弥散性血管内凝血快速实验室诊断指标的价值

目的 对弥散性血管内凝血（DIC）实验室快速诊断指标的敏感性、特异性及其改变的意义进行比较评估，提供理想的检测方案。方法 采用了一般实验室可行的DIC实验室诊断指标如抗凝血酶活性（AT：A，发色底物法）检测、凝血酶原时间（PT）、纤维蛋白原定量（Fbg）、D二聚体（D—D）、鱼精蛋白副凝固试验（3P）、凝血酶凝固时间（TT）等试验。结果 健康正常人77例，临床病例166例，在DIC组AT：A敏感率是91．9％，PT是89．2％，Fbg是86．5％，D—D是82．4％，3P是79．7％，TT是66．2％。结论 目前国内采用的DIC实验室诊断指标快捷实用，并具有一定的特异性和敏感性，但就诊断DIC而言多数存在较高的假阳性与假阴性。     

弥漫性血管内凝血实验诊断的系统评价

目的 评价并比较弥漫性血管内凝血(DIC)常用实验诊断指标的诊断效能。方法 按照纳入排除标准收集关于DIC实验诊断研究的一次文献17篇，利用Cochrane方法学协作组提供的Meta分析软件及Revman软件进行合并分析。结果 可溶性纤维蛋白单体(SFM)、纤维蛋白(原)降解产物(FDP)、D—二聚体(D—D)、凝血酶—抗凝血酶复合物(TAT)、凝血酶原时间(PT)、抗凝血酶活性(AT)、硫酸鱼精蛋白副凝固试验(3P)、部分活化凝血活酶时间(APTT)、血小板计数(PLT)、纤维蛋白原含量(FIB)的综合比数比(OR)分别为34．24、18．20、15．56、8．86、7，89、6．90、4．71、4．66、4．39、2．28。SFM、FDP、D—D、TAT、PT、AT、3P、APTT和FIB的综合ROC曲线下面积(AUC)分别为0．9378、0．9177、0．8793、0．7813、0．7893、0．8529、0．7849、0．7842、0．5553。不同文献报道D—D、3P、AT、FIB、APTT的结果间存在显著异质性，P值分别为0．0003、0．022、0．01、0．0007、0．01。结论 单个实验诊断指标如PLT、FIB、PT和APTT的诊断DIC的价值较低，而SFM、FDP、D—D的价值较高，其次是AT、TAT等。其中FDP的价值在于选择较低水平的界值作为DIC的筛选指标，而D—D的价值主要在于选择较高水平的界值作为DIC的确诊指标。     

弥散性血管内凝血诊断指南

<正>弥散性血管内凝血(disseminated intravascular coagulation,DIC)的诊断应包括临床和实验室资料(C级,水平Ⅳ)。国际血栓与止血委员会(ISTH)的DIC评分系统提供了客观的DIC诊断与治疗标准,该评分系统与临床和预后有关(C级,水平Ⅳ)。     

日本弥散性血管内凝血治疗指南解读

由日本血栓止血学会学术专门委员会弥散性血管内凝血(DIC)部组织撰写的日本DIC治疗指南,按照循证医学(EBM)概念进行系统的文献检索,参考日本血液学会和日本临床血液学会专家的反馈加以修改,论述并点评了DIC的基础疾病治疗、抗凝治疗、纤溶调节治疗和补充治疗,并就其可信度分级推荐.     

分子标物及常规血凝学指标测定在DIC临床诊断中的价值对比分析

目的对比分析常见血凝学指标和几种血栓前状态分子标志物定量测定在DIC诊断中的价值.方法收集了30例正常人和63例DIC患者标本,根据DIC病程分为DIC早期(初发高凝血期)、中期(消耗性凝血障碍期)和晚期(继发性纤溶亢进期),测定了常规血凝学指标,并用ELISA法测定了血栓前状态分子标志物凝血酶原F1+2、凝血酶-抗凝血酶复合物(TAT)、栓溶二聚体(D-dimer,D-D)含量.结果各期DIC患者的部分常规血凝学指标有一定规律;而分子标志物变化不同.早期DIC中,D-D含量为(1.62±1.46)mg/L,NC组为(0.51±0.12)mg/L;F1+2含量为(4.96±2.78)nmol/L,NC组为(0.73±0.42)nmol/L;TAT含量为(33.11±20.59)μg/L,NC组为(1.64±3.04)μg/L;中期DIC中D-D含量为(6.85±8.37)mg/L;F1+2含量为(4.36±2.44)nmol/L,TAT含量为(22.53±20.98)μg/L;晚期DIC中D-D含量为(10.32±5.85)mg/L,F1+2的含量为(6.44±3.51)nmol/L,TAT含量为(36.64±20.09)μg/L.F1+2与TAT在所有DIC患者中有显著性相关(r=0.679,P＜0.0001),而F1+2与D-D、TAT与D-D无相关性.结论综合应用不同的血栓前状态分子标志物的定量测定和常用血凝学指标,不但有助于早期诊断DIC,并且可用于判断DIC的发展情况.     

Pathophysiology, diagnosis and treatment of disseminated intravascular coagulation: an update

Disseminated intravascular coagulation (DIC) is a disorder characterized by an acute generalized, widespread activation of coagulation, which results in thrombotic complications, due to the intravascular formation of fibrin, as well as diffuse hemorrhages, due to the consumption of platelets and coagulation factors. In this review, we briefly report the present knowledge about the pathophysiology and diagnosis of DIC. We also focus on the current standard treatment of overt DIC in clinical practice. Particular attention is given to novel therapeutic strategies, which reflect the important progresses made in the understanding of the pathogenesis of this disorder in the last few years.     

Management of disseminated intravascular coagulation

Disseminated intravascular coagulation (DIC) is a complex condition in which diffuse clotting and profuse hemorrhaging occur simultaneously. It is a serious, often fatal, condition that is estimated to occur in approximately 10% of all patients diagnosed with cancer. No single laboratory test is available that is absolutely diagnostic for DIC; however, several laboratory results, combined with certain clinical findings, will support the diagnosis. Despite the lack of a standardized protocol for clinical management, aggressive medical and nursing care can play a prominent role in the clinical outcome of the patient with DIC.     

急性白血病与弥散性血管内凝血

目的分析急性白血病（AL）患者弥散性血管内凝血（DIC）的发生情况，凝血功能改变及其临床意义。方法对67例AL患者、25例AL完全缓解（CR）患者、20例健康体检者进行凝血常规、D-二聚体等检测。结果根据ISTH修订标准，15例AL患者合并DIC，发生率为22．4％，AML与ALL的DIC发生率AML-M3之间无统计学差异（P〉0．05），AML-M3与non-AML-M3的DIC的发生率之间有统计学差异（P〈0．05）。DIC组PT、APTT、TT较对照组、CR组及non-DIC组均明显延长（P〈0．01），而FIB则降低（P〈0．05）。结论AL尤其AML-M3患者容易合并DIC，观察患者凝血功能改变以及出血表现可有助于尽早发现DIC并指导临床预防及治疗，从而有利于改善AL合并DIC患者的临床预后。     

妊娠期高血压疾病与弥散性血管内凝血

妊娠期高血压疾病是妊娠期特有的疾病，也是产科常见的、严重威胁母儿安全的并发症。我国发病率为9．4％，国外报道为7％-12％。近年来的研究表明，妊娠期高血压疾病的发生与血管内皮细胞损伤及血管细胞因子的合成及障碍有关。其病理基础是全身小动脉痉挛，造成微小血管狭窄，血管壁渗透性增加。血液浓缩。此外，妊娠期高血压疾病患者的凝血因子活性多数增高，凝血功能亢进。上述病理生理变化，形成了妊娠期高血压疾病患者易发生弥散性血管内凝血（disseminated intravascular coagulation，DIC）的病理基础。     

重症感染并发播散性血管内凝血的临床特点与早期诊断探讨

总结180例重症感染患者的临床和实验室资料,发现75%(135例)合并有不同程度的凝血功能紊乱。按凝血试验的异常程度将患者分为4组;3项以上异常者(A组)71例(39.44%),2项异常者(B组)30例(16.67%),单项异常者(C组)34例(18.89%),无凝血异常者(D组)45例(45%),各组病死率及主要合并症(出血、休克、脏器功能衰竭)有显著性差异,病死率及合并脏衰个数与凝血功能异常程度呈正相关。反映凝血功能改变最敏感的指标是血小板数(Plt)和全血凝血时间(CT),与DIC相关性最大的指标依次是:Plt、CT、凝血酶原时间(PT)、部分凝血活酶时间(APTT),和纤维蛋白原(Fbg)。依据以上实验指标将感染合并凝血功能异常分为DIC前期(C组)、DIC早期(B组)和DIC期(A组)是符合临床实际情况的,并得到了统计学的支持。在此基础上提出了DIC的分期诊断标准。     

Another step in improving the diagnosis of disseminated intravascular coagulation in sepsis

The diagnosis of disseminated intravascular coagulation (DIC) based on composite scoring systems using routinely available coagulation tests has been greatly facilitated. Such scoring instruments not only adequately assess the presence of DIC but also have strong prognostic power for morbidity and mortality. In this issue of Critical Care, Gando and colleagues report on the prospective validation of the Japanese Association of Acute Medicine score for DIC in patients with severe sepsis.     

系统性红斑狼疮并发播散性血管内凝血的早期诊治

目的：早期发现和诊断系统性红斑狼疮（ＳＬＥ）并发的播散性血管内凝血（ＤＩＣ），并及时给予中西医结合治疗，以提高抢救的成功率。方法：ＳＬＥ并发ＤＩＣ患者４例中３例采用复方丹参注射液和西药治疗，１例仅用西药治疗。结果：３例亚急性ＤＩＣ患者在早期治疗后获成功，１例为急性ＤＩＣ患者死亡。结论：早期发现、早期诊断和中西医结合疗法可以提高治疗的成功率，这种疗法应用得越早，并发ＤＩＣ的ＳＬＥ患者预后就越好     

Recent acquisitions in the pathophysiology, diagnosis and treatment of disseminated intravascular coagulation

Background

Clinical trials have shown low-molecular weight heparin (LMWH) to be at least as safe and efficacious as unfractionated heparin (UFH) for preventing venous thromboembolism (VTE) in acutely-ill medical inpatients.

Objective

To compare clinical and economic outcomes among acutely-ill medical inpatients receiving the LMWH enoxaparin versus UFH prophylaxis in clinical practice.

Methods

Using a large, multi-hospital, US database, we identified persons aged ≥40 years hospitalized for ≥6 days for an acute medical condition (including circulatory disorders, respiratory disorders, infectious diseases, or neoplasms) from Q4 1999 to Q1 2002. From these patients, those who received thromboprophylaxis with either enoxaparin or UFH were identified. Surgical patients and those requiring or ineligible for anticoagulation were excluded. We compared the incidence of deep-vein thrombosis (DVT), pulmonary embolism (PE), and all VTE (i.e., DVT and/or PE). Secondary outcomes were occurrence of side-effects, length of hospital stay and total costs. RESULTS: 479 patients received enoxaparin prophylaxis and 2,837 received UFH. The incidence of VTE was 1.7% with enoxaparin prophylaxis versus 6.3% with UFH (RR = 0.26; p < 0.001). Occurrence of side effects, length of stay (10.00 days with enoxaparin vs. 10.26 days with UFH; p = 0.348) and total costs ($18,777 vs. $17,602; p = 0.463) were similar in the 2 groups.

Conclusion

We observed a 74% lower risk of VTE among patients receiving enoxaparin prophylaxis versus UFH prophylaxis. There was no significant difference in side effects or economic outcomes. These results provide evidence that the LMWH enoxaparin is more effective than UFH in reducing the risk of VTE in current clinical practice.