无肝素抗凝连续性血液净化治疗对脓毒症患者凝血功能的影响

目的 观察无肝素抗凝连续性血液净化治疗对脓毒症患者凝血功能的影响.方法 对27例脓毒症患者行49例次无肝素抗凝连续性血液净化治疗,在治疗前、治疗后及治疗后第3天观察患者急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ评分)及凝血功能相关参数的变化.结果 治疗后凝血酶原时间、活化部分凝血活酶时间均较治疗前延长(P＜0.05),纤维蛋白原下降;连续性血液净化治疗后第3天,APACHEⅡ评分下降,凝血酶原时间、活化部分凝血活酶时间仍延长,与常规治疗组比较差异有统计学意义(P＜0.05).结论 连续性血液净化是治疗严重脓毒症的有效措施之一,能改善患者凝血紊乱状态,其机制可能与多种因素有关.

Abstract：

Objective To evaluate the effect of continuous blood purification(CBP) without anticoagulation on the function of coagulation in the patients with severe sepsis. Methods 49 times CBP without anticoagulation were used in 27 patients with severe sepsis. APACHE Ⅱ score and some parameters of coagulation function in pre-CBP,post-CBP and the 3rd day after CBP were studied and compared. Results TT,APTT were longer in post-CBP and on the 3rd day after CBP than in pre-CBP ( P ＜ 0.05), Fg decreased significantly compared with control group. APACHE Ⅱ after CBP lowered obviously compared with pre-CBP (P＜0.01).Conclusion CBP is one of effective methods for the patients with severe sepsis, and can improve the coagulation function of these patients.     

肝素对急性肺损伤大鼠不同时期凝血功能影响

目的探讨肝素在急性肺损伤／急性呼吸窘迫综合征（acutelunginjur#acuterespiratorydisttesssyndrome,ALI／ARDS）不同时期对凝血功能的影响。方法将30只清洁级雄性SD大鼠随机分成5组,每组6只,空白组（A组）＋造模组（B组）＋0h肝素治疗组（C组）＋2h肝素治疗组（D组）＋4h肝素治疗组（E组）,肺损伤大鼠用尾静脉注射油酸0．2mL／kg联合4h后内毒素（LPS）（4mg／mL）5mg／kg腹腔注射,6h后处死动物并采血行凝血功能检测。结果C组及D组镜下病理表现较B组及E组：肺泡腔内炎性细胞渗出较少,出血较少。血浆纤维蛋白原（fibrinogen,FIB）各组间显著差异有统计学意义（P〈0．01）,B组和E组FIB显著下降,与A组比较差异有统计学意义（P〈0．05）。C组与D组FIB与A组比较无明显下降,差异无统计学意义。A组、C组以及D组与B组比较有显著的差异,差异有统计学意义（P〈0．05）,B组及E组与A组比较有显著差异,差异有统计学意义（P〈0．05）。结论较早使用肝素治疗对于改善FIB消耗有作用,可以减少肺组织炎症渗出,减轻肺组织充血。     

Management of acquired hemophilia A: Review of current evidence

Acquired hemophilia A (AHA) is a rare acquired bleeding disorder caused by autoantibodies against autologous factor VIII (FVIII). It is a disease that most commonly affects the elderly, but it has been described in children and during the post-partum period. It is idiopathic in 50% of cases and is associated with autoimmune disease, malignancy, pregnancy, infection or certain medications in the other 50%. The diagnosis should be suspected in patients with an isolated prolonged aPPT without previous personal or familial bleeding history. Treating the bleeding and eradication of the inhibitor is the mainstay of treatment. The first line of treatment for acute bleeding is the use of bypassing agents. The most commonly used method for eradicating the inhibitor is immunosuppression, namely corticosteroids alone or in combination with cyclophosphamide. This review summarises current knowledge and reviews management options and guidelines.     

Cardiac tamponade in a patient with moderate hemophilia A and factor VIII Inhibitors

Cardiac tamponade is a rare, life-threatening complication of hemophilia. The management of pericardial bleeding in hemophilia A patients with inhibitors is particularly challenging because antibodies to factor (F) VIII render the use of high-dose FVIII ineffective. Fortunately, the management of uncontrollable bleeding in patients with hemophilia and inhibitors has improved since the introduction of treatments that bypass the need for FVIII and FIX. A case of hemopericardium complicated by cardiac tamponade occurring one month following an upper respiratory tract infection in a patient with hemophilia and FVIII inhibitors is presented. Management of the present case was based on current guidelines on the use of recombinant FVIIa for acute bleeding in patients with hemophilia and inhibitors. The subsequent development of hemothorax in the present case indicates that a more protracted course of recombinant FVIIa is justified following pericardiocentesis for pericardial bleeding in hemophilia with inhibitors. Alternative approaches to the management of this complication are also reviewed.     

Haemostatic system in inflammatory bowel diseases: new players in gut inflammation

Inflammation and coagulation constantly influence each other and are constantly in balance.Emerging evidence supports this statement in acute inflammatory diseases,such as sepsis,but it also seems to be very important in chronic inflammatory settings,such as inflammatory bowel disease(IBD).Patients with Crohn's disease and ulcerative colitis have an increased risk of thromboembolic events,and several abnormalities concerning coagulation components occur in the endothelial cells of intestinal vessels,where m...     

Expression of tissue factor in pancreatic adenocarcinoma is associated with activation of coagulation

AIM: To study expression of tissue factor (TF) in pancreatic cancer and its role in the development of thromboembolism. METHODS: TF expression was studied in eight human pancreatic carcinoma cell lines by Northern blot and indirect immunofluorescence. Expression of alternatively spliced TF (asTF) was assessed by RT-PCR. In addition, TF expression was determined by immunofluorescence in pancreatic tissues of 19 patients with pancreatic adenocarcinoma (PCa), 9 patients with chronic pancreatitis (CP) and 20 normal controls. Plasma samples (30 PCa-patients, 13 CP-patients and 20 controls) were investigated for soluble TF levels and coagulation activation markers [thrombin-antithrombin III complex (TAT), prothrombin fragment 1 2 (F1 2)]. RESULTS: All pancreatic carcinoma cell lines expressed TF (8/8) and most of them expressed asTF (6/8). TF expression at the protein level did not correlate with the differentiation of the carcinoma cell line. All but two pancreatic cancer tissue samples stained positive for TF (17/19). In all samples of CP weak staining was restricted to pancreatic duct cells, whereas only a few subendothelial cells were positive in 9/20 of normal controls. TF and TAT levels in PCa patients were significantly elevated compared to controls whereas elevated F1 2 levels did not reach statistical significance compared to controls. In CP patients TAT and F1 2 levels proved to be significantly elevated compared to controls, although TAT elevation was less pronounced than in PCa patients. CONCLUSION: We conclude that in addition to the upregulated expression of TF on the cell membrane, soluble TF might contribute to activation of the coagulation system in pancreatic cancer.     

颅脑损伤后早期凝血-纤溶功能异常与进展性颅内出血关系的临床研究

目的研究急性颅脑损伤后早期凝血-纤溶功能的变化与进展性颅内出血（PIH）的关系。方法对498例急性颅脑损伤患者进行前瞻性研究,检测伤后早期血浆凝血酶原时间（PT）、部分凝血活酶时间（APTT）、纤维蛋白原（Fg）、凝血酶时间（TT）、D-二聚体（D-D）及血小板（PLT）的含量改变。同时,通过比较颅脑损伤患者连续头颅CT的表现,确定是否发生PIH。分析凝血-纤溶指标异常者PIH的发生率及PIH与非PIH患者凝血-纤溶指标含量的差异。结果在纳入研究的498例患者中,139人（27.91%）发生PIH。PT、Fg、TT、PLT、D-D异常者PIH的发生率均明显高于其正常者PIH的发生率（P〈0.05）。其中PIH患者在伤后早期血浆PT、D-D含量比非PIH患者明显升高,而血浆Fg含量显著下降（P〈0.05）。结论急性颅脑损伤早期血浆PT、D-D、Fg含量的变化,可作为PIH发生的预测因素,对凝血-纤溶功能异常者,应早期连续复查头颅CT,以使PIH患者能及时得到诊治。     

凝血与纤溶系统水平对围术期产妇弥漫性血管内凝血的诊断价值

目的：研究凝血与纤溶系统水平对围术期产妇弥漫性血管内凝血（DIC）的诊断价值。方法选择2007年10月-2012年10月在我院接受治疗的 DIC 产妇40例（DIC 组）,选取在我院体检正常的健康孕妇40例（健康孕妇组）,同时选取40例健康非孕妇（健康非孕妇组）为研究对象,对三组凝血与纤溶指标进行检测并比较分析。结果健康孕妇组与健康非孕妇组比较显示,PLT、FIB 明显升高,PT、TT、APTT 及 D-D 二聚体水平明显降低,差异有统计学意义（P ＜0．05）;DIC 组与健康孕妇组比较发现,PLT、FIB 明显降低,而 PT、TT 和 APTT 明显延长,D-D 含量明显升高,差异具有统计学意义（P ＜0．05）;DIC 组与健康非孕妇组比较,PLT、FIB 降低,而 PT、APTT 及 D-D 二聚体水平升高,差异有统计学意义（P ＜0．05）。除 APTT 与 PT 之间无关外,DIC 组组内其他的凝血与纤溶指标都具有一定的相互关系（P ＜0．05）。结论凝血与纤溶系统水平对于围术期产妇 DIC 具有重要的诊断意义,APTT、PT 和 TT 水平的升高提示患者凝血功能下降,而 D-D 的升高则说明纤溶的发生。     

神经外科手术应用注射用血凝酶止血的临床效果观察

目的 观察注射用血凝酶在神经外科手术中局部应用的止血效果及对凝血功能的影响.方法 选取我院诊治的60例神经外科手术患者,美国麻醉医师协会（ASA）分级Ⅰ、Ⅱ级,随机分为用药组30例和空白对照组30例.两组术前一天给予注射用血凝酶2U肌肉注射;术前30 min注射用血凝酶2U静脉注射;术后注射用血凝酶2U静脉注射,每天2次,连续用药3d.用药组术中应用注射用血凝酶4U＋生理盐水10 ml局部喷洒.比较两组患者的手术视野清晰度、手术出血量、术中输血量、术后引流量,并检测术前及术后凝血酶原时间（PT）、部分凝血活酶时间（APTT）、纤维蛋白原（FIB）定量、纤维蛋白原降解产物（FDP）、D-二聚体和血小板计数（PLT）,并于术后进行随访.结果 用药组手术视野有效改善率为70.0％ （21/30）,空白对照组手术视野有效改善例数为0,两组比较差异有统计学意义（P＜0.05）;用药组术中手术出血量[（680.00±95.22） ml],少于空白对照组[（790.00±47.00） ml],两组比较差异有统计学意义（P=0.034）;两组患者术后PLT计数与术前相比均明显减少（P＜0.05或P＜0.01）,但两组间相比差异无统计学意（P＞0.05）.术后随访两组患者术后恢复好,无不良事件发生.结论 注射用血凝酶局部喷洒用于神经外科手术可改善手术术野清晰度,减少手术出血量;不会影响患者凝血功能,不会增加血栓形成的危险.