血栓弹力图及下肢深静脉彩超在下肢骨折后围手术期的应用价值

Thrombelastography and color Doppler flow imaging in the perioperative period after closed lower limb fracture

目的通过观察下肢骨折后围手术期血栓弹力图（TEG）及下肢深静脉彩超（CDFI）的变化，探讨他们的临床应用价值。方法I组为（对照组）11例健康献血者，清晨空腹静脉采血。Ⅱ组为股骨闭合骨折组，Ⅲ组为胫骨闭合骨折组，各60例，均为未经抗凝治疗的并拟行切开复位内固定术的患者，均分别于骨折第2天（Ⅱ2 d、Ⅲ 2 d）、第6天（手术当天Ⅱ6 d、Ⅲ6 d）；术后第2天（Ⅱ8 d、Ⅲ8 d）、第7天（H13 d、Ⅲ13d）及第10天（Ⅱ16 d、Ⅲ 16 d）清晨空腹静脉采血。所有静脉血样均进行TEG检测。Ⅱ组和Ⅲ组患者分别于术前1d和术后第7天进行CDFI检查。结果Ⅱ2 Ⅱ6。Ⅱ8 d、Ⅱ13d和Ⅱ16d分别与I组比较：凝血反映时间和凝固时间缩短，凝固角（a角）、血栓最大幅度（MA）及凝血块强度（G）增大，凝血综合指数延长；Ⅱ6d、Ⅱ8d、Ⅱ13d 和Ⅱ16d分别与Ⅱ2d比较：a角、MA及G增大；Ⅱ8dⅡ13d和Ⅱ16d分别与Ⅱ6 d比较：a角、MA及G增大；Ⅱ13 d和Ⅱ16d分别与Ⅱ8d比较：旺角和MA增大；差异均有统计学意义（P〈0．05）。Ⅲ2d、Ⅲ6d、Ⅲ8d、Ⅲ13d、Ⅲ16d分别与I组比较：MA及G增大；Ⅲ8d和Ⅲ13d分别与Ⅲ2d或Ⅲ6d比较：MA及G增大；Ⅲ16d分别与Ⅲ2d、Ⅲ6d、Ⅲ8d、Ⅲ13d比较：MA及G差异均有统计学意义（P〈0．05）。II、Ⅲ组间同一时间点TEG各项参数比较差异均有统计学意义（P〈0．05）。通过CDFI检查：Ⅱ组有5例（8．3％）发生深静脉血栓形成（DVT），Ⅲ组术前有2例（3．3％）发生DVT，术后无DVT发生。结论创伤骨折后围手术期患者的高凝状态在骨折第6天和术后第2天达到高峰。股骨骨折患者比胫骨骨折患者围手术期的高凝状态更高。术前CDFI排查是必需的。

Objective To observe the changes of thrombelastography （TEG） and color Doppler flow imaging （CDFI） in the perioperative period after closed lower limb fracture. Methods Fasting venous blood samples in the morning from 11 healthy adults were used as controls （group I） . Sixty patients with closed femoral fracture were enrolled in group II, and another 60 patients with closed tibial fracture were enrolled in group III. The patients in both groups underwent open reduction and internal fixation without anti-coagulation treatment. Fasting venous blood sampling was performed in the early morning for all the patients on the 2nd day after fracture （ II2 d, II2 d）, the operative day （ II6 d, III6 d）, the 2nd day after operation （ II8 d, III8 d）, the 7th day after operation （ II 13 d, III 13 d） and the lOth day after operation （ II 16 d, III 16 d）. The TEG was observed double blindly by specialists for all the blood samples. CDFI was conducted for samples from groups II and III on one day before operation and the 7th day after operation. Results Compared with group I, the R and K time decreased and the values of a angle, MA, G and CI on II 2 d, II 6 d, II8 d, II 13 drand II 16 d increased with significant differences. The a angle, MA and G increased significantly on II 6 d, II 8 d, II 13 d and II 16 d compared with II 2 d. The a angle, MA and G increased significantly on II8d, II 13 d and II 16 d compared with II 6 d. The a angle and MA increased significandy on II13 d and II16 d compared with II 8 d. The MA and G increased significantly on III2 d, III6 d, III 8 d, III 13 d and III 16 d compared with group I. The MA and G increased significantly on III 8 d and III 13 d compared with III 2 d and III 6 d respectively. The MA and G increased significantly on III 16 d compared with III 2 d, III 6 d, III 8 d, III 13 d. Five patients in group II （8.3% ） developed deep vein thrombosis （DVT）, 4 before operation and one after operation. Three patients in group III （3.3%） developed DVT before operation but none after operation. Condusions The blood hypercoagulable state is increasing for patients following closed fracture of the lower limb, reaching the peak on the 6th day after fracture or the 2nd day after operation. Patients with closed femoral fracture tend to be in a more serious blood hypereoagnlable state than those with closed tibial fracture. CDFI is needed in the periooerative oeriod.