準確地反映血凝塊的形成、溶解的全過程，對術中的異常出血能在短時間內作定性診斷，尤其是在魚精蛋白綜合肝素不全時，時間內作定性診斷，尤其是在魚精蛋白綜合肝素不全時，teg teg 的的r r 值明顯增加，值明顯增加，其敏感性與特異性明顯優(yōu)于其敏感性與特異性明顯優(yōu)于actact。血栓彈性描記儀的臨床應用初探血栓彈性描記儀的臨床應

52、用初探劉克玄劉克玄 黃文起黃文起 等等. . 中山醫(yī)科大學附屬第一醫(yī)院麻醉科中山醫(yī)科大學附屬第一醫(yī)院麻醉科 現(xiàn)代醫(yī)學儀器與應用現(xiàn)代醫(yī)學儀器與應用20002000年年 1212卷卷 3 3期期 肝素檢測的敏感性雖然術后雖然術后actact恢復到術前水平恢復到術前水平, ,但魚精蛋白難以中和敏感性小分子量肝素但魚精蛋白難以中和敏感性小分子量肝素, ,殘余肝素殘余肝素仍影響術后凝血功能仍影響術后凝血功能, ,不能僅憑不能僅憑actact判斷魚精蛋白中和肝素的滿意程度判斷魚精蛋白中和肝素的滿意程度, ,提示我們提示我們, ,體體外循環(huán)中應選用大分子量肝素抗凝。用肝素酶中和肝素的外循環(huán)中應選用大分子量肝

53、素抗凝。用肝素酶中和肝素的tegteg可反映實際凝血功能可反映實際凝血功能, ,迅速排除肝素影響迅速排除肝素影響, ,也可在體外循環(huán)中進行監(jiān)測也可在體外循環(huán)中進行監(jiān)測, ,及早提供凝血異常的資料及早提供凝血異常的資料, ,指導術指導術后治療。后治療。用血栓彈力圖評價體外循環(huán)中凝血功能的改變用血栓彈力圖評價體外循環(huán)中凝血功能的改變王仕剛、倪虹王仕剛、倪虹 、龔慶成。阜外心血管病醫(yī)院體外循環(huán)科、龔慶成。阜外心血管病醫(yī)院體外循環(huán)科中華胸心血管外科雜志中華胸心血管外科雜志20032003年年1010月第月第1919卷第卷第5 5期期 teg 解析低凝狀態(tài)支持的研究royston d and von k

54、ier s. br j anaesth. 2001; 86:575. reduced hemostatic factor transfusion using heparinase-modified thrombelastography during cardiopulmonary bypass (cpb)在體外循環(huán)手術中用肝素酶檢測減少凝血因子的使用組組對照組對照組(n=30)teg-檢測檢測(n=30)輸血病人105*ffp 冰凍新鮮血漿(units)165*血小板 (units)91*12 hr胸腔引流 (ml)390470prospective, randomly controlled

55、studycardiac surgical patientsp 0.05ctd = chest tube drainageffp = fresh frozen plasmathrombelastography-guided algorithm reduces transfusions in complex cardiac surgery心外科的輸血在teg指導下減少shore-lesserson l, et al. anesth analg. 1999; 88:312-9 隨機對照 心外病人 只針對手術病人p 0.05ctd = chest tube drainageffp = fresh f

56、rozen plasmarbc = red blood cells# 輸血病人輸血病人對照對照(n=53)# 輸血輸血teg-檢測檢測(n=52)rbc紅細胞紅細胞術中1723術后1610總計3122ffp 冰凍新鮮血漿冰凍新鮮血漿術中83術后112*總計164*platelets 血小板血小板術中85術后93總計157*24 hr 胸腔引流胸腔引流(ml)901702teg 圖形正常 為什么病人還在出血？外科原因外科原因? (90% 可能可能)血管內皮相關的問題血管內皮相關的問題?血小板抑制藥的使用血小板抑制藥的使用?changes in transfusion therapy and re

57、-exploration rate after institution of a blood management program in cardiac surgical patients使用血制品管理制度后輸血和再探查的改變再手術的類型totalcabg開心手術監(jiān)測內容常規(guī)檢查 (單位)28/4885.7%16/3554.5%12/1339.0%teg (單位)9/5911.5%*6/4431.4%*03/1482.0%*spiess bd, et al. j cardiothorac vasc anesth. 1995; 9:168.teg 解析高凝狀態(tài)出血血栓急性血栓風險急性血栓風險血栓

58、形成的風險分層血栓形成的風險分層檢測藥物療效檢測藥物療效低纖維溶解活性低纖維溶解活性過多的凝血酶產生過多的凝血酶產生血小板活性亢進血小板活性亢進teg 解析高凝狀態(tài)血小板型高凝血小板型高凝酶動力型高凝酶動力型高凝酶動力和血小板型高凝酶動力和血小板型高凝stratification of thrombotic event using teg ma 用teg ma進行血栓事件分層高 ma 是評估缺血事件最敏感的參數80% 敏感性非心外手術病人 (n=240)mccrath et al. analg anesth 2005; 100:1576pci (n=192)gurbel et al. jacc

59、 2005; 46:1820teg 解析纖溶亢進出血血栓“ “急性急性” 凝血風險凝血風險原發(fā)纖溶和繼發(fā)纖溶的區(qū)別原發(fā)纖溶和繼發(fā)纖溶的區(qū)別teg 解析高纖溶狀態(tài)過多的纖溶酶過多的纖溶酶過多的纖維蛋白形成過多的纖維蛋白形成 tafi 活性不足活性不足tafitafi：凝血酶激活的纖溶抑制物：凝血酶激活的纖溶抑制物 原發(fā)性纖溶亢進原發(fā)性纖溶亢進繼發(fā)性纖溶亢進繼發(fā)性纖溶亢進纖維蛋白溶解原發(fā) vs. 繼發(fā)大綱 凝血原理 teg 分析儀的一般概念 teg 技術的應用普通檢測肝素酶檢測血小板圖檢測 teg質控 teg 軟件plateletmapping血小板圖是什么 檢測高凝的程度和抗血小板治療對血小板功

60、能的抑制效果 以病人的最大血小板功能作為參考點 測定病人血小板相對于參考點被抑制的比例血小板圖的理論基礎 1. 1. tanaka ka, sato n, kelly ab, szlam f, levy jh. monitoring platelet function during tanaka ka, sato n, kelly ab, szlam f, levy jh. monitoring platelet function during cardiopulmonary bypass in the presence of tirofiban. cardiopulmonary bypass