Achneck Hardean E, Sileshi Bantayehu, Lawson Jeffrey H
Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
Vascular. 2008 Mar-Apr;16 Suppl 1:S6-13.
To effectively balance bleeding and clotting in surgical patients, the surgeon needs a fundamental knowledge of coagulation biology. The endothelium and activated platelets play crucial roles in coagulation. Activated platelets and damaged endothelial cells provide a platform of negatively charged phospholipids that not only bind coagulation factors and their complexes but also accelerate the conversion of inactive zymogens to active serine proteases. Endothelial shear stress also plays a pivotal role in coagulation and thrombosis by stimulating release of nitric oxide (NO) at the vascular interface, upregulating endothelial nitric oxide synthase (eNOS), and further mediating eNOS activation through direct phosphorylation. The effects of low shear stress result in a prothrombotic state and have been implicated in the etiopathology of atherosclerosis. Correctly diagnosing and appropriately treating perioperative bleeding in surgical patients require a basic understanding of the most common bleeding and clotting disorders. This article provides an overview of the characteristic features of common coagulopathic conditions and their treatment options. Given the challenge of balancing bleeding and clotting in surgical patients, hemostatic management must be tailored to each patient and should take into account the patient's genetic and acquired risk factors and the acute disturbances in bleeding and clotting caused by surgical intervention.
为有效平衡外科手术患者的出血与凝血，外科医生需要掌握凝血生物学的基础知识。内皮细胞和活化血小板在凝血过程中发挥关键作用。活化血小板和受损内皮细胞提供了一个带负电荷的磷脂平台，该平台不仅能结合凝血因子及其复合物，还能加速无活性酶原向活性丝氨酸蛋白酶的转化。内皮剪切应力通过在血管界面刺激一氧化氮（NO）释放、上调内皮型一氧化氮合酶（eNOS）以及通过直接磷酸化进一步介导eNOS活化，在凝血和血栓形成中也起着关键作用。低剪切应力的影响会导致血栓前状态，并与动脉粥样硬化的发病机制有关。正确诊断和适当治疗外科手术患者的围手术期出血需要对最常见的出血和凝血障碍有基本的了解。本文概述了常见凝血病的特征及其治疗选择。鉴于平衡外科手术患者出血与凝血的挑战，止血管理必须因人而异，并应考虑患者的遗传和后天风险因素以及手术干预引起的出血和凝血急性紊乱。
