血栓弹力图对急性创伤性凝血病的诊疗价值

目的 急性创伤性凝血病是严重创伤早期发生的凝血功能障碍,其发生率、病死率高,较易发展为多器官功能衰竭,早期诊断和处理是急诊创伤外科治疗的重要内容,也是降低创伤病死率的关键.血栓弹力图能够全面评估血液凝固的各个阶段,早期诊断凝血障碍,指导治疗,降低并发症和病死率,减少医疗成本,已被广泛应用于创伤外科、肝移植、心脏外科手术中凝血功能的监测和指导治疗.本文主要就血栓弹力图(TEG)对急性创伤性凝血病的诊疗价值做一综述.     

血栓弹力图在深静脉血栓评分中高危患者中的应用探讨

目的：探讨血栓弹力图在深静脉血栓评分中高危患者的应用效果。方法整群选取2015年9月＿2016年6月于该院ICU治疗的85例深静脉血栓评分中高危患者的资料,根据血栓弹力图R值、MA值分为A组、B组、C组,给予相应治疗措施。比较治疗前血小板、凝血4项、D-二聚体与血栓弹力图的凝血异常发现率以及治疗前后其变化情况,并评价治疗效果。结果 A、B、C各组共85例患者血栓异常检查 D-二聚体、血栓弹力图的阳性率(29.41%、34.12%﹚高于血小板、凝血4项(8.24%、9.41%﹚,D-二聚体与血小板、凝血四项阳性率比较差异有统计学意义(P<0.05),血栓弹力图与血小板、凝血四项阳性率比较差异有统计学意义(P<0.05);抗凝、抗聚治疗5 d后,A、B、C 3组85例患者的血栓弹力图指标前后比较差异有统计学意义(P<0.05﹚。结论相比于传统凝血检查,血栓弹力图凝血异常发现率更高,更加及时,并能有效指导临床治疗,值得临床推荐。     

复发性流产孕妇早孕期血栓标志物筛查及干预

目的探讨复发性流产(RSA)后再次妊娠早孕期孕妇血栓标志物,并评估低分子肝素(LMWH)干预对血栓标志物水平异常RSA孕妇妊娠结局的影响。 方法选择2018年1月至2019年10月在苏州大学附属第二医院妇产科就诊的174例RSA早孕期孕妇(孕龄为7~10孕周)为研究对象,并纳入研究组。将同期在本院就诊并定期进行产前检查的78例健康孕妇纳入对照组。研究组174例孕妇中,血栓5项标志物[血栓弹力图(TEG)、抗凝血酶(AT)-Ⅲ、同型半胱氨酸(Hcy)、血小板最大聚集率(MAR)、D-二聚体(DD)]任意一项升高为139例,根据是否采取LMWH干预治疗,将其分为干预亚组(n＝91,采取LMWH干预治疗措施)和未干预亚组(n＝48,未采取LMWH干预治疗措施)。采用回顾性分析法,对研究组与对照组孕妇年龄、人体质量指数(BMI)和孕龄等一般临床资料进行分析,并对其血栓5项标志物水平进行比较。绘制Hcy、TEG最大振幅(MA)值和MAR诊断RSA孕妇血栓前状态(PTS)受试者工作特征(ROC)曲线,并计算ROC曲线下面积(ROC-AUC),根据约登指数最大原则,确定Hcy、MA值和MAR诊断RSA孕妇PTS的最佳临界值,并计算其诊断PTS的敏感度、特异度。本研究遵循的程序符合苏州大学附属第二医院伦理委员会规定,并获得该伦理委员会批准(审批文号：JD-LK-2018-030-03),与所有参与本研究的受试者签署临床研究知情同意书。 结果①研究组与对照组孕妇年龄、BMI及孕龄比较,差异均无统计学意义(P>0.05)。②研究组和对照组孕妇MA值、Hcy和MAR分别比较[(65.3±5.4) mm vs (62.3±5.2) mm、(8.3±3.2) g/L vs (7.4±1.9) g/L及(73.8±7.7)% vs (69.9±9.3)%],差异均有统计学意义(t＝5.135、3.512、4.724,P＝0.036、0.012、0.014)。③Hcy、MA值和MAR诊断RSA孕妇PTS的ROC-AUC分别为0.681(95%CI：0.611~0.750,P<0.001),0.712(95%CI：0.651~0.773,P<0.001),0.877(95%CI：0.838~0.916,P<0.001)。根据约登指数最大原则,Hcy、MA值和MAR诊断RSA孕妇PTS的最佳临界值分别为7.05 g/L、59.1 mm、70.5%,并且诊断RSA孕妇PTS的敏感度分别为73.3%、80.1%及70.1%,特异度分别为65.2%、55.0%、92.1%。④干预亚组、未干预亚组和对照组孕妇活产率、流产率、妊娠随访率、剖宫产率比较,差异均有统计学意义(P<0.05)。⑤随访期内干预亚组孕妇无一例出现血小板减少、严重变态反应及肝、肾功能受损等情况。 结论Hcy、MA值、MAR血栓3项标志物,对RSA孕妇的PTS诊断具有一定预警作用。建议对血栓标志物水平异常的RSA患者,应及时采取LMWH治疗措施,对于改善其妊娠结局有一定作用。     

国产与进口明胶行术前高容量血液稀释的临床对比研究

目的观察国产与进口明胶溶液行术前超容量血液稀释对机体血气分析及凝血功能的影响,同时比较两者的不良反应,以验证国产明胶的有效性和安全性。方法选择60例行择期腹部外科手术的患者,美国麻醉医师协会(ASA)分级Ⅰ～Ⅱ级,年龄18～55岁,随机均分为乳酸林格液组(L组,即对照组)、国产明胶液菲克雪浓组(F组)和进口明胶液佳乐施组(G组)。在麻醉诱导前以20ml·kg-1·h-1的速度扩容1h,在扩容前(T1)、扩容止(T2)、扩容后1h(T3)、扩容后2h(T4)采取静脉血样,采用血栓弹性描记仪(TEG)测定凝血R时间、K时间、α角、MA、CL30等值,同时测定各时点的血气分析、血红蛋白(Hb)、红细胞压积(Hct)、凝血酶原时间(PT)、部分凝血酶原时间(APTT)、纤维蛋白原(Fg)及血小板最大聚集率,记录有创血压(iBP)、中心静脉压(CVP)、心率(HR)、脉搏血氧饱和度(SpO2)。结果实验过程中所有病例均未发生过敏等不良反应。扩容前、后各组的血流动力学均保持平稳,血气水平均在正常范围内,PT、APTT、Fg和血小板最大聚集率均无明显变化。扩容后,3组的Hct、Hb均明显下降(P<0.05),G组和F组在扩容后2h仍明显低于L组(P<0.05),但前两组间的差异无显著性(P>0.05)。3组溶液扩容后R时间均明显延长(P<0.05)。结论应用乳酸林格液、国产明胶液菲克雪浓和进口明胶液佳乐施20ml·kg-1·h-1行术前超容量血液稀释是安全的。国产明胶液与进口明胶液佳乐施应用于临床患者的有效性和安全性相仿。     

血栓弹力图在血浆输注中的应用

目的探讨血栓弹力图（TEG）在非血液病患者手术后凝血功能监测中的应用价值;并根据检测结果对术后患者输注新鲜冰冻血浆（FFP）的疗效进行评估。方法选择非血液病患者38例,于术后输注FFP前、输注200 ml及输注400ml FFP后分别进行TEG及传统凝血象检测。对两种实验方法的结果进行分析,并对3种状态下TEG检测结果进行比较。结果在输注FFP前、输注200 ml及输注400 ml FFP后3种状态下,R时间、K时间、Angle值及凝血综合指数CI值的差异有统计学意义（F值分别为23.405、20.869、19.978和31.243,P值均〈0.01）,但最大振幅（MA）值在上述3种情况下的差异没有统计学意义（F=1.651,P〉0.05）。3种状态下,PT、APTT、纤维蛋白原含量及凝血酶时间的差异均有统计学意义（F值分别为5.374、8.382、117.049和23.029,P值均〈0.01）。3种状态下凝血象与TEG-CK检测结果比较,显示2种检测方法的差异有统计学意义（χ^2=4.433,P〈0.05）。结论TEG适用于患者术后凝血功能监测。TEG结果显示,输注不同量FFP后患者凝血功能得到显著改善。     

Reversal of hypercoagulability with hydroxyethyl starch during transplantation: a case series

During transplant surgery, clot formation resulting in life-threatening thromboembolic phenomena or graft loss may be a consequence unless close monitoring of coagulation and anticoagulation treatment is instituted in a timely manner. Three cases with a hypercoagulable state, as determined by thrombelastography at the time of surgery, but whose hypercoagulation was gradually attenuated with hydroxyethyl starch infusion during transplantation, are presented.     

Fibrinogen function is impaired in whole blood from patients with cyanotic congenital heart disease

Background

Patients with cyanotic congenital heart disease (CCHD) have haemostatic abnormities associated with bleeding and thrombo-embolic events. The haemostatic abnormalities are not fully understood, but recent studies indicate that elevated haematocrit and fibrinogen function may be of importance.The aim of this study was to characterise the haemostatic profile and examine the potential role of haematocrit on clot formation and strength in CCHD patients. Furthermore to examine whether CCHD patients with history of haemoptysis have diminished fibrinogen function compared to those without haemoptysis.

Methods

In a prospective study 75 adult CCHD patients had haematocrit, platelet count, and plasma fibrinogen concentration examined. Furthermore thrombelastography(TEG) as well as TEG Functional Fibrinogen(TEG FF) assay evaluating fibrinogen function(FLEV) was performed. Data were compared with historical data regarding previous haemoptysis in CCHD patients.

Results

Haematocrit was 57 ± 8% and platelet counts in the lower normal range. TEG revealed a hypocoagulable condition with impaired clot formation. TEG values were correlated to haematocrit, indicating that elevated haematocrit causes impaired clot formation and strength. Despite high levels of plasma fibrinogen, TEG FF demonstrated that FLEV was diminished and negatively correlated to haematocrit. Furthermore CCHD patients with previous history of haemoptysis had significantly lower FLEV compared to CCHD patients without haemoptysis.

Conclusion

Patients with CCHD are hypocoagulable mainly due to impaired fibrinogen function. Despite a low platelet count, platelet function does not seem to be severely affected in CCHD patients. Haemostasis, and especially fibrinogen function, is negatively affected by elevated haematocrit, and fibrinogen function is diminished in CCHD patients with haemoptysis.     

Upregulation of CD40/CD40L system in rheumatic mitral stenosis with or without atrial fibrillation

Thrombelastography (TEG) analyses the status of blood coagulation including abnormalities associated with low platelet count. The aim of this study was to investigate the changes in TEG parameters in idiopathic thrombocytopenic purpura (ITP) patients. Thirty nine patients with ITP (platelet count?<?100?×?103 µl^?1) were included in the study. Age-matched 17 patients with thrombocytopenia due to chemotherapy were selected as a control group. Platelet count was positively correlated with maximum clot formation (MCF) in INTEM (r?=?0.716, p?<?0.001) and MCF in EXTEM (r?=?0.679, p?<?0.001); negatively correlated with clot formation time (CFT) in INTEM (r?=??0.755, p?<?0.001) and CFT in EXTEM (r?=??0.585, p?<?0.001) in ITP patients. Platelet count was positively correlated with MCF in INTEM (r?=?0.776, p?<?0.001) and MCF in EXTEM (r?=?0.878, p?<?0.001); negatively correlated with CFT in INTEM (r?=??0.627, p?<?0.001) in control group. Receiver operating characteristic curves to describe the critical platelet count and fibrinogen level that affect MCF revealed 31?×?103?µl^?1 and 375 mg?dl^?1 as cut-off values, respectively. In conclusion, ROTEM determines the contribution of fibrinogen and platelets to clot strength in patients with ITP. MCF appears to be the most important TEG parameter in predicting bleeding in ITP patients that makes TEG superior to other hemostatic tests.     

The procoagulant properties of purified fibrinogen concentrate are enhanced by carbon monoxide releasing molecule-2

Introduction

Fibrinogen concentrate has been demonstrated to enhance coagulation in vitro and in several clinical settings of coagulopathy. We have recently demonstrated that carbon monoxide releasing molecule-2 (tricarbonyldichlororuthenium (II) dimer; CORM-2) enhances fibrinogen as a substrate for thrombin via an attached heme. The objective of this study was to determine if CORM-2 modified fibrinogen concentrate would enhance coagulation more effectively than CORM-2 naïve fibrinogen concentrate.

Materials and Methods

In the first series of experiments, fibrinogen concentrate (final concentration 300 mg/dl) was exposed to 0, 50 or 100 μM CORM-2 for 5 min at 37 °C prior to being added to citrated, fibrinogen depleted plasma. In another series of experiments, citrated plasma obtained from 12 normal subjects was 50% diluted with crystalloid to which was added fibrinogen concentrate (final concentration 300 mg/dl) exposed to 0 or 100 μM CORM-2. Coagulation was activated with tissue factor (n = 8 per condition). Thrombus growth was monitored with thrombelastography for 15 min.

Results and Conclusions

CORM-2 modification of fibrinogen concentrate significantly enhanced the velocity of clot formation (30-50%) and strength (15-31%) in fibrinogen deficient plasma. Similarly, while diluted plasma-derived thrombi demonstrated a marked decrease in velocity of formation (54%) and strength (61%), fibrinogen concentrate significantly enhanced velocity (217%) and strength (171%); however, CORM-2 modified fibrinogen concentrate significantly increased velocity (303%) and strength (205%) to a greater extent. Additional in vitro investigation and in vivo preclinical assessments of the hemostatic efficacy of CORM-2 modified fibrinogen concentrate are warranted.     

肢体缺血-再灌注损伤对凝血功能的影响

目的 探讨肢体缺血-再灌注损伤(I-RI)对患者凝血功能的影响.方法 18例择期在硬膜外麻醉下行单侧膝关节镜手术治疗患者,术中使用充气式止血带,肢体缺血时间(42±6)min.分别于止血带充气前(T_1)、肢体缺血30 min(T_2)、再灌注3 min(T_3和30 min(T_4)抽取静脉血,应用血栓弹力描记图(TEG)检测凝血功能.结果 与T_1时比较,TEG显示反应时间(R值)和凝同时间(K值)降低、凝固角(α角)和血栓最大幅度(MA值)增大,但其改变均在正常值范围,且与其他时点相比差异无统计学意义.结论 肢体I-RI对患者凝血功能没有显著影响.