血栓弹力图对产科出血及输血的指导意义

产科出血一直是导致孕产妇死亡的主要原因。血栓弹力图(thrombelastography, TEG)是反应血液凝固动态变化的指标，能够评价凝血功能，弥补常规检查不能反映纤溶系统和血小板功能的缺陷。TEG可以实现对产科出血进行快速、准确、动态、直观的监测，帮助预防严重的产科出血。TEG为临床治疗提供直观依据的同时，也为产科输血治疗提供依据和指导，减少并发症的发生，避免血制品滥用。     

Comparing of Light Transmittance Aggregometry and Modified Thrombelastograph in Predicting Clinical Outcomes in Chinese Patients Undergoing Coronary Stenting with Clopidogrel

Background:

Several platelet function tests are currently used to measure responsiveness to antiplatelet therapy. This study was to compare two tests, light transmittance aggregometry (LTA) and modified thrombelastography (mTEG), for predicting clinical outcomes in Chinese patients after percutaneous coronary intervention (PCI).

Methods:

Prospective, observational, single-center study of 789 Chinese patients undergoing PCI was enrolled. This study was investigated the correlations between the two tests and performed receiver operating characteristic curve (ROC) analysis for major adverse cardiovascular events (MACEs) at 1-year follow-up.

Results:

MACEs occurred in 32 patients (4.1%). Correlations were well between the two tests in the adenosine diphosphate induced platelet reactivity (Spearman r = 0.733, P < 0.001). ROC-curve analysis demonstrated that LTA (area under the curve [AUC]: 0.677; 95% confidence interval [CI]: 0.643–0.710; P = 0.0009), and mTEG (AUC: 0.684; 95% CI: 0.650–0.716; P = 0.0001) had moderate ability to discriminate between patients with and without MACE. MACE occurred more frequently in patients with high on-treatment platelet reactivity (HPR) when assessed by LTA (7.4% vs. 2.7%; P < 0.001), and by TEG (6.7% vs. 2.6%; P < 0.001). Kaplan–Meier analysis demonstrated that HPR based on the LTA and mTEG was associated with almost 3-fold increased risk of MACE at 1-year follow-up.

Conclusions:

The correlation between LTA and mTEG is relatively high in Chinese patients. HPR measured by LTA and mTEG were significantly associated with MACE in Chinese patients undergoing PCI.     

一氧化碳中毒患者凝血功能变化及预后评估

目的 探讨不同中毒程度的一氧化碳中毒（ACOP）患者凝血功能变化及对预后的评估价值。方法 选取2015年1月至2017年12月中国人民解放军第三七一中心医院收治的61例ACOP患者,根据一氧化碳中毒诊断及分级标准,分为轻度组（35例）和中重组（26例）,选取同期体检的30例健康者作为对照组,比较3组患者ICU住院时间（d）、机械通气时间（d）、碳氧血红蛋白含量（%）。同时检测并比较3组患者常规凝血功能指标[凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、凝血酶时间（TT）、纤维蛋白原（FIB）、D-二聚体（D-D）、纤维蛋白（原）降解产物（FDP）]及血栓弹力图（TEG）指标凝血反应时间（R）、血块形成时间（K）、血凝速率（Angle角）、血块强度（MA）、血凝综合指数（CI）,分析各指标之间的相关性。所有ACOP患者随访28天,根据预后情况分为存活组（42例）和死亡组（19例）,评估并比较两组患者凝血功能。结果 两组患者在ICU住院时间（d）、机械通气时间（d）、碳氧血红蛋白含量（%）比较,差异均有统计学意义（P<0.05）。3组患者常规凝血功能指标及TEG指标比较,差异均有统计学意义（P<0.05）。中重组患者PT、APTT、TT短于轻度组患者,D-D、FDP水平高于轻度组,差异均有统计学意义（P<0.05）,中重组与轻度组患者FIB比较,差异无统计学意义（P>0.05）。死亡组患者与存活组患者比较,PT、APTT、TT缩短,FIB、D-D、FDP水平升高,差异均有统计学意义（P<0.05）。TEG指标中,轻度组患者与对照组患者比较,R值缩短,MA值升高,差异均有统计学意义（P<0.05）。中重组患者R值、K值显著缩短（P<0.05）,Angle角、MA值、CI值显著升高（P<0.05）。死亡组患者与存活组患者比较,R值、K值缩短（P<0.05）,Angle角、MA值、CI值升高,差异均有统计学意义（P<0.05）。Pearson相关分析显示：TEG检测中R值分别与PT、APTT呈正相关（P<0.05）;K值与APTT呈正相关（P<0.05）,与FIB呈负相关（P<0.05）;Angle角分别与APTT呈负相关（P<0.05）,与FIB、D-D呈正相关（P<0.05）;MA值与FIB呈正相关（P<0.05）;CI值分别与PT、APTT呈负相关（P<0.05）,与FIB呈正相关（P<0.05）。结论 ACOP患者凝血功能紊乱程度与患者病情严重程度相关。常规凝血功能指标与血栓弹力图指标具有相关性,两者对监测ACOP患者凝血功能对临床治疗具有指导意义。     

凝血弹性图在活体肝移植术中应用的研究

目的对成人活体肝移植术中使用凝血弹性图进行凝血功能监测,探讨手术各阶段凝血紊乱的诱因及相应治疗方法。方法 33例行活体肝移植手术患者,于手术开始时(T_1)、无肝期再灌注前5min(T_2)、新肝期再灌注后5min(T_3)及再灌注后60min(T_4)进行肝素酶修正及自然全血凝血弹性图检测。结果 T_1及T_2肝素酶修正组与自然全血组凝血弹性图数值差异无统计学意义(P>0.05)。T_3时自然全血组与肝素酶修正组数据均显示低凝状态且肝素或肝素样物质为主要原因。T_4后肝素造成的凝血异常逐步改善,但较之T_1仍处于低凝状态。结论凝血弹性图对凝血状况的连续监测可以快速准确判断活体肝移植术中不同阶段凝血异常的原因,指导临床针对性治疗,并可评价治疗效果。     

Citrate artificially masks the haemostatic effect of recombinant factor VIIa in dilutional coagulopathy

Most often, thrombelastographic analyses are carried out using citrated blood and re-calcification. However, calcium chelation may affect dynamics of tissue-factor-initiated thrombin generation. The present study investigates the effect of sample anticoagulant on the response of a colloid induced dilutional coagulopathy model to recombinant activated factor VII (rFVIIa) as measured by thrombelastography. Thrombelastographic evaluation of whole blood coagulation activated with minute amounts of tissue factor in a model of in vitro haemodilution with hydroxyethyl starch (HES) 130/0.4 in a prospective laboratory study. Whole blood coagulation was evaluated before and after 30% dilution with HES 130/0.4, and following in vitro addition of rFVIIa to whole blood collected into tubes containing citrate, corn trypsin inhibitor (CTI), and no stabilizers. Haemodilution with HES 130/0.4 induces a coagulopathy characterised by a reduced maximum rate of clot formation and a pronounced reduction in the final clot firmness. With all test mediums investigated, rFVIIa significantly shortened clot initiation phase. In cases of native whole blood and CTI-stabilised whole blood, rFVIIa shortens the clotting time but also demonstrated an acceleration of the maximum velocity of clot formation. When citrate is used as anticoagulants in thrombelastographic clotting assays, these may artificially mask the haemostatic effect of rFVIIa in colloid haemodilution. The effect in vitro of rFVIIa in citrated blood samples may underestimate the haemostatic potential of rFVIIa. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

恶性肿瘤患者血栓弹力图检测的临床意义

目的：探讨恶性肿瘤患者体内凝血状态。方法：对65例恶性肿瘤患者于治疗前进行血栓弹力图（TEG）及常现凝血象的检测。结果：恶性肿瘤患者TEG大多数表现为高凝图象：γ值、K值、M值明显缩短，均值分别为2．80±0．81（分）、1．10±0．30（分）、26．40±5．98（分）。Ma值明显增宽，均值为66．42±8．11（mm）。少部分晚期肿瘤患者TEG表现为低凝图象：γ值、K值、M值明显延长，均值分别为8．88±1．51（分）、5．63±1．33（分）、38．89±6．95（分）。Ma值明显变窄，均值为46．08±4．85（mm）。结论：恶性肿瘤患者体内存在凝血功能异常，临床可根据TEG的改变来判断恶性肿瘤患者临床所处凝血状态，正确指导治疗。     

高血压及糖尿病人肾小球滤过率对血栓弹力图测定的凝血功能影响

目的：利用改良的血栓弹力图技术（TEG）评估老年高血压病、糖尿病患者抗血小板治疗后凝血功能变化,探讨肾小球滤过率（eGFR）对TEG各指标的影响.方法：选择TEG、常规凝血功能检查资料完整的住院患者87例,根据eGFR分为eGFR正常组（eGFR≥90ml· min 1·1.73m-2）52例,以及eGFR低下组（eGFR＜ 90ml·min-1·1,73m-2） 35例,比较两组间服用抗血小板药物（阿司匹林和/或氯吡格雷）治疗后常规凝血功能和TEG指标的差异,分析eGFR与TEG指标间的相关性.结果：抗血小板治疗后,与eGFR正常组比较,eGFR低下组TEG; K时间[K值,（1.59±0.53） min比（1.35±0.48） min]显著减少（P=0.037）,α角度[Angle值,（66.05±7,63）＆#176;比（69.49±7.58）°、MA30min血块减少速度（Ly30）：（0.99±1.88）％比（2.80±4.60）％]显著增加;血浆纤维蛋白原水平[（2.96±0.65） mg/L比（3.60±1.08） mg/L]显著升高（P＜0.05～＜0.01）;Pearson相关性分析显示,Angle值（r=-0.308,P=0.008）、Ly30值（r=-0.258,P=0.03）均与eGFR呈负相关.结论：抗血小板治疗后高血压、糖尿病慢性肾功能损害患者血凝度仍高于肾功能正常患者;这些患者应定期检查肾功能和血栓弹力图,以评估抗血小板的效果.     

血栓弹力图在高危妊娠中的研究进展

血栓弹力图(thrombelastography,TEG)是一种反映全血凝血功能的图像,是一种能从整体上动态评价凝血和纤溶过程的检测手段。妊娠期凝血-抗凝系统及纤溶-抗纤溶系统的变化使妊娠妇女的凝血系统处于高凝状态,这种高凝状态既是一种生理性保护机制,又是诱发凝血功能障碍的高危因素。一旦这种高凝状态的动态平衡被打破,可参与产科并发症的发生,严重威胁着孕产妇和胎儿的安全。TEG能够真实、全面地反映妊娠期妇女凝血功能的变化,对复发性流产、妊娠期高血压疾病、羊水栓塞、产后出血和产科血栓栓塞性疾病等高危妊娠及妊娠期并发症的预测及病情评估具有重要的临床价值,为指导临床决策、早期干预、缓解或延迟并发症和预防不良妊娠结局提供科学依据。