如何处理大出血病人dicPPT.pptx

怎么处理大出血病人DIC昆明医科大学第二附属医院麻醉科思永玉CASE多发性性创伤，术中4000ml血压几乎测不出，狂推肾上腺素。所有创面渗血，无法止血CASEAPTT 120 s, PT 120s , Fib 0.6g/L问题：怎么了？A ： DICB： 凝血功能障碍APTT（延长）：血浆加入接触因子+磷脂+Ca2+32—43秒，延长10秒凝血因子↓Fib↓凝血酶原↓肝素或类肝素↑FDP抗凝活性↑ PT （延长）：血浆加入组织因子+Ca2+11—13秒，超过对照值3秒以上为异常凝血因子↓Fib↓Clot formation at injury site- B.Bolliger et al. Anesthesiology 2010; 113:1205–19Clot formation at injury site- C.Bolliger et al. Anesthesiology 2010; 113:1205–19Clot formation at injury site- D.Bolliger et al. Anesthesiology 2010; 113:1205–19为什么产生凝血功能障碍？Effects of Hemodilution on Coagulation Factorscrystalloids, colloids, erythrocytesEffects of Hemodilution on Coagulation FactorsFVIII and von Willebrand factor can be acutely increasedrelease from endothelium by stress hormones, including epinephrine and vasopressinEffects of Hemodilution on Coagulation Factors and Blood ComponentsFibrinogen = 1 g/L, loss of about 150% of circulating blood volumeTthe critical concentrations of enzymatic coagulation factors and platelet count are reached after a loss of 200% of blood volumeEffects of Hemodilution on anticoagulant factorAntithrombin 抗凝血酶 (formerly antithrombin III) activity decreases to below 30% after 1:6 dilution with saline in vitro.Decreased antithrombin activity prolongs the half-lives of thrombin and activated FX Bolliger D, et al. Br J Anaesth 2009; 102:793–9.Jesty J, et al. Arterioscler Thromb Vasc Biol 2005; 25:2463–9Effects of Hemodilution on Coagulation FactorsBolliger D, I，et al. Br J Anaesth 2010; 104: 318–25.Effects of Hemodilution on Plateletplatelet count is often higher than predicted by the extent of dilutionrelease of platelets from the spleen and lungs and from the bone marrow in premature formsReed RL, 2nd, et al. Ann Surg 1986; 203:40 – 8Role of the Activated PlateletSystemic hypoperfusion drive acute coagulopathy - anticoagulationBrohi et al. Current Opinion in Critical Care 2007, 13:680–685Systemic hypoperfusion drive acute coagulopathy - HyperfibrinolysisBrohi et al. Current Opinion in C