Zaburzenia fizjologicznej hemostazy mogą być przyczyną krwotoków śród- i pooperacyjnych, a także powikłań zakrzepowo zatorowych. Dlatego tak ważny jest dokładny wywiad z pacjentem przed operacją.
Jeżeli natomiast nie mamy pewności warto oznaczyć morfologię, czas protrombinowy (PT), czas częściowej tromboplastyny po aktywacji (APTT), stężenie fibrynogenu, liczbę płytek krwi oraz INR.
Wśród najczęstszych problemów z hemostazą w chirurgii wyróżnia się trombogenezę, trombofilię, a także rozsiane krzepnięcie wewnątrznaczyniowe.
Trombogeneza jako zaburzenie krzepnięcia krwi
Trombogeneza charakteryzuje się powstawaniem zakrzepów, które tworzą się głównie przez zwolnienie przepływu krwi, zmiany składu krwi, czyli nadkrzepliwość, a także uszkodzenie ściany naczynia. Mogą się wówczas tworzyć zakrzepy tętnicze oraz żylne.
Zakrzepy tętnicze tworzą się na skutek oddziaływania płytek krwi z uszkodzonym śródbłonkiem. Profilaktycznie stosuje się wówczas leki hamujące agregację płytek krwi, takie jak m.in. kwas acetylosalicylowy, tyklopidynę czy klopidogrel.
W wyniku zastoju krwi, miejscowej aktywacji układu krzepnięcia krwi oraz zmniejszenia aktywności fibrynolitycznej tworzą się zakrzepy żylne. Aby im zapobiec należy zastosować leki hamujące układ krzepnięcia krwi, takie jak heparynę czy doustne antykoagulanty.
Trombofilia jako zaburzenie krzepnięcia krwi
Trombofilia jest kolejnym zaburzeniem hemostazy, które charakteryzuje się powstawaniem zakrzepów, szczególnie w żyłach. Trombofilię wrodzoną odnotowuje się częściej niż skazy krwotoczne. Zaburzenie to jest jednym z głównych czynników ryzyka choroby zakrzepowo-zatorowej. Wrodzona trombofilia powstaje najczęściej w wyniku niedoboru antytrombiny białka C i S.
Rozsiane krzepnięcie wewnątrznaczyniowe (DIC) jako zaburzenie krzepnięcia krwi
Rozsiane krzepnięcie wewnątrznaczyniowe to wewnątrznaczyniowa aktywacja układu krzepnięcia krwi, któremu towarzyszy tworzenie się zakrzepów w mikrokrążeniu. To właśnie one są przyczyną niedokrwienia różnych narządów.
Zaburzenie to występuje przy okazji operacji płuc, trzustki i gruczołu krokowego, rozległych urazów wielonarządowych czy wstrząsu różnego pochodzenia. Pojawia się również u pacjentów z oparzeniami, sepsą, a także jako powikłanie ciąży i porodu. Objawem tego rodzaju zaburzenia krzepnięcia krwi są:
- krwawienie o różnym nasileniu z ran pooperacyjnych czy pourazowych, układu moczowego, przewodu pokarmowego, dróg rodnych czy miejsc nakłucia żył,
- wybroczyny i podbiegnięcia krwawe na błonach śluzowych i skórze,
- niewydolność różnych narządów.
Aby rozpoznać rozsiane krzepnięcie wewnątrznaczyniowe niezbędny będzie dokładny wywiad, powyższe objawy, jak również badania krwi, wskazujące na małopłytkowość, zmniejszenie stężenia fibrynogenu, zmniejszenie wartości wskaźnika Quicka i stężenia D-dimerów.
Tego rodzaju zaburzenie hemostazy wiąże się z ryzykiem wystąpienia wstrząsu, ostrej niewydolności nerek, a także zespołu ostrej niewydolności oddechowej. Aby uniknąć wystąpienia DIC należy zastosować heparynę drobnocząsteczkową. Natomiast jeżeli dojdzie już do rozsianego krzepnięcia wewnątrznaczyniowego, aby zahamować krzepnięcie krwi stosuje się heparynę. Dodatkowo podaje się pacjentom antytrombiny, osocze, fibrynogen oraz koncentrat krwinek płytkowych.
Źródło: Noszczyk W., Chirurgia Repetytorium, Wydanie II uaktualnione Warszawa 2019, s. 22-23
Przeczytaj także: Autorzy nowego typu opatrunku wyróżnieni w 7. edycji konkursu „Eureka! DGP – odkrywamy polskie wynalazki”
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