COAGULACION INTRAVASCULAR DISEMINADA
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Transcript of COAGULACION INTRAVASCULAR DISEMINADA
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COAGULACION INTRAVASCULAR
DISEMINADADR. JORGE A. ESPINOSA LEON. R4MI
HOSPITAL GENERAL AGUSTIN O’ HORAN
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Introducción
Síndrome plurietiologico agudo o cronico inducida por procoagulantes.
Actividad excesiva de proteasas sanguíneas que inducen formación de fibrina y activación secundaria de fibrinolisis
Current concepts CID. NEJM, Agosto, 2005.
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Coagulopatia de consumo
Sindrome de desfribinacion
Disbalance proteolitico y sistemico (Risberg) Hemorragia y trombosis microvascular
Current concepts CID. NEJM, Agosto, 2005.
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Historia
1884. Dupuy. Tejido cerebral 1865. Trousseau. Tumores 1873. Naunyn. Hematies disueltos
Wooldridge et al. Estroma de eritrocitos 1875. Landois. Sangre humana 1950. W.H. Seegers
“Factors in the control of bleeding”
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1955. Ratnoff & Pritchard “Hemorragic State During Pregnancy”
1955. Crowell. “Shock irreversible” 1959. McKay & Hardaway “concepcion CID” 1961. Lasch et al. “coagulopatia consumo” 1965. McKay. Plurietiologico 1970. Criterios clinicos
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Fisiología de la hemostasia
Fase vascular
Fase plaquetaria
Coagulacion plasmatica
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Ca+
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FTPI
trombomodulina
Proteina c
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Antitrombina III Tb, X,IX,XI,XII PLM, KK. V Y VIII
Cofactor II-Heparina Alfa 2 macroglobulina Alfa 1 antitripsina
Debil Inhibidor TB y KK Inh. C1 de la estereasa
Inhibe la cascada de complemento, fibrinolisis
ANTI-PROTEASAS
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Crit Care Med 2007 Vol. 35, No. 9
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Etiologic Factors and Disorders Causing Disseminated Intravascular Coagulation
Liberation of tissue factors Obstetric syndromes abruptio placentae, amniotic fluid embolism, retained dead fetus, second trimester abortionHemolysisNeoplasms, particularly mucinous adenocarcinomas, acute promyelocytic leukemiaIntravascular hemolysis Fat embolism Tissue damage—burns, frostbite, head injury, gunshot wounds
Endothelial damageAortic Aneurysm Hemolytic uremic syndrome Acute glomerulonephritis
Vascular malformation, decreased blood flow Kasabach-Merritt syndrome
InfectionsBacterial: staphylococci, streptococci, pneumococci, meningococci, gram-negative bacilliViral: arboviruses, varicella, variola, rubellaParasitic: malaria, kala-azar Rickettsial: Rocky Mountain spotted feverMycotic: acute histoplasmosis
Modified from RI Handin, RD Rosenberg, in Hematology, 4th ed, WS Beck (ed), Cambridge, MA, MIT Press, 1985.
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Current concepts CID. NEJM, Agosto, 2005.
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Current concepts CID. NEJM, Agosto, 2005.
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X
Current concepts CID. NEJM, Agosto, 2005.
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t-PA
Current concepts CID. NEJM, Agosto, 2005.
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Anticoagulante
Procoagulante
Anticoagulante
Procoagulante
Endotelio normal Endotelio alterado
ENDOTELIO Y
COAGULACION
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Papel del endotelio vascular
Mantiene función no trombogenica y trombogenica paralela
Predominio actividad procoagulante ante lesion
PAF, FvW, 13-HODE regulan adhesión a plaquetas
Adhesión leucocitaria al endotelio mediante ELAM-1 y Selectina E, ICAM 1. Selectina P.
PAI-1 Regulador dominante de actividad fibrinolitica
Produccion de adenosina, Oxido nitrico y Serotonina
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Papel de leucocitos y productos de secreción en la CID.
Promueven coagulacion al secretar TNF,IL-1, IL-8 y PAF.
Incrementan produccion de FT
Inactivacion de antiproteasas C1-INH. Alfa1-AT. Beta2-M y AT-III
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Papel de la endotoxina
La infección es la causa mas frecuente de CID
Mecanismo mas complicado y extensamente estudiado
Acción directa por radicales O2 Acción indirecta por enzimas
proteoliticas Activación vía coagulación intrínseca Activación vía coagulación extrínseca
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Exposicion sangre circulante a grandes cantidades de FT
Depleción factores coagulación por hemorragia Múltiples transfusiones sin FV y FVIII, Hemodilucion por fluidoterapia Traumatismo hepático directo Septicemias superimpuestas Daño tisular adicional por reperfusión post-isquèmica Embolismo graso Quemaduras extensas con exposición FT
pacientes politraumatizados
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CID Y HEPATOPATIA
Sintesis reducida de factores de coagulacion y anticoagulacion
Vida media corta de FIB, elevacion Dimero D.
Disminuye el aclaramiento de FIX,FX,FXI.
No reponen factores de la coagulacion.
Realizar determinacion de fragmentos 1-2 de PTB, Complejos TAT, dimero D
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Mecanismos de control Trombomodulina
Complejos con AT-III-Heparan sulfato endotelial Activa PC anticoagulante
Inh. FV y FVIII, inhibe PAI-1.
Fagocitos mononucleares Retiran FT SOLUBLE Retiran fibrina Complejo con TRM endotelial
Hepatocitos Aclara Factores IX.X, y XI activados, t-PA Repone factores
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Clínica
Variables: Fiebre Hipotension Acidosis Proteinuria Hipoxia Petequias, purpura, bullas hemorragicas Disfuncion sistemica
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Clínica
HEMORRAGIAS
Directamente proporcional al grado de fibrinolisis Tracto gastrointestinal Sistema nervioso central Orbita Glándula adrenal Diferencia en hepatopatia y sepsis
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Clínica
TROMBOEMBOLISMOS
Pulmonar Cerebral Venas renales Hepaticas Intestinales Afeccion hipofisiaria FOM
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Clínica
Shock Disfunción renal Disfunción hepática Disfunción del sistema nervioso central Disfunción pulmonar
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Clínica
Hipoxemia transitoria Hemoptisis Disnea Taquipnea Dolor torácico Crepitantes y roce pleural Aumento permeabilidad por los PDF`s
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Diagnostico
Test globales de coagulacion Tiempo de PTB (TP): elevado en 75%, normal a
rapido en 25% TTPa: alargado en 50-60% TT y Reptilasa: prolongados Lisis de coagulo
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Diagnostico
Dosificación de factores Cuantificación de factores coagulación
controversial Cuantificación inhibidores de coagulación (TAT) Trombocitopenia ( F4-plaquetario, b-
trombomodulina) Calicreina, neopterina, colagenasa
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Diagnostico
Complejos enzima/Inhibidor
TAT (AT-III—TB)
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Péptidos de activación y productos degradación
Fibrinopeptido A y f-B-beta-15-42 FPB
Monomeros de fibrina
PDF: 85-100% de enfermos con CID
Test Dímero D-D
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Committee of the International Society of Thrombosis and Haemostasis
Taylor FB Jr, Toh CH, Hoots WK, et al: Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost 86:1327, 2001.
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Committee of the International Society of Thrombosis and Haemostasis
Taylor FB Jr, Toh CH, Hoots WK, et al: Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost 86:1327, 2001.
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Committee of the International Society of Thrombosis and Haemostasis
Taylor FB Jr, Toh CH, Hoots WK, et al: Towards definition, clinical and laboratory criteria, and a scoring system for disseminated intravascular coagulation. Thromb Haemost 86:1327, 2001.
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Pautas para el tratamiento
Eliminar proceso precipitante
Minimizar la afección local (endotelio)
Detener la actividad proteolítica
Reposición de componentes deplecionados
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