งานนำเสนอกำลังจะดาวน์โหลด โปรดรอ

งานนำเสนอกำลังจะดาวน์โหลด โปรดรอ

 Thrombosis : formation, from constituents of the blood, of an abnormal mass within the vascular system of a living animal  Rudolph Virchow : Virchow.

งานนำเสนอที่คล้ายกัน


งานนำเสนอเรื่อง: " Thrombosis : formation, from constituents of the blood, of an abnormal mass within the vascular system of a living animal  Rudolph Virchow : Virchow."— ใบสำเนางานนำเสนอ:

1

2  Thrombosis : formation, from constituents of the blood, of an abnormal mass within the vascular system of a living animal  Rudolph Virchow : Virchow triad 1859

3 Virchow triad Blood stasis Hypercoagulability Vessel wall -age -obesity -pregnancy -paralysis -Rt side heart failure -venous compression -long haul flight HereditaryAcquired -Vasculitis -Endothelial injury -intravascular catheter -trauma -surgery

4 Coagulation pathway Intrinsic Extrinsic PK, HMWK XII XIIa XI XIa IX IXa VIIa-Tissue factor VIII VIIIa X Xa -ve Va XIII -ve -ve Thrombin XIIIa Fibrin monomer Polymer Cross-linked fibrin polymer APC Plasminogen Plasmin Thrombomodulin -ve plasminogen activator inhibitor X,Y,D,E -ve FDP D-Dimer Protein C Protein S Prothrombin V A n t i t h r o m b i n Fibrinogen

5 Thrombophilia Hereditary Acquired Mixed or unknown -APC resistance due to Fc V Leiden mutation -Antithrombin def. -Protein C def. -Protein S def. -Prothrombin G20210A mutation -Dysfibrinogenemia -Ass. with physiologic/ thrombogenic stimuli pregnancy immobilization trauma postoperative state advancing age estrogen use prolonged air travel -Antiphospholipid syndrome -Malignancy -NS -HIT -TTP -PNH -Myeloproliferative disorders -Hyperhomocysteinemia -APC resistance : other -Elevated Fc VIII, XI, IX -Elevated TAFI

6 Clinical Venous systemArterial system -DVT ขาบวมปวด Homans sign -PE sudden dyspnea,chest pain,hypoxia,hemopthysis -Superficial thrombophlebitis ( Trousseau’s syndrome) proteinC, proteinS, CA metastasis -Cerebral vein thrombosis ปวดศีรษะรุนแรง,localizing sign, ชัก,papilledema,CN6palsy -Hepatic vein thrombosis (Budd Chiari Syndrome) ปวดท้อง ตับม้ามโต เหลือง N/V ascites,varice -Portal vein thrombosis ม้ามโต esophageal varices bleed -Mesenteric vein thrombosis acute/subacute colicky pain ถ่ายเป็นเลือด peritonitis -SVC thrombosis หน้า คอ แขน บวม UAO เส้นเลือดโป่งที่คอ และหน้าอก -IVC thrombosis ปวดหลัง ขาบวม 2 ข้าง เส้นเลือดโป่งที่ท้องและหลัง -Stroke -Coronary artery thrombosis -Peripheral arterial insufficiency -Ocular involvement

7  Hereditary : AD, age <45, FH,uncommon site of thrombpsis  APC resistance due to Fc V Leiden mutation most common of hereditary G1961A Arg 506 Gln, AD  Antithrombin deficiency antithrombin จับกับ active site ของ thrombin, AD, 1 st thrombosis ปี  Protein C deficiency AD trait/acquire,1 st thrombosis ก่อน 30 ปี, warfarin-induce skin necrosis Homozygote-purpura fulminans neonatalis ; nonthrombocytopenic purpura ไข้ ซีด เลือดออกตามผิวหนัง ความดันต่ำ Heterozygous : DVT, PE, thrombophlebitis

8  Protein S deficiency AD, 1 st thrombosis ปี, act as AT & protein C  Prothrombin G20210A mutation prothrombin มี mutation G A at  Dysfibrinogenemia AD, bleed/thrombosis, a/v thrombin จับกับ fibrin ที่ผิดปกติไม่ได้ thrombin เพิ่ม fibrin ที่ผิดปกติ ไม่สามารถกระตุ้น t-PA – plasmin จึงย่อย สลายลิ่มเลือดไม่ได้

9  Hyperhomocysteinemia AR : homocystein รบกวน cross-linking ของ collagen : ตา กระดูก หลอดเลือด lens หลุดง่าย, osteoporosis, arterial/venous thrombosis, ปัญญาอ่อน heterozygous : thrombosis  Antiphospholipid syndrome Antiphospholipid Ab – lupus anticoagulant, anticardiolipin,PTT ยาว clinical triad : arterial/venous thrombosis : recurrent abortion : thrombocytopenia mechanism : phospholipid membrane – platelet aggretion : phospholipid membrane – emdothelium- B2 glycoprotein : inhibit protein C/S acquire APC resistance

10  Malignancy blood stasis : นอนพักนาน, tumor กดทับ vessel, เลือดหนืด, สร้างหลอด เลือดผิดปกติ coag. : หลั่ง tissue factor และ cancer procoagulant(vitK): factorX กระตุ้น mononuclear cell ให้หลั่งสาร coagulant fibrinolysis : activity platelet : turnover เพิ่ม, survival time ลด, consumptive-low grade DIC nonbacterial thrombotic endocarditis : arterial emboli  HIT/HATT (heparin-associated thrombocytopenia and thrombosis) type 1 : early onset 2-5 d type 2 : late onset >6d – more severe, arterial thrombosis IgG/IgM Ab heparin-PF4 cpx. TXA2 plt.aggregate platelet may arterial embolism, skin necrosis

11  PNH unclear : CD55, CD59 plt-surface + compliment & platelet CD87 fibrinolysis  NS Protein loss : Antithrombin  Estrogen use factor VII, X, XII, XIII ; protein S, antithrombin fibrinolytic activity but down regulation

12  PH of thromboembolism location : venous/arterial/microvascular diagnostic study : venography, scans predisposing factor : surgery, trauma, pregnancy therapy : duration, efficacy, complications  Disease associated with thrombois  FH  Medication Estrogen, chemotherapy, tobacco, alcohol, illicit drugs

13 Investigation Venous Arterial Microvascular CBC APC-resistance assay Prothrombin gene mutation Factor VIII activity Antithrombin activity Protein C Protein S Homocysteine Fibrinogen Thrombin time Lupus anticoagulant Anticardiolipin CBC Lupus anticoagulant Anticardiolipin Homocysteine(R to L shunt) Colony assays Lipid profile High-sensitivity CRP CBC, PBS DIC screen Lupus anticoagulant Anticardiolipin Protein C Protein S HIT assay

14  Timing : 2-3 wk after off oral anticoagulant Acute thrombosis : AT, Protein C & S Heparin : AT Warfarin : Protein C & S activity  FH : Hereditary : plan for FH

15  Recurrent thrombosis  FH of thrombosis  Thrombosis < 45  Thrombosis : other site,except DVT  Multiple site of thrombosis  Thrombosis without atherosclerosis  Both arterial & venous thrombosis BUT ALL CASE

16 Clinical Risk factor Hereditary risk Acquire risk Hereditary risk Acquire risk

17  Heparin 80 u/kg iv bolus, then 18 u/k/hr  PTT q 6 hr : x  Warfarin : INR >2 *2d then off heparin  LMWH  Antithrombin concentrate AT deficiency with high dose heparin/recurrent thrombosis 50 u/kg then 60% of first dose q 24 hr keep >80%

18  Protein C deficiency : warfarin induce skin necrosis Rx : off warfarin : Vit K & Heparin : FFP, protein C concentration ---- before warfarin  Lupus anticoagulant : PTT prolong --- FcX or thrombin LMWH  Other -Elastic stocking prevent post thrombotic syndrome -Thrombolytic agent - massive PE, Phlegmasiacerulia dolens -IVC filter : contraindication of anticoagulant

19  Venous valve incompetence venous reflux venous HT  Leg pain & swelling, chronic skin ulcer  Recurrent DVT : risk 6 time  Dx : doppler U/S : reflux in popliteal vein : descending venogram

20  Rx : หลีกเลี่ยงการยืนหรือนั่งนานๆ : graduated compression stocking : intermittent compressive pump, pressure 40 mmHg : venous ulcer : dressing & debridement & unna boot : Pentoxifylline : Sx : ligation, stripping, valve reconstruction  Prevention : Elastic compression stocking 2 yr : prevent recurrent DVT

21  Aim : prevent early recurrent thrombosis  High recurrent in unknown risk factor  Evaluate : site & severity : risk factor : clot formation : เพศ อาชีพ

22 Thrombosis Idiopathic Thrombophilia Risk factor Heterozygous FV Leiden Homozygous FV Leiden, AT Protein C&S def. APA ชั่วคราวยังมีต่อ 1 st : > 6 mo 2 nd long life >12 mo or long life 3 mo or risk หาย Long life Or >6mo ถ้า risk หาย

23  FH : 1 st degree relation 50% - female : no pill : no hormone replacement - prophylaxis anticoagulant/AT, Protein C conc. :-Antithrombin deficiency : Protein C & S deficiency : Lupus anicoagulant : Sx, pregnancy, post- partum - Hyperhomocysteinemia : B6,12, folic acid  On warfarin : plan of pregnancy---stop warfarin


ดาวน์โหลด ppt  Thrombosis : formation, from constituents of the blood, of an abnormal mass within the vascular system of a living animal  Rudolph Virchow : Virchow.

งานนำเสนอที่คล้ายกัน


Ads by Google