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1、危重患者血小板减少的诊治四川省肿瘤医院ICU刘真君2022.4第一页，共五十二页。1.概述血小板减少的定义、机制、诊断思路、常用的检查方法2.危重患者中血小板减少的诊断和治疗3.总结4.病例讨论第二页，共五十二页。血小板减少thrombocytopenia定义为各种遗传或获得性因素导致的血小板减少，血小板计数7.9flcouldpredicthyperdestructivesensitivityof82.3%(95%CI:70.5-90.8),specificityof92.5%(95%CI:79.6-98.4),positivepredictivevalueof94.4%(95%CI:84.
2、6-98.8),negativepredictivevalueof77.1%(95%CI:62.7-88.0)Aprospectiveevaluationofnormalmeanplateletvolumeindiscriminatinghyperdestructivethrombocytopeniafromhypoproductive0thrombocytopenia.Internationaljournaloflaboratoryhematology,2022Oct;30(5):408-14.第十八页，共五十二页。 血小板指数platelet indices，包括MPV, 血小板体积变异宽
3、度platelet size deviation width ，PDW) 和大血小板比率 platelet-to-large-cell ratio ，P-LCR) The study group was divided into two categories: hypoproliferative and destructive thrombocytopenia All the threeplateletindiceswere significantly higher in destructive group as compared to the hypoproliferative catego
4、ry第十九页，共五十二页。134thrombocytopenicpatients(69men,65women)whoweredividedintotwogroupsgroupI(n=63)includedITPpatientsgroupII(n=71)includedpatientswithHTduetomyelosuppressionsecondarytochemotherapyConcerningMPVandPDWindices,sensitivity,specificity,positiveprognosticvalue,negativeprognosticvalue,efficienc
5、yandYoudenindexwere100%forthediagnosisofITP.Onthecontrary,thevaluesforP-LCRweresignificantlylower。第二十页，共五十二页。血小板指数的局限性在于血小板严重下降的患者10 x10(9)/L结果有较大的偏差，输血等治疗措施影响对结果的判断。在ICU的应用价值需要再评估。Roleofplateletvolumeindicesinthedifferentialdiagnosisofthrombocytopenia:asimpleandinexpensivemethod.Hematology(Amsterda
6、m,Netherlands),2022Jun;14(3):182-6.Increasedvaluesofmeanplateletvolumeandplateletsizedeviationwidthmayprovideasafepositivediagnosisofidiopathicthrombocytopenicpurpura.ActaHaematol.2022;119(3):173-7.第二十一页，共五十二页。未成熟血小板比例和网织血小板比例 Group 1. CentralthrombocytopeniaIPF 8.67% (6.49-10.46%) RP 4.08% (2.86- 5
7、.30%) Group 2. Thrombocytopenia as a result of enhanced peripheralplateletdestruction6.80% (12.20-21.39%) ，16.14% (9.89-22.40%). (P 0.01). Group 3. Peripheral non-immune thrombocytopenia by abnormaldistribution9.04% (6.95-11.14%) ，5.23% (3.41-7.05%). Correlation between immature platelet fraction an
8、d reticulated platelets. Usefulness in the etiology diagnosis of thrombocytopenia.Eur J Haematol. 2022 Aug;85(2):158-63.第二十二页，共五十二页。促血小板生成素Thrombopoietin，TPO)在生成障碍患者，特别是再障患者明显升高，但在鉴别诊断中的价值有限。血小板相关抗体在免疫性血小板减少中有一定的价值，但检测方法的标准化和特异性需要再评估。Isthethrombopoietinassayusefulfordifferentialdiagnosisofthrombocyt
9、openia?Analysisofacohortof160patientswiththrombocytopeniaanddefinedplateletlifespan.ClinChem.2001Sep;47(9):1660-5.Attempttoimprovethediagnosisofimmunethrombocytopeniabycombineduseoftwodifferentplateletautoantibodiesassays(PAIgGandMACE).Haematologica.2002Oct;87(10):1046-52.Quantificationofplatelet-as
10、sociatedIgGfordifferentialdiagnosisofpatientswiththrombocytopenia.ThrombHaemost.2000Nov;84(5):779-83.第二十三页，共五十二页。 以上是简易流程，最常见的几种疾病。针对住院特别是ICU患者情况可能更复杂，更多的是根底疾病和治疗性因素导致的血小板减少，医院获得性血小板减少Hospital-acquired thrombocytopenia。 Hospital-acquired thrombocytopenia.Hosp Pract (1995). 2022 Oct;42(4):142-52. Thr
11、ombocytopenia in the intensive care unit patient.Hematology Am Soc Hematol Educ Program. 2022;2022:135-43. 第二十四页，共五十二页。Infectionisacommoncauseofthrombocytopenia.Viralinfectionsassociatedwiththrombocytopeniaincludethehumanimmunodeficiencyvirus,hepatitisCvirus,andEpstein-Barrvirus，cytomegalovirusThrom
12、bocytopeniaisalsofrequentinpatientswithbacterialinfectionsandsepsisorseveresepsis.Mechanismsofinfection-inducedthrombocytopeniaaremultipleandmayincludebonemarrowsuppression,peripheralimmunedestruction,andactivationandconsumption.Thefallinplateletcountassociatedwithsepsisistypicallygradual,occurringo
13、ver5to7days,andthethrombocytopeniaischaracteristicallymild.Managementconsistsoftreatmentoftheunderlyinginfectionandsupportivecare.1.感染第二十五页，共五十二页。2primarymechanisms：decreasedplateletproductionsecondarytobonemarrowsuppression(eg,chemotherapeuticagents)andincreasedplateletdestructioncausedbydrug-induc
14、edimmunethrombocytopenia(DITP)后者更难以识别。2.药物诱导免疫性血小板减少第二十六页，共五十二页。Drug-inducedimmunethrombocytopeniatypicallypresentsinadelayedfashion,5to10daysafterinitiationoftheoffendingdrug.Thereare2exceptionstothisrule:(1)patientspreviouslyexposedtoadrug2patientsmaydevelopthrombocytopeniaimmediatelyafterinitiati
15、onofaglycoproteinIIb/IIIainhibitor(eg,eptifibatide,tirofiban,andabciximab)第二十七页，共五十二页。ThefollowingclinicalcriteriahavebeenproposedtoestimatethelikelihoodthatagivendrugisthecauseofDITP:(1)thrombocytopeniaoccursafterexposuretothedrugandimprovesafterthedrugisstopped;(2)thecandidatedrugistheonlydrugused
16、beforetheonsetofthrombocytopenia,orotherdrugsarecontinuedorreintroducedwithoutaffectingtheplateletcount;(3)othercausesofthrombocytopeniaareexcluded;(4)thrombocytopeniarecursifthedrugis restarted但在ICU的环境下，多种药物使用，合并多种疾病，可能难以判断。第二十八页，共五十二页。万古霉素青霉素哌拉西林头孢曲松甲氧苄氨嘧啶/磺胺甲恶唑利福平卡马西平苯妥英丙戊酸阿昔单抗替罗非班依替巴肽奎宁对乙酰氨基酚布洛芬米氮平雷尼替丁第二十九页，共五十二页。SuspectedDITPistreatedbydiscontinuingthepotentiallyoffendingdrug.Theplateletcounttypicallybeginstoimprovewithin1to2daysafterthedrugisstopped.Themediantimetorecoveryofplateletcountis
