如何處理大出血病人DIC

1、n多發(fā)性性創(chuàng)傷，術(shù)中多發(fā)性性創(chuàng)傷，術(shù)中4000mln血壓幾乎測不出，狂推腎上腺素。血壓幾乎測不出，狂推腎上腺素。n所有創(chuàng)面滲血，無法止血所有創(chuàng)面滲血，無法止血APTT（延長）：血漿加入接觸因子+磷脂+Ca2+3243秒，延長10秒凝血因子Fib凝血酶原肝素或類肝素FDP抗凝活性 PT （延長延長）：）：血漿加入血漿加入組織因子組織因子+Ca2+1113秒，秒，超過對照值超過對照值3秒以上為異常秒以上為異常凝血因子凝血因子FibTT（不變不變）：）：（凝血酶時間）（凝血酶時間）標(biāo)準(zhǔn)化凝血酶標(biāo)準(zhǔn)化凝血酶+血漿血漿16-18s，延長延長3s以上以上肝素或類肝素肝素或類肝素，F(xiàn)ibFDP抗凝活性抗凝活

2、性Clot formation at injury site- A.Bolliger et al. Anesthesiology 2010; 113:120519Clot formation at injury site- B.Bolliger et al. Anesthesiology 2010; 113:120519Clot formation at injury site- C.Bolliger et al. Anesthesiology 2010; 113:120519Clot formation at injury site- D.Bolliger et al. Anesthesio

3、logy 2010; 113:120519Effects of Hemodilution on Coagulation Factors and Blood ComponentsnFibrinogen = 1 g/L, loss of about 150% of circulating blood volumenTthe critical concentrations of enzymatic coagulation factors and platelet count are reached after a loss of 200% of blood volumenAntithrombin 抗

4、凝血酶抗凝血酶 (formerly antithrombin III) activity decreases to below 30% after 1:6 dilution with saline in vitro.nDecreased antithrombin activity prolongs the half-lives of thrombin and activated FX Bolliger D, et al. Br J Anaesth 2009; 102:7939.Jesty J, et al. Arterioscler Thromb Vasc Biol 2005; 25:2463

5、9Bolliger D, I，et al. Br J Anaesth 2010; 104: 31825.Reed RL, 2nd, et al. Ann Surg 1986; 203:40 8Systemic hypoperfusion drive acute coagulopathy - anticoagulationBrohi et al. Current Opinion in Critical Care 2007, 13:680685Systemic hypoperfusion drive acute coagulopathy - HyperfibrinolysisBrohi et al

6、. Current Opinion in Critical Care 2007, 13:680685Bolliger D, I，et al. Br J Anaesth 2010; 104: 31825.Regulation of fibrin polymerization and fibrinolysis within the clotBolliger D, I，et al. Br J Anaesth 2010; 104: 31825.Fibrin Polymerization and FibrinolysisBolliger D, I，et al. Br J Anaesth 2010; 10

7、4: 31825.John R. Hess. Blood and Coagulation Support in Trauma Care. Hematology Am Soc Hematol Educ Program. 2007:187-918.Changes in thrombin-generation kinetics after hypothermia- and acidosis-induced in pigsMartini WZ, et al. J Trauma. 2005;58:10021009; discussion 10091010.nHypothermia primarily i

8、nhibits thrombin generation in the initiation phasenAcidosis severely impairs thrombin generation in the propagation phaseWenjun Zhou Martini. J Trauma. 2009;67: 202209Hypothermia and Acidosis: Fibrinogen AvailabilitynHypothermia inhibits fibrinogen synthesisnAcidosis accelerates fibrinogen degradat

9、ion, leading to a potential deficit in fibrinogen availability. Wenjun Zhou Martini. J Trauma. 2009;67: 202209nInitial Volume Resuscitationncrystalloids and colloidsVolume Resuscitation：crystalloids VS colloidsndilute the coagulation factorsnstabilize systemic circulationVolume Resuscitation：Transfu

10、sion of erythrocytesnimprove oxygen carrying capacitynfacilitate platelet aggregation by releasingadenosine diphosphate under shear flowsJoist JH, et al. Platelet adhesion and aggregation in pulsatile shear flow: Effects of red blood cells. Thromb Res 1998; 92:S4752Fresh Frozen PlasmanFFP contains a

11、ll the components in donor plasmanProcoagulantn anticoagulantnantifibrinolytic factorsn albuminn immunoglobulinsDownes KA, et al. Transfusion 2001; 41:570Brian P. McGlinch. Anesthesia for Trauma & Emergency Surgery. In: John F. Butterworth IV, David C. Mackey, John D. Wasnick. Morgan & Mikha

12、ils Clinical Anesthesiology. 5th ed. New York: McGraw-Hill Education, 2013:87-122.The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital RBC : FFPoverall mortality (%) hemorrhage mortality (%)8:1 6592.52.5:134781.4:11937Borgma

13、n MA et al . J Trauma. 2007 Oct;63(4):805-13. massive transfusion protocols should utilize a 1:1 ratio of plasma to RBCscoagulation productsnplasma, PLT, and cryoprecipitate products significantly increased 30-day survival in trauma patientsShaz BH, et al. Transfusion 2010; 50:493500Evidence-based p

14、ractice guidelines for plasma transfusionnShould plasma transfusion (vs. no plasma) be used in trauma patients requiring massive transfusion?nRecommendation: We suggest that plasma be transfused to trauma patients requiring massive transfusion (quality of evidence = moderate).John D. Roback et al. T

15、RANSFUSION 2010;50:1227-1239. Evidence-based practice guidelines for plasma transfusionnShould a plasma : red blood cell (RBC) transfusion ratio of 1:3 or more (vs. 1:3) be used in trauma patients requiring massive transfusion?nRecommendation: We cannot recommend for or against transfusion of plasma

16、 at a plasma : RBC ratio of 1:3 or more in trauma patients during massive transfusion (quality of evidence = low).John D. Roback et al. TRANSFUSION 2010;50:1227-1239. ncryoprecipitate is rich in fibrinogen, FXIII, von Willebrand factor, and FVIIIn歐洲麻醉學(xué)會的指南推薦Fib1.52g/L就輸注冷沉淀n歐洲的創(chuàng)傷出血管理指南：Fib1g/L，輸注冷沉淀

17、Rolf Rossaint, et al. Management of bleeding following major trauma: an updated European guideline. Critical Care 2010, 14:R52.Sibylle A, et al. Management of severe perioperative bleeding Guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2013; 30:270382.nOne unit (15 ml) o

18、f cryoprecipitate per 10 kg of body weight is estimated to increase plasma fibrinogen by 0.5 g/l in the absence of continuing bleeding.n30 ml/kg FFP is required to raise the plasma fibrinogen level by 1 g/lSolomon C， et al. Br J Anaesth 2010; 104:555 62 Chowdhury P, et al. Br J Haematol 2004; 125: 6

19、9 73Platelet Concentratesnthe administration of platelet concentrates has to be considered if platelet count falls below 50 109/L阿司阿司匹林匹林氯吡格氯吡格雷（波雷（波立維）立維）nCorrection of excessive microvascular bleeding (i.e., coagulopathy) in the presence of a PT greater than 1.5 times normal or INR greater than 2.

20、0, or an aPTT greater than 2 times normaln correction of excessive microvascular bleeding secondary to coagulation factor deficiency in patients transfused with more than one blood volume (approximately 70 ml/kg) and when PT or INR and aPTT can not be obtained in a timely fashionAnesthesiology, V 10

21、5, No 1, Jul 2006nurgent reversal of warfarin therapyncorrection of known coagulation factor deficiencies for which specific concentrates are unavailablenheparin resistance (antithrombin III deficiency) in a patient requiring heparin.Anesthesiology, V 105, No 1, Jul 2006失血量失血量30% 100% 200% 300% 400%

22、 500%術(shù)后術(shù)后APTT延長延長2.41.81.51.61.62.11.6PT延長延長1.51.41.51.72.42.11.8Fib（g/L)11.42.31.51.60.92.2Hb(g/L)827885906888110Plt109795950413044FFP 或冷沉淀RBC冷沉淀冷沉淀 RBC:FFP 【 1:1 】【 2:1 】【】【3:1】血小板血小板目標(biāo)：目標(biāo)：Hb 7g/dLtranexamic acid 負荷量負荷量 1 g 10 min持持續(xù)續(xù)輸注輸注1 g over 8 hCRASH-2 trial collaborators. Lancet 2010; 376:23

23、32 Shakur H, et al. Lancet 2010; 376:2332controlled TXArelative riskall-cause mortality16.0%14.5%0.0035 0.91deaths due to bleeding5.7%4.9%0.0077 0.85without increasing vascular occlusive eventsPier mannuccio mannucci . hemostatic drugs. N Engl J Med. 1998. 339(4): 245-253European guideline: Manageme

24、nt of bleeding following major traumantranexamic acid 10 to 15 mg/kg followed by an infusion of 1 to 5 mg/kg /hRossaint et al. Critical Care 2010, 14:R52蛇毒血凝酶蛇毒血凝酶n類凝血激酶活化類凝血激酶活化因子因子、和和，并刺激血小板，并刺激血小板的的凝集凝集n類類凝血激酶在血凝血激酶在血小板因子小板因子存在存在下，可促使凝血下，可促使凝血酶原變成凝血酶酶原變成凝血酶康佐文， et al. 立止血的酶學(xué)特性及其作用機理.蛇志，2001，13 (1) :5961.腎上腺素升壓腎上腺素升壓nFVIII and von Willebrand factor can be acutely increased release from end