TEG技術與檢驗科及應用

大綱正常凝血

It’sallaboutbalance凝血‘可控的’激活‘可控的’抑制血凝塊最后的結果‘可控的’抑制出血事件血栓血栓與出血的形成是多因素、多系統(tǒng)病理生理變化的結果，涉及到血管內皮、血小板、凝血因子、抗凝因子、纖溶系統(tǒng)及血液流變學的變化。這些因素是“對立統(tǒng)一”的。 所謂“對立”，是指它們的功能是相反的，有的促凝、有的抗凝；所謂“統(tǒng)一”，是指諸因素在神經(jīng)和體液的調節(jié)下，達到平衡，保持健康生理狀態(tài)。一旦平衡被打破，或是形成血栓，或是出血不止。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，2002，9；中華檢驗醫(yī)學雜志

目前對凝血檢測的認識Interactive凝血因子血小板血管凝血的組成:

Virchow’s三角纖維蛋白溶解纖維蛋白溶解外傷“暴露”初始的凝血酶反應

膠原vWFVVVVVV監(jiān)測凝血

步驟血塊強度血小板初始的凝血CoagulationTF血管血流表面凝血因子反應第二階段凝血血小板第三階段凝血凝血監(jiān)測

相互關系

出血血栓血管血小板凝血因子纖維溶解藥理學感染炎癥機械原因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)反應模式血管血小板凝血因子纖維溶解初始凝血第二階段凝血第三階段凝血監(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<5%總凝血酶PT/INR:coumadin(華法林)aPTT:肝素凝血連續(xù)反應的一個階段PT:10-12secINR:0.9-1.1aPTT:28-34secAccessed7/29/06INR=internationalnormalizedratio監(jiān)測:級聯(lián)反應模式

常規(guī)檢查血小板計數(shù)初始的凝血正常值:100-300K/ml低:血小板減少癥高:血小板增多癥數(shù)量vs.功能纖維蛋白原水平初始和第二階段凝血正常值:200-400mg/d急性階段的蛋白監(jiān)測:常規(guī)檢查

纖維蛋白溶解(一)纖溶活性的檢測優(yōu)球蛋白溶解時間(euglobulinlysistime,ELT)纖維蛋白平板溶解試驗(lysistestoffibrinplate)組織纖溶酶原激活物(t-PA)測定尿激酶(uk)測定纖溶酶原(PLG)測定(發(fā)色底物法)纖溶酶測定(剛果紅顯色法)(二)纖溶抑制物檢測纖溶酶原激活物抑制物(PAI)測定a2-纖溶抑制物(a2-PI)測定(三)纖維蛋白(原)降解產物(FDP)測定血漿硫酸魚精蛋白副凝試驗(plasmaprotamineparacoagulationtest,3P試驗)FDP乳膠凝集試驗(latexagglutinationtest,LAT)血漿D-二聚體測定監(jiān)測

細胞基礎模式血管血小板凝血因子纖溶初始凝血第二階段凝血第三階段凝血IIa

大綱TEG?分析儀

特點兩個獨立的通道溫度顯示&控制電腦數(shù)據(jù)收集&儲存0.36ml毫升全血試杯感應針電磁場血塊彈性的改變血塊發(fā)展的過程:凝血時間（與PT、PTT類似）血塊硬度的速度血塊最大時的強度血塊穩(wěn)定性(消融)

ＴＥＧ?血栓彈性描記儀

——全血的凝血全過程監(jiān)測分析普通檢測凝血全過程描記：判斷低凝＼高凝＼纖溶亢進肝素酶檢測監(jiān)測肝素作用：普通肝素＼低分子肝素＼類肝素物質血小板圖檢測檢測不同的抗血小板藥物的療效，為個性化抗血小板治療提供科學依據(jù)R凝血時間IIa生成的纖維蛋白形成凝血旁路參數(shù)r凝血狀況凝血成分低凝高凝-R(min)ˉR(min)

K(min)ˉ

a(deg)ˉK(min)-a(deg)ˉMA-MA血塊穩(wěn)定性血塊強度的減弱纖維溶解血塊速率纖維蛋白X-聯(lián)結纖維蛋白

血小板凝血旁路血小板Ka最大血塊強度（血小板–纖維蛋白原)相互作用血小板(~80%)纖維蛋白原(~20%)MA30minLY30EPLLY30>7.5%EPL>15%N/ACI功能紊亂4-8min47°-74°1-4min55-73mm-3.0–3.00-8%0-15%凝血時間R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K評估血凝塊強度達到某20mm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CI綜合凝血指數(shù),R,K,alpha,MA結合推算出。CI=0.2454R+0.0184K+0.1655MA-0.0241a-0.0220）血塊穩(wěn)定性LY30EPLMA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)USPatent6,787,363低凝高凝纖溶亢進從a至o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:1,2,3,5,6,7,8,9,11,12,13,26,27h: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a至o步驟的參考文獻

MallettSV,CoxJA."[Thrombelastograph?Analysis]".BritishJournalofAnaesthesia.1992,69:307-313.KangYG,GasiorTA."BloodCoagulationDuringLiver,Kidney,Pancreas,andLungTransplantation."PerioperativeTransfusionMedicine.1998.KangY."[Thrombelastograph?Analysis]inLiverTransplantation."SeminarsinThrombosisandHemostasis.1995.V21Supplement4.KangYG,LewisJH,NavalgundA,RussellMW,BontempoFA,NirenLS,StarzlTE."Epsilon-aminocaproicAcidforTreatmentofFibrinolysisDuringLiverTransplantation."Anesthesiology.1987:66(6):766-773.KangYG,MartinDJ,MarquezJ,etal."IntraoperativeChangesinBloodCoagulationand[ThrombelastographMonitoringinLiverTransplantation."AnesthesiaandAnalgesia.1985.64(9):888-896.KangYG,"MonitoringandTreatmentofCoagulation."HepaticTransplantation.1986.151-173.VonKierS,SmithA.Hemostaticproducttransfusionsandadverseoutcomes:focusonpoint-of-caretestingtoreducetransfusionneed.JCardiothoracVascAnesth2000;14(3Suppl1):15–21.Shore-LessersonL,ManspeizerHE,DeperioM,etal.Thromboelastography-guidedtransfusionalgorithmreducestransfusionsincomplexcardiacsurgery.AnesthAnalg,1999,88:312-319.SpiessBD."PerioperativeCoagulationMonitoring."PerioperativeTransfusionMedicine.1998.GibbsNM,CrawfordGPM,MichalopoulosN."[ThrombelastographPatternsFollowingAbdominalAorticSurgery."Anaesth.IntensCare.1994:22:534-538.SpiessBD,IvankovichAD."[Thrombelastograph?Analysis]:ACoagulation-MonitoringTechniqueappliedtoCardiopulmonaryBypass."MonographoftheSocietyofCardiovascularAnesthesia.Ed.EllisonandJobes:1988.Sharma,SK.Philip,J;Whitten,CW.MD;Padakandla,UB.MD;Landers,DF.AssessmentofChangesinCoagulationinParturientswithPreeclampsiaUsingThromboelastography.ClinicalInvestigationsAnesthesiology.90(2):385-390,February1999.SharmaS.K.;VeraR.L.;StegallW.C.;WhittenC.W.ManagementofaPostpartumCoagulopathyUsingThrombelastography.JournalofClinicalAnesthesia,Volume9,Number3,May1997,pp.243-247從a至o步驟的參考文獻

WhittaRKS,CoxDJA,MallettSV."[Thrombelastograph?Analysis]revealstwocausesofhaemorrhageinHELLPsyndrome."BritishJournalofAnaesthesia.1995:74:464-468CapriniJA,ArcelusJI,LaubachM,etal."Postoperativehypercoagulabilityanddeep-veinthrombosisafterlaparoscopiccholecystectomy."SurgicalEndoscopy.(1995)9:304-309.R.Rai,E.Tuddenham,L.Regan.Pre-pregnancythrombophilicabnormalitiesareassociatedwithsubsequentspontaneousabortionHUMREPROD.1999.15:168-169TumanKJ,SpiessB,McCarthyR,IvankovichAD."EffectsofProgressiveBloodLossonCoagulationasMeasuredby[Thrombelastograph?Analysis]."AnesthAnalog.1987:66:856-63.CapriniJA,ZuckermanL,CohenE.VagherJP,LippV."TheIdentificationofAcceleratedCoagulability."ThrombosisResearch.1976:9:167-180.H.W.Grant?G.P.HadleyPredictionofneonatalsepsisbythromboelastography.PediatrSurgInt.1997:12:289-292.KaufmannCR,DwyerKM,CrewsJD,DolsSJ,TraskAL."Usefulnessof[Thrombelastograph?Analysis]inAssessmentofTraumaPatientCoagulation."JournalofTrauma,Injury,Infection,andCriticalCare.1997:V42,No4.VigS,ChitolieA,BevanDH,HallidayA,DormandyJ.Thromboelastography:ASimpleScreenforHypercoagulableStates,HyperhomocysteinaemiaandaPredictorofFailureFollowingPeripheralArterialIntervention.AbstractpresentedattheSurgicalResearchMeeting,RoyalFreeHospital,London,England,December2,1999.NgKF,LoJW.Thedevelopmentofhypercoagulabilitystate,asmeasuredbythrombelastography,associatedwithintraoperativesurgicalbloodloss.AnesthIntensiveCare,1996,24:20-25.RuttmannTG,JamesMFM,ViljoenJF."HaemodilutionInducesaHypercoagulableState."BritishJournalofAnaesthesia.1996:76:412-414.MardelSN,SaundersFM,AllenH,MenezesG,EdwardsCM,OllerenshawL,BaddeleyD,etal."Reducedqualityofclotformationwithgelantin-basedplasmasubstitutes."BritishJournalofAnaesthesia.1998;80:204-207.HeatherBP,JenningsSA,GreenhalghRM."Thesalinedilutiontest-apreoperativepredictorofDVT.Br.J.Surg.1980;V67:63-65.從a至o步驟的參考文獻D.RoystonandS.vonKier.Reducedhaemostaticfactortransfusionusingheparinase-modifiedthrombelastographyduringcardiopulmonarybypass.BrJAnaesth86:575-578,2001.MonganP,HoskingM."TheRoleofDesmopressinAcetateinPatientsUndergoingCoronaryArteryBypassSurgery."Anesthesiology.1992:77:38-46.NgKFJ,LamCCK,ChanLC.Invivoeffectofhaemodilutionwithsalineoncoagulation:arandomizedtrial.BrJAnaesth2002;88:475–80.ColmanRWetal.HaemostasisandThrombosis,BasicPrinciplesandClinical...Neoplasia2001;3:371–384.ColmanRWetal(eds)HaemostasisandThrombosis,BasicPrinciplesandClinical...Neoplasia2001;3:371–384.Lbid,pp.1534-1538Lbid,pp.795-804HensleyFA,MartinDE.A.practicalapproachtocardiacanesthesia,2.nd.ed.Boston:Little,.BrownandCompany,2001,451-461.VanderLinden,J,etal.Aprotinindecreasespostoperativebleedingandnumberoftransfusionsinpatientsonclopidogrelundergoingcoronaryarterybypassgraftsurgery.Circulation2005;112:I276-I280.7000…………..TEG治療指導TEG?參數(shù)值臨床分析建議治療說明R<4min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46—54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、Ⅷ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VWF因子疾?。篤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）或FFP/冷沉淀（含有VWF因子）。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：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5—7mm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<14min凝血因子

x2FFPor8ml/kg7、8、26R>14min凝血因子

x4FFPor16ml/kg1、5、2646mm<MA<54mm血小板功能

0.3mcg/kgDDAVP27、11##41mm<MA<45mm血小板功能

x5u血小板8、26MA

≤

40mm血小板功能

X10u血小板5、26、8、1MA>73血小板型高凝抗血小板治療

R<4,MA>73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、28α<45°纖維蛋白原水平

0.06u/kg冷沉淀5LY30≥7.5%,C.I.＜3.0原發(fā)性纖溶亢進抗纖溶藥物5、1LY30≥7.5%,C.I.＞3.0繼發(fā)性纖溶亢進抗凝藥物5、1、15LY30＜7.5%,C.I.＞3.0血栓前狀態(tài)抗凝藥物11、15

大綱TEG?解析

低凝狀態(tài)出血血栓急性出血風險血制品管理再探查TEG?解析

低凝狀態(tài)未成熟的血塊消融凝血酶產生降低弱的血凝塊動力/外科原因血小板粘附降低血小板抑制藥低凝血因子造成低凝可利用的工具

CLOT—血滴圖低血小板數(shù)量/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(shù);肝功;腎功;凝血四項;凝血因子(Ⅱ、Ⅶ、Ⅷ、Ⅸ、Ⅹ、Ⅻ)活性TEG檢測：血小板功能/計數(shù)異常血小板功能檢測：血小板聚集功能測試血小板膜糖蛋白GPⅡb/Ⅲa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TheTEG?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(0.005U/ml)的UFH,LMWH,DPD.對于低濃度(0.005-0.05U/ml)的UFH,TEG肝素酶測試的敏感性比抗FXa活性測試高.《TEG檢測與傳統(tǒng)凝血檢測(PT,aPTT,TT,抗FXa活性測試)對UFH,LMWH,DPD監(jiān)測結果的比較》BloodCoagulFibrinolysis.2006Mar;17(2):97-104.

CoppellJA,ThalheimerU,ZambruniA,aHaemophiliaCentreandHaemostasisUnitbLiverTransplantationandHepatobiliaryMedicine,RoyalFreeHospital,UK.肝素檢測的敏感性對于殘留肝素的抗凝效果，ACT比aPTT,TEG和全血肝素測試的敏感性更低。Heparindetectionbytheactivatedcoagulationtime:acomparisonofthesensitivityofcoagulationtestsandheparinassays.《ACT檢測肝素:凝血測試與肝素測試敏感性的比較》CardiothoracVascAnesth.1997Feb;11(1):24-8.MurrayDJ,BrosnahanWJ,DepartmentofAnesthesia,WashingtonUniversitySchoolofMedicine,St.Louis,MO63110,USA.肝素檢測的敏感性血栓彈性描記儀的臨床應用初探劉克玄黃文起等.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》2000年12卷3期肝素檢測的敏感性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、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》2003年10月第19卷第5期

TEG?解析

低凝狀態(tài)支持的研究RoystonDandvonKierS.BrJAnaesth.2001;86:575.組對照組(n=30)TEG?-檢測(n=30)輸血病人105*FFP冰凍新鮮血漿(units)165*血小板(units)91*12hr胸腔引流(ml)390470Prospective,randomlycontrolledstudyCardiacsurgicalpatientsp<0.05CTD=chesttubedrainageFFP=freshfrozenplasmaThrombelastography-guidedalgorithmreducestransfusionsincomplexcardiacsurgery

心外科的輸血在TEG指導下減少Shore-LessersonL,etal.AnesthAnalg.1999;88:312-9p<0.05CTD=chesttubedrainageFFP=freshfrozenplasmaRBC=redbloodcells#輸血病人對照(n=53)#輸血TEG?-檢測(n=52)RBC紅細胞術中1723術后1610總計3122FFP冰凍新鮮血漿術中83術后112*總計164*Platelets血小板術中85術后93總計157*24hr胸腔引流(ml)901702TEG?圖形正常為什么病人還在出血？外科原因?(90%可能)血管內皮相關的問題?血小板抑制藥的使用?Changesintransfusiontherapyandre-explorationrateafterinstitutionofabloodmanagementprogramincardiacsurgicalpatients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監(jiān)測內容常規(guī)檢查(單位)TEG?(單位)Total28/4885.7%9/5911.5%**CABG16/3554.5%6/4431.4%**開心手術12/1339.0%03/1482.0%**SpiessBD,etal.JCardiothoracVascAnesth.1995;9:168.TEG?解析

高凝狀態(tài)出血血栓急性血栓風險血栓形成的風險分層檢測藥物療效低纖維溶解活性過多的凝血酶產生血小板活性亢進TEG?解析

高凝狀態(tài)血小板型高凝酶動力型高凝酶動力和血小板型高凝StratificationofthromboticeventusingTEG?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(shù)80%敏感性PCI(n=192)Gurbeletal.JACC2005;46:1820TEG?解析

纖溶亢進出血血栓“急性”凝血風險原發(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維蛋白形成TAFI活性不足TAFI：凝血酶激活的纖溶抑制物

原發(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

TanakaKA,SatoN,KellyAB,SzlamF,LevyJH."MonitoringPlateletFunctionduringCardiopulmonaryBypassinthePresenceofTirofiban."AnesthAnalg.2003;96,SCA53.WatersJH,AnthonyDG,GottliebA,SprungJ."BleedinginaPatientReceivingPlateletAggregationInhibitors."AnesthAnalg.2001;93:878-882.StogermullerB,StarkJ,WillschkeH,FelfernigM,HoeraufK,Kozek-LangeneckerSA."TheEffectofHydroxethylStarch200kDonPlateletFunction."AnesthAnalg.2000;91:823-827.NielsenVG,GearyBT,BairdMS."EvaluationoftheContributionofPlateletstoClotStrengthby[Thrombelastograph?Analysis]inRabbits:TheRoleofTissueFactorandCytochalasinD."AnesthAnalg.2000;91:35-39.MousaS,KhuranaS,ForsytheMS."ComparativeInVitroEfficacyofDifferentPlateletGlycoproteinIIb/IIIaAntagonistsonPlatelet-MediatedClotStrengthInducedbyTissueFactorwithUseof[Thrombelastograph?Analysis]."ArteriosclerThrombVascBiol.2000;V20:1162-1167.McCarthyRJ,TumanKJ,ChenB,IvankovichAD."PlateletIntegrinInhibitionwithc7E3EnhancestheCorrelationbetweenPlateletAggregometryand[Thrombelastograph(TEG)MAValues."AnesthAnalg.1998;86;S219.GreilichPE,CarrME,CooleyMV,etal."DoseDependentEffectsofc7E3FabonModified[Thrombelastograph?Analysis

]inHealthyVolunteers."AnesthAnalg.1998;86;S64.McNultySE,SassoP,VesciJ,SchierenH."PlateletConcentrateEffectson[Thrombelastograph?Analysis]."JournalofCardiothoracicandVascularAnesthesia.December1997:V11,No.7,pp828-830.血小板圖的理論基礎HeerdenPVV,GibbsNM,MichalopoulosN."EffectofLowConcentrationsofProstacyclinonPlateletFunctioninvitro."AnesthesiaIntensiveCare.1997;25:343-346.KhuranaS,MattsonJC,WestleyS,O'NeillWW,TimmisGC,SafianRD."MonitoringplateletglycoproteinIIb/IIIa-fibrininteractionwithtissuefactor-activated[Thrombelastograph?analysis]."JLabClinMed1997:V130,No.4,401-411.GreilichPE,AlvingBM,O‘NeillKL,ChangAS,ReidTJ.“AModified[Thrombelastograph

MethodforMonitoringc7E3FabinHeparinizedPatients."AnesthAnalg.1997;84:31-8.KlindworthJT,MacVeighI,ErethMH."ThePlateletActivatedClottingTest(PACT)PredictsPlateletDysfunctionAssociatedWithCardiopulmonaryBypass(CPB)."AnesthAnalg.1996;82;SCA99.PatelR,TumanKJ,PatelRB,McCarthyRJ,IvankovichAD."Comparisonof[Thrombelastograph?Analysis]andPlateletAggregometry."Anesthesiology.Sept.1991:V72,No3A.RoystonD."AprotininPreventsBleedingandHasEffectsonPlateletsandFibrinolysis."JournalofCardiothoracicandVascularAnesthesia.1991:5(6):18-23.GaetanoG,BottecchiaD,VermylenJ."EffectofPlateletsonClotStructuration.A[Thrombelastograph

Study."ThrombosisResearch.1973:V3,425-435.XIIIXIIIa可溶性纖維單體血小板聚集(GPIIb/IIIa+纖維蛋白原)強的血小板-纖維蛋白網(wǎng)纖維蛋白網(wǎng)弱的血小板血塊弱纖維蛋白血塊血小板聚集+纖維蛋白網(wǎng)血塊發(fā)展血小板被激活纖維蛋白原靜止的血小板凝血酶凝血因子/旁路血小板聚集+纖維蛋白網(wǎng)弱纖維蛋白血塊XIIIXIIIa強的血小板-纖維蛋白血塊凝血因子/旁路纖維蛋白原靜止的血小板Kaolin激活的血液樣本MAtotal(MAKH)纖維蛋白網(wǎng)弱纖維蛋白血塊可溶性纖維單體弱的血小板血塊血小板聚集(GPIIb/IIIa+纖維蛋白原)血塊發(fā)展凝血酶血小板被激活凝血酶XIIIXIIIa纖維蛋白網(wǎng)弱的纖維蛋白血塊纖維蛋白原靜止的血小板肝素化的血樣MAfibrin激活劑FXX凝血因子/旁路可溶性纖維單體纖維蛋白網(wǎng)血塊發(fā)展XIIIXIIIa血小板-纖維蛋白血塊肝素化的血樣MAPiActivatorFXXXXXXXXXXXXADPorAAXX凝血因子/旁路纖維蛋白原靜止的血小板凝血酶可溶性纖維單體纖維蛋白網(wǎng)血小板聚集+纖維蛋白網(wǎng)血塊發(fā)展血小板聚集(GPIIb/IIIa+纖維蛋白原)結果結果TEG?分析和血小板抑制對下列血小板抑制劑敏感Aspirin阿司匹林Clopidogrel(Plavix)波立維Dipyridamol(Persantine)潘生丁GPIIb/IIIa抑制劑(ReoPro,Aggrastat,Integrilin)血小板圖的相關研究

血小板圖的相關研究

PlateletMapping?檢測A–激活劑F?ADP–ADP激活劑AA–AA激活劑CKAADPAA抽血針管MATHROMBINMAFIBRINMAADPMAAA肝素化血樣KaolinCaCl2枸櫞酸化血樣PlateletMapping?的血樣準備自然全血+肝素化全血(綠蓋試管)1通道(KH):自然全血+肝素酶杯2,3,4通道:肝素化全血+普通杯枸櫞酸化全血(藍蓋試管)+肝素化全血(綠蓋試管)1通道(KH):枸櫞酸化全血(+CaCl2)+肝素酶杯2,3,4通道:肝素化全血+普通杯肝素化全血(綠蓋試管)1通道(KH):肝素酶試管+肝素酶杯2,3,4通道:普通杯PlateletMapping?計算和結果%抑制率=100–[(MApi-MAf)/(MAt-MAf)]*100%聚集率=[(MApi-MAf)/(MAt-MAf)]*100 =inhibitedplateletaggregation(IPA)備注:MApi=MAADPorMAAAMAf=MAfibrinMAt=MAthrombinorMAKHP1ADPAAKHMA=69.1mm:纖維蛋白原+凝血酶激活的血小板功能MA=10.0mm:纖維蛋白原(沒有血小板功能)MA=69.3mm:纖維蛋白原+ADP激活的血小板功能MA=54.6mm:纖維蛋白原+AA激活的血小板功能ADP:0%抑制率/100%聚集率AA:24.5%抑制率/75.5%聚集率PlateletMapping?:結果血小板圖檢測試劑包含有ADP和AA的全套試劑包，或者ADP或AA獨立檢測的試劑包。敏感性和有效性血小板圖藥物檢測分類AA%抑制率：

Aspirin阿斯匹林ADP%抑制率：Clopidogrel(Plavix)波立維Dipyridamol(Persantine)潘生丁GPIIb/IIIa抑制劑(ReoPro,Aggrastat,Integrilin)PlateletMapping?測試的應用KHADPAAFibrinogen出血風險:可能較低ADPAAFibrinogenKH出血風險:可能較高Inhibition<50%Inhibition>50%PlateletMapping?:預測出血風險PlateletMappingassay

TEGanalysis–氯吡格雷抵抗%Inhibition=8.4%Aggregation=91.6PlateletMappingassay

TEGanalysis–阿司匹林抵抗MATHROMBINMAAAMAFIBRIN%Inhibition=0.0%Aggregation=100加用雙倍劑量血小板圖的相關研究

FADPAAADPinhibition:99.5%

AAinhibition:0.5%KHMA(mm)75.818.318.675.5PlateletMapping?:監(jiān)測抗血小板藥物治療FADPAAADPinhibition:91.1%AAinhibition:67.6%KHMA(mm):73.618.323.236.2PlateletMapping?:監(jiān)測/調節(jié)抗血小板治療為什么需要“參照點”

(基線)?

個性化的抗血小板治療血小板圖的相關研究

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