检验科与临床血凝检测的有效沟通

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1、检验科与临床血凝检测的有效沟通上海交通大学医学院附属瑞金医院王学锋目的•互相沟通、理解不仅仅是打电话•促进医疗质量提高•更好服务患者重视环节•检测前•检测中•检测后检测前•患者准备•抽血•标本输送案例(1)某院患者于×，男，25岁。因患法乐氏四联征拟进行手术治疗，术前检查凝血常规，PT多次在30～40秒（正常对照12.5秒），APTT在50～70秒（正常对照25秒）。体检发现患者口唇紫绀，挫状指明显，听诊心前区可闻明显杂音。肝肾功能正常。结合影像学和其他资料，内科诊断患者为法乐氏四联征合并多个凝血因子缺乏，给予维生素K

2、，新鲜冰冻血浆治疗，凝血像改善不明显思路•PT、APTT同时延长，共同途径一个或多个因子缺乏？肝病？•凝血因子检测，抗体产生？•维生素K及FFP补充治疗多日无效，其他原因？思路•长期“法四”，缺氧，刺激红细胞增生•超出抗凝剂调节范围•重新计算抗凝剂剂量查血常规报告？思路•血常规报告血细胞比容70％•重新调增抗凝剂用量•PT、APTT均恢复正常范围•顺利手术案例(2)患者80岁，男性，口服华发林5mg/d，在某家医院检测PT始终在正常范围内。但患者主诉小便出血，尿检红细胞4＋，皮肤有瘀斑思路•老年患者用药是否过量？•是否

3、合用其他药物？食物影响？•PT检测试剂ISI是否合格？•MNPT是否使用得当？•检测仪器是否在控？WarfarinMechanismofActionWarfarin:Indications•Prophylaxisand/ortreatmentof:–Venousthrombosisanditsextension–Pulmonaryembolism–ThromboemboliccomplicationsassociatedwithAFandcardiacvalvereplacement•PostMI,toreduceth

4、eriskofdeath,recurrentMI,andthromboemboliceventssuchasstrokeorsystemicembolization•PreventionandtreatmentofcardiacembolismWarfarin:MajorAdverseEffect—Hemorrhage•Factorsthatmayinfluencebleedingrisk:–Intensityofanticoagulation–Concomitantclinicaldisorders–Concomit

5、antuseofothermedications–QualityofmanagementWarfarinDosinginElderlyPatientsMeanWarfarinDailyDose(mg)PatientAge<5050–5960–6970–79>80Gurwitz,etal,19926.45.14.23.6ND(n=530patientstotalstudy)James,etal,19926.15.34.33.93.5(n=2,305patientstotalstudy)Increasingagehasbe

6、enassociatedwithanincreasedresponsetotheeffectsofwarfarinGurwitzJH,etal.AnnIntMed1992;116(11):901-904.JamesAH,etal.JClinPath1992;45:704-706.INREquationPatientPatient’’sPTinSecondssPTinSecondsISIISIINR=INR=(())MeanNormalPTinSecondsMeanNormalPTinSecondsINR=Interna

7、tionalNormalizedRatioISI=InternationalSensitivityIndexRelationshipBetweenINRandEfficacy/Safety•Low-intensitytreatment:–EfficacyrapidlydiminishesbelowINR2.0*–NoefficacybelowINR1.5•High-intensitytreatment:–SafetycompromisedaboveINR4Effectivebelow2.5问题解决方法•Lossofac

8、curacywith•UsethromboplastinhighISIthromboplastinsreagentswithlowISIvalues(lessthan1.5)•IncorrectISIassignment•UseplasmacalibrantsbymanufacturerwithcertifiedINRvalues