血栓弹力图法评估凝血紊乱与儿童脓毒症严重程度及预后的相关性

目的 通过血栓弹力图(thromboelastography,TEG)结果分析凝血紊乱与脓毒症严重程度、器官功能障碍和预后的关系.方法 收集2014年2月至2015年1月我院PICU诊断脓毒症和严重脓毒症患儿(n=62)的临床资料,于诊断脓毒症当天(D1)、第2天(D2)、第3天(D3)检测患儿血常规、炎症指标(C-反应蛋白、降钙素原)、器官功能指标(ALT、TBiL、ALB、Cr、BUN、PaO2/FiO2)、乳酸、传统凝血功能检测指标(APTT、PT、INR、Fib、D-dimers)、TEG指标(R、K、α、MA、LY30、CI).(1)比较脓毒症、严重脓毒症组组间D1～3 TEG结果;比较低凝、高凝组组间D1炎症指标、D1危重评分.(2)比较低凝、高凝组组间D1器官功能指标(ALT、TBiL、ALB、Cr、BUN、PaO2/FiO2)、D1～3儿童多器官功能障碍评分和器官功能障碍数目.(3)比较存活、死亡组组间D1～3 TEG结果;采用Kaplan-Meier生存曲线、Log Rank检验分析D1CI和APTT、PT结果与脓毒症28d生存率的关系.结果 (1)凝血紊乱与脓毒症严重程度的关系:严重脓毒症组(n=21)较脓毒症组(n=41) D1～3TEG结果呈持续低凝状态:D1～2R及D1、D3K延长,D1～3α减小,D1～3MA、CI降低(P＜0.05);低凝组(n=16)D1PRISM Ⅲ高于高凝组(n=26) (P＜0.05);低凝组D1中性粒细胞计数低于高凝组(P＜0.05).(2)凝血紊乱与多器官功能障碍综合征(multiple organ dysfunction syndrome,MODS)的关系:低凝组D1器官功能损害重于高凝组:D1Cr、BUN、ALT升高(P＜0.05);低凝组D1儿童多器官功能障碍评分、D1～3器官功能障碍累积数目高于高凝组(P＜0.05).(3)凝血紊乱与脓毒症预后的关系:低凝组病死率高于高凝组(62.5％ vs.15.4％,P=0.002);死亡组(n=18)较存活组(n=44) D1～3TEG结果呈持续低凝状态:D1～2R及D1、D3K延长,D1～3α减小,D1～3MA、CI降低(P＜0.05);Kaplan-Meier生存分析显示低凝、高凝、正常组28d生存曲线分布差异有统计学意义(P＜0.05).结论 TEG结果呈持续低凝状态可反映患儿脓毒症和MODS严重程度,TEG对预测脓毒症28d预后有参考价值.TEG对于综合判断脓毒症严重程度、MODS和预测脓毒症转归具有重要意义.     

血栓弹力图评价服用不同剂量阿司匹林对血小板抑制率的影响

目的 探讨血栓弹力图评价服用不同剂量阿司匹林对血小板抑制率的影响.方法 将符合入选条件的缺血性脑卒中或短暂性脑缺血发作(TIA)患者180例按就诊顺序随机分为阿司匹林100 mg/d组、阿司匹林200 mg/d组、阿司匹林300 mg/d组,每组60例,在服药前及服药后7d、6个月、1年应用血栓弹力图检测花生四烯酸途径诱导的血小板抑制率并进行比较.结果 三组服药后各时间点血小板抑制率与服药前比较差异有统计学意义(P＜0.05).服药后阿司匹林100 mg/d组和阿司匹林200 mg/d组血小板抑制率呈逐步减低趋势,而阿司匹林300 mg/d组呈轻度递增趋势.三组服药前、服药后7d、服药后6个月血小板抑制率比较差异均无统计学意义(P＞0.05),而服药后1年比较差异有统计学意义(P＜0.05),两两比较阿司匹林300 mg/d组血小板抑制率[(93.8±18.6)％]显著高于阿司匹林200 mg/d组[(83.7±11.2)％]和阿司匹林100 mg/d组[(76.6±12.8)％](P＜0.05).阿司匹林100 mg/d组血小板抑制率低于50％者9例,阿司匹林200 mg/d组5例,阿司匹林300 mg/d组3例,阿司匹林300 mg/d组1年内发生消化道溃疡出血2例.结论 适当的阿司匹林剂量(100、200、300 mg/d)均能起到很好的抗血小板作用,在100 mg/d基础上增加剂量血小板抑制率在短期内(≤6个月)未见明显增加,但长期(1年)存在差异,可能与阿司匹林抵抗发生较少有关,而出血风险却相对增大.     

血栓弹力图检测在指导心脏术后患儿成分输血中的应用价值

目的 探讨血栓弹力图(TEG)检测在指导心脏术后患儿成分输血中的应用价值.方法 选择心脏术后患儿103例,均在输血前检测TEG,根据R值、K值及MA值分别将患儿分为R值正常组(R≤10 min)85例及R值延长组(R>10 min)18例;K值正常组(K≤3 min)47例及K值延长组(K>3 min)56例;MA值正常组(MA≥50 mm)42例及MA值降低组(MA<50 mm)61例,记录其术后血浆和PLT的输注情况,比较组间术后输血情况以及输血前后相应的参数值.结果 R值延长组、K值延长组术后输注血浆者比例及血浆输注量分别高于R值正常组、K值正常组(P<0.05);R值延长组、K值延长组输注血浆后相应参数较前缩短,而R值正常组、K值正常组输注血浆前后相应参数无明显变化(P>0.05).MA值降低组术后输注PLT者比例及PLT输注量均高于或多于MA值正常组(P<0.05),但两组术后输注血浆者比例及血浆输注量比较差异均无统计学意义(P>0.05);MA减低组输注PLT后MA值较前升高(P<0.05),而MA正常组输注PLT前后MA值无明显变化(P>0.05).结论 TEG的R值、K值和MA值对心脏术后患儿成分输血具有指导意义.     

血栓弹力图在妊娠合并血小板减少症患者中的应用

目的探讨血栓弹力图(thromboelastography,TEG)在妊娠合并血小板减少症患者(PAT)中的应用。方法收集我院2016年4月～2019年3月确诊的60例妊娠合并血小板减少症患者,按照1∶1比例配对法分为两组,对照组30例,行常规凝血功能检测;观察组30例,进行常规凝血功能检测及血栓弹力图检测评估,分析两组的分娩情况、术中术后出血情况及实验室指标检测结果。结果两组ALT、AST、PT、APTT、TT、FIB无明显差异(P0.05),观察组阴道分娩率高于对照组、术中出血量高于对照组(P0.05),但两组的术后出血量及产后大出血发生率无差异(P0.05)。结论血栓弹力图用于PAT患者凝血的监测,可评估出血风险,为分娩方式的选择提供指导依据。     

Association of hemodilution and blood pressure in uncontrolled bleeding

Background

Hemodynamic status and coagulation capacity affect blood loss after injury. The most advantageous fluid and blood pressure to optimize resuscitation and minimize perturbation of coagulation are unclear. We investigated interactions of isovolumic hemodilution on hemodynamics, coagulation, and blood loss after injury.

Methods

Twenty-five male rats were randomized into three groups (Whole Blood Uncontrolled Blood Pressure [WBU], n = 7; Lactated Ringers Uncontrolled Blood Pressure [LRU], n = 10; Whole Blood Controlled Blood Pressure [WBC], n = 8) with isovolumic hemodilution of 50% blood volume, with and without control of pre-injury blood pressure. All rats underwent uniform grade IV liver injury 30 min after serial exchanges. Post-injury blood loss and coagulation function were measured.

Results

Dilution occurred, determined by hematocrit, with LRU having a greater reduction. Pre-injury mean arterial pressure (MAP) decreased compared with baseline (98 ± 7 mmHg) with LRU (62 ± 14 mmHg) and WBC (61 ± 10 mmHg), resulting in WBU (101 ± 13 mmHg) being significantly higher and not changed from baseline. Post-injury, MAP decreased from pre-injury, with LRU significantly lower than the other two groups. No differences were observed in prothrombin time/international normalized ratio or thromboelastography. Bleed volume was significantly different between groups: WBU < WBC < LRU and associated with the pre-injury MAP. Controlling baseline MAP, dilution with Lactated Ringers (LR) resulted in greater blood loss than whole blood (3.0 ± 0.4 versus 1.9 ± 0.3 mL).

Conclusions

In this rat model of liver injury, blood loss was associated with baseline MAP and type of fluid used for dilution. Hemodilution with LR did not produce coagulopathy based on laboratory values. When controlling baseline MAP, dilution with LR increased bleeding, confirming a functional coagulopathic state.     

血清D-二聚体、纤维蛋白原检测联合血栓弹力图对急性心肌梗死预后的评估价值

目的 探讨血清D-二聚体（D-D）、纤维蛋白原（Fib）检测联合血栓弹力图（TEG）对急性心肌梗死（AMI）预后的评估价值。方法 选取2018年8月～2021年2月我院收治的AMI患者126例,所有患者均接受经皮冠状动脉介入（PCI）治疗,根据患者随访期间是否发生主要心血管不良事件（MACE）将患者分为预后不良组（n=41）和预后良好组（n=85）。比较两组患者的一般临床资料、血清D-D、Fib和TEG指标,分析D-D、Fib和TEG指标的相关性,采用受试者工作特征曲线（ROC）分析D-D、Fib和TEG指标对AMI患者预后的评估价值。结果 预后不良组患者的收缩压（SBP）、舒张压（DBP）水平明显小于预后良好组,心率（HR）明显高于预后良好组（均P＜0.05）;预后不良组患者的血清D-D、Fib水平高于预后良好组,两组患者的TEG指标凝血反应时间（R）、凝血形成速率（Angle角）、血栓最大振幅值（MA）和凝血综合指数（CI）比较,差异有统计学意义（均P＜0.05）。Logistic回归分析结果显示,血清D-D、Fib、R、Angle角、MA和CI是影响患者预后的独立危险因素（P＜0.05）;相关性分析结果显示,D-D与R呈负相关,与Angle角、MA值和CI均呈正相关（P＜0.05）;Fib与MA值、CI呈正相关（P＜0.05）。ROC曲线分析结果显示,D-D、Fib、R、Angle角、MA值和CI评估AMI患者预后的AUC值分别为0.838、0.824、0.791、0.780、0.808、0.677,联合检测的AUC值为0.863,对AMI患者预后的评估有统计学意义（均P＜0.05）。结论 血清D-D、Fib和TEG指标的变化与AMI患者PCI术后MACE发生存在相关性,对AMI患者预后不良的评估具有一定临床价值。     

Perioperative therapeutic plasma exchange in a patient with rare Factor XIII inhibitor

IntroductionFactor XIII deficiency is a rare bleeding disorder which could be severe if inherited or less severe if acquired. We report a case of acquired Factor XIII inhibitor in a 75-year-old male with a suspicious left renal mass treated perioperatively with therapeutic plasma exchange (TPE).Patient and methodTo perform kidney biopsy and ablation of the renal mass, six daily TPE treatments were performed before and after biopsy to minimize bleeding risk because the patient did not respond to drug therapy. Both thromboelastography (TEG) and laboratory-based coagulation tests were performed to assess coagulation status prior to and after TPE.ResultsThe biopsy indicated oncocytoma which was removed by surgical procedure. Factor XIII activity remained below 15 % throughout TPE treatments, but Factor XIII inhibitor titer reduced from initial positive value of 1:40 to negative following the third TPE and remained negative through the sixth TPE. Unfortunately, the inhibitor titer was positive at 1:20 in the fifth month and 1:5 in the sixth month during follow-up.ConclusionsTPE is useful in removing XIII inhibitory factor, but the effects are only short term.