Materials for auditory self-work
4.1. List of study practical tasks necessary to perform at the practical class.
Materials and methods: coagulograms sets.
Task 1. Coagulogram for DIC-syndrome (disseminated intravascular coagulation) diagnostics
Next coagulogram (tests set) is essential for proper DIC-syndrome diagnostics:
Norm:
1. Thromboelastogram: R 9-14 minutes
K 5-8 minutes
mA 48-52 mm
2. Thrombocytes 180-400 x 109/l
3. Thrombocytic aggregation: spontaneous absent
on ADP present
4. Thrombin time 15-18 sec
5. Fibrinogen 2-4 g/l
6. Antithrombin III 80-100%
7. Ethanole test negative
8. Prothamine-sulphate test negative
9. Fibrinogen “B” negative
10. Fibrinogen degradation (derivative) products 7,3±3,9 mg %
11. Euglobuline fibrinolysis 120-240 min
DIC-syndrome is rather widely-spread pathological state. Particularly, such reaction is observed at:
· shocks different forms;
· sepsis;
· acute intravascular hemolysis;
· massive hemotransfusions syndrome;
· therminal states;
· acute kidney insufficiency;
· malignant tumors;
· traumatical operations;
· oesophageus and stomach chemical burns;
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· obstetric pathology;
· physiological labors;
· intoxications and so on.
Possible DIC-syndrom reasons in dentistry:
· after shock;
· facial-mandibular region traumatic injuries;
· malignant tumors;
· facial-mandibular region abscesses and phlegmones;
· jaws fractures and so on.
Acute DIC-syndrome determining is elicitated by the fact that it may be one hemostasis disorder at some pathology types. For example, at shocks, therminal states, sepsis hard forms, massive traumas and burns, acute intravascular hemolysis DIC is disease constant component, its inalienable part. DIC is diagnosed similtaneosely with main disease recognizing and its therapy is begun immediately.
First, for DIC-diagnosis one can perform simple methods: blood coagulation general time (norma: 5-8 min), prothrombin and thrombin time, paracoagulational tests indexes (ethanole, protamine-sulphate), platelet amount. Then one can add also other tests that prove DIC-syndrome picture.
In a whole, in clinic practice for DIC-syndrome diagnostics one should perform next tests: platelet amount, platelet aggregation, fibrinogen content, APTT (activated partial thromboplastin time in plasma pour on thrombocytes), recalcification time, prothrombin time, antithrombin III (in plasma pour on platelets), fibrinogen degradation products, soluble fibrin-monomers determining – ethanole and prothamin-sulphate probes (in plasma pour on thrombocytes), fibrinolysis (in plasma pour on thrombocytes), fragmented erythrocytes determining.
Changes at acute DIC-syndrome form:
· platelets amount is up to 150 x 109/l and less;
· fibrinogen concentration is up to 1,5 g/l and less;
· activated partial thromboplastin time is up to 50 sec and more (norm: 30-40 sec) – hypocoagulation sign;
· recalcification time is up to 80 sec and more.
These changes are connected with plasma factors consumption as well as fibrin derivative products antithrombin action. Other disorders are the following:
· prothrombin time prolonging (due to platelets and blood coagulation factors consumption as fibrin derivative products antithrombin action) – at acute and subacute forms;
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· thrombin time prolonging on 10 seconds comparatively to normal indexes (it is linked with hypofibrinogenemia and fibrin derivative products antithrombin action);
· at platelets aggregation investigation with main biological stimulators (ADP, adrenaline, collagen) in patients with acute and subacute DIC-syndrome forms expressed platelets hypoaggregation is observed as a result of hypothrombocyteaemia and transitory hypofunction caused by thrombine, ADP, adrenaline, prostaglandine and other proaggregants action to thrombocytes (it leads to platelets degranulation);
· positive probes on gel-formation with ethanol and prothamine-sulphate are very essential at DIC-syndrome diagnostics: intermediate products of fibrinogen transformation in fibrin are occurred in blood in course of this syndrome; these substances form fibrin-like gel at presence of mentioned substances (ethanol, beta-naphtol and prothamine-sulfate); such a phenomenon is named as paracoagulation; under norma concentration of these products is still small that ethanol and prothamine-sulphate don’t cause gel formation (negative probe); fibrin degradation products content is more than 10 mcg/ml at DIC-syndrome that is delt with fibrinolysis secondary activation and plasmin occurrence in blood in concentrations significantly more than under norma; sometimes it leads to decomposition of not only fibrinogen and fibrin but also other blood coagulation factors.
For secondary fibrinolysis fast diagnosis one of optimal test is the following: healthy person native blood, healthy and sick person native blood mixture + thrombin; then to observe formed blood clots dissolving. At high fibrinolysis level blood clot formed in healthy and sick blood mixture is dissolved before observant eyes (melt like sugar in a cup of tea); at the same time blood clot of a healthy person doesn’t dissolve for many hours.
DIC-syndrome specific expression is microangiopathic hemolytic thrombotic anemia, signs of which are observed at all this syndrome forms. Its essence is in following: fibrin fibres are accumulated in microcirculative vessels; these fibres injure erythrocytes stroma and retard their passage through capillaries. As a result of this erythrocytes haemolysis acceleration occurs; their osmotic resistance decreasing, plasma satiation with bilirubin (free, non-conjugated).
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Proggressing antithrombin III content decreasing is one of the earliest DIC-syndrome sign. Being main physiological anticoagulant, antithrombin III reacts to any activation of haemostatic system procoagulant link. Given progress is the most expressed in DIC-syndrome patients in consumption coagulopathie stage. It explains heparin application ineffectiveness without simultaneous antithrombin III concentration introduction (it contains in fresh-frozen plasma or the “freshest” warm donor blood but in conserved blood antithrombin III is absent!)
If it’s impossible to perform all mentioned tests under laboratory conditions then obligatory for DIC-syndrome diagnosis are the following methods: platelet number, prothrombin and thrombin time, probe with ethanole and prothamine-sulphate, antithrombin III and fibrinolysis. The other methods may be used as addictive and proving the diagnosis.
But every doctor must take into account that in every specialized clinics DIC-syndrome course (and its therapy correspondingly) are strongly differentiated.
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